PRACTICE REPORTS Transition-of-care activities
PRACTICE REPORTS
Variations in pharmacy-based transition-of-care activities in the United States: A national survey Kristine A. Kern, James S. Kalus, Colleen Bush, David Chen, Edward G. Szandzik, and Nadia Z. Haque
Scan to access AJHP Voices
T
An audio interview that supplements the information in this article is available on AJHP’s website at www.ajhp.org/ site/misc/podcasts.xhtml.
ransition of care (TOC) can be defined as the coordination and continuity of health care as a patient transfers between different locations or different levels of care in the same location.1 Patient transitions of care are a major cause of medication errors and adverse drug events (ADEs).2,3 Rozich and Resar4 reported that 60% of medication errors in a Wisconsin community hospital occurred when patients were admitted to, discharged from, or transferred from the hospital. Up to 20% of ADEs have been attributed to medication changes that occurred during TOC involving the patient’s home, hospital, and nursing home.2,3 These ADEs are associated with increased lengths of stay and significant costs.5 In an effort to minimize adverse events during TOC, the Joint Com-
Purpose. A national survey was conducted to assess pharmacist roles in transition-ofcare (TOC) activities in the United States. Methods. An online survey was sent to 1246 pharmacy directors who were members of the American Society of Health-System Pharmacists to assess their involvement in TOC activities including medication reconciliation, admission histories, medication counseling, and postdischarge follow-up; pharmacy student and pharmacy technician involvement in TOC activities; the use of technology to facilitate TOC activities; and barriers to performing such activities. Results. A total of 393 respondents completed the survey (31.5% response rate). Twenty-seven percent of respondents indicated that pharmacists complete medication histories on admission, and 5% indicated that pharmacy technicians complete medication histories. Most respondents indicated that pharmacists do not routinely or consistently provide patients with tools to facilitate medication adherence before hospital discharge and that pharmacists do not routinely or consistently follow up with
mission’s National Patient Safety Goals require hospitals to “maintain and communicate accurate patient
Kristine A. Kern, Pharm.D., is Clinical Pharmacy Specialist, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI. James S. Kalus, Pharm.D., BCPS (AQ-Infectious Diseases), is Senior Manager, Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI. Colleen Bush, B.S., PRC, is Manager, Market Research; and David Chen, B.S.Pharm., M.B.A., is Director, Pharmacy Practice Sections and Section of Pharmacy Practice Managers, American Society of Health-System Pharmacists, Bethesda, MD. Edward G. Szandzik,
648
Am J Health-Syst Pharm—Vol 71 Apr 15, 2014
patients after discharge. Fifty-six percent of respondents indicated that pharmacists provide patient education for specific medications or for medications for specific diseases. Few respondents indicated that student pharmacists are involved with TOC activities. Most respondents either agreed or strongly agreed that it is important for pharmacists to be involved in TOC activities for hospitalized patients. Conclusion. Approximately one third of survey respondents indicated that pharmacists complete medication histories. Most respondents indicated that pharmacists do not routinely or consistently provide patients with tools to facilitate medication adherence before hospital discharge or follow up with patients after discharge. Lack of pharmacy staff resources and insufficient recognition of the value of pharmacists’ provision of TOC by health care executives, medical staff, nursing staff, and other health care professionals were the most frequently cited barriers to pharmacists assuming more significant roles in the TOC at the respondent’s institution. Am J Health-Syst Pharm. 2014; 71:648-56
medication information.”6 Pharmacists are uniquely qualified to identify and resolve medication-related
B.S.Pharm., M.B.A., is Director, Department of Pharmacy Services; and Nadia Z. Haque, Pharm.D., M.H.S.A., BCPS, is Pharmacy Manager, Department of Pharmacy Services, Henry Ford Hospital. Address correspondence to Dr. Haque ([email protected]). Ms. Bush and Mr. Chen are employees of the American Society of Health-System Pharmacists. The other authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130510
PRACTICE REPORTS Transition-of-care activities
