Improving transitions of care is a goal of intense interest in hospital pharmacy practice. However, at the present time, there is no gold standard for how pharmacists should approach these critical interactions and offer interventions. When effective transitions of care services are provided to patients—for example, medication reconciliation—patient outcomes may improve and hospital readmissions can be avoided.
Exeter Health Resources network comprises Exeter Hospital, Core Physicians, and Rockingham Visiting Nurse Association and Hospice (RVNA). Exeter Hospital, a non-profit organization, is located within the Seacoast region of New Hampshire. Each of these entities utilizes its own electronic health record (EHR), and these EHRs are not integrated throughout the health system. In 2015, RVNA received a grant that allowed it to employ a pharmacist 16 hours per week to perform medication chart reviews and medication reconciliation. At that time, the pharmacist on staff noted a 96% discrepancy rate between the medication discharge list and the outpatient medication list. Additionally, patients with a diagnosis of congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) were readmitted to the hospital at rates greater than 10%. Thus, it was clear that a pharmacy intervention was required in order to improve medication reconciliation and prevent readmissions for these patients.
Developing a Strategy to Improve Care
A pilot group was formed in early 2016 to explore the need for further intervention beyond our part-time medication reconciliation pharmacist. Representatives from ambulatory care, including the director of Core Physicians, the director of pharmacy, the director of RVNA, the hospitalists group, a case management representative, and several support staff from each of these areas of care came together to discuss options.
New Pilot Program
A new pharmacist position was created to initiate a pharmacist home visit program as well as serve as a medication expert to clinical staff. Having several years’ experience in medication reconciliation and the ambulatory care setting, I applied for an was hired for this role. In developing the job description and responsibilities, the pilot group researched work done by other pharmacists in role of transition of care, and provided a wealth of information for me to review prior to taking on these new responsibilities. The goals were to reduce phone traffic between visiting clinicians and primary care offices for medication clarification, and ultimately to decrease 30-day readmissions of patients with CHF and COPD. In addition, a new pharmacist home visit pilot program was implemented for these high-risk patients.
The pilot program went live in June 2016 with an initial focus on identifying patients who would benefit from the new service. Upon admission, patients are screened based on primary care provider, diagnosis, and discharge plan. To be eligible for pharmacist home visits, patients must receive their primary care from Core Physicians, have a history of CHF or COPD, and be discharged with RVNA services. Each patient’s medication list is reconciled by a team of highly qualified nurses and pharmacists utilizing patient interviews and in-depth record checking. As the pharmacist in charge, I am the only staff member permitted to read and write in each of the three EHRs. Once qualified patients are identified, they receive a pharmacist visit during rounds to make an introduction and explain the role of a pharmacist in their care. This approach has been essential to establishing rapport with each patient early in their hospitalization. When the patient is ready for discharge, I return to provide counsel on new medications, medication changes, and to ask patients to self-assess their confidence in managing medications upon discharge. To simplify this process, we use the Wasson Health Confidence tool (detailed information about this tool is available at: https://howsyourhealth.org/static/HealthConfComboHYH.pdf.) Finally, a follow-up appointment in the patient’s home is scheduled, preferably within 24 to 48 hours of discharge.
Building a relationship with the patient when they are in the hospital is critical to earning patients’ trust so that they are then comfortable welcoming the pharmacist into their home. During the home visit, the patient’s medication list is reconciled with Exeter Hospital’s EHR, and then each of the other systems is also updated to ensure accuracy across the health system.
The 96% discrepancy rate for medication reconciliation has dropped to 0% for patients receiving medication reconciliation at discharge and home visits (see FIGURE 1).
Structure of the Home Visit
The home visit can vary in format. Typically, the RVNA nurses and other clinicians (including physical therapists, occupational therapists, etc) are scheduled to see these patients within the first 24 hours after discharge. It is preferable that the pharmacist see the patient at the same time as the nurse or directly before or after. When that is not possible, the pharmacist informs the primary nurse once the patient has been seen and the medication reconciliation has been completed.
A typical pharmacist visit consists of medication reconciliation, medication therapy management, and motivational interviewing. It is extremely helpful to be physically present in a patient’s home and see exactly how they are managing their medications. Each medication is discussed in depth to explore the patient’s understanding of the medication as well as to stress the importance of medication adherence.
The goals of this program are to prevent patients from returning to the hospital and to improve their quality of life by taking steps to decrease polypharmacy. Many of these high-risk patients have multiple prescribers, which can increase the complexity of medication management. The medication list is comprehensively reviewed in the home and then reconciled in real time with RVNA’s EHR. If the patient has experienced adverse drug reactions or needs to change medications for any other reason, a request can be sent through their primary care physician’s EHR to approve such changes. Turnaround is almost immediate and, more importantly, this allows the patient and the visiting nurse to focus on other areas of care rather than making phone calls to request medication changes.
