EXPERIENCE
Impact of a transition-of-care pharmacist during hospital discharge Lauren Balling, Brian L. Erstad, and Kurt Weibel
Abstract Objective: To assess the impact of a transition-of-care pharmacist during hospital discharge. Setting: An academic medical center in southern Arizona. Practice description: One pharmacist coordinated patient discharges in two inpatient units from August 2012 through July 2013. The pharmacist attended interdisciplinary discharge coordination meetings, ensured appropriate discharge orders, facilitated the filling of medications, and educated patients on discharge medications. Practice innovation: The implementation of a transition-of-care pharmacist to provide discharge medication reconciliation and education. Main outcome measures: Readmission rates and medication interventions made by the pharmacist at discharge. Results: The pharmacist was involved in the education of 1,011 patients and performed 452 interventions. There were more readmissions per month in the control year versus the year of pharmacist involvement (median 27.5 vs. 25, P = 0.0369). Interventions made by the pharmacist to improve discharge management included starting an omitted medication (23.5%), preventing multiple discharge problems (16.4%), avoiding duplication of therapy (15.7%), correcting insurance issues related to medication coverage (12.2%), changing an improper medication dose or quantity (11.3%), changing an inappropriate prescription for a medication (5.1%), preventing a drug interaction (3.3%), and resolving other problems (12.6%). The most common medication classes involved were antimicrobial agents (9.1%), anticoagulants (8%), antihyperglycemic agents (3.8%), other drug classes (24%), and multiple drug classes (35%).
Lauren Balling, PharmD, Clinical Pharmacist, Banner University Medical Center, Tucson, AZ; at time of study, Clinical Staff Pharmacist and Instructor, College of Pharmacy, University of Arizona, Tucson, AZ, and Banner University Medical Center, Tucson, AZ Brian L. Erstad, PharmD, Professor and Head, Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ Kurt Weibel, MS, PharmD, Director, Pharmacy Services, Banner University Medical Center, Tucson, AZ Correspondence: Lauren Balling, PharmD, Banner University Medical Center, 1501 N. Campbell Ave., P.O. Box 245009, Tucson, AZ 85724; lauren.balling@ bannerhealth.com Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Previous presentation: Portions of the work were presented as a poster presentation at the American College of Clinical Pharmacy 2014 Virtual Poster Symposium, May 20, 2014, where it was a finalist and selected as runner-up. Received May 5, 2014. Accepted for publication January 14, 2015.
Conclusion: A transition-of-care pharmacist is in a unique position to educate patients on hospital discharge, to intercept a substantial number of medication errors, and to resolve insurance issues that may lead to adherence problems. These improvements in care may result in reduced hospital readmission rates. J Am Pharm Assoc. 2015;55:443–448. doi: 10.1331/JAPhA.2015.14087
Journal of the American Pharmacists Association
j apha.org
JU L/A U G 2015 | 55:4 |
JAPhA 443
EXPERIENCE
TRANSITION-OF-CARE PHARMACIST
T
ransitions of care describes patient movement from one health care setting to another. An estimated 60% of all medication errors occur during times of care transitions, and one in five patients discharged from hospitals has a related adverse event, 72% of which are related to medications.1 Data suggest that counseling patients before discharge reduces medication discrepancies and improves adherence.2 Pharmacists are medication experts and are in a unique position to provide such counseling and ensure medication reconciliation during the discharge process.3–5 Further, pharmacists can facilitate patient access to all medications prescribed by making sure patients can afford them.6 Pharmacists are currently underused in care transitions. In a review of pharmacists’ services in U.S. hospitals, only 5% of hospitals reported that pharmacists provided admission histories, and only 49% reported that pharmacists provided medication counseling.7 Differences in hospital and outpatient formularies and the initiation or discontinuation of medications at discharge increase the chance of drug-related problems that pharmacists can help intercept.8
Objective The purpose of this quality improvement project was to assess the impact of a transition-of-care pharmacist during hospital discharge.
Methods This project was conducted at a 487-bed academic teach-
Key Points Background: ❚❚ ❚❚ ❚❚
Transitions-of-care will continue to be a focus of hospitals due to a readmission reduction program from Medicare that started in 2012. There are currently few studies showing the impact that pharmacists can have in the discharge process and preventing readmissions. Several studies have shown that there are a large number of medication errors at hospital discharge and that a large percentage of hospital readmissions are due to a medication adverse event.
Findings: ❚❚
❚❚
A transition-of-care pharmacist is in a unique position to education patients on hospital discharge, to intercept a substantial number of medication errors, and to resolve insurance issues that may lead to adherence problems. These improvements in care may result in reduced hospital readmission rates.
