New program may help reduce hospital readmission rates for high-risk seniors

SCAN Health Plan and Lakewood IPA have partnered with Dovetail Health in a program designed to reduce readmission rates for high-risk seniors following discharge from hospitals and skilled nursing facilities.

Under the new program, high-risk SCAN Health Plan members in Southern California whose primary care physicians are part of Lakewood IPA are now being referred into Lakewood's "Healthy Transitions" program upon discharge. Led by Dovetail, the Healthy Transitions program combines elements of existing transition management programs - such as improved discharge planning and telephonic case management - with a unique focus on medication optimization and adherence.

"We believe that this program will lessen the number of seniors readmitted to a hospital for reasons that are totally avoidable," said Timothy Schwab, MD, chief medical officer for the not-for-profit SCAN Health Plan. "By focusing on those problems most commonly found and tailoring the program to each individual, we can make a significant, positive impact in the lives of many of our members."

In general, patients enrolled in the program take an average of 12 medications and have chronic conditions such as diabetes, chronic obstructive pulmonary disease, congestive heart failure and renal disease. More than 75 percent are at increased risk of falls. One in five seniors nationwide is readmitted within 30 days of discharge at a staggering cost of over $17 billion, and medication-related issues are frequently a factor.

The Healthy Transitions program sends pharmacists to meet patients in their homes following discharge from hospitals and skilled nursing facilities. Healthy Transitions pharmacists review every prescription and over-the-counter medication. During the visits they clarify orders, educate patients and caregivers, identify opportunities to optimize medication schedules, and address issues such as non-adherence. Easy-to-read reports are printed for patients, and a version is prepared for their physicians with key questions or issues highlighted.

In addition to medication counseling and support, the Healthy Transitions program follows patients for 30 days to provide ongoing guidance around chronic illnesses, safety, advance-care planning and other potential readmission risk factors. At the end of 30 days, patients are referred back into the appropriate care-management programs at SCAN or Lakewood IPA.

"Our patients have been very open to having the home visit. The comprehensive counseling, support and assessment from the pharmacist are an asset to the physician and the case managers in the continued coordination of care for these high-risk members," said Robin Tufono, director of outreach programs at Coast.

Up and running for over five months, the Healthy Transitions program is already having a positive impact. "We have clearly seen instances when potential readmissions were avoided," said Sylvia Hastanan, director of clinical operations at Dovetail Health. "In one case, for example, a patient was missing a prescription for a critical antibiotic medication required to treat a urinary tract infection."