By Dorothy Brooks
When cost-cutting is a priority, some leaders look to their onsite pharmacies as a ripe target for elimination. But this can make it harder for patients about to be discharged from the ED to access medications that were prescribed during their visit.
This is particularly true in regions where there is not easy access to pharmacies — either because the pharmacies are closed when patients are discharged, or the pharmacies may be too far away and hard to access for those with limited transportation options. Affordability and/or payor issues also can be problematic.
Regardless of the circumstances, if patients cannot access their prescribed medicines timely, their infections, chronic diseases, or other conditions can worsen, resulting in repeat visits to the ED.
Despite the closure trend, some healthcare leaders are moving in the opposite direction, concluding that an onsite, hospital-based pharmacy is a critical resource for their patients and for the surrounding communities.
For example, in February 2023, the University of Louisville (KY) Health reopened a hospital-based pharmacy at Mary & Elizabeth Hospital, a facility in the medically underserved region of South Louisville. Robert Fink, PharmD, MBA, FACHE, FASHP, BCPS, BCNSP, vice president of pharmacy services for the health system, says the onsite pharmacy had been closed by the hospital’s previous owners. University of Louisville Health had been working toward reopening the facility since it purchased Mary & Elizabeth Hospital three years ago.
Since then, at least two community pharmacies have pulled out of the region, leaving patients discharged from the hospital without easy access to medications.
“The [commercial pharmacies] closed their stores within probably a four- or five-block radius of the hospital,” Fink explains. “We had physicians calling us to ask how their patients can get medications.”
Also figuring into the health system’s thinking was data from a new technical report from the American Academy of Pediatrics (AAP) noting that a high percentage of patients fail to obtain their prescribed medications after they have been discharged from the ED.1
The AAP report authors argued the ability to dispense medications from within the hospital setting can go a long way toward addressing access barriers while also improving the likelihood patients will take their medications as directed. Further, they pointed to several other studies that revealed low medication adherence among patients following ED visits.
For example, the AAP researchers cited one study that revealed one-third of insured pediatric patients failed to pick up what investigators referred to as priority medications — new prescriptions that were needed for an acute condition or refills of medications that had been prescribed — following ED visits.2 Other studies in the AAP report concerned Medicaid patients and adolescents diagnosed in the ED with sexually transmitted infections.3-5
Fink explains that beyond providing easy, onsite access, a hospital-based pharmacy offers multiple advantages that can help ensure patients secure their prescribed medications. Emergency pharmacists and emergency physicians can coordinate prescriptions so medications are dispensed to patients as they discharge.
When medications require preauthorization, pharmacists can work through that process and make the medications available for patients when they are discharged.
“If the prescription is sent to an outside pharmacy, the authorization process is not always completed, causing delays,” Fink observes.
In other cases, insurers may not cover the prescribed medication, and switching to an alternative medication can cause additional delays.
“Our pharmacists can anticipate that work with the medical team so we have a seamless transfer upon the patient’s discharge,” Fink says.
For the University of Louisville Health, putting antibiotics in the hands of those who need them is a priority. Fink says leaders are working on a project that will enable urgent care centers to provide the first dose of antibiotics to appropriate patients during their care encounters.
“In the community, patients may have to wait several hours before a prescription can be filled, and we don’t want to have that patient’s antibiotic therapy delayed,” he says.
Opening and maintaining an onsite pharmacy is not a simple or inexpensive task. At Mary & Elizabeth Hospital, there was already a suitable space. That was a significant, cost-saving advantage not available to all. But Fink notes there are many other expenses to consider, such as needed computer systems and the personnel to operate the pharmacy.
Further, Fink notes it takes time to make an onsite pharmacy function.
“You can get a pharmacy license within a month or so, but the problem is being able to establish all of the contracts necessary to be able to adjudicate claims,” he says.
At Mary & Elizabeth Hospital, the pharmacy had to secure Medicare approval, along with the state Medicaid plans in Kentucky and Indiana, since the hospital serves many patients from both states.
“That process can take six months, even after getting a pharmacy license,” Fink says. “You also have to work with computer vendors to be able to establish connections, get the equipment installed, and get people trained.”
Nevertheless, Fink notes the pharmacy has been profitable since day one, and it has been well-received by both hospital providers and patients.
The AAP report acknowledged a few states limit the ability of inpatient facilities to dispense outpatient medications. Thus, healthcare leaders in these states must be creative in designing solutions to medication access problems for patients about to be discharged.
The AAP report authors cited several workaround policies that have been proposed to address some medication access barriers: leveraging electronic prescribing from the ED so providers will know quickly whether medications are available in a specific outpatient pharmacy, administering first antibiotic doses in the ED, and providing a few days’ worth of medication to patients about to be discharged.
REFERENCES
1. Mazor SS, Barrett MC, Shubin C, et al. Dispensing medications at the hospital upon discharge from an emergency department. Pediatrics 2023;151:e2023062144.
2. Kajioka EH, Itoman EM, Li ML, et al. Pediatric prescription pick-up rates after ED visits. Am J Emerg Med 2005;23:454-458.
3. Wang NE, Gisondi MA, Golzari M, et al. Socioeconomic disparities are negatively associated with pediatric emergency department aftercare compliance. Acad Emerg Med 2003;10:1278-1284.
4. Lieberman A, Badolato GM, Tran J, Goyal MK. Frequency of prescription filling among adolescents prescribed treatment for sexually transmitted infections in the emergency department. JAMA Pediatr 2019;173:695-697.
5. Goyal M, Hayes K, Mollen C. Sexually transmitted infection prevalence in symptomatic adolescent emergency department patients. Pediatr Emerg Care 2012;28:1277-1280.
There are some other possible workarounds, such as leveraging electronic prescribing from the ED so providers will know quickly whether medications are available in a specific outpatient pharmacy, administering first antibiotic doses in the ED, and providing a few days’ worth of medication to patients about to be discharged.
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