444 JAPhA | 5 5:4 | JUL /AUG 2 0 1 5
ja p h a.org
ing hospital located in southern Arizona. No pharmacist was solely dedicated to providing medication reconciliation and education to patients being discharged from the hospital before the addition of this transition-of-care pharmacist. Before the implementation of this project, medication reconciliation was primarily performed by the discharging physician with discharge education routinely provided by physicians and nursing staff. This project was reviewed by a member of the University of Arizona Institutional Review Board and found to be a quality improvement project, and approval was received from the Department of Pharmacy Services, Banner University Medical Center. One transition-of-care pharmacist with residency training and expertise in community and ambulatory care practice was assigned to the project for the entire evaluation. The pharmacist conducted the program on two inpatient units (adult medical/surgical) with historically high readmission rates. Eligible patients were those who were discharged from either unit between August 1, 2012, and July 3, 2013. One unit was a cardiac step-down floor; most patients had recent cardiac surgery or heart and lung transplant, or had heart failure. The second unit was a lower acuity medicine–surgery area with mixed patient populations, including those on hemodialysis or peritoneal dialysis, those with endstage liver or renal disease, or those with infectious diseases. Approximately 60 patients on both units were discussed in daily care coordination rounds. The pharmacist was responsible for assisting with these patients at discharge, but not all patients were seen by the pharmacist. Patients who were discharged between approximately 8:30 am to 5:00 pm on Monday through Friday were included because of pharmacist availability; the pharmacist also assisted in the discharge process outside these hours if alerted ahead of time by the physicians or nurses caring for the patient. In these cases, the pharmacist counseled these patients about medications before discharge, coordinated receiving prescriptions from physicians in advance to facilitate prior authorizations, or filled and delivered medications to the nurse before discharge. The pharmacist attended interdisciplinary care coordination rounds daily with nurses, case managers, and social workers to discuss barriers to patient discharges and to assist in planning safe discharges. For the first few months of the evaluation, the pharmacist had to rely on other members of the medical team for alerts of discharges. Starting in November 2012 the pharmacist was subscribed to the discharge paging system and was alerted when a discharge order was placed. Because of this change, more patients were seen by the pharmacist near the end of the evaluation period compared with the beginning. Hospital policy states that patients should be out of the hospital within 2 hours of a discharge, so the pharmacist did not have time to cover Journal of the American Pharmacists Association
TRANSITION-OF-CARE PHARMACIST
all discharge patients. Before patient discharge, the pharmacist reviewed patient information including insurance coverage, medication adherence, and history and physical at admission. The pharmacist also verified with their outpatient pharmacy, if needed, to determine if prescribed medications would be covered or if there were any barriers to dispensing medications at discharge. Once the discharge order was placed, the pharmacist performed medication reconciliation to identify and resolve discrepancies. The pharmacist provided medication and disease counseling to help improve adherence. For patients not able to obtain their discharge medications at an outside pharmacy on the day of discharge, the pharmacist facilitated the dispensing and delivery of medications to the patient. The pharmacist made sure patients were able to afford all prescriptions at discharge and recommended generic alternatives when available. Further, the pharmacist worked with the outpatient pharmacy to waive patient copayments if the patient could not afford them. For uninsured patients without funds to pay for medications, the pharmacist worked to obtain medications at no cost until case managers could get the patients a low-cost clinic appointment. Nurses, case managers, social workers, and outpatient pharmacy technicians assisted, when needed, in the discharge process after problems were identified. The pharmacist contacted patients to resolve problems not solved before discharge. The pharmacist did not routinely call all patients after discharge. The pharmacist tracked the number of patients who were assisted with discharge, including those in need of discharge counseling. The pharmacist also collected information such as the type of intervention (action taken to improve a situation) performed, medications that required changes to ameliorate or prevent medication errors (any errors or mistakes occurring during the medication-use process), and how much time was spent interacting with each patient. The pharmacist did not contact patients by telephone after discharge unless alerted to a discharge problem by a nurse or unless a patient contacted the pharmacist after discharge with a question or problem (pharmacist business cards were given at discharge). For the purpose of comparison, monthly hospital discharge and readmission rates during discharge with pharmacist involvement were compared with the previous year during which pharmacists were not involved in discharge programs.
