Impact of a Pharmacy Benefits Manager (PBM) Clinical Program on Transitions of Care

Purpose: Medication-related discrepancies and adverse drug events are leading causes of hospital readmissions, many of which are preventable with proper coordination of care and patient education. Once a patient leaves the hospital, contact and follow-up is frequently lost. Approximately 50% of all patients in the United States do not take their medications as prescribed by their doctors, and about 20% of adverse drug events are attributed to poor communication at transitions of care.

A pharmacy benefits manager (PBM) designed and implemented a transitions-of-care (TOC) program utilizing a care team comprised of a hospital-embedded care manager (TOC nurse), clinical pharmacist, and pharmacy technicians to reduce hospital readmission rates, decrease health plan expenditure, and improve overall patient outcomes by increasing patient engagement, optimizing medication regimens, and ensuring access to medication therapy.

The hospital-embedded TOC nurse has the ability to impact the population being served through modeling and supporting interprofessional relationships while utilizing assessment skills, advocacy, and joint care planning to engage patients in their own care and optimize interventions.

Methodology: Members with a designated insurance are identified upon admission to a local hospital. The hospital-embedded TOC nurse follows each member from admission to discharge. The nurse is responsible for completing a discharge assessment as well as preventative multidisciplinary discharge planning for each plan member and communicating all information obtained and medication-related problems (MRPs) to the PBM pharmacist. The nurse determines members’ understanding of illness and outpatient management of illness in addition to evaluating, coordinating, and implementing discharge needs for all short- and long-term needs across disciplines including but not limited to PCP changes and appointments, home care, skilled nursing facility (SNF), durable medical equipment (DME), pharmacy, transportation, and CM referrals. The nurse, pharmacist, and technicians collaborate to resolve identified issues related to medications and care coordination prior to hospital discharge. The nurse offers each member a telehealth consultation with the pharmacist while inpatient; once discharged, the pharmacist will outreach to complete a comprehensive medication review to address new or unresolved MRPs.

Evaluation and outcomes: Preliminary data shows a positive impact on overall healthcare costs and hospital readmission rates, with an estimated 36% reduction in readmissions for engaged patients. Updated results are pending, but thus far, nurse-led PBM involvement at transitions of care has shown to positively impact healthcare costs, readmission rates, medication-related problems, and patient engagement.