Promoting Medication Compliance

Set Patients Up for Success to Reduce Readmissions

Introduction

Medication errors cause a fifth of hospital readmissions,[1] contributing considerably to an expensive problem: Unplanned readmissions cost $20 billion annually[2] and often go unreimbursed if they are due to preventable complications.

The CMS Hospital Readmissions Reduction Program cuts hospital payments based on readmission rates for certain conditions, which are frequently medication dependent. For example, patients with heart failure can quickly become fluid-overloaded if they don't take diuretic medication. In one study, researchers found medication adherence was the best predictor of whether these patients would be rehospitalized.[3]

Factors Contributing to Medication Noncompliance

There are many reasons a patient may not use medication safely. Keeping track of everything after hospital discharge is challenging, especially when facing a new diagnosis. Medication use involves many details. Patients may not understand what they should take and how to take it.

Financial constraints, pharmacy stock issues, and insurance denials can make it difficult to get medication or get refills. Even driving to the pharmacy to pick up a prescription can be out of reach for someone with limited resources. The care team can address these problems proactively.

Educating for Medication Safety After Discharge

To follow a medication plan, patients must understand what medication they need, how to take it, and why it is important. Cover all these aspects when educating patients.

Research shows that patients forget 40% to 80% of medical information they are taught. When they do remember, almost half the information they report is partly incorrect. It is crucial to provide written materials and organizational tools such as:

• Medication lists, schedules, and calendars

• Materials describing the purpose of medications and side effects

• Technology to track medication use

For better retention when teaching, engage patients and family members in an active discussion using the teach-back technique. Teach-back has been extensively studied[4] and improves recall and understanding by at least 37%.[5]

To use teach-back, ask patients to restate what you have said with a statement like, "Tell me which three medications you are taking for heart failure and why you are taking them."

Do this frequently. This opens conversation and is an excellent opportunity for questions.

Helping Patients Overcome Medication Adherence Barriers

Buy-in and clear understanding don't help if patients can't get their medication.

Handling Prior Authorizations

Picture this: At discharge, a patient’s prescription is sent to their pharmacy. Insurance requires prior authorization, and the pharmacy requests one from the prescribing doctor's office. But the office doesn't have the staff to complete it immediately. They have new staff who haven’t been trained in prior authorizations. They miss sending some information. After a denial and an appeal, it goes through, but the patient has gone three weeks without getting the medication they need. 

This situation is not uncommon.

Ninety-four percent of physicians report treatment delays with prior authorizations, sometimes with profound consequences: 25% say a prior authorization delay has led to rehospitalization, and 33% say the delays have caused harm, including death.[5]

Use these strategies to minimize prior authorization delays:

• Start early. Send prescriptions a few days before anticipated discharge to give time for prior authorization.

• Use a dedicated team. A team with expertise in prior authorizations can complete them efficiently and accurately.

• Keep communication open. Timely communication between the prior authorization team and the prescribing doctor can minimize delays with alternative prescriptions if needed.

More Barriers

As of 2022, 27.6 million Americans remained uninsured.[6] For people with insurance, high copays or pharmacy stock issues can be barriers to getting medication. In 2023, drug shortages reached a 10-year high, with a staggering 301 drugs in shortage as of April—100 times more than at the same time five years ago.[7]

To help patients navigate these challenges, try these strategies:

• Stay in the know about shortages and communicate them to prescribing physicians. The Food and Drug Administration (FDA) publishes a drug shortages list that is updated daily.[8]

• Local pharmacy stocks may vary. Check with them frequently.

• Consider offering a medication delivery program to provide patients with discharge prescriptions before they leave.

Potential financial resources include:

• Insurance. Evaluate if uninsured or underinsured patients qualify for Medicare, Medicaid, or insurance through the health insurance marketplace.

• State-sponsored programs. 48 states have pharmaceutical assistance programs that help specific patient populations.[9]

• Drug company-sponsored programs. Over 200 medications have patient assistance programs offered by their manufacturers.[10]

• Coupon cards. Check for prescription discounts through discount cards and direct pharmacy programs.

• Hospital programs. Many hospitals offer medication assistance. The cost is often less than the cost of preventable readmissions, and such programs help nonprofit hospitals meet community benefit requirements. [11],[12]  

Follow-up

Patients will encounter questions and challenges at home. A follow-up phone call within 72 hours of discharge is a great opportunity to check for medication difficulties.  

Conclusion

With proactive planning and communication, you can reduce medication-related readmissions. Teach clearly and provide education materials to help patients understand how to use medications safely. Address insurance issues, shortages, and financial challenges for the best possible outcomes.

References:

[1] El Morabet N, Uitvlugt EB, van den Bemt BJF, van den Bemt PMLA, Janssen MJA, Karapinar-Çarkit F. Prevalence and preventability of drug-related hospital readmissions: A systematic review. J Am Geriatr Soc. 2018;66(3):602-608. doi:10.1111/jgs.15244

[2] Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/nejmsa0803563

[3] Riegel B, Knafl G. Electronically monitored medication adherence predicts hospitalization in heart failure patients. Patient Prefer Adherence. 2013;8:1. doi:10.2147/ppa.s54520

[4] Talevski J, Wong Shee A, Rasmussen B, Kemp G, Beauchamp A. Teach-back: A systematic review of implementation and impacts. PLoS One. 2020;15(4):e0231350. doi:10.1371/journal.pone.0231350

[5] Mahajan M, Hogewoning JA, Zewald JJA, Kerkmeer M, Feitsma M, van Rijssel DA. The impact of teach-back on patient recall and understanding of discharge information in the emergency department: the Emergency Teach-Back (EM-TeBa) study. Int J Emerg Med. 2020;13(1). doi:10.1186/s12245-020-00306-9

[6] U.S. Uninsured Rate Dropped 18% During Pandemic. Cdc.gov. Published May 18, 2023. Accessed November 7, 2023. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2023/202305.htm

[7] Continuum SP. Drug-Shortages-Reach-10-Year-High-ASHP-Report. Specialtypharmacycontinuum.com. Accessed November 6, 2023. https://www.specialtypharmacycontinuum.com/Policy/Article/06-23/Drug-Shortages-Reach-10-Year-High-ASHP-Report/70318?ses=ogst

[8] Center for Drug Evaluation, Research. Frequently Asked Questions about Drug Shortages. U.S. Food and Drug Administration. Published October 11, 2023. Accessed November 7, 2023. https://www.fda.gov/drugs/drug-shortages/frequently-asked-questions-about-drug-shortages

[9]State Pharmaceutical Assistance Programs. Ncsl.org. Accessed November 6, 2023. https://www.ncsl.org/health/state-pharmaceutical-assistance-programs

[10] Burley MH, Daratha KB, Tuttle K, et al. Connecting patients to prescription assistance programs: Effects on emergency department and hospital utilization. J Manag Care Spec Pharm. 2016;22(4):381-387. doi:10.18553/jmcp.2016.22.4.381

[11] Charitable Hospitals - General Requirements for Tax-Exemption Under Section 501(c)(3). Irs.gov. Accessed November 6, 2023. https://www.irs.gov/charities-non-profits/charitable-hospitals-general-requirements-for-tax-exemption-under-section-501c3

[12] Nonprofit Hospitals’ Community Benefit Requirements. Project HOPE; 2016.