Data analysis Data were initially entered into an Excel spreadsheet for subsequent analysis using Stata 13.0 (StataCorp LP, College Station, TX). Categorical comparisons were performed using chi-square or Fisher’s exact test. Other group comparisons were performed using the two-sample Wilcoxon rank-sum test. The level of significance Journal of the American Pharmacists Association
EXPERIENCE
was set at P
Impact of a transition-of-care pharmacist during hospital discharge Lauren Balling, Brian L. Erstad, and Kurt Weibel
Abstract Objective: To assess the impact of a transition-of-care pharmacist during hospital discharge. Setting: An academic medical center in southern Arizona. Practice description: One pharmacist coordinated patient discharges in two inpatient units from August 2012 through July 2013. The pharmacist attended interdisciplinary discharge coordination meetings, ensured appropriate discharge orders, facilitated the filling of medications, and educated patients on discharge medications. Practice innovation: The implementation of a transition-of-care pharmacist to provide discharge medication reconciliation and education. Main outcome measures: Readmission rates and medication interventions made by the pharmacist at discharge. Results: The pharmacist was involved in the education of 1,011 patients and performed 452 interventions. There were more readmissions per month in the control year versus the year of pharmacist involvement (median 27.5 vs. 25, P = 0.0369). Interventions made by the pharmacist to improve discharge management included starting an omitted medication (23.5%), preventing multiple discharge problems (16.4%), avoiding duplication of therapy (15.7%), correcting insurance issues related to medication coverage (12.2%), changing an improper medication dose or quantity (11.3%), changing an inappropriate prescription for a medication (5.1%), preventing a drug interaction (3.3%), and resolving other problems (12.6%). The most common medication classes involved were antimicrobial agents (9.1%), anticoagulants (8%), antihyperglycemic agents (3.8%), other drug classes (24%), and multiple drug classes (35%).
Lauren Balling, PharmD, Clinical Pharmacist, Banner University Medical Center, Tucson, AZ; at time of study, Clinical Staff Pharmacist and Instructor, College of Pharmacy, University of Arizona, Tucson, AZ, and Banner University Medical Center, Tucson, AZ Brian L. Erstad, PharmD, Professor and Head, Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ Kurt Weibel, MS, PharmD, Director, Pharmacy Services, Banner University Medical Center, Tucson, AZ Correspondence: Lauren Balling, PharmD, Banner University Medical Center, 1501 N. Campbell Ave., P.O. Box 245009, Tucson, AZ 85724; lauren.balling@ bannerhealth.com Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Previous presentation: Portions of the work were presented as a poster presentation at the American College of Clinical Pharmacy 2014 Virtual Poster Symposium, May 20, 2014, where it was a finalist and selected as runner-up. Received May 5, 2014. Accepted for publication January 14, 2015.
Conclusion: A transition-of-care pharmacist is in a unique position to educate patients on hospital discharge, to intercept a substantial number of medication errors, and to resolve insurance issues that may lead to adherence problems. These improvements in care may result in reduced hospital readmission rates. J Am Pharm Assoc. 2015;55:443–448. doi: 10.1331/JAPhA.2015.14087
Journal of the American Pharmacists Association
j apha.org
JU L/A U G 2015 | 55:4 |
JAPhA 443
EXPERIENCE
TRANSITION-OF-CARE PHARMACIST
T
ransitions of care describes patient movement from one health care setting to another. An estimated 60% of all medication errors occur during times of care transitions, and one in five patients discharged from hospitals has a related adverse event, 72% of which are related to medications.1 Data suggest that counseling patients before discharge reduces medication discrepancies and improves adherence.2 Pharmacists are medication experts and are in a unique position to provide such counseling and ensure medication reconciliation during the discharge process.3–5 Further, pharmacists can facilitate patient access to all medications prescribed by making sure patients can afford them.6 Pharmacists are currently underused in care transitions. In a review of pharmacists’ services in U.S. hospitals, only 5% of hospitals reported that pharmacists provided admission histories, and only 49% reported that pharmacists provided medication counseling.7 Differences in hospital and outpatient formularies and the initiation or discontinuation of medications at discharge increase the chance of drug-related problems that pharmacists can help intercept.8
Objective The purpose of this quality improvement project was to assess the impact of a transition-of-care pharmacist during hospital discharge.
Methods This project was conducted at a 487-bed academic teach-
Key Points Background: ❚❚ ❚❚ ❚❚
Transitions-of-care will continue to be a focus of hospitals due to a readmission reduction program from Medicare that started in 2012. There are currently few studies showing the impact that pharmacists can have in the discharge process and preventing readmissions. Several studies have shown that there are a large number of medication errors at hospital discharge and that a large percentage of hospital readmissions are due to a medication adverse event.
Findings: ❚❚
❚❚
A transition-of-care pharmacist is in a unique position to education patients on hospital discharge, to intercept a substantial number of medication errors, and to resolve insurance issues that may lead to adherence problems. These improvements in care may result in reduced hospital readmission rates.
