For many years, pharmacy leaders have debated the merits of decentralized versus centralized approaches to medication distribution in the hospital setting. Certainly there are advantages and disadvantages to both approaches, but the current literature has yet to define one method as superior to the other. While a consensus exists among pharmacy leadership that narrowing the gap between clinical practice and direct patient care can be of particular benefit to the entire health care enterprise, specific best practices and a comprehensive program model have yet to be delineated. The various roles of pharmacists in patient-centric practice settings have been chronicled in the literature,1,2 but descriptions of an ideal support model remain vague at best. However, decentralizing pharmacists and having them practice alongside providers can reap particular benefits.
A unit-based clinical pharmacy program model was first deployed in 2011 at the Hospital of the University of Pennsylvania (HUP), a 750-bed academic medical center, and subsequently in 2012 at the Penn Presbyterian Medical Center (PPMC), a 350-bed medical center within the University of Pennsylvania Health System in Philadelphia.
Adopting a Patient-Centric Pharmacy Model
The initial adoption of a patient-centric approach began in 1996. At that time, HUP implemented a model whereby decentralized pharmacists were deployed to the patient care units. These pharmacists had responsibility for between two and three units, resulting in a patient-to-pharmacist ratio of between 75 and 90 to one. Their primary responsibilities included processing orders and dispensing medications; in addition, when time permitted, they provided clinical services such as medication education and dosing adjustments based on renal and hepatic dysfunction, attended code calls, and performed pharmacokinetic monitoring. These activities were primarily retrospective in nature and focused mainly on providing the right medication to the right patient in a timely manner, whereas the provider remained largely responsible for drug selection. Ultimately, we coupled this decentralized model with a clinical specialist model wherein year one and two post-graduate residents were deployed in specialty areas and interdisciplinary team-based areas, including critical care, infectious diseases, and oncology.
As the hospital’s payment structure underwent changes, our health system leadership focused on reducing readmissions, improving medication reconciliation, increasing patient education, and ensuring patient satisfaction, in addition to the areas previously emphasized, such as quality and safety. Accordingly, a transformative pharmacy practice model was strategically developed at HUP to realize these initiatives. The goal of the new model was to move from retrospective, targeted review of patients’ drug therapies to a more proactive, patient-centered care approach that included all hospitalized patients.
Unit-Based Pharmacy Responsibilities
Our current unit-based model facilitates medication reconciliation within 24 hours of admission. During hospitalization, pharmacists provide the aforementioned medication education and ensure medications are ordered and dispensed appropriately. As such, it is even more common for pharmacists to assist with interventions regarding medication selection, dosage adjustments, and pharmacokinetics, along with early input into the development of therapeutic plans. Pharmacists are able to interact directly with providers and care teams during multidisciplinary discharge rounds to better understand and assess patient needs. This patient-centered approach also includes patients’ families, who often are responsible for extended patient care. Furthermore, pharmacists interact with home care specialists, case managers, and retail pharmacists, among other health disciplines, to ensure appropriate transitions of care post-discharge.
Once a patient is deemed ready for discharge, a pharmacist prepares the medication reconciliation documents and then discusses and modifies any discrepancies with the providers. The pharmacist also provides medication education regarding indications and side effects, and completes a medication action plan to guide the patient’s personalized medication regimen after discharge. This plan is intended to serve as a visual tool for high-risk populations, such as those older than 65 years, patients with multiple inpatient admissions and emergency department visits, and for patients with selected disease states (eg, solid-organ or bone marrow transplant, congestive heart failure).
Program Initiation Steps
The process of integrating 34 (11 of these new) pharmacists into all of the inpatient units at HUP was not an easy task. Central to our success was the development of a pro forma that designated the necessary financial and personnel resources, and delineated the responsibilities required to support the program. Due in large part to the significant number of personnel that needed to be hired and trained, the deployment of our patient-centered practice model occurred over the course of 2 years. The majority of the new staff mainly comprised pharmacists in each area, who were supported by a team of managers, clinical specialists, and technicians.
When we began to roll out the unit-based pharmacy personnel, we first populated areas of clinical significance, such as oncology, general medicine, and surgery during phase one, with cardiology, transplant, and critical care units following in phase two. Although critical care is certainly clinically significant, that unit (as well as a few others) already had a clinical pharmacy specialist on staff, so it was assigned to the second phase of the program adoption.
