CHPPC Module 39, Section 2: Pharmacist Contributions to Readmission Reduction and Length-of-Stay
MODULE 39: HOSPITAL QUALITY METRICS & THE PHARMACIST’S ROLE

Section 2: Pharmacist Contributions to Readmission Reduction and Length-of-Stay

Explore two of the most significant drivers of hospital costs. We will focus on the tactical skills of medication reconciliation, discharge counseling, and transitions of care that have a proven impact on keeping patients safely at home and reducing their time in the hospital.

SECTION 39.2

Readmission Reduction & Length-of-Stay Optimization

Guarding the Exit: The Pharmacist’s Role in Ensuring a Safe and Efficient Discharge.

39.2.1 The “Why”: The Revolving Door and the Overstayed Welcome

In the value-based care landscape, two metrics stand out as paramount indicators of a hospital’s efficiency and quality: the 30-day readmission rate and the average length-of-stay (LOS). These are not merely clinical statistics; they are multi-million dollar issues that keep hospital CEOs awake at night. A high readmission rate—the “revolving door”—suggests that patients are being discharged prematurely or with inadequate support, only to decompensate and require a second, costly hospitalization. A prolonged length-of-stay—the “overstayed welcome”—indicates inefficiencies in care, delayed treatments, or preventable complications that keep patients in expensive hospital beds longer than necessary.

CMS has targeted these two areas with powerful financial incentives and penalties. The Hospital Readmissions Reduction Program (HRRP), for example, can penalize hospitals up to 3% of their total Medicare reimbursement for having excess readmissions for specific conditions. Similarly, since hospitals are largely paid a fixed amount for a given diagnosis (known as a Diagnosis-Related Group, or DRG), every additional day a patient stays beyond the expected LOS erodes the hospital’s margin, potentially turning a profitable admission into a financial loss. The mandate from hospital leadership is therefore crystal clear: ensure every patient is discharged safely, efficiently, and has the tools and support to stay healthy at home.

This is where you, the hospital pharmacist, become an indispensable asset. Study after study has identified one of the single greatest predictors of post-discharge failure: medication-related problems. Adverse drug events, patient non-adherence, confusion about complex regimens, and lack of access to affordable medications are leading drivers of readmissions. Likewise, medication issues are a primary cause of prolonged LOS, whether it’s a delay in switching from IV to oral antibiotics, an adverse event that causes a new complication, or suboptimal therapy that slows a patient’s recovery. Your expertise is the antidote to these problems. The tactical skills you will master in this section—expert medication reconciliation, effective patient counseling, and seamless transitions of care—are the hospital’s most potent strategies for reducing both readmissions and length-of-stay. You are not just a member of the care team; you are the guardian of the patient’s safe passage from the hospital back to the community.

Retail Pharmacist Analogy: The “Rebound” Customer vs. The Successful Follow-Up

Imagine a customer comes into your pharmacy with a nasty cough and congestion. You have two choices.

Scenario A (The “Rebound”): You quickly sell them a box of pseudoephedrine and send them on their way. The transaction is fast. But you didn’t ask about their health conditions. The customer, who has uncontrolled hypertension, takes the pseudoephedrine, and their blood pressure spikes, landing them in an urgent care clinic the next day. They return to your pharmacy angry, feeling worse, and having wasted their money. This is a readmission. The initial, efficient transaction was a failure because the transition back to “self-care” was unsupported and unsafe.

Scenario B (The Successful Follow-Up): You take an extra two minutes for a consultation. You ask, “Do you have any health conditions, like high blood pressure?” When they say yes, you counsel them away from pseudoephedrine and recommend a safer alternative like an intranasal corticosteroid and saline rinses. You explain exactly how to use them for best effect. You might even call them the next day to see how they’re doing. The customer uses the products correctly, their symptoms improve, and they are grateful for your expertise. You have prevented a complication, ensured a successful outcome, and built a loyal relationship.

Your role in hospital transitions of care is to be the expert in Scenario B. A quick discharge without proper medication reconciliation and counseling is like selling the pseudoephedrine and hoping for the best. A pharmacist-managed discharge is a professional consultation that ensures the patient not only has the right medications but also the knowledge, access, and support to use them safely and effectively after they leave the hospital’s direct supervision. This is the core of readmission prevention.

