According to the most recent CMS data, nearly 20 percent of Medicare patients discharged from a hospital are readmitted within 30 days. And on average, these readmissions bloat costs by an additional $26 billion per year.
The primary cause? Poorly coordinated transitions of care.
But in today’s world of overburdened and overworked providers, ineffective transitions of care aren’t the byproduct of low-quality care teams. They’re a byproduct of schedules being stretched thin and poor communication channels.
Here, we’ll detail how to help relieve workloads, personalize care at scale, and boost health outcomes for patients with a value-based pharmacy system.
Create a single source of truth for patient data
Each transition of care occurs within the continuum of care cycle, whether from outpatient to inpatient or inpatient back to outpatient. But these transitions also expose a patient’s care regimen vulnerabilities.
Without a way to instantly unify, track, and share changes in patient records, for example, care teams may be forced to rely on dated information. Or they may need to spend precious time manually tracking and cross-referencing paper trails of allergy information, medication histories, and previous care plans.
This is, in a word, suboptimal.
EHRs, however, enable pharmacists and other care team members to access and update patient records in real time from any location. This helps drive more personalized and accurate medication management, which lowers the risk of hospitalization.
RxLive’s value-based pharmacy system deepens the value of patient data. By integrating into a health system’s EHR, RxLive’s platform streamlines complex portions of a transition of care, like medication reconciliation, by guiding treatment plans with predictive analytics and flagging risks for nonadherence.
Let’s say a patient is being treated for atrial fibrillation with Eliquis. They have a check-up appointment three months post-discharge. In advance of this appointment, the patient’s pharmacy team logs into RxLive to view the patient’s profile. There, they can see the patient’s diagnostic determinants – and that the patient hasn’t refilled their prescription once.
With this in mind, the pharmacy team can follow up and determine the root cause of this medication nonadherence. Once they’ve identified the cause, pharmacists then create a plan that encourages medication adherence, promotes positive health outcomes, and keeps the risk of hospitalization low.
Relieve provider burnout with the power of a fractional network
Even the most technology-enabled care teams today likely face shortages and burnout. And with transitions of care models demanding the level of precision they do, the more impacted a team is by burnout or shortages, the greater the chances a mistake will be made during the transition of care.
Complicating this further, there’s rarely room in the budget to solve these issues by simply hiring more physicians, pharmacists, or care coordinators. So providers are often forced to cut back in certain areas, whether that be medication consultations with patients or patient protocol refinement.
Tapping into RxLive’s fractional network of pharmacists helps solve this issue. Let’s consider the example above with the patient who was prescribed Eliquis. Without the requisite bandwidth – or specialization of pharmacists – a care team might not have the time to thoroughly explore solutions for the medication nonadherence.
This means that if the cause was financial, the care team may not have time to research biosimilars, potential assistance programs, or other cost-cutting measures. Not only that, but the care team also likely wouldn’t have the time to consult the patient on these cost-cutting measures. The same logic holds true if the underlying cause for nonadherence was, say, the patient misunderstanding their medication regimen.
In both situations, RxLive’s fractional network of pharmacists helps promote healthy outcomes for the patient and minimizes the burden on-the-ground care teams face.
Simplify and improve the patient experience with telehealth
In the first few months of the pandemic, health systems and networks implemented or scaled their use of telehealth platforms. At times when transmission risks were particularly high – prior to vaccine rollouts – these virtual systems were critical to care delivery.
Cut to today and the staying power of telehealth hasn’t diminished. For at-risk populations (the immunocompromised, disabled, elderly, etc.) telehealth remains a vital tool. And for others, the convenience of receiving care from the comfort of your own home is unparalleled.
Rather than traveling to and from various healthcare facilities for routine checkups in any transition of care, patients can stay at home and receive personalized insights from a technology-powered pharmacist.
Telehealth platforms – and a fractional network of pharmacists – don’t just lead to more convenient and impactful consultations, though. These platforms also let pharmacists and patients correspond more frequently. So if a patient wants to review a medication change prior to a scheduled appointment, the pharmacist can meet with them for a quick virtual chat.
This personalized approach to patient consults might seem simple or even unspectacular. But when the most common alternative to this form of care is patients visiting hospitals for consultations, the benefit is clear. Telehealth helps remove barriers to medication adherence and promotes positive health outcomes for patients.
Impactability is vital to a successful transition of care plan
Identifying patients is often the first step in any transition of care. But that’s not where the transition of care model stops. A successful transition of care also involves identifying patients at risk for poor transitions or hospitalization.
This is where impactability comes in. At a time of deepening provider shortages and escalating burnout, a care team’s bandwidth is limited, and they need to spend it on the duties that will have the greatest benefit for their patients and the healthcare system as a whole.
With a comprehensive value-based pharmacy system, physicians and pharmacists and care coordinators don’t have to guess which actions have the greatest impact – they’ll know. That’s because systems like RxLive equip providers with the tools they need to promote medication adherence and limit hospitalization.
If you’re interested in learning more about how technology-powered pharmacists can streamline transitions of care and relieve the administrative burden on your care team, reach out to us here.