problems associated with the TOC and provide medication education to patients and their caregivers. Pharmacists can play many roles in the TOC of patients, including obtaining a medication history on admission,7,8 initiating medication reconciliation when patients are transferred within the hospital, 9 providing inpatient education, performing medication reconciliation at discharge,8,10,11 providing discharge counseling regarding medication therapy,10,11 and instituting postdischarge telephone-call programs or follow-up visits.12 Many of the key recommendations of the American Society of Health-System Pharmacists (ASHP) Pharmacy Practice Model Initiative (PPMI) involve the development of plans to reallocate resources to devote significantly more pharmacy department resources to medication management services.13 Literature relating to pharmacists’ participation in TOC activities outside of medication reconciliation, discharge counseling, and followup outpatient care often describes the pharmacist’s role in managing single medications, such as warfarin. However, pharmacy services where follow up to an outpatient anticoagulation clinic was coordinated before a patient was discharged from the hospital have been described,14,15 as has pharmacists’ involvement in multidisciplinary teams providing general discharge counseling and medication reconciliation.11,16 Pharmacists’ involvement in TOC activities has been described infrequently in the literature, and the magnitude of their involvement in such activities on a national level is unknown. The purpose of this study was to assess pharmacists’ roles in the TOC of hospitalized patients in the United States. Methods The department of pharmacy services at Henry Ford Hospital and ASHP worked together to develop and disseminate an online survey us-
ing Qualtrics software, version 2012 (Qualtrics Research Suite, Provo, UT). The survey contained questions about common TOC activities, including medication reconciliation, medication education, and followup care after an inpatient stay. As a means for pharmacy directors to share unique pharmacy services nationally, space was provided for writing in additional TOC activities not described in the survey questions. Before survey distribution, the survey was pilot tested by five clinicians at Henry Ford Hospital to ensure clarity of the survey questions and that survey participants would understand the intent of the questions. An e-mail invitation explaining the purpose of the study was sent to pharmacists identified in ASHP membership records as pharmacy directors of acute care hospitals and health systems in the United States. A link to the online survey was included in the invitation. The survey launched on May 31, 2012, and closed June 25, 2012, with three reminder e-mails sent on June 6, 14, and 21 to encourage participation. This study was approved by the institutional review board at Henry Ford Hospital. The Web-based survey collected demographic data about each pharmacy director’s organization; pharmacist involvement in TOC activities at admission, during patient transfer, and at discharge; patient education; involvement of student pharmacists and pharmacy technicians in TOC activities; and general information regarding TOC activities at the organization. Results The survey was sent to 1246 pharmacy directors, of whom 393 (31.5%) responded. All completed surveys were included in the analysis. Respondent demographics are shown in Table 1. The representation of larger hospitals (400 beds or more) by respondents was disproportionately high compared with na-
tional data (22% versus 8%, respectively),17 while the representation of smaller hospitals (fewer than 100 beds) in the survey population was disproportionately low compared with national data (32% versus 53%, respectively).17 Medication histories and medication reconciliation. The involvement of pharmacists and other health care professionals in the completion of medication histories and medication reconciliation on admission reported by survey respondents is shown in Table 2. The majority of medication histories were reported as completed by nurses (56%) and pharmacy staff (31%) on admission. Few respondents indicated that pharmacists completed admission medication reconciliation in the emergency department (12%). Special populations and unique pharmacy services. Twenty-five percent of respondents indicated that their organization had a pharmacy initiative or service in place that targeted special patient populations. These included patients older than 65 years, taking multiple drugs, transferred from long-term care facilities, or admitted to medical–surgical and telemetry units. Other targeted populations included those that were medication specific (patients taking warfarin or other anticoagulants), those associated with high risk or high cost (patients with any readmission within 30 days; patients undergoing bone marrow transplantation, solid organ transplantation, or orthopedic joint replacement; or patients with pneumonia, cancer, or myocardial infarction), and those that were chronic disease specific (patients with cancer, neurologic diseases, congestive heart failure, asthma or chronic obstructive pulmonary disease, cystic fibrosis, endstage organ disease, diabetes with a glycosylated hemoglobin value of >9%, or psychiatric crisis). Patient education. The survey also asked about pharmacists’ role in
Am J Health-Syst Pharm—Vol 71 Apr 15, 2014
649
PRACTICE REPORTS Transition-of-care activities
Table 1.
