Pharmacists’ involvement in transitions of care (TOC) has evolved over the past decade. The American College of Clinical Pharmacy (ACCP) recently published a white paper that describes various ways pharmacists assist in TOC and recommends quality measures (QMs) for their processes.1
“A lot has changed in the last 10 years,” says Philip K. King, PharmD, BCPS, lead author of the white paper and clinical pharmacy specialist in internal medicine at Indiana University Health — Methodist Hospital. “There’s a tremendous gap in the way that quality is measured during transitions of care for pharmacy services. A lot of that gap is due to a lack of standardization of the very terminology we use when we talk about transitions of care and the services we provide.”
King and colleagues provided two pages of definitions, including:
- Medication reconciliation: “Process for reviewing the patient’s complete medication regimen at the time of admission, transfer, and discharge, and comparing it with the regimen being considered for the new setting of care in order to avoid inadvertent inconsistencies across TOC.”
- Transition of care: “Movement of a patient from one setting of care to another.”
Pharmacists can perform medication reconciliations and help physicians with complicated dosing, including dosing for anticoagulants, says Warren Gavin, MD, a hospitalist at Indiana University Health — Methodist Hospital.
“Each patient who comes to our facility gets a medication reconciliation by pharmacy within the first 24 hours, and it’s published as a note in the computer,” Gavin explains. “That is such a big help. It started on our floor and spread throughout the system.”
Research shows pharmacist-directed processes to identify medication discrepancies result in positive outcomes.1 “As a doctor, I’m reliant on pharmacy to tell me what patients put in their mouths each day,” Gavin notes.
Medication reconciliation involves more than just listing patients’ medications. Pharmacists also check patients’ lists to see which are duplicates, which could be causing side effects, or which could lead to a prescribing cascade.
“Prescribing cascade is when you give a patient a medication to treat a condition, and maybe the condition improves, but it comes at the expense of a new side effect that is not linked to the new treatment,” King explains. “Rather than changing the original treatment, we prescribe something else [to treat the new symptoms].”
If someone had noticed the new symptom was a medication side effect, then the original prescription could have been changed. Instead, the patient now has to take more medications.
“You have a patient who started out with two to three medications that made sense, and then all of a sudden, the medication list is up to a dozen medications,” King says. “What pharmacists do is focus on how do we take this back to square one, looking at every diagnosis and medication, line by line, to see how it fits.”
They check which medications are compounding problems for the patient’s other diagnoses.
An example of prescribing cascade is what happens when patients with diabetes experience nerve pain, King says. Some common medications, like pregabalin, are used to treat nerve pain/neuropathy. But these drugs can cause lower extremity edema in about one out of 10 patients. When patients with diabetes develop lower extremity swelling, physicians often will prescribe diuretics.
“But it happens that diuretics won’t solve this problem if they don’t have heart failure or another real reason to be on a water pill,” King says. “They increase the dose of the water pill and don’t get much resolution of fluid in the lower leg because that’s not the problem.”
Typically, patients are not in the hospital long enough for every problem, such as edema, to be resolved. The patient could be discharged with medication that does not fix their problem.
“Pharmacists are primed for identifying these unique things,” King adds. “We gather more history from patients and decide on the next best step for them.”
This is why medication reconciliation should occur both at admission and at discharge. The information should be included in discharge summaries sent to patients’ primary care providers.
“The main purpose is to get an accurate list of what’s happening vs. what is intended to be happening,” King explains. “When we get the discharge paperwork, we re-reconcile the medication list with the new information we obtained during the hospitalization.”
Pharmacists also are integral in a patient-centered discharge process, meaning the patient and TOC team would meet to discuss medications and prevent errors.
“We were developing a process where we could go to the bedside with patients, but COVID put a wrench in that,” Gavin says. The patient-centered TOC approach did result in a lower readmission rate, he adds.
Including pharmacists in transitions of care teams is not cheap, but there are ways to demonstrate cost savings, Gavin says. For example, if a patient is taking an expensive antibiotic, and the pharmacist can find a cheaper and effective alternative, then that saves costs.
Also, pharmacists’ involvement at discharge can help improve bed turnover. “I can discharge patients sooner when I do certain things with the help of a pharmacist,” Gavin says.
The pharmacist’s involvement also benefits patients. “Sometimes, a case manager will [learn] that a medication is very expensive, and the patient cannot afford them, so they can do contingency medications to help,” Gavin says. “But the pharmacist will work with the case manager to find more financially reasonable alternatives.”
Pharmacists assist with patient education, finding gaps in communication that can lead to preventable hospital readmissions. For instance, King met a patient with a heart failure diagnosis who had been readmitted to the hospital almost a dozen times over two years.
“I asked her, ‘Do you know why you take these medications? Do you know what they do?’” King recalls. “She said, ‘No. No one has ever explained that to me.’”
King explained what each medication was and why she needed it for her illness and symptoms. “I used patient-friendly language, and she actually began to cry because she said no one had ever taken the time to explain the why of her medications,” he says. “I teach students and medical residents that you have to explain that, and it only takes a few more minutes, but you may have prevented a whole year’s worth of hospitalization for that disease state because the patient will know it.”
The goals for pharmacists in transitions of care is to standardize the language and correlate those to healthcare utilization benefits for patients and the institution. This also can lead to better satisfaction, better engagement with patients, and finding the most cost-effective medication for patients to minimize their out-of-pocket costs without sacrificing quality. “We are preventing unnecessary healthcare utilization while increasing appropriate healthcare utilization,” King adds.
Including a pharmacist on the transitions team is key. “We work very close here — care manager, pharmacist, and team — a triad that’s inseparable,” Gavin says.
REFERENCE
- King PK, Burkhardt C, Rafferty A, et al. Quality measures of clinical pharmacy services during transitions of care. J Am Coll Clin Pharm 2021;4:883-907.
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