EXECUTIVE SUMMARY
Including pharmacists on care transition teams can help health systems improve outcomes and meet patient care goals, researchers suggest.
- The results of one study revealed transitions of care interventions led by pharmacists reduced readmissions and improved treatment adherence.
- Pharmacists can reconcile patients’ medications and monitor adherence to their medication regimens.
- A barrier to pharmacist involvement is the lack of awareness that this resource can produce qualitative and quantitative benefits to care transitions.
The results of recent research suggest case management and transitions of care (TOC) teams that include pharmacists see greater success keeping patients healthier and out of the hospital.
“Having a clinical pharmacist intimately associated with our accountable care team is absolutely imperative,” says Warren Gavin, MD, a hospitalist at Indiana University Health Methodist Hospital. “One of the big pressures on hospital physicians is length of stay. If I have a [pharmacy] clinician right there next to me who can help me make decisions, I will discharge faster.”
One study revealed a barrier to pharmacy involvement in care transitions is incomplete communication between pharmacists and providers.1
A study on pharmacy-led care plans for patients with COPD revealed positive outcomes when pharmacists participated in patient education.2 Investigators found a pharmacist intervention led to improved inhaler knowledge. The median baseline score of correct inhaler use was 81.8% before the intervention. After the pharmacist education, their scores increased to a median of 100%.
A third study revealed lower readmissions and improved treatment adherence among patients with coronary artery disease when pharmacists led a TOC intervention.3
One important strength of including pharmacists in care transitions is their skill and experience with medication reconciliation and medication adherence.
“We guide [health plan] members, every day, through management of chronic disease states,” says Joseph Mayer, RPh, pharmacist diabetes educator at Highmark Health in Pittsburgh. “We monitor patients for adherence to medications for chronic disease states management, and that goes to their general health and quality of care.”
Pharmacists have always made patient education a priority, but they have only recently received attention for this role.
“When I first came out of school, I quickly learned we were able to assist patients and guide them,” Mayer says. “As a pharmacist, you’re highly accessible to the healthcare community. We provide direct real-time interventions for patients and assist them to make better decisions.”
For instance, pharmacists can give other providers insights to patient care and help guide patients’ therapy. They provide advice to prescribers about different covered medications.
TOC teams of allied healthcare professionals can include social workers, nurse case managers, dietitians, mental health professionals, and pharmacists. “We look at taking care of the total patient, breaking down barriers to care,” Mayer says.
From a pharmacist’s perspective, interacting with patients is a wonderful and rewarding experience, Mayer adds.
A top barrier to including pharmacists on TOC teams is a lack of awareness about the benefits of their participation.
“One of the biggest things I’ve noticed is there’s a general lack of awareness that there are pharmacists in positions to help with transitions of care,” says Philip K. King, PharmD, BCPS, a clinical pharmacy specialist in internal medicine at Indiana University Health — Methodist Hospital. “I hope it gets to the point where pharmacists are part of the conversation early on. With transitions of care, there consistently is an inaccurate medication list problem.”
When patients are admitted to hospitals, clinicians sometimes assume their medication list is accurate. This leads to inaccuracies remaining in the chart, throughout the hospital stay. More medication issues can occur when patients are discharged.
“That’s the biggest thing that pharmacists are primed and ready to resolve — correcting the medication list on the front end to prevent hospital readmissions,” King says. “[During a recent discharge], we identified a medication list that had not been verified by a pharmacist at admission. As we were ready to discharge the patient, we discovered four mistakes in that list.”
This is a widespread problem in every health system, he notes. It is not that no one attempted medication reconciliation — the issue often is a lack of in-depth checking of lists.
“Many times, a patient will come into a hospital, and there’s usually an intake done by a physician or advanced practice provider or nurse, who asks what medications the patient takes,” King explains. “The patient responds, ‘It’s in the computer system.’ That gets checked off that the medications are accurate, and that’s the extent of the verification.”
Pharmacists take the verification several steps further, confirming whether patients are taking the right medication. They also check frequency of dosing, dosage formulation, and side effects.
Another barrier to pharmacist participation is a lack of adequate communication between pharmacists and during TOC handoffs. One of the main reasons pharmacists reported not using patient health information was a lack of information, according to the results of a recent study.4
“Patients’ health information can often be scattered, incomplete, or wrong,” says Stephanie Gernant, PharmD, MS, assistant professor at the University of Connecticut School of Pharmacy. “However, the most common problem with patients’ health information is that it’s inaccessible. If healthcare sites don’t get direct financial benefit from exchanging patients’ information, they simply won’t do it.”
