Life Sciences

Could fewer formulary restrictions across settings reduce readmissions?

Medicare & Reimbursement Advisor Weekly, September 14, 2009

MRAW asked skilled nursing facilities and hospitals this summer as part of a transition of care study to provide suggested solutions to reduce readmissions and rate how much their suggestions could reduce hospitalizations and rehospitalizations.

Participants were given a rating on a scale of 1–7, where 1 represented highly unlikely to help reduce, 4 represented no opinion, and 7 represented highly likely to help reduce.

In the open-ended question, five solutions garnered a 6 or 7 rating (highly likely to reduce readmissions) among at least 50% of the 443 skilled nursing facilities and 352 hospitals participating in this study. Responses were open-ended and grouped into categories.

Chronic obstructive pulmonary disease, sepsis, congestive heart failure/acute coronary syndrome, renal disease, diabetes, and urinary tract infections were the six diseases/conditions nursing homes rated most susceptible for readmission among hospitals.

Results of the complete study, including suggested solutions as well as disease category–specific responses, will be published shortly.

To qualify, hospital respondents were registered nurses (RN) in charge of their institution’s case management or care management department; nursing home respondents were RNs in charge of care coordination, administration, or the nursing staff.

From a payer/formulary perspective, these responses tell us that changing medications for nonmedical reasons can in some cases disrupt continuity of care, potentially leading to downstream costs or adherence issues.

Customer comment

Here is one comment from one of the survey participants:

“For short-term admissions in particular, we try not to change too many medications so as not to further complicate the discharge/treatment plan,” says Lynn Veith, RN, administrative director of care coordination at McLean Care in Simsbury, CT. “We evaluate the cost of the drug during the SNF stay, the cost to the patient postdischarge (to enhance continuity), and efficacy, but the bottom line is multiple changes in meds confuses the already changing situation, and very often patients do not know which drugs to take upon discharge, are frequently hesitant to stop a drug they already have and fill a new script. There is such a large amount of clinical time involved in verifying orders and so many inconsistencies in formularies or restrictions; forcing medication changes seem counterproductive, costly, and not in the best interest of the patient.” If you have questions about this study, please e-mail