From One Place to Another

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From One Place to Another 

By Karla Taylor

Four pharmacy schools are using creative transitions of care programs to improve care for patients and encourage better teamwork.

It’s a burning question for every healthcare provider: When patients move among hospitals, skilled nursing facilities and home, how can you be sure that the correct medications move with them—and that the patients will understand how to use them correctly?

Across the country, pharmacy schools are answering that question with practical programs aimed at improving transitions of care. Students are learning how to work in interprofessional teams, enhancing patient care and holding down costly readmissions.

Home Is Where the Pharmacist Is

In October 2012, the University of Minnesota College of Pharmacy and Hennepin County Medical Center launched a pilot program to provide medication therapy management (MTM) to patients moving from hospital discharge at HCMC to skilled nursing facilities (SNF) and then back home. A central feature: in-home follow-ups to the medication reconciliation and review that were conducted in the SNF. Especially with the frail elderly, “in the home, you can pick up on medication-related problems that you don’t see in a clinic,” said Associate Professor Shannon L. Reidt, Pharm.D. “You get a sense of how the environment might affect their medication-taking behavior.”

Key to success: The partnership between HCMC and the College of Pharmacy is based on the shared goal of helping a large population of underserved patients who are at risk for readmission. As Dr. Haley Holtan, ambulatory care pharmacy manager at HCMC, noted, “Knowing that poor medicine reconciliation can be a major cause of hospital readmissions, we were thinking, ‘How can we ensure safe medical practice for patients in all areas of the care transition?’ ”

The student angle: Reidt and six fourth-year students worked with 50 patients over the 2012–13 school year. In addition to emphasizing the importance of communication and documentation from setting to setting, “going to patients’ homes is really eye-opening for students,” Reidt said. They may witness first-hand patients’ financial stress, life in multigenerational households and other factors that can affect a medication regimen.

Program challenges:

  • Information-sharing among healthcare providers as the patient moves through care settings, especially since the partner institutions do not share the same electronic health record.
  • Ensuring that as many patients as possible receive MTM interventions in the skilled nursing facility and at home, which is difficult since Reidt is in practice only three days a week.
  • Outlining a clear evaluation and data collection plan, which can be hard because information is pulled from multiple electronic health records and the transitions of care process is so dynamic.

In summer 2013, the team will begin data collection for an evaluative study. The goals are to see (1) whether providing MTM at an SNF at time of discharge, and with a home visit after SNF discharge, affects hospitalizations and emergency department visits; and (2) whether MTM interventions increase patients’ likelihood of following up with their own primary care providers. In addition, in fall 2013, the College of Pharmacy will introduce a new curriculum that covers transitions of care and includes didactic and practical experience.

Tearing Down Silos

Two transitions of care programs place Northeast Ohio Medical University (NEOMED) pharmacy faculty and students within area health systems to learn about and meet the needs of patients in community settings. The goal: to provide patient education and prevent readmissions.

Working with Summa Health System, Associate Professor Michelle L. Cudnik, Pharm.D., and fourth-year student pharmacists serve on the medical team at a clinic for adults who have no insurance, suffer from chronic diseases such as diabetes and hypertension, and take numerous medications. Having pharmacists in direct patient care wasn’t a new idea, Cudnik said, but having pharmacists in the ambulatory care setting was. Started in 2006, the program showed how pharmacists could work with team members to go beyond traditional dispensing roles.

Working with Akron General Medical Center, Assistant Professor John M. Moorman, Pharm.D., fourth-year students and pharmacy residents collaborate with a multidisciplinary team that created an inpatient consult service and an outpatient transitions of care clinic for high-risk patients with diabetes. Starting in 2009, Moorman participated in everything from generating buy-in for the program to designing its infrastructure. Today, the program has expanded to identify all at-risk diabetic patients and educates them about their illness and medications.

Key to success: NEOMED’s pharmacy program stresses teamwork. Pharmacists coordinate care with care managers, social workers, nurse practitioners, diabetic educators and dieticians, as well as attending physicians.

The student angle: In both programs, the goal is to deepen students’ experience and teach them not to think, “I’m just a pharmacist” but rather “I’m an equal partner on the medical team,” said Cudnik. “Students see this teamwork and have an ‘Ah-ha!’ moment.”

Program challenges:

  • Billing. “People aren’t used to pharmacists billing for their services,” Moorman said, especially when the pharmaceutical services are conducted in a clinic within a private practice office. Often, incident-to-billing can be submitted by a pharmacist through a collaborative practice agreement with the physician. However, in a private practice setting where the physician is paid by an entity outside the hospital, this type of billing is not possible. Moorman is exploring ways to overcome this obstacle.
  • Communicating value across silos. “It’s important to be engaged with executive administrators within health systems to articulate the value pharmacy adds to the triple aim of improving the patient care experience (both quality and satisfaction), improving the health of populations and reducing healthcare costs,” said Dr. Charles T. Taylor, dean of the College of Pharmacy.
  • Getting the required resources. Even with the backing of Summa and NEOMED, it took a year to get Cudnik’s program’s infrastructure in place, and another six to 12 months to get the program up and running. Now Cudnik spends 80 percent of her time with it.