Other barriers are receiving incorrect information, experiencing delays in information, and not enough time.4
“One major problem is that it’s very hard for institutions to get paid for their pharmacists’ transitions of care work,” Gernant says. “Despite the uncontroversial evidence that these services improve patients’ health and reduce overall healthcare costs, private and public insurances won’t cover them.”
Pharmacists, despite six to eight years of training and, in many cases, post-doctoral training, are underused in transitions of care services.
“Sadly, it’s just another example of our broken healthcare system,” Gernant laments.
When pharmacy is included in the TOC loop, their expertise can help with medication decisions and medication adherence.
“We make sure we have the most current medication data in the system,” Mayer explains. “It’s not uncommon to find a newly prescribed medication for a patient and discover they may have stopped taking it due to side effects.”
Part of the pharmacist’s role is ensuring physicians know about any medication issues a patient might experience, and preventing an information gap that could be harmful to the patient.
“When we do medication reconciliation with the patient, we say, ‘OK, this medication is on your profile,’ and the patient sometimes informs us that they stopped taking it or have modified the way they are taking it,” Mayer says. “We tell patients not to modify their medication regimen without consent of their prescriber.”
Pharmacists also notify physicians when patients are not taking their prescribed medication. They help physicians find an alternative drug if noncompliance is related to side effects or cost.
“If a patient is having difficulty accessing a medication, we explore every avenue with the patient to try to get them to obtain the medication the physician feels they should have,” Mayer says. “Many times, this could mean getting them a starter pack, or a sample, or aligning the patient with various secondary aid that makes the process more affordable.”
A pharmacist-driven care transitions clinic could help reduce overall rehospitalizations for people with various diagnoses, including COPD and pneumonia.5 Clinic pharmacists assisted in transitions by providing additional drug therapy, as needed, addressing adverse drug reactions and allergies, decreasing pill burden, eliminating duplication of therapy, providing subtherapeutic dosing, educating patients on their medication, and performing medication reconciliation.
The TOC pharmacist program works so well that a health system recently expanded it to all disease states for Medicare patients admitted to one of its four hospitals within the last 30 days, says Brekk Feeley, PharmD, CPH, DPLA, MA, lead clinical pharmacy specialist at Health First Holmes Regional Medical Center in Melbourne, FL.
“In September, I hired our first full-time transitions of care pharmacist,” Feeley adds.
Sometimes, pharmacists are the missing piece of a case management or care transition team, says Michael Sanchez, PharmD, BCCCP, pharmacy residency coordinator at Health First Holmes Regional Medical Center. (See story on pharmacist-led TOC program in this issue.)
“If there’s not a pharmacist setting eyes on that medication reconciliation or discharge of care, then something can slip through the cracks,” Sanchez says. “In putting together the pieces of the puzzle and helping with the complex process of discharge and transitions of care, pharmacists are a key component.”
Pharmacists are well-trained on medication, which encompasses most readmissions and problems that occur in the community setting.
“Why not [use] someone who specializes in that field?” Feeley asks.
REFERENCES
- Vossen RK, Liu Y, Kuehl PG. Community pharmacists’ experiences and perception about transitions of care from hospital to home in a Midwestern metropolis. Pharmacy (Basel) 2021;9:193.
- Warunek LN, Cieri-Hutcherson NE, Kersten BP, Hassan AK. Interventional, quasi-experimental study of a chronic obstructive pulmonary disease education care plan for hospital discharge. Pharmacy (Basel) 2021;9:202.
- Weeda E, Gilbert RE, Kolo SJ, et al. Impact of pharmacist-driven transitions of care interventions on post-hospital outcomes among patients with coronary artery disease: A systematic review. J Pharm Pract 2021 Dec 28;8971900211064155.
- Wooster J, Bethishou L, Gernant S, et al. Methods and barriers to communication between pharmacists during transitions of care. J Pharm Pract 2021 Dec 28;8971900211064154.
- Parodi M, Feeley B, Sanchez M. Impact of a pharmacist-driven transitions of care clinic for a multisite integrated delivery network. Am J Health Syst Pharm 2022 Jan 27;zxac029. doi: 10.1093/ajhp/zxac029. [Online ahead of print].
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