One of the most common causes of hospital readmissions is medication related issues. Medication side-effects, interactions, errors, unintentional overdose, underdose, and lack of education.
Having worked in transitional care for the past 5 years, the pharmacy component of transitional care had our team stumped…until recently.
Silos on Top of Silos
There are several hurdles to overcome in reducing medication complications in transitions of care.
- Contractual, formulary, and provider preference changes. When a patient is admitted to an acute care hospital, inpatient rehab facility, long-term acute care facility or skilled nursing facility the patient’s care is taken over by someone other than his/her primary care physician. These facilities often have contractual agreements and there may be formulary changes or provider preferences resulting in changes to an “equivalent” medication within the same class of medications, or as close as they can get. Or a patient is placed on a medication covered in the acute care setting, but not in the community such as a newer generation blood-thinner. This has several potential effects. It can cause confusion for the patient. In addition, when the patient is discharged and they go to pick up the medications from the community pharmacy they can be surprised by sticker shock and not able to afford the medication. Then they refuse the medication. Then the discharging prescribing physician and/or community physician has to be contacted to find a reasonable alternative.
- Dispensing location preferences. In a recent transitional care meeting to discuss a high-risk patient with whom medication compliance was an issue, the pharmacist present noted the patient had filled at 2 different Walgreen’s locations and 2 different local community pharmacies within the last 30 days! System software and communication is improving, but there are still many gaps in communication. Filling prescriptions from one pharmacy enhances continuity of care.
- Patient education. 3 predominant issues come to mind as classic examples to illustrate the importance of patient education. Proper diuretic use in CHF, diabetic related medications (oral or injectable) and blood-thinners. As a physician, I can tell you we often don’t have or take the time to educate patients adequately regarding their medications and I would argue we are not the best suited for this compared to a patient oriented clinical consultant pharmacist.
As you can see, the pharmacy component of healthcare has its own silos, now overlay that on existing silos of care…mind blowing!
The Prescription- Consultant pharmacists in a transitional care framework
It is essential to incorporate clinical consultant pharmacists into your transitional care programs. To be truly effective this needs to take place at the clinical level, not just at the administrative level.
Our team was fortunate to cross paths with a clinical consultant pharmacist familiar with the post-acute setting, associated regulations, and motivated to improve transitions of care. We were able to combine his vision within our framework and amazing things are happening to reduce readmissions and complications. An effective transitional care consultant pharmacist must understand the post-acute space and associated regulations. This pharmacists does not necessarily need to be the dispensing pharmacist. This pharmacist needs direct access to physicians to be effective. Face time between the physicians and pharmacists is essential.
Medical reconciliation- The elusive holy grail
Historically, medication reconciliation has presented a challenge for providers and healthcare systems. It seems the greater the attempts at automation and simplification the worse we become at it. If an EMR has a medication list and requires a med rec before a note can be signed, my observation is most physicians simply check the boxes and move on. Particularly as a specialist, the long list of medications that is often inaccurate or outdated does not pertain to our visit. Check the box. Move on. This is not achieving the intended goal, but it looks like it has to an outside observer and data collector.
Enter the consultant pharmacist. These highly trained, doctorate level, clinicians can quickly scan a list of medications to identify duplicates and high-risk medications or high-risk combinations. Unfortunately, these pharmacists often work in a separate parallel clinical universe to physicians. It is time for this to change. With a consultant pharmacist on your clinical transitional care team medications can be reviewed on admission and in plenty of time before discharge back to the community to make course corrections well before discharge for a fluid transition to the community dispensing pharmacy.
Effective transitional care must include pharmacy incorporation. Having seen firsthand the benefits of utilizing a clinical consultant pharmacist, I’m convinced this is the answer to closing the pharmacy gaps in care. This can greatly reduce medication related readmissions, but more importantly improves care for the patient.
There is legwork to be done from a policy standpoint, but the following points facilitate successful incorporation of pharmacists into transitional care.
- Allowing pharmacists to practice in their scope of practice. This varies from state to state, but many laws are in place that allow pharmacists to manage many medication related health issues through collaborative practice agreements. The industry and providers need to be educated on this as well and align regulations to realize the potential, particularly in the post-acute space with regards to state survey teams and associated regulations.
- Give pharmacists access to patients. The consultant pharmacist can see patients in a billable encounter under certain conditions and in certain locations. This is a great tool to facilitate transitions, educate patients, improve compliance and augment physician’s care of patients. I highly support this practice. It needs to be preserved and expanded.
- An effective transitional care framework is essential for this to be effective. The most ambitious clinical consultant pharmacist is limited without an effective clinical transitional care program led by engaged physicians.
No longer is the pharmacy component of transitional care an unsolvable puzzle. There is work to be done with education and regulations, but the growing field of consultant pharmacists is providing an attractive and viable solutions. Dispensing pharmacies can expand this opportunity to their pharmacists and work collaboratively with unaffiliated consultant pharmacists to improve care for patients and make transitional care programs much more effective.