Finance modeling in the delivery of medical care in tertiary-care hospitals in the Department of Veterans Affairs

There's no place like home-Integrating a pharmacist into the hospital-in-home model

BACKGROUND

Hospital-in-home (HIH) is an innovative model that provides hospital-level care in a patient's home. Pharmacists can enhance the HIH model through medication reconciliation and medication optimization.

OBJECTIVES

To integrate a clinical pharmacist into the HIH model and to conduct a formative evaluation of pharmacist contributions, including medication discrepancy resolution, cost savings, and cost avoidance.

PRACTICE DESCRIPTION

This is a prospective quality improvement study conducted at the Veterans Affairs Boston Healthcare System.

PRACTICE INNOVATION

We integrated a pharmacist into the HIH model. The pharmacist conducted a medication reconciliation at hospital discharge and after discharge through home video telehealth and provided longitudinal medication management.

EVALUATION METHODS

We adapted the PRECEDE-PROCEED model to guide program implementation. We conducted a formative evaluation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, evaluating the reach, efficacy, adoption, and implementation of the pharmacist in the HIH team. We calculated cost savings associated with pharmacist-managed home intravenous (IV) therapy, cost avoidance from deprescribing, and cost avoidance from earlier hospital discharge.

RESULTS

The HIH program enrolled 102 patients from May 2019 to March 2020. The pharmacist completed 99 (97%) discharge and 95 (93%) postdischarge medication reconciliations, most of which 71 (75%) were conducted using home video telehealth. The pharmacist identified and resolved a total of 453 medication discrepancies: 181 (40%) at discharge and 272 (60%) during postdischarge medication reconciliation. A total of 84 (19%) discrepancies were considered high risk. The pharmacist managed 104 days of home IV therapy, resulting in a cost savings of approximately $17,000. The cost avoided by identifying and deprescribing 145 inappropriate medications was approximately $51,000. The cost avoided by earlier hospital discharge was $1.2 million.

CONCLUSION

Integrating a pharmacist into the HIH model enables the detection and resolution of medication discrepancies. Cost savings from medication deprescribing, cost avoided from pharmacist-managed home IV therapy, and cost avoided from early hospital discharge totaled $1268 million.

Quality and Value of Health Care in the Veterans Health Administration: A Qualitative Study

Background

The attitudes of Department of Veterans Affairs (VA) cardiovascular clinicians toward the VA's quality‐of‐care processes, clinical outcomes measures, and healthcare value are not well understood.

Methods and Results

Semistructured telephone interviews were conducted with cardiovascular healthcare providers (n=31) at VA hospitals that were previously identified as high or low performers in terms of healthcare value. The interviews focused on VA providers’ experiences with measures of processes, outcomes, and value (ie, costs relative to outcomes) of cardiovascular care. Most providers were aware of process‐of‐care measurements, received regular feedback generated from those data, and used that feedback to change their practices. Fewer respondents reported clinical outcomes measures influencing their practice, and virtually no participants used value data to inform their practice, although several described administrative barriers limiting high‐cost care. Providers also expressed general enthusiasm for the VA's quality measurement/improvement efforts, with relatively few criticisms about the workload or opportunity costs inherent in clinical performance data collection. There were no material differences in the responses of employees of low‐performing versus high‐performing VA medical centers.

Conclusions

Regardless of their medical center's healthcare value performance, most VA cardiovascular providers used feedback from process‐of‐care data to inform their practice. However, clinical outcomes data were used more rarely, and value‐of‐care data were almost never used. The limited use of outcomes data to inform healthcare practice raises concern that healthcare outcomes may have insufficient influence, whereas the lack of value data influencing cardiovascular care practices may perpetuate inefficiencies in resource use.

See Editorial Heidenreich et al