Orlando, Fla.—Although a growing number of hospital pharmacies are adding medication reconciliation to their list of services, two new studies show that repeating the process in ambulatory pharmacy clinics and providing other transitional care programs can reduce 30-day readmissions and the utilization of urgent-care resources.
Both research efforts garnered 15th Annual Best Practices Awards in Health-System Pharmacy, which were presented at the American Society of Health-System Pharmacists (ASHP) 2013 Midyear Clinical Meeting.
The first study, by investigators at the Eastside Adult Internal Medicine Clinic, a patient-centered medical home (PCMH) that is part of Denver Health Medical Center, focused on the use of pharmacist-conducted telephone follow-up post-discharge. Sarah Anderson, PharmD, a clinical pharmacy specialist at at PCMH, said the strategy served as an important “safety net” for patients.
“Our ambulatory-based program has reduced the incidence of medication-related problems and directs individuals who are registered with our PCMH to follow up with their primary care physician [PCP], rather than going to the emergency room,” Dr. Anderson explained.
As part of a multidisciplinary transitional care team at her PCMH, Dr. Anderson is notified regularly of any of the clinic’s patients who are discharged into the community from the health system’s hospital. The Denver Health Medical Center has an integrated electronic health record (EHR) system, which Dr. Anderson and her colleagues use to review each patient’s course of hospital treatment, compare the pre- and post-hospitalization medication regimens and determine whether the patient has a follow-up appointment scheduled with his or her PCMH-based PCP.
All of these patients receive a phone call within four days of hospital discharge and are asked which medications they have at home and which they are taking. Patients receive medication-use education, and they can discuss their discharge instructions as well as any drug-related questions. If they do not have a follow-up PCP appointment scheduled, Dr. Anderson’s team helps arrange one. The content of each call is documented in the patient’s EHR so that both hospital staff and the PCP know of any drug-related issues or other concerns.
Between July 1, 2010 and June 30, 2011, when the program was piloted, Dr. Anderson and a fellow clinical pharmacy specialist tried to contact 470 patients after discharge, successfully reaching 207 individuals.
“Many of those who were not reachable were Medicaid patients who may not have had a phone, for example,” Dr. Anderson explained, noting her team attempts three phone calls before deeming an individual unreachable. “Unfortunately, we do not have the resources to verify a correct address and send someone to the patient’s home if they can’t be reached by phone.”
She said 11% of contacted patients required at least one pharmacist intervention, such as medication or non-medication counseling, scheduling of an anticoagulation clinic follow-up appointment, or help picking up or refilling their medication.
Those patients successfully contacted were more likely to attend a PCP follow-up appointment at the medical home (66.2% vs. 44.5% for contacted vs. not contacted; P<0.01) and were less likely to be readmitted to hospital within 30 days of discharge (10.6% vs. 19.8%; P<0.01), she found. With a three-day hospital stay costing an estimated $10,000 to $15,000 based on Medicare reimbursement, the averted readmissions during the 12-month pilot period amounted to a savings of $300,000 to $450,000, Dr. Anderson said. Health systems that serve a larger population of insured individuals are likely to achieve greater savings, she noted.
“In light of the success of our intervention, we’ve added resources and we now have nine slots per week for post-discharge visits with a clinical pharmacy specialist,” Dr. Anderson said. “At the same time, our health system has hired non-pharmacist patient navigators who conduct the initial phone calls and triage patients to us as needed.”
Hae Mi Choe, PharmD, who is the director of Innovative Ambulatory Pharmacy Practices at University of Michigan Health System in Ann Arbor, and who was not involved in Dr. Anderson’s program, said the findings demonstrate the marked benefits of having pharmacist-led transitional care in the ambulatory setting.
“We need more efforts like Dr. Anderson’s in order to demonstrate the impact of these interventions and to strengthen the financial and clinical case for pharmacist-led transitional care programs based in the ambulatory environment,” said Dr. Choe, who is also a clinical associate professor of pharmacy in the College of Pharmacy at the University of Michigan in Ann Arbor.
At Rosa Parks, More Medical Home Benefits
A similar phone-based, pharmacist-guided intervention implemented at the Rosa Parks Wellness Institute for Senior Health, which is a medical home that is part of the Detroit Medical Center, resulted in improved patient safety and lower health care utilization.
Candice Garwood, PharmD, a clinical pharmacy specialist at Rosa Parks who helped create the program and whose work also was recognized by the ASHP with a Best Practices award, said her PCMH patients receive medication reconciliation at the time of hospital discharge. But that process is not perfect, she stressed: there can be “confusion, medication duplication and other medication-related problems after patients have arrived at home.”
“As a PCMH, we receive our patients back into the community after discharge and care for them going forward,” explained Dr. Garwood, who is also a clinical associate professor at Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, in Detroit. “So, when we call them after a few days of being at home, we are in a good position to help them integrate their hospital discharge medications into their real-world supply of medications.”
During a seven-month pilot of her institution’s phone-based intervention (Figure), she and a team of pharmacy residents and pharmacy students attempted to contact 178 patients and conducted medication reconciliations in 93 of them. In most cases where medication reconciliation was not conducted, there was no answer or the patient’s phone number was incorrect. However, nearly 18% of patients who were contacted declined involvement in the program, Dr. Garwood said, noting that her team is trying to create processes that will allow them to connect with more individuals.
Figure. Clinic care transitions process at Rosa Parks Wellness Institute for Senior Health.
MRP, medication-related problems
Among those patients who had medication reconciliations done, Dr. Garwood and her colleagues uncovered an average of three (±2) drug-related issues per patient, warranting interventions ranging from patient education (37.1% of calls) to immediate medication changes (6.3%).
“Since we have a collaborative practice agreement with the primary care doctor at our medical home responsible for these patients, we can address some drug-related issues that we catch,” she said. For example, in patients who are taking two statins unnecessarily, she can discontinue one of the prescriptions.
Similar to Dr. Anderson’s intervention, Dr. Garwood’s program has led to positive outcomes, although an analysis showed they were not statistically significant. She found that in the group who received medication reconciliation, the rates of 30-day readmission and acute care utilization were 20% and 21%, respectively, compared with 27% and 35%, respectively, among patients who did not receive medication reconciliation (P=NS for both).
In the group of patients who did visit the hospital after discharge, individuals who received medication reconciliation returned after an average of 52 days, compared with 38 days among those who did not undergo medication reconciliation (P=NS).
Dr. Choe commented that an important aspect of Dr. Garwood’s program was the utilization of pharmacy students and pharmacy residents. “Getting the infrastructure and funding in place to support the additional pharmacist time required for these programs is challenging, so making use of students and residents is one way to implement a program like this.”
More Positive Outcomes
Toni Fera, BS, PharmD, a consultant with the Pittsburgh Regional Health Initiative, has implemented a care transition pharmacist role in two community hospitals and reported similar, positive results at the ASHP 2013 Summer Meeting, in Minneapolis. Patients discharged from the Monongahela Valley Hospital who were contacted by a pharmacist were 48% less likely to require an acute care visit within 30 days of discharge, compared with patients not contacted by a pharmacist.
“The pharmacist role in the ambulatory setting will continue to evolve,” Dr. Fera told Pharmacy Practice News. “The evidence clearly demonstrates the value of medication management in the ambulatory setting by reducing hospital admissions and readmissions.”
None of the participants reported relevant conflicts of interest.