THE CENTERS for Medicare & Medicaid Services began reducing reimbursement to hospitals with high 30-day readmission rates in October 2012, and 2592 hospitals received lower payments as penalty in fiscal year 2016 for their higher readmission rates.1 According to most recent national data, there were 136.3 million emergency department (ED) visits in the United States and 12% of the visits resulted in hospital admission.2 In a recent population-based study of over 4 million adult patients in 3 states (California, Florida, and Nebraska), Vashi et al3 showed that ED visits not resulting in admission (treat-and-release encounters) accounted for nearly 40% of all hospital-based acute care visits during the 30-day postdischarge period. Focusing on readmissions only would have omitted approximately half a million ED treat-and-release encounters in these three states and significantly underestimated post-acute care utilization. Brennan et al4 in a retrospective study of 13 449 patients from 2 hospitals found that 18.2% of patients had an ED visit within 30 days of hospital discharge, half of those patients were readmitted, and more than one-third had multiple ED visits. High rates of postdischarge ED use may be a reflection of ineffective care transition from hospital to home.3 , 5 Better use of community resources can play an important role in improving care for patients with chronic illness.4
Care coordination is an important underpinning to improve care for individuals. The American Nurses Association considers care coordination a competency for registered nurses (RNs).6 Successful transitional care models are reported in the literature including Project RED,7 Care Transitions Model,8 Transitional Care Model,9 and Project BOOST.10 RNs are the main providers in these models. Successful models view hospitalization as part of a care continuum with a focus on bridging hospital to community transitions, with a goal of reducing unplanned readmissions and ED visits. In a recent survey of 32 Magnet hospitals, most had adopted 1 or more transitional care models focused on readmission reduction.11 Successful discharge preparation interventions include adjusting education to health literacy level,7 developing a prioritized discharge plan, and providing a callback number that patients can use to ask questions about the home care plan.12
Postdischarge interventions are focused on supporting communication with community-based providers including transmission of discharge summaries, appointment scheduling with the provider, postdischarge telephone calls, and home visits. Suggested evidence-based organizational strategies include creating an interdisciplinary team before selecting interventions and matching the intensity of transition interventions to the patient's risk for readmission.13 Intervention strategies that minimize organizational investments and provide individualized transition plans are likely to prove cost-effective for the organization in reducing readmissions.13
The Affordable Care Act established several programs to encourage the development of transitional care, including the Community-based Care Transitions Program, Center for Medicare & Medicaid Innovation, and Medicare Shared Savings Program.14 Medicare-defined Transitional Care Management (TCM) services allow for reimbursement of transitional care from an acute care setting to the community. The services include 3 components that must occur during the 30 days following hospital discharge to home: (1) an interactive contact, (2) certain non–face-to-face services, and (3) a face-to-face visit. Non–face-to-face services include obtaining and reviewing discharge information; following up on referrals, diagnostic tests, and treatments; and providing education to patients and/or caregivers.15 The TCM services require that medication reconciliation and management be furnished no later than the date of the face-to-face visit.15 The TCM services can be provided by nurses who are authorized providers in the state, for example, nurse practitioners and clinical nurse specialists.
Chronically ill individuals transitioning home who do not have access to the TCM services may face challenges when managing multiple medications, often with new prescriptions added at each hospitalization. Medication teaching completed at discharge does not ensure the patient will understand the required regimen when returning home. Lack of medication reconciliation during care transition is a potential hazard for patient health and safety, especially in a complex and fragmented care system such as that of the United States.5 Medication reconciliation involves comparing the patient's current medication regimen with the admission, transfer, and/or discharge orders, with the goal to identify discrepancies.16 A medication discrepancy is the lack of agreement between different medication regimens during transition from acute care to post–acute care.17 In various studies, the prevalence of medication discrepancies between post–hospital discharge medication orders and home medications ranged from 14% to 94%.17–20 Experiencing post–hospital medication discrepancies at home was shown to be a significant predictor of 30-day hospital readmission.17
However, little is known about a potential association between medication discrepancies at home and post–hospital ED visits. We hypothesized that medication discrepancies are positively associated with ED visits as it is with hospital readmission since a strong relationship between ED and hospital-based acute care visits exists.3 The objective of this study was to evaluate a potential association between medication discrepancies found during home visits after hospital discharge and 30- and 90-day ED utilization.