Moorman’s service was created as an expansion of the clinical services provided by an endocrinology consult service. Although much of the infrastructure was already in place, it took several months to provide staff education, increase physician buy-in and develop a workflow that allowed for a smooth inpatient-to-outpatient transition.

Ask the Right Questions

Started as a small pilot in 2010, the goal of the CARE-PACT program (Collaborating and Advancing Relationships-Pharmacist Advocates in Care Transitions) is to identify and resolve medication-related problems and reduce readmissions. The program integrates pharmacists as patient advocates during transitions of care while helping the University of Pittsburgh Medical Center (UPMC) make the most of limited resources.

Keys to success: Three major factors got the program off to a strong start, said Dr. Kim C. Coley, professor of pharmacy and therapeutics at the University of Pittsburgh, who helped found the program.

  • Paying attention to people skills. Because success depends on pharmacist-patient interaction, the pharmacists, residents and students involved had to be comfortable doing a lot of direct patient care, Coley said.
  • Empowering pharmacists to go beyond medication reconciliation and uncover problems before patients were released. To untangle the complicated reasons why patients may struggle with their medications, Coley developed a simple five-item questionnaire called the Medication Access and Adherence Tool. It asks whether patients think they need their medications, can take them as prescribed, can pay for them and whether they suffer from side effects. The pharmacist can work with patients and the healthcare team to solve problems before patients go home.
  • Having the same pharmacist who talks to the patients inside the hospital handle the follow-up calls at home. Given how disorienting hospitalization can be, consistent contact with a familiar professional makes all the difference, Coley said.

The pilot ended in 2012. Metrics indicated improvement in everything from lower medication discrepancies to lower 30-day readmission rates. The School of Pharmacy is now working with UPMC to expand the program throughout the hospital as well as in other hospitals within the UPMC health system.

The student angle: Recognizing the potential for real-world learning experiences, the School of Pharmacy has now provided UPMC with a regular pool of students for its transitions of care programs. According to Coley, the students like being involved in patient care and identifying better outcomes. They’re also learning about issues related to medication affordability and access.

Program challenges:

  • Lack of resources. Some hospital administrators say they can’t see paying pharmacists to do follow-up when someone else could do it for less. “But it’s the best part of the program,” Coley said, because pharmacists have the knowledge to improve medication-related outcomes and help prevent readmits.
  • Fear of turf invasion. This usually falls away when, for example, nurses realize that having a pharmacist involved saves them time because they don’t have to call the pharmacy.

Prepping Students to be Proactive

Since 2009, the University of Michigan’s College of Pharmacy has undertaken transitions of care programs in both outpatient and inpatient settings.

The outpatient program is based in a primary-care office. The goal: to facilitate the move from hospital to home for recently discharged patients who receive primary care in a geriatric clinic. Within two weeks of discharge, Clinical Associate Professor of Pharmacy Tami L. Remington, Pharm.D., and her students call patients at home to check the accuracy and completeness of their medications. She also does a cursory assessment to determine if the patient is deteriorating clinically so that, if necessary, the medical appointment can be scheduled sooner. In addition to improving patient care, this pharmacist assessment cuts down on the time physicians spend on medication reviews during appointments.

On the hospital side, pharmacists and students conduct in-person visits or phone calls with patients in U-M’s general medicine health centers. The pharmacists and students also work on tasks ranging from medication reconciliation to order verification to sharing care responsibilities with physicians and nurses. Students work from various areas throughout the hospital and clinics to conduct chart reviews and evaluation, go onto the floor to talk to patients, and then review with their preceptors, said Dr. Lindsey R. Kelley, assistant director of pharmacy, Ambulatory Care Services, at the University of Michigan Health System.

Key to success: For the outpatient program for older adults, it’s invaluable to base pharmacists in a clinic instead of a call center or hospital, and to take an interprofessional approach. For the inpatient program, the key to making it work is the communication, coordination and relationships among the providers and their teams, Kelley noted.

The student angle: The programs build on students’ clinical knowledge and didactic education, give them experience with electronic medical records and train them in interviewing.

Program challenges:

  • The difficulty of finding enough preceptors to support the large numbers of students involved.
  • The problem of finding the right patient populations to serve—ones that the hospital needed help with and students would find interesting.
  • The fact that the outpatient program transfers doctors’ problems with no-shows to the pharmacists. At one point, the geriatrics clinic documented a 50 percent no-show rate because patients were too sick to come, forgot their appointments, had transportation problems, etc.

As the experiences of these four institutions show, progress can be made while solutions to evolving challenges are still being developed. But as students are learning, it’s clear the pharmacists have an important role in transitions of care.

Karla Taylor is a freelance writer and communications consultant based in Bethesda, Md.

 

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