Demographics of Survey Respondentsa Characteristic
No. (%) Respondents
Type of hospital (n = 373) Community (not-for-profit) For profit Critical access hospital University Government Other No. staffed beds (n = 373)
PRACTICE REPORTS
Variations in pharmacy-based transition-of-care activities in the United States: A national survey Kristine A. Kern, James S. Kalus, Colleen Bush, David Chen, Edward G. Szandzik, and Nadia Z. Haque
Scan to access AJHP Voices
T
An audio interview that supplements the information in this article is available on AJHP’s website at www.ajhp.org/ site/misc/podcasts.xhtml.
ransition of care (TOC) can be defined as the coordination and continuity of health care as a patient transfers between different locations or different levels of care in the same location.1 Patient transitions of care are a major cause of medication errors and adverse drug events (ADEs).2,3 Rozich and Resar4 reported that 60% of medication errors in a Wisconsin community hospital occurred when patients were admitted to, discharged from, or transferred from the hospital. Up to 20% of ADEs have been attributed to medication changes that occurred during TOC involving the patient’s home, hospital, and nursing home.2,3 These ADEs are associated with increased lengths of stay and significant costs.5 In an effort to minimize adverse events during TOC, the Joint Com-
Purpose. A national survey was conducted to assess pharmacist roles in transition-ofcare (TOC) activities in the United States. Methods. An online survey was sent to 1246 pharmacy directors who were members of the American Society of Health-System Pharmacists to assess their involvement in TOC activities including medication reconciliation, admission histories, medication counseling, and postdischarge follow-up; pharmacy student and pharmacy technician involvement in TOC activities; the use of technology to facilitate TOC activities; and barriers to performing such activities. Results. A total of 393 respondents completed the survey (31.5% response rate). Twenty-seven percent of respondents indicated that pharmacists complete medication histories on admission, and 5% indicated that pharmacy technicians complete medication histories. Most respondents indicated that pharmacists do not routinely or consistently provide patients with tools to facilitate medication adherence before hospital discharge and that pharmacists do not routinely or consistently follow up with
mission’s National Patient Safety Goals require hospitals to “maintain and communicate accurate patient
Kristine A. Kern, Pharm.D., is Clinical Pharmacy Specialist, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI. James S. Kalus, Pharm.D., BCPS (AQ-Infectious Diseases), is Senior Manager, Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI. Colleen Bush, B.S., PRC, is Manager, Market Research; and David Chen, B.S.Pharm., M.B.A., is Director, Pharmacy Practice Sections and Section of Pharmacy Practice Managers, American Society of Health-System Pharmacists, Bethesda, MD. Edward G. Szandzik,
648
Am J Health-Syst Pharm—Vol 71 Apr 15, 2014
patients after discharge. Fifty-six percent of respondents indicated that pharmacists provide patient education for specific medications or for medications for specific diseases. Few respondents indicated that student pharmacists are involved with TOC activities. Most respondents either agreed or strongly agreed that it is important for pharmacists to be involved in TOC activities for hospitalized patients. Conclusion. Approximately one third of survey respondents indicated that pharmacists complete medication histories. Most respondents indicated that pharmacists do not routinely or consistently provide patients with tools to facilitate medication adherence before hospital discharge or follow up with patients after discharge. Lack of pharmacy staff resources and insufficient recognition of the value of pharmacists’ provision of TOC by health care executives, medical staff, nursing staff, and other health care professionals were the most frequently cited barriers to pharmacists assuming more significant roles in the TOC at the respondent’s institution. Am J Health-Syst Pharm. 2014; 71:648-56
medication information.”6 Pharmacists are uniquely qualified to identify and resolve medication-related
B.S.Pharm., M.B.A., is Director, Department of Pharmacy Services; and Nadia Z. Haque, Pharm.D., M.H.S.A., BCPS, is Pharmacy Manager, Department of Pharmacy Services, Henry Ford Hospital. Address correspondence to Dr. Haque ([email protected]). Ms. Bush and Mr. Chen are employees of the American Society of Health-System Pharmacists. The other authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130510
PRACTICE REPORTS Transition-of-care activities