444 JAPhA | 5 5:4 | JUL /AUG 2 0 1 5
ja p h a.org
ing hospital located in southern Arizona. No pharmacist was solely dedicated to providing medication reconciliation and education to patients being discharged from the hospital before the addition of this transition-of-care pharmacist. Before the implementation of this project, medication reconciliation was primarily performed by the discharging physician with discharge education routinely provided by physicians and nursing staff. This project was reviewed by a member of the University of Arizona Institutional Review Board and found to be a quality improvement project, and approval was received from the Department of Pharmacy Services, Banner University Medical Center. One transition-of-care pharmacist with residency training and expertise in community and ambulatory care practice was assigned to the project for the entire evaluation. The pharmacist conducted the program on two inpatient units (adult medical/surgical) with historically high readmission rates. Eligible patients were those who were discharged from either unit between August 1, 2012, and July 3, 2013. One unit was a cardiac step-down floor; most patients had recent cardiac surgery or heart and lung transplant, or had heart failure. The second unit was a lower acuity medicine–surgery area with mixed patient populations, including those on hemodialysis or peritoneal dialysis, those with endstage liver or renal disease, or those with infectious diseases. Approximately 60 patients on both units were discussed in daily care coordination rounds. The pharmacist was responsible for assisting with these patients at discharge, but not all patients were seen by the pharmacist. Patients who were discharged between approximately 8:30 am to 5:00 pm on Monday through Friday were included because of pharmacist availability; the pharmacist also assisted in the discharge process outside these hours if alerted ahead of time by the physicians or nurses caring for the patient. In these cases, the pharmacist counseled these patients about medications before discharge, coordinated receiving prescriptions from physicians in advance to facilitate prior authorizations, or filled and delivered medications to the nurse before discharge. The pharmacist attended interdisciplinary care coordination rounds daily with nurses, case managers, and social workers to discuss barriers to patient discharges and to assist in planning safe discharges. For the first few months of the evaluation, the pharmacist had to rely on other members of the medical team for alerts of discharges. Starting in November 2012 the pharmacist was subscribed to the discharge paging system and was alerted when a discharge order was placed. Because of this change, more patients were seen by the pharmacist near the end of the evaluation period compared with the beginning. Hospital policy states that patients should be out of the hospital within 2 hours of a discharge, so the pharmacist did not have time to cover Journal of the American Pharmacists Association
TRANSITION-OF-CARE PHARMACIST
all discharge patients. Before patient discharge, the pharmacist reviewed patient information including insurance coverage, medication adherence, and history and physical at admission. The pharmacist also verified with their outpatient pharmacy, if needed, to determine if prescribed medications would be covered or if there were any barriers to dispensing medications at discharge. Once the discharge order was placed, the pharmacist performed medication reconciliation to identify and resolve discrepancies. The pharmacist provided medication and disease counseling to help improve adherence. For patients not able to obtain their discharge medications at an outside pharmacy on the day of discharge, the pharmacist facilitated the dispensing and delivery of medications to the patient. The pharmacist made sure patients were able to afford all prescriptions at discharge and recommended generic alternatives when available. Further, the pharmacist worked with the outpatient pharmacy to waive patient copayments if the patient could not afford them. For uninsured patients without funds to pay for medications, the pharmacist worked to obtain medications at no cost until case managers could get the patients a low-cost clinic appointment. Nurses, case managers, social workers, and outpatient pharmacy technicians assisted, when needed, in the discharge process after problems were identified. The pharmacist contacted patients to resolve problems not solved before discharge. The pharmacist did not routinely call all patients after discharge. The pharmacist tracked the number of patients who were assisted with discharge, including those in need of discharge counseling. The pharmacist also collected information such as the type of intervention (action taken to improve a situation) performed, medications that required changes to ameliorate or prevent medication errors (any errors or mistakes occurring during the medication-use process), and how much time was spent interacting with each patient. The pharmacist did not contact patients by telephone after discharge unless alerted to a discharge problem by a nurse or unless a patient contacted the pharmacist after discharge with a question or problem (pharmacist business cards were given at discharge). For the purpose of comparison, monthly hospital discharge and readmission rates during discharge with pharmacist involvement were compared with the previous year during which pharmacists were not involved in discharge programs.
Data analysis Data were initially entered into an Excel spreadsheet for subsequent analysis using Stata 13.0 (StataCorp LP, College Station, TX). Categorical comparisons were performed using chi-square or Fisher’s exact test. Other group comparisons were performed using the two-sample Wilcoxon rank-sum test. The level of significance Journal of the American Pharmacists Association
EXPERIENCE
was set at P
