Rosemont, Ill.—Pharmacists can capitalize on the strengths of their hospitals to foster improvements in transitions of care, according to presentations at the annual American Society of Health-System Pharmacists (ASHP) leadership conference.
Find the people in your organization who are innovating in ways that support accountable care and effective care transitions, and capitalize on those efforts with your own ideas, initiative and expertise, urged speaker Lindsey R. Kelley, PharmD, MS, the coordinator of ambulatory pharmacy initiatives and transitions of care at the University of Michigan Hospital and Health System (UMHS), in Ann Arbor.
This year’s meeting, themed “Leading the Pharmacy Enterprise: Advancing Practice with Transitions in Health Care,” included a breakout session devoted to helping pharmacists define their roles in improving care transitions. During the session, Dr. Kelley encouraged pharmacy leaders to use an “opportunistic” approach—to identify places where innovation around accountable care is already happening—and then to build on that work, with an eye on the smart use of pharmacists’ time and energy, “so that you are the best steward of your resources.”
For example, said Dr. Kelley, “it’s possible that you might get involved with medication reconciliation. It’s possible that you might get involved with care coordination. It depends on … the strengths of your organization and the areas of opportunity. If the strength already exists, see if you can … partner with the people who are already doing it. You don’t … have to reinvent the wheel,” she said.
At UMHS, Dr. Kelley and her colleagues saw an opportunity in the physician group practice demonstration that has served as the prototype for the institution’s accountable care organization (ACO). Following the completion of a successful pharmacist-driven pilot project, pharmacists now have scheduled, 30-minute, face-to-face visits or 15- to 30-minute phone consultations with patients at 14 of the system’s general medicine health centers, “and they bill for these visits,” said Dr. Kelley. Preliminary data from the first year showed that patients with a baseline A1c >7.0% (n=270) experienced a mean decrease in A1c of 0.8% (95% CI 0.6-1.0; P<0.001). Higher risk patients with a baseline A1c >9.0% (n=118) experienced a mean decrease of 1.4% (95% CI 1.1-1.8; P<0.001). In addition, pharmacists generated $150,000 in revenue during the first year in billings.
Pharmacists participate in interdisciplinary care with physicians and nurses, verify orders, answer patients’ medication-related questions, lead in-services for nurses and handle medication reconciliation and other tasks.
“The preliminary data is meaningful to the clinic because they’re meeting their goals,” she said. “And they’re doing it through pharmacist work. I think this is the way that we demonstrate our value and we continue to grow.”
Several of the institutions recently cited for “best practices” by the Medication Management in Care Transitions Project (MMCT) of the American Pharmacists Association and ASHP employ similar strategies, according to Cynthia Reilly, BS Pharm, the director of practice development at ASHP (sidebar). “A lot of what I see in some of these care transition winners is the way in which they’ve bundled [interventions], really taking a comprehensive approach to care transitions,” she said.
Several organizations have built on established medication reconciliation programs, for example, “and extended that outreach to the community,” noted Ms. Reilly. “So seven, 10, 15, sometimes even 30 days after the patient has been discharged, they are reaching out to patients to try to prevent readmissions by assuring that [patients are] understanding how to use their medications correctly. In several of the programs, we’re seeing the same pharmacist who took care of the patient in the inpatient setting doing that intervention” to enhance continuity of care, she said.
“Medicare drives what we do” for clear reasons, said Dr. Kelley. Research shows that 19.6% of Medicare patients are rehospitalized within 30 days of discharge; up to 19% of patients experience adverse events within five weeks of discharge, and approximately 66% of those adverse events are medication-related (N Engl J Med 2009;360:1418-1428; Ann Intern Med 2003;138:161-167; Ann Intern Med 2005;20:317-323).
Outpatient Geriatrics a Focus
At UMHS, a pharmacist spotted opportunities to address these medication-related issues in the outpatient geriatric clinic, and developed a multifaceted intervention to increase the accuracy and completeness of medication histories that involves providers, pharmacy technicians, pharmacy interns and medical assistants. “Usual care” consisted of medication reconciliation performed by a medical assistant in the clinic’s hallway during patient check-in. The enhanced pharmacist-led protocol includes phone calls to patients one to three days before clinic visits by pharmacy technicians. These technicians have physician authorization to enter updated information directly into the electronic medical record (EMR). The technicians also report changes and discrepancies to physicians via the EMR.
A key component of the intervention is structured training for the medical assistants and pharmacy technicians on medication history taking and medication reconciliation, Dr. Kelley said. If a technician is not able to reach a patient by phone before a visit, an “enhanced” (trained) medical assistant takes the medication history in the examination room.
The initiative illustrates the intelligent stewardship of pharmacy resources because pharmacists are using their expertise to drive process improvement rather than to perform all of the “hands-on” work of medication reconciliation. In some instances, the best strategy is to use the people who are already doing the work, Dr. Kelley said.
That approach reflects the goals and intent of ASHP’s Pharmacy Practice Model Initiative, which emphasizes “the idea of everyone working at the top of their license,” Dr. Kelley said in an interview with Pharmacy Practice News. “I really like that. It really engages staff. It encourages them to think of ways to be better and make the best use of their brain.”
The American Pharmacists Association and the American Society of Health-System Pharmacists have recognized eight hospital-based pharmacy programs for innovation in the area of care transitions through the Medication Management in Care Transitions Project.
The “best practices” developed by these institutions will be shared with health care providers and organizations, government agencies and other stakeholders in a report published later this year. Case studies also will be presented in a session at the ASHP Midyear Meeting, Dec. 2-6, in Las Vegas.
The models use a variety of strategies to address such overarching issues as preventing adverse drug events, reducing readmissions and increasing access to medications. The institutions are: