By Melinda Young
Hospital discharges and care transitions across the continuum are vulnerable time points for medication mismanagement. About 60% of all medication errors occur during transitions of care.1
Case managers working with pharmacists and providers can help prevent medication errors and omissions as patients transition home or to another care facility. Collaboration is key.
Healthcare has to be a collaborative team effort to work optimally, says Tina Lipscomb, CCM, MSN, RN, a case manager at Duke University Hospital in Durham, NC. “It’s a complicated system. Most providers — whether they are physicians, physician assistants, [or] pharmacists — are overworked and overburdened,” she says. “They have a lot of responsibility and a heavy workload.”
Working as a team, collaborating to make use of each team member’s strengths, is the only way to be successful, Lipscomb adds. Coordination between case managers, who attend to social determinants of health that affect medication management, and pharmacists, who can identify medication omissions and duplications, is a natural fit.
“If a patient is discharged from the hospital on a new medication, is the patient insured or uninsured?” Lipscomb asks. “If uninsured, how will they afford the medication? Are they eligible for patient assistance programs?”
Also, someone has to take the lead in completing paperwork for any new medication coverage. Pharmacists know of pharmaceutical company discounts and coupons.
“The case manager and pharmacist can work together as a team,” Lipscomb says. “They can look at the barriers to using this new medication and address them.”
Pharmacists Can Educate Patients
Pharmacists can help educate patients on their medications. They can tell patients about side effects and how the medication works. “When most people think of a pharmacist, they think of going to a community pharmacy, like Walgreens or CVS, and they forget your pharmacists have a whole wealth of knowledge in other settings,” Lipscomb says. “What we’re trying to do is educate case managers and the public on where to find pharmacists and how to tap into that expertise they have and bring it to the forefront to work together on patients’ medication adherence.”
For instance, hospital case managers have access to the expertise of hospital pharmacists. Some primary care centers also have a pharmacy on site or near the clinic. When a facility is not near a pharmacy, then care coordinators could get to know pharmacists at local chain pharmacies and find out how they could help answer questions for patients who fill their prescriptions there.
Case managers also should think of medication management as much more than medication adherence. “It’s deeper than that,” Lipscomb says.
Patients also should be educated about asking pharmacists questions when they do not understand something about their medication.
“How many people walk into a pharmacy, stand in line, wait to get their medication, and then someone asks them if they have any questions, and the person has two seconds to say ‘yes’ or ‘no?’” Lipscomb asks. “It’s not an easy process. If you say, ‘Yes, I want to talk to a pharmacist,’ they push you to the side and you wait until the pharmacist is available.”
A lot of people do not know what to ask. However, a case manager can educate them. Examples could include the following:
- Can I take this medication with my vitamins?
- What side effects should I expect?
- What happens if I stop taking the medication?
Case managers also need to know more about the pharmacists who will be working with patients when they are transferred to a rehabilitation facility or skilled nursing facility, Lipscomb says. “A lot of skilled nursing facilities contract with a pharmacy service, and some are lucky enough to have one on site,” she explains.
For instance, large continuing care retirement communities might employ a lead pharmacist in the facility. When patients are transitioned to the community, that pharmacist can be helpful in their medication management and reconciliation.
Even if case managers do not interact directly with the pharmacist at the next level of care, they need to know who will be working with the patient and who could answer any concerns the patient might have about their medication.
It is helpful to know where the skilled nursing facility gets its medications and whether they have access to a pharmacist on site or a pharmacist located miles away and who handles medication management remotely, Lipscomb says. “When we look at transitions of care from a hospital to a nursing home, medications and medication-related problems are one of the top things that patients complain about — and they can be one of the top things that lead to readmission,” she says.
Transitions Are Critical
Transitions from the hospital to a nursing home are crucial. It is important for someone — such as a case manager — to make sure the patient receives all the necessary medications. For example, a patient who has been prescribed antibiotics in the hospital may be leaving the hospital at 2 p.m. The patient’s next antibiotic is due at 2 p.m., but the skilled nursing facility’s pharmacist needs to get this order, process it, and have it sent to the nursing home. This could take several hours, Lipscomb explains. “The patient may miss a dose of medication in that transition,” she adds.
In other cases, a patient who had been on blood pressure medication before an emergency department visit and inpatient hospital stay could be transferred to a rehab facility for pain from a major fracture, and the blood pressure medication is overlooked for days in the post-acute care facility.
“Most people don’t realize what happens, and most case managers have incredibly heavy caseloads,” Lipscomb says.
Case managers have the pressure of transitioning patients quickly to make beds available for the next patient. They may not have enough time to call the skilled nursing facility in advance and ensure the patient’s daily medications are ordered.
“They may not know what happens to the patient unless the patient is readmitted,” Lipscomb notes.
Solutions could include case managers giving patients their afternoon medications before they leave the hospital or having the patient’s caregiver pick up the medication at an outpatient pharmacy. They could print the discharge medication list and have it ready for when the patient leaves the hospital, Lipscomb says.
Rushed discharges sometimes result in medication omissions and errors. “Here’s a lady with a fractured back, in a lot of pain, and the pain is impacting her blood pressure, so can she have pain medication before she leaves the hospital, in a timely manner?” she says. “Communicate with the nursing home and rehab staff.”
Everyone has a personal story about what they have seen as failures in transitions of care, but these can drive case managers to do more to prevent problems and resolve medication management issues.
“It’s going to involve having really good communication to say what the patient needs and what will happen,” Lipscomb says.
REFERENCE
- Kee KW, Char CWT, Yip AYF. A review on interventions to reduce medication discrepancies or errors in primary or ambulatory care setting during transition from hospital to primary care. J Family Med Prim Care 2018;7:501-506.
Hospital discharges and care transitions across the continuum are vulnerable time points for medication mismanagement. About 60% of all medication errors occur during transitions of care. Case managers working with pharmacists and providers can help prevent medication errors and omissions as patients transition home or to another care facility. Collaboration is key.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content