Sample and data
A secondary data analysis was carried out using information from a study conducted in 2012 and designed to improve hospital discharge care transition using health coaching and medication reconciliation.21 A total of 88 adult participants were enrolled from 2 inpatient medical units in an urban tertiary care hospital in the mid-Atlantic region. From those enrolled, 60 participants received home care visits from hospital-based master's prepared RNs within 14 days of discharge following a 48-hour postdischarge phone call. Inclusion criteria for study participants were as follows: (1) 18 years and older, (2) ability to speak English, (3) residing within a 10-mile radius around the health care institution, (4) having at least 1 chronic illness, and (5) taking a minimum of 4 prescription medications at the time of enrollment. Data on patient gender, age, race, education, and marital status collected at the recruitment stage of the original study in the hospital21 were used in the secondary data analysis. Lists of hospital discharge medications and ED visit history were accessed through the hospital electronic health record (EHR) system.
During home visits, the study nurses assessed the number of medication discrepancies by comparing the patients' hospital discharge medication lists with actual medications in their homes. The medication discrepancies identified during the home visit were used for the secondary analysis. If any discrepancies were noted, resolutions were made according to the Medication Discrepancy Tool (MDT),22 which included encouraging the patients to discuss medications with their primary care physicians or specialists, addressing knowledge deficits, and providing resource information to facilitate adherence. During the home visit, all participants received a wallet-sized card with a medication list and a pillbox. The institutional review board designated this secondary data analysis as not human subjects research.
Descriptive statistics were computed and inferential data analyses were performed using the SPSS (version 21; IBM Corp; 2012). Simple logistic regressions were conducted to explore associations between 30- and 90-day postdischarge ED visits and potential covariates such as gender, age, and the number of discharge medication (Table 1). Multiple logistic regression was performed to examine the associations while controlling for other covariates. Following the suggestion by Hosmer and Lemeshow,23 only the covariates with a P value less than .25 in simple logistic regressions were selected for the multiple logistic regression.
Nearly half (n = 46; 52%) of the 88 study participants were female; 74 participants (84%) were black (vs nonblack); 59 (67%) had a high school education or lower (vs more than high school); and 72 (82%) were not married. On average, the patients were 57.2 years old (SD = 13.8; range, 25-97 years) and had 10.7 medications prescribed at discharge (SD = 4.1; range, 2-18). Among 60 patients who received home visits by an RN, 50 patients had 1 or more medication discrepancies (83%), with an average of 3.4 discrepancies per patient (SD = 3.0; range, 0-12).
Approximately 14% of the patients were admitted to the ED within 30 days of hospital discharge and 28.4% within 90 days. When associations between each covariate and 30- and 90-day ED admissions were examined, the number of medication discrepancies at the home visit showed a significant association with ED admission within 90 days (unadjusted odds ratio [OR] = 1.32; 95% CI, 1.07-1.62; P = .01). More specifically, for every dis-crepant medication, the odds of being admitted to the ED within 90 days increased by 32%. No other covariates were significantly associated with ED admissions, although there was a borderline significance in the relationship between the number of medication discrepancies at home visit and ED admission within 30 days (unadjusted OR = 1.27; 95% CI, 0.99-1.59; P = .06).
The association between the number of medication discrepancies at home and ED admission within 90 days remained significant when other potential risk factors, age and education, were adjusted for (adjusted OR = 1.31; 95% CI, 1.05-1.63; P = .02) (Table 2). More specifically, for every discrepant medication, the odds of being admitted to the ED within 90 days increased by 31%. The number of medication discrepancies was not correlated with ED admissions within 30 days (adjusted OR = 1.20; 95% CI, 0.93-1.54; P = .17).
Our study showed that 83% of the participants experienced medication discrepancies at home. The number of medication discrepancies found during the home visit was a risk factor for 90-day ED admission after hospital discharge, with an increase in the odds of being admitted to the ED increased by 31% (OR = 1.31).
According to Coleman et al,17 the contributing factors of medication discrepancies occur at the patient or system level. The former includes nonintentional and intentional nonadherence. In a home visit study with a similar sample, most discrepancies were at the patient level: nonintentional nonadherence was due to omission of drugs, being confused with instructions, use of expired drugs, and financial difficulty.18 This study could not examine whether associations may vary between these factors and patient ED visits due to the small sample size. Further study may reveal these potential associations.
Our study complements the findings from a study that showed no significant association between complexity of hospital discharge medication regimen and 30-day ED use in patients transitioning from hospital to home care.24 Using the Medication Regimen Complexity Index,25 bachelor's prepared nurses measured the complexity based on the number of medicines in the regimen, dosage form, dosing frequency, and additional instruction. Our results imply that complexity of the medication regimen may be associated with medication discrepancies at home. For example, complex dosage forms or frequencies present at hospital discharge may cause discrepancies at home when patients are unable to understand the instructions clearly or purchase the drugs due to financial difficulty. Complexity of the medication regimen at discharge and medication discrepancies in patient homes may be best understood as separate but related events (or processes) that occur longitudinally in the spectrum of transitional care. Studies that examine both medication complexity at hospital discharge and actual medication discrepancies during patient home visits may increase understanding of this process.
The reason for the association of medication discrepancies with 90-day ED visits but not with 30-day ED visits is unclear. It is suggested that the risks of readmission to hospital remain increased well beyond 30 days after hospital discharge for heart failure, acute myocardial infarction, and pneumonia.26 One possible explanation is that potential adverse effects from medication discrepancies accumulate as the months pass without the discrepancies being properly addressed. In the original study,21 we coached patients to address medication discrepancies according to the MDT22 resolutions; however, we did not examine whether the discrepancies were resolved because of limited participation of the patients in our follow-up telephone calls after the home visits.
At discharge in the original study, each patient was given a medication card to assist with reconciliation during the next health care visit to their primary care providers. The use of the card is not known. In the survey of Malaysian General Practitioners, Hassali et al27 found 90% agreed that a medication reconciliation card would be useful to primary care practitioners.
Medication reconciliation completed by telephone after hospital discharge has been reported as a successful intervention in some studies.28 , 29 In the original study, the study nurses attempted to call patients to complete medication reconciliation over the telephone 48 hours post–hospital discharge; however, participants were difficult to reach. Those who were contacted by phone were reluctant to spend the time needed to reconcile numerous medications; however, immediate questions concerning medication regimen were answered. It is not known whether this reluctance to complete reconciliation was related to the knowledge that the nurses were scheduled to come to the home at a later date.
The current study adds knowledge about the importance of medication reconciliation in patient homes and provides a potential strategy to reduce post–hospital ED visits. Based on our finding that the decreased number of medication discrepancies was associated with fewer ED visits, assessing and reducing medication discrepancies through medication reconciliation may decrease unnecessary ED utilization. Conducting home visits by a nurse is a strength in that it could identify discrepancies that may not be detected by telephone interview.18 A follow-up transitional care intervention to determine whether home visit medication discrepancies are resolved could prove valuable in reducing future ED visits. Establishing a handoff liaison with a community pharmacist12 , 30 and a home health nurse31–33 could potentially fill the transitional care gap. In addition, with reimbursement established for the TCM services, the advanced practice nurse in primary care can fill an important role in discovering and resolving medication discrepancies in the chronically ill Medicare population in the 30-day post–hospital period.
The study has several limitations. Patients in the community may have accessed different hospitals for their ED visits. While the hospital EHR network is most inclusive in the area and patients were likely to use one of the network hospitals for their ED visits due to proximity, the EHRs may have not captured all the participant ED visits. Also, the sample was of a small size and from a single hospital, which restricts generalizability. Twenty-eight of the participants, who agreed to participate in the study while in the hospital, did not participate in a home visit. The experience is similar to that of Voss et al,34 who found low participation rate (55%) and lower agreement to a home visit (14%). The presence of medication discrepancies among the 28 participants not receiving a home visit is not known.
We evaluated a potential association between post–hospital medication discrepancies found during home visits and ED utilization. A higher number of medication discrepancies were associated with a higher chance of 90-day ED admission. High prevalence of medication discrepancies was also identified at patient homes after hospital discharge. Addressing the discrepancies during home visits by nurses may be an effective method to reduce unnecessary ED visits. Consideration should be given to beginning transitional care interventions at time of discharge and extending transitional care management programs beyond 90 days postdischarge. While this study may not be generalized to a greater population, it offers insights into the impact of post–hospital medication discrepancies found during home visits on ED utilization among an urban-residing minority population with a high school or lower education level. Targeting a similar population, further studies may focus on contributing factors for medication discrepancies, completing resolution of discrepancies during the home visit, and establishing a follow-up liaison to evaluate the impact on decreasing ED utilization.
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