problems associated with the TOC and provide medication education to patients and their caregivers. Pharmacists can play many roles in the TOC of patients, including obtaining a medication history on admission,7,8 initiating medication reconciliation when patients are transferred within the hospital, 9 providing inpatient education, performing medication reconciliation at discharge,8,10,11 providing discharge counseling regarding medication therapy,10,11 and instituting postdischarge telephone-call programs or follow-up visits.12 Many of the key recommendations of the American Society of Health-System Pharmacists (ASHP) Pharmacy Practice Model Initiative (PPMI) involve the development of plans to reallocate resources to devote significantly more pharmacy department resources to medication management services.13 Literature relating to pharmacists’ participation in TOC activities outside of medication reconciliation, discharge counseling, and followup outpatient care often describes the pharmacist’s role in managing single medications, such as warfarin. However, pharmacy services where follow up to an outpatient anticoagulation clinic was coordinated before a patient was discharged from the hospital have been described,14,15 as has pharmacists’ involvement in multidisciplinary teams providing general discharge counseling and medication reconciliation.11,16 Pharmacists’ involvement in TOC activities has been described infrequently in the literature, and the magnitude of their involvement in such activities on a national level is unknown. The purpose of this study was to assess pharmacists’ roles in the TOC of hospitalized patients in the United States. Methods The department of pharmacy services at Henry Ford Hospital and ASHP worked together to develop and disseminate an online survey us-
ing Qualtrics software, version 2012 (Qualtrics Research Suite, Provo, UT). The survey contained questions about common TOC activities, including medication reconciliation, medication education, and followup care after an inpatient stay. As a means for pharmacy directors to share unique pharmacy services nationally, space was provided for writing in additional TOC activities not described in the survey questions. Before survey distribution, the survey was pilot tested by five clinicians at Henry Ford Hospital to ensure clarity of the survey questions and that survey participants would understand the intent of the questions. An e-mail invitation explaining the purpose of the study was sent to pharmacists identified in ASHP membership records as pharmacy directors of acute care hospitals and health systems in the United States. A link to the online survey was included in the invitation. The survey launched on May 31, 2012, and closed June 25, 2012, with three reminder e-mails sent on June 6, 14, and 21 to encourage participation. This study was approved by the institutional review board at Henry Ford Hospital. The Web-based survey collected demographic data about each pharmacy director’s organization; pharmacist involvement in TOC activities at admission, during patient transfer, and at discharge; patient education; involvement of student pharmacists and pharmacy technicians in TOC activities; and general information regarding TOC activities at the organization. Results The survey was sent to 1246 pharmacy directors, of whom 393 (31.5%) responded. All completed surveys were included in the analysis. Respondent demographics are shown in Table 1. The representation of larger hospitals (400 beds or more) by respondents was disproportionately high compared with na-
tional data (22% versus 8%, respectively),17 while the representation of smaller hospitals (fewer than 100 beds) in the survey population was disproportionately low compared with national data (32% versus 53%, respectively).17 Medication histories and medication reconciliation. The involvement of pharmacists and other health care professionals in the completion of medication histories and medication reconciliation on admission reported by survey respondents is shown in Table 2. The majority of medication histories were reported as completed by nurses (56%) and pharmacy staff (31%) on admission. Few respondents indicated that pharmacists completed admission medication reconciliation in the emergency department (12%). Special populations and unique pharmacy services. Twenty-five percent of respondents indicated that their organization had a pharmacy initiative or service in place that targeted special patient populations. These included patients older than 65 years, taking multiple drugs, transferred from long-term care facilities, or admitted to medical–surgical and telemetry units. Other targeted populations included those that were medication specific (patients taking warfarin or other anticoagulants), those associated with high risk or high cost (patients with any readmission within 30 days; patients undergoing bone marrow transplantation, solid organ transplantation, or orthopedic joint replacement; or patients with pneumonia, cancer, or myocardial infarction), and those that were chronic disease specific (patients with cancer, neurologic diseases, congestive heart failure, asthma or chronic obstructive pulmonary disease, cystic fibrosis, endstage organ disease, diabetes with a glycosylated hemoglobin value of >9%, or psychiatric crisis). Patient education. The survey also asked about pharmacists’ role in
Am J Health-Syst Pharm—Vol 71 Apr 15, 2014
649
PRACTICE REPORTS Transition-of-care activities
Table 1.
Demographics of Survey Respondentsa Characteristic
No. (%) Respondents
Type of hospital (n = 373) Community (not-for-profit) For profit Critical access hospital University Government Other No. staffed beds (n = 373)
