Transitions in care, especially at hospital discharge, can be stressful experiences for hospitalized patients, particularly when complex medication and therapy regimens are involved. While hospitalized, patients have their medication management needs handled by providers, nurses, and pharmacists, but upon discharge, many patients and their caregivers are left unprepared for this new, self-directed medication management. In addition, at discharge, patients and caregivers often receive a significant amount of information that is confusing or incomplete and they have little time (or may not be in a proper state of mind) to ask questions or seek clarification.
Further complicating the situation, medication regimens are commonly altered at discharge; doses may be changed or discontinued, and new treatments added. Likewise, a patient’s regimen may be modified after the patient leaves the hospital setting, which can lead to discrepancies between what was directed at discharge and what should be taken at home moving forward. These discrepancies can result in adverse drug events and increase the risk of readmission. Conversely, instituting a proper discharge and intervention program can help prevent medication discrepancies and any resulting adverse events, ultimately mitigating readmissions.
Concierge Service Offsets Medication Reconciliation Shortfalls
Medication reconciliation and patient/pharmacist counseling upon discharge have been shown to reduce drug discrepancies by providing the patient with an accurate list of medications and doses. However, there may be additional external factors, such as the patient’s relative adherence or compliance to directions, that can significantly influence the risk of medication errors and the potential for subsequent readmissions. Furthermore, patients may not fill their discharge prescriptions due to perceived inconvenience or financial constraints. The combination of these factors ultimately increases overall health care expenditures due to worsening conditions, increased emergency department visits, and hospital readmissions. Focusing on determining an accurate list of medications for the patient to take home upon discharge, explaining any subsequent changes to that list, emphasizing the need to follow through on therapy regimens, and providing resources for patients to acquire the indicated medications are the primary functions of a comprehensive discharge medication reconciliation program.
In an effort to address these issues at Penn Presbyterian Medical Center (PPMC), the pharmacy department chose to implement an outpatient concierge pharmacy service, pairing the medication reconciliation process with the delivery of discharge prescriptions to the bedside. Coined myPennPharmacy (MPP), this pharmacy program provides patients with their prescriptions at the time of discharge, via the efforts of a comprehensive team, including inpatient pharmacists, clinicians, nurses, social workers, as well as outpatient technicians and pharmacists.
The goal in creating this team is to work collaboratively to create a smooth discharge process for all patients. The primary objective of the program is to enable patients to receive medication reconciliation education at discharge, and have take-home prescriptions filled prior to discharge. This allows a clinical pharmacist to complete medication counseling and education with the medication in hand; a process thought to assist with improving patient adherence and satisfaction. Of note, an added benefit of this program is the generation of further revenue for the outpatient pharmacy.
Required Resources and Equipment
In order to implement this service effectively, we hired a new, full-time technician dedicated solely to the program. The role of this technician is to market the program, obtain prescription benefit information, process and retrieve discharge prescriptions upon pharmacist check, and then initiate bedside delivery and payment. The MPP technician is responsible for coordinating with the clinical pharmacists, nursing staff, social workers, providers, and outpatient pharmacy staff.
In addition, we purchased a powered workstation on wheels to house a laptop with the outpatient pharmacy software application, a prescription scanner, a point-of-sale device, and a receipt printer (See Figure 1). The workstation provides mobility, allowing the technician to move easily between patient-care units, thus reducing the overall time required to process prescriptions.
Program Workflow is Key
Defining the workflow was a key factor in the successful implementation of this program. We wanted the dedicated technician to participate in interdisciplinary patient care rounds, in order to stay abreast of patients nearing discharge. Patient care rounds occur at staggered times across nursing units, so this allows the pharmacy to gradually enroll patients without feeling too overwhelmed. Once discharge patients have been identified, the technician interviews each patient to determine eligibility. During this interview, the technician markets and explains the benefits of the concierge program, records the patient’s demographic and insurance information, gives a relative time frame for prescription turnaround, and answers any of the patient’s questions. The technician then enters those patients who are interested in filling their prescriptions with the discharge program into the system via the mobile workstation. Providers, nurses, and inpatient unit-based pharmacists also assist in the marketing of this program.
Essential to this process is having providers write the necessary prescriptions in a timely manner, and ensuring that each discharge patient interested in participating in the program is entered into the system following the preliminary interview. Thus, identifying potential candidates early on is vital for a smooth workflow. Furthermore, prescriptions that are written early in the discharge process have a greater chance of being processed on time.
