Las Vegas—Hospitals are starting to see the results of ambitious efforts to implement the principles of the Pharmacy Practice Model Initiative (PPMI) into their culture and operations. OSF Saint Francis Medical Center, in Peoria, Ill., and the Cleveland Clinic Florida, in Weston, were among the centers presenting their successful PPMI projects during the American Society of Health-System Pharmacists Midyear Clinical Meeting.
Implementation of key PPMI precepts triggered a major realignment of pharmacy resources at the 616-bed Saint Francis Medical Center, leading to expanded use of automation, increased pharmacist decentralization and more clinical interventions.
The pharmacy documented the effect of those interventions and used the information to support its case for further growth of clinical pharmacist activities at the tertiary care center, said Ed Rainville, MSPharm, clinical coordinator. “Using our electronic medical record [EMR], we incorporated pharmacist interventions into the standard care process, and we document each time a pharmacist conducts patient care activities,” he said.
Mr. Rainville and his colleagues compared two six-month periods, one before and one after the practice model change. They recorded a 21.6% increase in the number of monthly pharmacist interventions, from 5,393 to 6,557, on average. The most frequent interventions included lab follow-up recommendations, order clarification, pharmacokinetic and warfarin dosing consults and antibiotic stewardship. Using software that assigns monetary values to clinical interventions, the researchers estimated cost savings of more than $290,000.
The concurrence of two events accelerated the pharmacy’s swing toward decentralization: the closure of a satellite pharmacy that served critical care areas, and staff reductions in the main pharmacy caused by increased verification of drug orders by decentralized pharmacists, said pharmacy director Jerry Storm, BSPharm. Pharmacists displaced from the satellite and central pharmacies were repositioned to various hospital units and began participating in multidisciplinary patient rounds. “They [are] now much more involved in clinical decisions,” said Mr. Storm.
The evolving model is in keeping with the PPMI’s emphasis on direct contact between pharmacists and patients, and it has raised awareness of the role of clinical pharmacists among other providers at the hospital. “It has allowed our staff to build relationships with other interdisciplinary team members,” said Mr. Storm. “Overall, the demand for our services has increased. Nursing … has continually expressed their desire to have a pharmacist present on the floors.”
Mr. Storm added that the adjustments took time, particularly for pharmacists and technicians who had worked in the satellite. “Some of them felt a real ownership of the critical care pharmacy,” he said. “When it closed, they felt like they were losing their professional homes. Now, I don’t know of a single pharmacist who wants to go back to the way things were.”
“This is a well-directed implementation of a practice model change toward more patient-centered care, followed by an assessment of the results,” said Steve Nelson, BSPharm, MS, the director of the Center on Pharmacy Practice Advancement at the ASHP. “While an increase in the number of interventions is not a direct measure of improved patient care, it certainly has been used as an indirect measure.”
Adjusting Workflow Enhances Reach of Pharmacists
At the 150-bed Cleveland Clinic Florida, a new standardized, electronic monitoring and documentation system supported a comprehensive shift in the hospital’s pharmacy practice model.
“We created a new workflow where pharmacy services could better provide patient-centered care. Our goal was to have every patient receive medication counseling from a pharmacist in the hospital,” said Darshika Patel, PharmD, BCPS, a clinical informatics pharmacist.
The restructuring moved away from the previous emphasis on specialty care, in which pharmacists were primarily responsible for the clinical services in their respective specialty areas (e.g., nutrition support or anticoagulation), toward a more generalist approach. Pharmacists, regardless of their specialty training and certification, were assigned to hospital units and expected to assume full responsibility for medication management of all patients.
To facilitate the transition, the pharmacy dispensed with paper-based records as well as any electronic tools that were not consistent or shared among the staff and introduced a standardized electronic monitoring and documentation tool, according to Dr. Patel. One function of the tool prioritizes patients who are scheduled for discharge and alerts pharmacists to visit them for discharge counseling that includes a discussion of discharge drug regimens. Patients are also offered the option to have their prescriptions processed and delivered by discharge technicians to their bedside before discharge. Discharge technicians also are responsible for completing any insurance prior authorizations and addressing other insurance-related concerns to ensure that patients have all their medications before leaving the hospital.
The EMR now allows pharmacists to record patient progress notes as well, avoiding replication or confusion that had frequently occurred with paper-based records. “Through the EMR, the pharmacist can see exactly what clinical tasks have been completed for a patient that day and identify any outstanding or new tasks,” said Dr. Patel. For example, if a pharmacist adjusts the vancomycin dose of an ICU patient who then transfers to a general care floor, the EMR displays that, and any other therapy changes and dosage trends, on a clinical “dashboard” that covers the patient’s entire hospital stay.
Dr. Patel’s team tracked the change in the number of monthly pharmacist interventions before and after the practice model transition. The mean number of monthly interventions increased from 3,126 before to 4,322 after; the mean number of interventions per patient-day increased from 0.84 to 1.14.
“This is another example of the pharmacy moving toward a patient-focused model and making a concerted effort to assess the impact of that change after moving from a cumbersome paper-based process to an electronic process,” said Mr. Nelson. He added that he hopes the researchers go a step further and assess other effects of the changes, such as on Centers for Medicare & Medicaid Services (CMS) core measures and the number and types of adverse drug events. Dr. Patel said that those types of measurements are in their plans. “We haven’t measured those outcomes yet, but we are planning that next.”
Another group of investigators at the Cleveland Clinic found that practice model shift led to other measurable effects, including a sharp decrease in 30-day readmission rates for patients with chronic heart failure (CHF) and an increase in Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS) scores related to medications.
“We specifically set out to reduce readmission rates and see if we could influence our HCAHPS scores,” said clinical pharmacist Amanda Brahim, PharmD, BCPS. “Our thought was that by having clinical generalists participating in patient rounds and providing individual medication counseling sessions with each patient assigned to their floor, they were bound to have frequent contact with patients, which we could leverage to increase patient education and satisfaction,” she said. Pharmacy students and residents were used as “pharmacist extenders” to help counsel and triage patients.
As part of the practice model change, all patients admitted with CHF as a primary or secondary diagnosis received intensive inpatient pharmacist discharge counseling and disease-specific patient education material. Additionally, pharmacists made weekly follow-up phone calls to assess medication adherence and monitor for signs and symptoms of decompensation. Patients requiring intervention received specific instructions or were referred to a cardiologist for an outpatient visit.
A comparison of 30-day readmission rates and patient satisfaction scores before and after the practice model change revealed that all-cause readmission rates remained about the same, but the mean CHF readmission rate declined by 15.6% (P=0.04). From Sept. 1, 2011 through Jan. 30, 2012, pharmacists reached 106 CHF patients at home by phone. One out of five required additional intervention beyond education reinforcement. The HCAHPS medication-specific score improved in four of the five months under study.
“We put a lot of focus on CHF patients. Each one gets an additional 30-minute lesson specifically about their disease state, plus written material,” said Dr. Brahim. “That reinforcement and the follow-up phone calls made a difference.”
Dr. Nelson agreed that through these types of efforts, “pharmacists can make a difference in terms of CHF readmission.”
All three studies, he added, reflect a larger trend toward a more generalist approach to pharmacy practice through greater decentralization of staff. “National data show that there’s a movement away from the clinical specialist model and toward the clinical generalist model [Am J Health Syst Pharm 2010;67:542-558]. Hospitals are striving to provide greater continuity of clinical services throughout the week, and that’s more difficult to accomplish under a specialist model.”
Mr. Rainville, Mr. Storm, Mr. Nelson, and Drs. Patel and Brahim reported no relevant financial conflicts of interest.