In 2012, the health system decided to implement a similar model at PPMC. A total of four unit-based pharmacists were deployed to areas requiring the most pharmaceutical expertise: those that had the highest readmission risk, HCAHPS scores, and adverse event profiles. The daily activities of the PPMC pharmacists were laid out to mirror those of the HUP pharmacists. These unit-based clinical pharmacists also attend weekly unit-based clinical leadership meetings to assist with quality-improvement projects, medication safety initiatives, and transition-of-care initiatives.
In the past 2 years, both institutions also have added a concierge pharmacy program, which delivers discharge prescriptions to the patient beside, allowing the pharmacist to educate patients with their medications in hand.
A recent evaluation of metrics used at both institutions to determine the impact of these programs reported some interesting results. Prior to program implementation at HUP, we performed about 4,500 to 6,500 pharmacist interventions each year. Since the establishment of a formal unit-based model, pharmacy interventions have increased to over 10,000 per month. There was a similar increase at PPMC, where we went from 600 interventions per month to over 2,000 (see SIDEBAR).
Likewise, our cost avoidance rates associated with prevention of adverse drug events, patient education, and medication reconciliation have improved from $1,750,000 a year to $6,000,000, annually, since 2010. Most importantly, the corresponding decreases in medication error rates associated with medication reconciliation conducted by pharmacy staff, and pharmacist review of medication reconciliation, have reduced 30-day unplanned readmission rates from greater than 20% to 12% a month. Specifically, the 30-day unplanned readmission rate for patients with congestive heart failure at PPMC demonstrated a 30% decrease from 15.08 admits per 100 heart failure discharges to 11.64. For the units with unit-based pharmacists, the rate dropped from 15.53 to 11.03 admits per 100 heart failure discharges.
At both facilities, HCAHPS scores in the medication communication domain (which includes questions related to communication about what a medication is used for and what side effects may occur) demonstrated substantial improvement. Prior to the implementation of our unit-based model, our HCAHPS scores in the medication domain categorized as Percent Always were 58% at HUP and 63% at PPMC. As of FY 2013, these scores had increased to 65% for HUP, and for the PPMC units where patient-centered care pharmacists were deployed, the HCAHPS Top-Box Always scores now range between 65.9% and 69.3%.
As the number of interventions and the complexity of care have increased, embedding pharmacists on the patient care units has become a necessity. Our unit-based pharmacy model has fostered patient-centered care, which facilitates pharmacists practicing at the top of their licenses. The model brings pharmacists in direct contact with patients, allowing for active participation and provision of pharmaceutical care. As part of this program, we have integrated pharmacists into multidisciplinary discharge rounds, unit-based clinical leadership teams, and associated initiatives involving transitions of care. Our pharmacists provide comprehensive medication education, discharge counseling, and medication reconciliation, which contribute significantly to successful patient transitioning, as evidenced by the decrease in medication discrepancies and adverse drug events avoided.
The impact of this program is now extending into other areas, such as HCAHPS scores and readmission rates. Most importantly, we have been able to implement a sustainable, highly beneficial practice model across both an academic medical center and a community-based teaching institution.
Richard Demers, MS, RPh, FASHP, is the assistant executive hospital director and the director of pharmacy at the Hospital of the University of Pennsylvania. He is a graduate of Northeastern University and received his MS and residency training at the Ohio State University. Richard’s professional interests include working to develop innovative practice models for advancing the practice of pharmacy.
Nishaminy Kasbekar, BS, PharmD, FASHP, is the corporate director of pharmacy at the University of Pennsylvania Health System and the director of pharmacy at the Penn Presbyterian Medical Center. She received her BS in pharmacy and PharmD degrees at the Philadelphia College of Pharmacy and Science and her residency training at the Hospital of the University of Pennsylvania. Nishaminy’s professional interests include information technology, professional organizations, and advancing pharmacy practice.
Example of a Pharmacy Intervention
Diltiazem ER 120 mg every 8 hours was ordered for a patient. While conducting medication reconciliation, pharmacy questioned the dose, as it appeared erroneous. The outpatient pharmacy and mail order pharmacy were contacted and the patient subsequently was put on the correct dose of diltiazem ER, 120 mg daily.