Prescription turnaround time is estimated at one hour (per patient) from the time the technician enters the provider’s order in the workstation until the medications are delivered to the bedside Once the prescriptions have been entered, the outpatient pharmacy designates them to be filled immediately and they are set aside for the concierge technician to pick up. During slow periods, the technician will deliver the hard copies of each prescription taken in the interim to the outpatient pharmacy. The paper prescriptions are exchanged for the filled medications, which are then delivered to the patient rooms.
Using the point-of-sale tablet and receipt printer, the MPP technician is able to perform bedside check out. In order to make it convenient for patients, we accept cash and credit payments. Once prescriptions have been delivered, the concierge technician notifies the pharmacists. We strive to simultaneously pair the bedside delivery of medications with inpatient pharmacist medication education, so that ideally, the discharge process is complete and the patient is ready to leave after education.
The MPP technician is responsible for stratifying prescriptions and updating patients on expected delivery times. Thus, patients who are leaving sooner are prioritized and processed before those slated to be discharged at a later time. The technician also must balance entering and processing prescriptions with medication delivery and payment processing. Implementing a detailed and organized process has allowed our program to be successful and provide a satisfying experience for our patients.
Overall, the program has been well received by both patients and practitioners. Our current challenge is changing physician workflow so that prescriptions are consistently written early enough to allow for processing without delaying patient discharge; too often providers write or change prescriptions right up to the time of discharge. On certain nursing units, this problem has been mitigated by having pharmacy meet with providers to emphasize the benefits of the program and request that prescriptions are written earlier in the discharge process. We encourage 24-hour advance notice for routine medications and a two to three hour advance notice for new or titrating medications.
Another obstacle is obtaining complete patient pharmacy benefit information, which can be a cumbersome task. Fortunately, the MPP technician is aggressive in obtaining this information by calling care providers, primary pharmacies, and insurance companies as needed.
Program Benefits and Results
As the program has evolved, we have enjoyed some unexpected benefits. Our MPP technician is able to handle complicated medication regimens requiring prior authorizations and this has reduced the amount of time and effort required by our case management team and providers. This has also enabled the facility to improve patient communication and solve medication issues while the provider is present and the patient is still under the hospital’s care. Medications can be changed as a result of these discussions and that change occurs with the approval of the patient’s provider.
The provider is now a part of financial discussions, including identifying patient co-pays by medication tiers. This affords more flexibility for health care providers in terms of prescription choices and allows the patient and provider to make decisions together in a cost-effective manner. In the past, higher co-pays often delayed the discharge prescription ordering process or led to the patient refusing to fill those medications.
Our pharmacy technician also works collaboratively with case management and nursing in order to determine the best method for filling prescriptions. On occasion, for patients using mail order pharmacy, the technician is able work with the provider and the social worker to obtain two sets of prescriptions: one set of prescriptions can be filled for a one-month supply via the concierge discharge program, while the second set is given to the patient for their 90-day mail-order pharmacy supply. This allows the patient to start their medication immediately upon discharge, while continuing to use their home mail order pharmacy for future refills.
Future Expansion and Expectations
In designing the metrics of this program, the pharmacy director worked with corporate finance to develop a detailed pro forma outlining the financial structure of this program. The program was initiated on one nursing unit (a cardiology unit) with the intent of filling eight prescriptions per day or 40 prescriptions per week. In the first month of implementation, we met the pro forma expectations for volume and generated a proof of concept allowing expansion to other floors. We currently cover three units and generate a monthly volume of approximately 500 new prescriptions—a positive contribution margin of $10,000 to $15,000 per month. The intent is to expand the program facility-wide by the end of 2013.
We believe that the concierge pharmacy discharge program will assist in improving patient satisfaction and decreasing medication related issues that occur post discharge. In addition, it will help meet the medication management needs of patients and improve medication adherence, enhance medication education, and serve as a source of revenue for the institution.
Nishaminy Kasbekar, PharmD, FASHP, is the director of pharmacy at PENN Presbyterian Medical Center. She received her BS in pharmacy and PharmD at the Philadelphia College of Pharmacy and Science.
Justin Kuratnick, PharmD, is the pharmacy system analyst at the PENN Presbyterian Medical Center. He received his PharmD degree from Rutgers University in 2007.
John Pilla is currently a pharmacy student at Thomas Jefferson University School of Pharmacy and will graduate in 2014. He is also employed as a pharmacy intern at the PENN Presbyterian Medical Center.