Patricia Johnson is surprised, but welcoming, when William Vouk comes to her door.
A pharmacist, Vouk had made an appointment to visit with Johnson in her traditional, two-story Lincoln Park home. But at 73, and only recently out of rehab care that followed a hospital visit, Johnson simply had forgotten.
It was the hospitalization that had brought Vouk to Johnson's home. He works for New Jersey-based healthcare provider Tabula Rasa, which has contracted for the past three years with Blue Cross and Blue Shield of Minnesota to provide post-hospital pharmacy visits for a certain group of its members.
The goal: To keep those members from returning to the hospital anytime soon.
"It’s in our members’ best interests to help them in any way that we can to prevent readmissions to the hospital," said Victoria Losinski, director of pharmacy services for the insurer.
Indeed, patients returning to the hospital within a short time of their initial care is a substantial cost of heathcare in the United States.
According to a 2019 report from United Health Foundation's "America's Health Rankings," 16 percent of elderly adults in the U.S. return to the hospital within 30 days of being discharged. Using data from the Dartmouth Atlas of Health Care, it reported that hospital readmissions in the U.S. cost $41.3 billion in 2011, with Medicare absorbing $24 billion of that.
No one wants hospital readmissions to occur. Patients certainly don't, and neither do their insurers. Hospitals don't like it, either. Under the Affordable Care Act, the Centers for Medicare and Medicaid Services penalizes hospitals for what it considers to be "excess" readmissions. From the beginning of the program on Oct. 1, 2012, through fiscal year 2017, the penalties cost hospitals $1.9 billion, the American Hospital Association reports.
The first reason for readmissions listed in America's Health Rankings: "Confusion about what prescribed medications should be taken and when they should be taken."
Blue Cross recognizes the problem, Losinski said.
"When we looked at what our members’ needs were and how critical it is to make sure that the medications are right when they’re leaving the hospital, it really was a no-brainer," she said.
Blue Cross contracted with Tabula Rasa three years ago, Losinski said. Pharmacists already were making house calls in Minnesota, but she said she thought those programs targeted smaller groups and were inconsistent. The Blue Cross program is for all members on its Secure Blue Medicare plan, which means they qualify for the state's Medicaid plan but are old enough to receive Medicare.
"They’re ... very frail elderly , (with) very complex healthcare conditions and often are in need of a lot of different means of support," she said.
In three years, there hasn't been any turnover among the pharmacists, Losinski said, and they've been well-received.
"Our patients generally love this service," she said. "Sometimes, people are a little leery to have someone else come into their home. But the patients that have participated, and especially Bill’s patients, absolutely love him. "
The goal is to have a pharmacist in a patient's home within 72 hours of discharge, Losinski said, but that's not always possible.
It hadn't been in Johnson's case. She had been hospitalized on May 6 and kept for three days before being discharged for rehabilitation at Ecumen Lakeshore. She came home on May 30, and Vouk's visit was on June 7.
Although connected to oxygen and moving gingerly, Johnson was in a cheerful, chatty mood, once stopping the conversation about medications to tell a joke. Right away, she urged Vouk to check out her remodeled second-floor bathroom. He did so, and in the process illustrated that his concern for Johnson's care went beyond medications. To a reporter and photographer tagging along, he pointed out that there weren't any security bars in the bathroom.
Returning to Johnson's kitchen, he casually brought that up.
Vouk: “I was wondering if they’ll put bars in the bathroom?”
Johnson: “They’re going to do that on Monday.”
He asked if an occupational therapist has come, and when Johnson said "no," he promised to look into that. He also said he'd check with her care coordinator to see if there was a way she could get a ride to a place where she could exercise.
Johnson's numerous orange pill bottles were positioned neatly on an easy-to-reach kitchen shelf — the ones on the left for morning pills, the ones on the right for evening pills, and the ones in the middle for two times a day.
Once he sat down at her table to go through the medications with Johnson, Vouk was unfailingly calm, courteous and willing to digress. But he always brought the matter back to the pharmaceuticals.
He indicated surprise that Johnson's daily dose of aspirin had been increased. "I don't think you need that," Vouk said. "I'm going to ask your doctor about that."
Finding an allergy drug on Johnson's list of medications, Vouk learned that she didn't have it yet.
“Good," he said. "Because that’s a medication I wouldn’t recommend for you. There’s so many medications that are better for allergies, especially for someone your age. “
Departing after close to an hour, Vouk had a short drive home ahead. That's not always the case. His territory runs to southern Isanti County in the south, west to Moorhead, and north to the Canadian border.
He showed quiet satisfaction in the impact his work makes, citing research that shows pharmacist house calls reduce hospital readmissions by 30 percent.
Losinski said Blue Cross hasn't yet accumulated sufficient data to evaluate its use of the Tabula Rasa home pharmacy program. But there's enough research on such programs in the scientific literature to give Blue Cross confidence that it's a worthwhile investment.
"It isn’t that the providers or the hospitals or doctors aren’t doing part of their job," she said. "They’re doing everything they can to make sure this is a successful transition. But being able to offer that pharmacist in homes across the whole state I think is really looking to address that gap of what’s physically going on in the home."