Motivational interviewing is a technique employed in the field to provide guidance and support in a specific format. The approach utilizes a series of open-ended questions that are designed to lead the patient to the desired conclusion, allowing them to arrive at this conclusion on their own. The motivational interviewing has become the most successful aspect of our home visit program, as patients feel supported by a familiar staff member.
Questions such as Do you think it is important to take your medications? or Why is it important to take your medications as prescribed? open up a productive dialogue between the patient and the caregiver, which can lead to a discussion of techniques to ensure medication adherence, such as pill organizers, calendars, and other systems. When the patient is in the hospital or medical office environment, it may seem best to simply tell the patient to use a medication box, but when discussing the topic in the patient’s home, while assessing their health literacy, it may become clear that a medication box is not the best option. Some patients do well with other strategies, such as medication calendars, journals, and checklists. Due to varying levels of literacy, a single approach cannot be effective for all patients. While visits focus on medication information and adherence, oftentimes other issues, such as diet, exercise, and cost will be addressed in the discussion. Fortunately, RVNA has a nutritionist and a social worker available on staff for referrals if there is a need for these services. At the conclusion of each visit, the Wasson Health Confidence tool is once again employed to gauge any improvements in the patient’s comfort with managing medications as a result of the pharmacist’s guidance.
Implementing the transitions of care program at Exeter Health Resources has been a complex process. The patient screening process, initial patient meeting, and the format for the patient home visit were all developed internally, which required a significant networking effort with other pharmacists.
In addition, one of the most significant challenges has been convincing patients that they would benefit from a pharmacist home visit. This hesitation on the part of patients was the impetus for developing the initial patient meeting, well ahead of the discharge medication meeting. The initial patient meeting provides an opportunity to explain the importance of a pharmacist home visit to the patient and gain their buy-in.
The success of the program has exceeded the expectations of the members of the pilot group. Of the 96 home visits that occurred within the initial 18 months of program, only 4 of these patients were readmitted, resulting in a readmission rate of 4.17% (see TABLE). This is a vast improvement from the 15% and 16% readmissions rates that Exeter Hospital experienced in 2015 and 2016, respectively. The decrease in readmissions is not only beneficial for the hospital, but it also contributes to improvements in the patients’ quality of life.
The response from patients has been overwhelmingly positive. They rate the services well and are particularly pleased that the program is provided at no cost. Additionally patient confidence in managing medications at home improves, on average, from point of discharge to post-home visit. However, it is difficult to assess the accuracy of a tool that is based solely upon what the patient reports. Typically, patients are eager to be discharged when the tool is initially employed. It is common for patients to overestimate their ability to self-manage medications, as seen in FIGURE 2 below.
Patients enrolled in the transition of care pharmacist program are staying healthier at home for a longer period of time, as they experience significant improvement in self-managing their medications, which in turn leads to enhanced quality of life. Clinicians in the field are able to focus on other pursuits, such as wound care, vital signs, and disease management, rather than medication management and making phone calls to providers for medication verification. Primary care is provided with the most up-to-date, accurate medication information and knowledge of the patient’s status in the home.
The future state of the program will include a more in-depth examination of the program’s impact, as well as its potential for expansion. At this point, the transitions of care program has been so successful that it is now included in the budget and is no longer supported only via grants. Therefore, it is critical to perform a financial analysis to gain future buy-in and illustrate the benefits of reducing readmission to the organization. Additionally, broadening the scope of the program to include more patients with CHF, or other disease states, is the next phase of this project. If that were to occur, additional staff would be warranted.
Pharmacist-based transition of care ownership at Exeter Health Resources has been effective in reducing both medication reconciliation error rates as well as 30-day readmissions to the hospital. Patient quality of life and confidence in self-management of medications has also improved. The most important factor in the success of the program is implementation of the pharmacist home visit. Further exploration into the financial impact of this program will be critical to justifying the program’s cost and exploring options for expansion.
Implementing the program has provided valuable lessons to pharmacy, as developing close relationships with patients is not typical in pharmacy. The transitions of care program illustrates the value of having a direct conversation with patients to improve care and quality of life, as well as reducing readmissions.
Sarah Bonafede, BS, PharmD, is the transition of care pharmacist at Exeter Health Resources in Exeter, New Hampshire. Her responsibilities include medication management services for patients throughout the transition from the acute care setting back into the community as well as in home medication therapy management. Sarah earned her Doctor of Pharmacy from Northeastern University in 2011. Her professional interests include ambulatory medicine, medication therapy management, and alternative therapies.
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