The more than 1,200 recently hospitalized patients had been discharged and sent home. For many, it was a time of confusion and uncertainty: patients missed taking their medications or were uncertain about their dosage, had been reluctant to make follow-up appointments and also may have wondered if a return trip to the hospital was in their near future.
One by one, these patients were getting phone calls from about two dozen University of Buffalo School of Pharmacy and Pharmaceutical Sciences fourth-year advanced pharmacy practice experience (APPE) students who worked vigorously to prevent lapses in care. The calls lasted only a few minutes, but the discussions were focused and powerful for the patients who had complex medical histories. The student pharmacists asked questions before the calls ended: Did they understand what their medications were for? Did they know the kind of diet they were on? The callers counseled patients and urged follow-up care with their doctors.
After many months of working with the patients, there were huge successes, including a significant reduction in the number of patients returning to the hospital as readmissions within 30 days. Of 1,200 patient encounters examined, 67 percent had decreased odds of all-cause 30-day readmissions and decreased odds of related readmissions. The program included patients contacted from June through November 2017.
The outreach by these student pharmacists working in tandem with community pharmacists made a “significant impact on reducing hospital readmission rates,” according to a study of the program published earlier this year by the Journal of the American Pharmacists Association.
“Post-discharge follow-up by community pharmacists has the potential to dramatically affect the rate of 30-day hospital readmissions,” the study noted. “Integration of student pharmacists or residents can provide a low-cost strategy to facilitate implementation and expansion.”
That period between the time when patients are discharged from hospitals and the time they are recovering is sensitive, wrought with potential problems. The transitions of care (TOC) stage is a continued target in a burdened healthcare system in the effort to reduce costs and improve quality.
Student Pharmacists Smoothing Transitions
Transitions of care are well documented as one of the most vulnerable times for patients, whether they experience a medication error, adverse event or other complications, the researchers said. And high readmission rates have imposed a significant clinical and economic burden on the U.S. healthcare system. About 20 percent of Medicare patients are unexpectedly readmitted within 30 days of hospital discharge, amounting to a cost of $41.3 billion, according to figures reported in 2011. The result also could be huge penalties against hospitals.
“Transitions of care is something we’ve been developing the past four or five years, how pharmacists are impacting transitions of care,” said Rebecca Brierley, assistant dean of external affairs, director of communications and alumni relations for the University at Buffalo School of Pharmacy and Pharmaceutical Sciences. “We are doing some creative things within the TOC model and are excited to share with the academic community.”
Dr. Amy Shaver, now a post-doctoral research fellow, was in rotation at the High Street Prescription Center as an APPE student and became curious about the TOC program at the pharmacy located in the lobby of the hospital. She thought it was terrific but wondered what kind of data was behind it. It was then she began working on the study along with other officials.
“They had this wonderful program that on its face looked like it was helping people, but they had no proof and I didn’t know it was statistically significant,” Shaver said. “You could tell they were doing good but you couldn’t prove it unless you studied it. I already completed my MPH and had a feel for study design and thought we should publish this.”
The Buffalo study demonstrates the role that student pharmacists can play in multifaceted transitions of care plans, university officials said. “To our knowledge, this is the first published study to evaluate the impact of a TOC program that is driven primarily by APPE-level student pharmacists. The use of student pharmacists is a low-cost and effective strategy for staffing a TOC program,” according to the study.
Using one to three APPE-level student pharmacists working full time on the calls, at an average of less than five minutes each, “allowed for a further-reaching intervention than would have been possible” with a TOC pharmacist alone, which contributed to a significant reduction in readmission rates, researchers added.
The students’ phone calls were made to patients within two to seven days after discharge and focused on medication counseling as well as promoting physician follow-up visits. Although the length of calls ranged from one to 40 minutes, the average counseling session required less than five minutes. The pharmacists worked with outpatient providers to resolve any medication-related problems such as inappropriate therapy, duplicative therapy and potential drug interactions. Patients were also advised to schedule post-hospitalization follow-up appointments as recommended in their discharge paperwork. A TOC pharmacist was available to answer questions or concerns raised by the student pharmacists.
“It’s a newer area that pharmacists are involved in,” said Dr. Erin M. Slazak, clinical assistant professor at the Department of Pharmacy Practice, of the TOC model. The Buffalo student pharmacists were deeply involved in designing and implementing the research, she said. “Most of the research out there has focused on in-patients and involved discharge counseling and medication reconciliation. I’m passionate about what pharmacists can do outside the hospital after a patient is discharged. This study gave the students the skills to implement the program from the ground up, see the impact of the data and show how they can make a difference.”
When the pharmacy school created its strategic plan, “one of the things we wanted to implement in our clinical practice models was a focus on transitions of care and partnering with our affiliate sites,” recalled Dr. William A. Prescott Jr., interim department chair. That occurred after a clinical practice committee determined that a transitions of care program was needed, based “on metrics and reimbursement penalties. We were looking for ‘win-wins’ between our school and affiliate sites,” Prescott said.