39.2.2 Masterclass on Readmission Reduction: The Pharmacist’s Three Pillars

Preventing hospital readmissions is a complex, multidisciplinary effort, but the pharmacist’s contribution rests on three core competencies: flawless medication reconciliation, impactful patient education, and proactive transitions of care coordination. Excelling at these three skills is arguably the single most important thing a pharmacist can do to improve quality and reduce costs for the hospital.

The Alarming Statistic: The Root of the Problem

Numerous studies have shown that up to 66% of medication errors occur at interfaces of care—admission, transfer between units, or discharge. Furthermore, adverse drug events are implicated in as many as 1 in 5 hospital readmissions. This is not a peripheral issue; it is a central challenge to patient safety, and it is a problem that pharmacists are uniquely equipped to solve.

Pillar 1: Gold-Standard Medication Reconciliation

Medication reconciliation (“med rec”) is far more than an administrative task of comparing lists. When performed at a high level, it is a clinical investigation designed to create the single, definitive source of truth for a patient’s medication regimen. It is the foundation upon which all safe inpatient and discharge prescribing is built. A flawed med rec on admission guarantees a flawed med rec at discharge, planting the seeds for post-discharge failure.

The Best Possible Medication History (BPMH): Your Investigative Mandate

The process begins with obtaining a Best Possible Medication History upon admission. This cannot be accomplished by simply asking the patient, “What medications do you take?” It requires a systematic process of interviewing and cross-verification using multiple sources.

Source for BPMH Strengths Weaknesses & Pharmacist Pitfalls
The Patient or Caregiver Interview The best source for adherence information, “as needed” medication use, and OTC/herbal supplement use. Patients often have poor health literacy, forget doses/names, or don’t consider OTCs or samples as “real” medications. Pitfall: Accepting the patient’s list at face value without verification.
The Patient’s Prescription Bottles Provides exact drug name, dose, sig, prescriber, and fill date. An excellent source of truth. The label may not reflect how the patient is *actually* taking the medication (e.g., doctor told them to cut tablets in half). It won’t include discontinued meds. Pitfall: Assuming the sig on the bottle is the current instruction.
The Retail Pharmacy Fill History Provides a longitudinal record of what was dispensed and when. Excellent for clarifying last fill dates and identifying multiple prescribers or pharmacies. Does not reflect adherence (a filled script isn’t a taken script). May not include samples or meds from mail-order/VA. Pitfall: Mistaking a fill history for an actual medication list. A patient may have stopped a drug months ago.
The Previous Hospital’s Discharge List Useful for recent, acute changes. Provides a snapshot of the intended regimen at the last transition. Can be wildly out of date. The patient’s PCP may have changed doses or stopped meds since the last discharge. Pitfall: The “copy and paste” error— blindly accepting a prior discharge list as the current home med list. This is a major source of error.
The Pharmacist’s BPMH Interview Playbook

A great medication history interview is a skill. It uses open-ended questions and systematic probing to uncover the full story.

  1. Start Broad: “Please tell me about all the medications you take, including prescriptions, over-the-counters, vitamins, herbals, and any samples your doctor might have given you.”
  2. Probe by Indication: Go through their medical conditions. “I see you have a history of high blood pressure. What do you take for that?” … “What about for your diabetes?”
  3. Use the Review of Systems Approach: “Do you take anything for pain?” “Anything to help you sleep?” “Any eye drops or inhalers?” “Any creams or patches?”
  4. Clarify the “As Needed” Meds: For PRN meds, quantify the use. “I see you have an albuterol inhaler. How often have you actually been using it in the past week?” “The bottle for your tramadol says ‘as needed for pain.’ On a typical day, how many tablets do you find yourself taking?”
  5. The Adherence Question: Ask in a non-judgmental way. Instead of “Do you miss any doses?”, try “It can be tough to remember every single dose. In a typical week, how many doses of your blood pressure pill would you say you miss?”
  6. The Final Check: “Is there anything else you take that we haven’t talked about?” This final open-ended question often catches the one last thing the patient forgot to mention.

Pillar 2: High-Impact Discharge Counseling

Even with a perfect medication list, a discharge can fail if the patient does not understand their regimen. Effective discharge counseling is not a rapid recitation of drug names; it is an interactive educational session focused on empowering the patient for self-management. The goal is to ensure the patient can answer three basic questions before they walk out the door: 1) What is this medication for? 2) How do I take it correctly? and 3) What are the most important side effects to watch for?

The Peril of Health Illiteracy

It is estimated that nearly half of all American adults have difficulty understanding and using health information. A pharmacist who uses complex medical jargon (“This is for your hypertension,” “Take it twice a day,” “It might cause hyperkalemia”) is likely to be completely misunderstood. You must speak in plain, simple language and continuously check for understanding. Assume nothing.

