imageCollaboration between inpatient and ambulatory care pharmacists can improve the detection and resolution of drug therapy problems for patients about to be discharged from the hospital, according to a small clinical trial.

The study was undertaken to assess whether this strategy could enhance the quality of care transitions at FirstLight Health System, a critical-access hospital in Mora, Minn., according to Mariette Sourial, PharmD, who conducted the study while she was an ambulatory care pharmacy resident at the facility.

Prior to implementation, there was a definite need for improvement, noted Dr. Sourial, who is now an assistant professor of pharmacy practice at Palm Beach Atlantic University, in West Palm Beach, Fla. “During the transition from inpatient to outpatient [care settings], we saw great interventions being initiated by hospital pharmacists,” she said. “But the hospitalist often deferred carrying out those interventions because they were more focused on managing acute care conditions rather than chronic disease.”

To help resolve that implementation gap, Dr. Sourial helped develop a protocol in which an inpatient pharmacist conducted medication reconciliations for hospitalized patients, identified actual or potential drug therapy problems (DTPs), and proposed interventions designed to resolve them to the hospitalist. Information about DTPs that were not successfully resolved at the hospital was relayed to an ambulatory care pharmacist, who addressed them at the patient’s follow-up clinic visit, Dr. Sourial reported during a 2012 “Virtual Poster” session convened by the American College of Clinical Pharmacy.

Twenty patients were enrolled in the program. The five subjects who were successfully followed had 27 DTPs, 21 of which were resolved in the ambulatory care setting. The most common medication-related problem was an indication without a drug—that is, a condition such as diabetes not treated with appropriate medications (11 instances). Rounding out the list were wrong drug administered (7); drug without indication—that is, an unneccessary drug being taken by the patient, which may include recreational drug use, duplicate therapy, etc. (4); drug overdose (3); adverse drug reaction (1); and issues with patient compliance (1).

Although the study involved a very small number of patients, Dr. Sourial noted that the results demonstrate the ability that interpharmacy cooperation has to fill gaps in the continuum of care. That, in turn, may result in more comprehensive medication therapy management during the crucial period when patients shift between inpatient and outpatient environments—a time when medication management efforts can become scrambled because of inadequate communication between various providers, she noted.

The success of Dr. Sourial’s initiative helped to advance some long-term process changes at the hospital. For example, follow-up visits with an ambulatory care pharmacist are now written into the discharge orders, according to Brent Thompson, PharmD, FirstLight’s pharmacy director. “A lot of the interventions take place here in the hospital, but more importantly, medication therapy management services are being provided to more discharged patients,” he said.

Important Work

Marialice S. Bennett, RPh, FAPhA, a professor of clinical pharmacy at The Ohio State University (OSU) College of Pharmacy, in Columbus, said the FirstLight Health System study is somewhat limited by the small number of patients included. Still, the initiative “is an example of how communication among pharmacists from different environments can improve the transition of care.” Many times, she noted, “the coordinated transition of care stops at discharge, and we don’t see much communication with community or ambulatory care pharmacists about medication-related issues.”

That gap is unfortunate, because “relationships between inpatient and outpatient pharmacists are key to preventing [hospital] readmissions,” added Ms. Bennett, who is also the residency director of OSU’s ambulatory and community care residency programs.

She cautioned that coordinated transitions of care are simpler to establish at a small, rural facility such as FirstLight than at larger facilities. For instance, the system’s ambulatory care clinics are in the same building as the hospital, or are located nearby, and the hospital and its clinics are linked by the same information technology system. In contrast, large urban medical centers draw patients from an immense geographic area, and many patients receive post-discharge care from providers who have no affiliation with the hospital.

“Patients leave the hospital with a stack of prescriptions, drive many miles home and give them to a pharmacist who doesn’t know who wrote them and doesn’t know which old medications should be stopped and which should be maintained,” Ms. Bennett said. “That missing information is key, but it’s very cumbersome for hospitals to have to coordinate with health care providers outside of their system.”

Building such ambitious networks among pharmacists and other providers will require insurers and health systems to act on the growing body of evidence showing that greater pharmacist involvement in transitions of care reduces the numbers of medication-related errors and adverse events. That, in turn, can reduce the number of costly hospital readmissions, Ms. Bennett noted.

“If health insurance plans would pay for services related to transitions of care,” she said, “the result likely would be far better communication among providers, including hospital pharmacists, community pharmacists and ambulatory care pharmacists, regardless of which health care network they belong to.”