Focusing on Cardiac Patients
Cardiovascular conditions were chosen as main priorities for the study. Not only was there a major cardio patient population but Buffalo General Medical Center and the Gates Vascular Institute are well known for their cardiovascular services, officials said. The reasons were personal as well: Patients are often unaware of the importance of medication adherence, especially if there are silent symptoms involving the heart.
While the study focused on cardiology patients, student involvement in a TOC program “can easily be expanded to other high-risk groups,” said Dr. David M. Jacobs, assistant professor. “I don’t think the function of what they did is specific to heart patients. I think there is a tremendous opportunity for pharmacists, faculty and student pharmacists to impact care transitions not only in cardiology but also in respiratory disease and complex regimens. We are looking at this not only for in-patient but outpatient settings, community and primary care.”
The study began with then-student Shaver and other students working with an outpatient pharmacy—the High Street Prescription Center—located at the Buffalo General Medical Center, a 457-bed academic medical center. The pharmacy is part of Kaleida Health, which had a TOC program for several years.
The TOC program developed from a “meds to beds” initiative known as Prescriptions Plus. Interaction with patients allowed pharmacists to consider myriad issues, such as discharge paperwork, medication questions and other potential obstacles to a smooth transition, the study said. Under the Prescriptions Plus program, patients also are provided with a 30-day medication supply and counseling at the hospital bedside before discharge from the Buffalo General Medical Center. “This program has been initiated, conducted, tweaked and perfected all by our students,” said Dr. Melissa Morano, a University at Buffalo graduate and manager of the High Street Prescription Center, in a statement.
Shaver credited preceptor Morano for initiating the TOC program at the pharmacy. “The TOC program itself was Melissa’s idea and was in existence long before I came around,” she said. “It is definitely her baby.” Besides Shaver, Morano and Slazak, others involved in the study were UB School of Pharmacy and Pharmaceutical Sciences alumni including Dr. David Essi, Dr. Stacy Frederick and Jill Pogodzinski, who also works at the High Street Prescription Center.
Connecting With Patients
As students talked to patients, both groups learned some things. During the calls, the students stressed the importance of adhering to physician instructions about taking medications. Yet students often found patients were uncertain about taking their medications or having physician visits. They also found flaws in the healthcare process, particularly related to patient communication with physicians.
Too often, patients experience adverse events when they don’t properly take their medicine, a major culprit in leading to hospital readmissions. As the student pharmacists said, medication management is essential to a good discharge plan.
“We found quite a few patients were confused when they went home,” Morano noted, forgetting their medication or feeling uncertain about discharge paperwork or the necessity of their appointments. There were other instances where patients didn’t comprehend the side effects of drugs, “situations where we as pharmacists can guide the patient through that,” she added.
“There were some people who didn’t know what their medication was for,” Morano said. “In some cases, patients asked if they should call a doctor or an ambulance if they felt sick.” She recalled that one student’s action might have averted not only an immediate re-hospitalization but also more dangerous problems for the patient. “I had one student call a patient who was not acting normally. A family member had expressed concern,” Morano said. “The student was able to pick it up right away: it was low blood sugar masked by a beta-blocker. It was a serious drug interaction. But just by talking to the patient, that made a serious impact.”
By reviewing records with patients, the students also found some discrepancies in medical care linked to incomplete or inaccurate prescriptions, according to Morano. “It was eye-opening to see the scripts coming down and comparing the chart.” Sometimes prescriptions were supposed to be made but the correct orders were not directed to the pharmacy, Morano said, noting technology failures along the way. The pharmacists were able to intervene on potential errors, she said. “If it doesn’t get routed to the pharmacy it can be a pretty big deal depending on the medication.”
Over time as the students made the phone calls, Shaver said she could see the differences in the patients as well as the future pharmacists. Often, elderly patients were grateful. “There was a comfort level. Many times there was a simple ’thank you’ for the calls. Those little extra words were important to them,” she said. In one instance, Shaver noted that a patient was supposed to be on the DASH diet. The patient didn’t know what she was talking about. “It was on the chart. I said ‘you should be on the diet.’ I mailed it to him.”
Shaver said she reacted differently as the study progressed in working with student pharmacists. “I was much more comfortable speaking to different groups, with various demographics and backgrounds in all this complexity. It was amazing,” she said. “You would see students on rotation, you can tell at the beginning they weren’t as comfortable as they felt at the end. They were coming into their own as pharmacists.”
When she reflects on the study, Shaver said she didn’t think anybody was surprised by the ”tremendous impact.” Each call didn’t take that much time but the words had so much influence. That’s what stunned her. “I think we were surprised by how simple it was.”
Joseph A. Cantlupe is a freelance writer based in Washington, D.C.