Masterclass Table: The Anatomy of a Perfect Discharge Counseling Session
Phase Key Objectives Pharmacist Script & Action Examples
1. The Introduction & Agenda Setting Establish rapport, state the purpose of the visit, and manage expectations. “Hi Mr. Smith, I’m Jane, one of the pharmacists. I’m here to go over your discharge medications to make sure everything is clear before you head home. This should take about 10-15 minutes. We’ll talk about what each medicine is for, how to take it, and what to watch out for. Does that sound okay?”
2. The “Side-by-Side” Review Physically review each medication, comparing the new discharge prescriptions to what they were taking at home. Explicitly address every change. “Okay, let’s start with your heart medications. At home, you were taking metoprolol tartrate 50mg twice a day. In the hospital, the doctors switched you to this one, metoprolol succinate 100mg, which you only have to take once a day. This is a new strength and a new instruction. So you will stop taking the old one and only take this new one.” (Physically show them the bottle/paperwork).
3. High-Risk Medication “Deep Dive” Slow down and provide extra focus on high-risk drugs (anticoagulants, insulin, opioids). “Now let’s talk about this new blood thinner, Eliquis. This is a very important medicine to prevent blood clots, but we also have to be careful about bleeding. The most important things to watch for are any unusual bruises, nosebleeds, or if you ever see blood in your stool. If you see any of those things, you need to call your doctor right away.”
4. The “Teach-Back” Method The most critical step. You must verify the patient’s understanding by asking them to explain the information back to you. “I know we’ve covered a lot. Just to make sure I did a good job explaining, can you tell me in your own words how you’re going to take this new metoprolol?” … “And for that new blood thinner, what are the two main things you need to watch out for and report to your doctor?”
5. Assess & Address Barriers Proactively identify and solve potential adherence barriers, especially cost and access. “Sometimes these new medicines can be expensive. Do you have any concerns about being able to afford your prescriptions?” (If yes, engage social work, provide manufacturer coupons, or discuss therapeutic alternatives with the provider *before* discharge). “Do you have a ride to the pharmacy to get these filled today?”
6. The Closing & Follow-Up Plan Provide clear written materials and establish a plan for follow-up. “Okay, we’re all set. Here is a simplified list of all your medicines and what they are for. I’ve highlighted the ones that are new. My name and number are at the bottom. Please don’t hesitate to call if you have any questions at all when you get home. A pharmacist may also give you a call in a few days just to check in and see how you’re doing.”

Pillar 3: Proactive Transitions of Care (TOC)

The pharmacist’s responsibility does not end when the patient leaves the hospital. The most vulnerable period for a patient is the first few days and weeks after discharge. Proactive follow-up and coordination with outpatient providers are essential for preventing readmissions.

The “Meds-to-Beds” Program: A Game-Changer

One of the most effective TOC strategies is a “Meds-to-Beds” program. In this model, the hospital’s outpatient or discharge pharmacy fills the patient’s discharge prescriptions and a pharmacist or technician delivers them directly to the patient’s bedside before they leave. This eliminates the major barrier of the patient having to go to a pharmacy on their way home. It ensures they have their critical first doses in hand and provides one final opportunity for counseling and to answer questions. Pharmacist-led Meds-to-Beds programs have been shown to significantly reduce 30-day readmission rates.

The Post-Discharge Follow-Up Call

A structured phone call from a pharmacist 2-5 days after discharge is a powerful intervention. It allows you to identify and resolve problems before they escalate into a need for an ED visit or readmission.

Component of the Follow-Up Call Pharmacist Script & Rationale
Introduction & Confirmation “Hi Mr. Smith, this is Jane, the pharmacist from the hospital calling to check in on you after your discharge a few days ago. Do you have a few minutes to talk about your medications?” (Rationale: Confirms identity, states purpose, asks permission).
Medication Access “Were you able to pick up all of your new prescriptions from the pharmacy?” (Rationale: The first and most important question. If the answer is no, nothing else matters. You must problem-solve this immediately).
Adherence & Understanding Check “How have you been taking the new blood thinner, the Eliquis?” (Rationale: An open-ended question is better than “Are you taking your Eliquis?”). This forces them to describe their process, which can reveal misunderstandings.
ADR & Side Effect Screening “Have you noticed any new problems or side effects since you started the new medications? Anything like dizziness, upset stomach, or anything else that’s bothering you?” (Rationale: Proactively screens for common side effects that can lead to non-adherence).
Follow-Up Appointment Status “I see the doctor wanted you to follow up with your primary care physician, Dr. Allen, next week. Have you had a chance to schedule that appointment yet?” (Rationale: Reinforces the importance of medical follow-up, which is crucial for long-term stability).

39.2.3 Masterclass on Length-of-Stay (LOS) Reduction

While readmission reduction focuses on a safe discharge, LOS reduction focuses on inpatient efficiency. The goal is to get the patient to their clinical endpoint for discharge as safely and quickly as possible. Every day a patient spends in the hospital carries risks (e.g., hospital-acquired infections, VTE) and significant costs. Pharmacists can directly accelerate a patient’s journey through the hospital by optimizing their medication therapy.

Masterclass Table: Key Pharmacist-Driven LOS Reduction Strategies

Strategy The Rationale (Why it Reduces LOS) The Pharmacist’s Tactical Playbook
IV-to-PO Conversion Protocols Intravenous medication is expensive, labor-intensive for nursing, and tethers a patient to an IV pole, limiting their mobility. Switching to an equivalent oral medication as soon as a patient is clinically stable allows for IV line removal and facilitates an earlier discharge.
  • Champion a Protocol: Work with the P&T committee to get a pharmacist-driven IV-to-PO conversion protocol approved. This empowers you to make these changes automatically without waiting for a physician’s order.
  • Daily Screening: Generate a daily report of all patients on target IV medications (e.g., fluoroquinolones, azithromycin, PPIs, metronidazole).
  • Assess for Stability: Review the chart to ensure the patient meets the criteria for conversion: afebrile, trending-down white blood cell count, able to tolerate oral intake (not NPO), and functioning GI tract.
  • Execute the Switch: Make the change per protocol, ensuring the oral dose is therapeutically equivalent to the IV dose. Document your intervention clearly.
Timely Therapeutic Drug Monitoring (TDM) For drugs with a narrow therapeutic index like vancomycin and aminoglycosides, getting the patient to a therapeutic level quickly and safely is critical. Delays in obtaining levels or adjusting doses can lead to sub-therapeutic treatment (prolonging infection) or toxicity (causing kidney injury), both of which extend LOS.
  • Pharmacist-to-Dose Protocols: The gold standard is a pharmacist-managed TDM service. The physician orders “Vancomycin per pharmacy,” and you take over all ordering of levels and dose adjustments.
  • Proactive Level Orders: If no protocol exists, be proactive. When you verify a new vancomycin order, immediately enter a future order for the trough level to be drawn at the correct time (e.g., before the 4th dose). Don’t wait for the provider to remember.
  • Rapid Dose Adjustment: As soon as the lab result is available, use pharmacokinetic calculations to immediately recommend the optimal dose adjustment to the provider.
Antimicrobial Stewardship Using overly broad-spectrum antibiotics for too long can lead to C. difficile infection or other complications that significantly prolong LOS. Narrowing or “de-escalating” therapy based on culture results is a core stewardship and LOS reduction strategy.
  • Daily Culture Review: Make it a habit to review the microbiology reports for all of your patients every morning.
  • Identify De-escalation Opportunities: Look for mismatches. Is your patient on broad-spectrum Zosyn, but their blood culture grew a simple E. coli that is sensitive to ceftriaxone? This is an opportunity to de-escalate.
  • Communicate with Confidence: Contact the provider with a clear recommendation: “Dr. Smith, the final blood culture results for Mr. Green are back and show E. coli sensitive to ceftriaxone. Would you like to de-escalate his Zosyn to ceftriaxone to provide more targeted therapy?”
Proactive ADE Prevention & Management Every adverse drug event is a potential cause of a longer LOS. Preventing an ADE is the most effective way to keep a patient’s hospital course on track.
  • Renal Dose Adjustments: This is a fundamental daily task. Screen all renally-cleared medications against the patient’s latest creatinine clearance.
  • Opioid Stewardship: Recommend multi-modal pain regimens (e.g., scheduled acetaminophen and NSAIDs) to reduce the total amount of opioids needed. This prevents opioid-induced constipation and over-sedation, which can delay mobility and discharge.
  • Rapid Reversal: When an ADE does occur (e.g., over-anticoagulation), ensure you can act quickly. Do you know your hospital’s protocol for warfarin reversal with Vitamin K and Kcentra? Your ability to guide this process can save days of hospital stay.