The time immediately following a patient’s return home from a hospital or post-acute care setting is one of the most delicate and critical times in a patient’s journey. Managing this period, known as transitional care management, can be a startling reality for many individuals and families and have a profound impact on a center’s rehospitalization rates.
There appears to be, in many cases, a significant gap in care, particularly for those at high risk of rehospitalization due to multiple chronic conditions and complex medication management protocols. Without home health care, individuals are at a higher risk of missing doses, not refilling prescriptions on time, and allowing health problems to persist due to lack of access to primary care.
PharMerica, part of the BrightSpring Health Services family of brands, created Continue Care to better care for people in this transitional care gap. Continue Care combines PharMerica’s pharmacy services with BrightSpring’s home care services to deliver hands-on, person-centered interventions that help prevent costly rehospitalization for medically complex patients returning home.
“About 40% of rehospitalizations can be attributed to medication errors and nonadherence to medication,” said Jennifer Yowler, president of PharMerica. “If we can eliminate this through our clinical and pharmaceutical expertise at home, we are truly in a position to reduce one of the leading causes of readmission.”
Residents who participate in Continue Care receive a 14-day supply of all medications prescribed by their doctor in easy-to-use multi-dose packages before leaving the skilled nursing facility. This ensures that for the next two weeks, individuals have precise and clear instructions on when and how to take each of their medications, which have been sorted into the correct dosages with easy-to-understand instructions.
“A great example of an ideal continuing care patient is someone who has six or more chronic conditions, as they typically take 10 or more medications,” said Dr. Bill Mills, senior vice president of medical affairs, BrightSpring. . “We are well aware that the more drugs people take, the greater the risk of potential adverse drug interactions, emergency room visits, and drug-related hospitalizations.”
According to Dr. Mills, the Continue Care program combats two significant issues that impact both individual health outcomes and readmission rates to long-term care facilities: polypharmacy and medication adherence. .
The Continue Care solution offers a streamlined process for delivering quality home care. Anyone discharged home from a skilled nursing facility is eligible for continuing care services, but those who seem to benefit the most are patients with 8-12 medications, complex comorbidities and addressable chronic conditions, and high or high expenses. – people at risk of hospitalization. Upon leaving the centre, the patient receives their 14-day supply of medication and a call from the care manager within the first 48 hours.
As part of the continuing care program, a nurse practitioner will call to follow up on the patient during their first week at home and schedule an in-home appointment within 14 days of discharge. Home care allows a provider to see the person, talk with them about how things are going, assess their environment for any medical issues, and determine if an appropriate prescribing protocol is in place and working for them. the person. This is also when medication refills are done so the patient has everything they need to continue beyond their first two weeks at home.
This in-home attention and emphasis on medications is key to helping maintain the individual’s health, which, in turn, leads to lower rehospitalization rates. According to Continue Care, home-based primary care is associated with a 50% reduction in hospital readmissions and a 20% reduction in emergency room visits.
These statistics add up to significant benefits for skilled nursing facilities, but there are more impacts than those on readmissions alone. Better medication adherence and fewer hospitalizations created two streams of savings for the centers. First, the overall cost of care is lower. Continue Care found that program participation in the medication care management model was associated with a reduction of $2,400 per member per year in total cost of care, representing a 5% reduction in average costs while improving medication adherence. Second, Continue Care noted improved plan reviews for participating centers, which led to increased quality bonus payments through the Medicare program.
“In today’s world, where operators of skilled nursing facilities are increasingly facing financial hardship, many companies that had post-discharge programs are reducing those programs,” said Jeremy Colvin, Senior Vice President, Growth and Market Development, PharMerica. “This program is more longitudinal than anything that exists. We strive to make this transparent for the patient and transparent for the centre, so that everyone benefits.
The initial Continue Care pilot program also includes a Continuing Care Support Program that goes beyond medication management to include condition monitoring, virtual nurse check-ins, 24-hour triage support, 7 days a week and medication reminders. The results were 100% adherence to medication among participants, prevention of hospitalizations and diversions to the emergency room.
These results are just the beginning for Continue Care, which is expanding its services through its pilot program with the goal of serving as many people as possible. The combined expertise of PharMerica and BrightSpring Health Services enables Continue Care to have the capacity to serve more than 350,000 patients per day in 50 states, integrating more than 10,000 clinical providers and pharmacists serving more than 3,100 facilities.
To learn more about implementing Continue Care as part of your center’s discharge planning, visit www.continuecare.com or contact 1-844-931-1545.