An initial partnership with a relatively small Indiana hospital begat Walgreens' WellTransitions program, which has shown a 46% reduction in unplanned hospital readmissions for the patients who use it.
Seven years ago, Marion General Hospital, which is actually a health system with multiple locations in two counties in Marion, Indiana, had no idea of the eventual implications of its decision to sell its pharmacy to Walgreen's in 2007.
For the record, neither did the retail chain with more than 8,200 stores.
Nevertheless, that move was the catalyst for a major reduction in preventable readmissions for the health system, and ultimately, a new line of business for the national drugstore chain.
The pharmacy, located across the street from Marion General's main hospital in the system's ambulatory surgery building, was the birthplace for what eventually became WellTransitions, a contractual relationship by which Walgreen's works directly with hospital staff on medication reconciliation, education, take-home prescription fulfillment, and follow-up for patients about to be discharged.
An April 2014 study, in which the chain researched 744 matched pairs of WellTransitions patients and non-patients retrospectively to evaluate the effectiveness of the program, found that program patients were 46% less likely to experience an unplanned hospital readmission within 30 days than the control group. But that came much later.
In 2010, the head pharmacist at the location, Steve Kroh, who had previously been a Marion General employee, came to discuss the beginnings of what would become WellTransitions with Marion General's leadership team, including Bernadine Wallace, MSN, RN, who is the health system's chief nursing and operating officer.
"One of our largest challenges at the time was medication reconciliation," says Wallace.
'Sounded Like a Dream Come True'
Kroh brought an idea to the meeting. Walgreen's wanted to pilot a new program in which its pharmacists would do bedside delivery of medications, reconciliation with those meds and the patient's current regimen, and provide advice and follow up for such patients post discharge.
That would include follow-up phone calls with the patient or their caregiver on day 2, day 10 and day 30 post-discharge, as well as a central contact for questions that pop up in between those follow up calls. Patients must choose to be in the WellTransitions program.
"It sounded like a dream come true for us," Wallace says. "We had been working with them on a bedside delivery program within ambulatory surgery. We decided to expand that program to all our patients in the hospital, which is terrific, because if you get them their meds before they leave the hospital, they're more compliant."
The opportunity to make a positive difference in readmission rates was a key motivator in deciding to be, in effect, an alpha test site for the WellTransitions program, says Wallace.
At the time, readmission penalties from the Centers for Medicare and Medicaid Services hadn't been fully implemented yet, and no hospitals had been fined for exceeding readmission limits. But word was out that it would be happening soon, and that up to 3% of a hospital or health system's Medicare reimbursement would eventually be at risk through readmission penalties.
Marion General's leadership team knew this was destined to become a big problem if left unaddressed. Indeed, some 2,610 hospitals nationwide incurred readmission penalties by late 2014.
"Although our rates were better than a lot of the national numbers, we knew there was room for improvement, in high-risk areas especially," Wallace says. "Another area was in improving HCAHPS scores. At one time we were in the top 10% but we had seen a decrease in those scores."
Even though there were many possible advantages, not the least of which would be taking some responsibility from the nursing staff for this type of work, the effectiveness of the program didn't become clear immediately.
"We've had a lot of growing pains in that it took a while to see outcomes, but it has been wonderful," says Wallace. Challenges included getting the right information to work with the hospital's IT system and convincing the nursing staff that Walgreens' involvement with discharge did not mean more responsibility for nurses.
"We weren't giving up on it, but took a while to reap the benefits from it," she says. Once-monthly meetings over issues in the program have moved to quarterly maintenance, and the hospital did not have to hire additional labor to accommodate WellTransitions.
'Significant' Improvements to HCAHPS Scores
Now, in addition to follow up post-discharge calls that were already being made by the nursing staff regarding nursing issues, Walgreen's calls the patient within 72 hours, at 14 days and at 30 days post-discharge to help resolve medication issues.
Nurses let patients know to expect these calls, but that's the extent of their involvement beyond the nursing-oriented discharge calls the nursing staff does with every patient within two days of discharge.
"We do let [patients] know they'll receive another call from a pharmacist who is part of the program, and that it's for their safety," says Wallace.
She says Marion General has seen improvement in its readmission rates and a marked difference between those patients who elect the WellTransitions program and those who don't.
Marion General has also seen "significant" improvements to its HCAHPS scores of 5–6 percentage points. But she notes that the real challenge is to sustain that improvement as organizations are measured against an average of hospitals.
"The real challenge is to stay ahead of everyone else," Wallace says. She says that Marion General's success with readmissions reiterates how important it is to partner with other companies or entities that have special expertise.
"We're truly taking a team approach, where we both agreed we're in this for the long haul," she says.
The program has matured, says Harry Leider, MD, Walgreens' chief medical officer, and now 20 hospitals and health systems have partnered with the drugstore chain through the WellTransitions program.
"Many times, the discussion with the hospital boils down to 'why can't we do this?'" he says. "The difference is in the data system to track the patients and more importantly, how we follow them into the community, and their interactions with our stores."
Enabling More Profitable Admissions
Of course, many hospitals are skeptical of the full effect of the readmission penalties on the financial health of the organization. Although they would like to avoid them, reducing either readmissions or admissions can be damaging to finances, given the inherent problems with fee-for-service reimbursement.
"This is the core of one of the issues," says Leider. "For many hospital systems, the penalty for readmissions might not be enough to overcome the additional revenue from readmissions."
But if avoiding the penalties isn't enough to encourage hospitals to take control of readmissions, another way of thinking about it is that with so many hospitals at or near capacity, beds can be freed up for more "profitable" admissions, Leider says.
"In the economic analysis on this, many of the clinical conditions that drive readmissions like COPD, uncontrolled diabetes, asthma, tend not to be financially positive for the hospitals," he says. "They would do much better on neuro or surgical case, for example. So this not only can reduce Medicare penalties, but can free up beds for more profitable admissions."
Philip Betbeze is the senior leadership editor at HealthLeaders.