Pharmacists’ Involvement in Medication Management Along the Continuum of Care: Challenges, Lessons Learned, and Implications for Health Systems

From The Johns Hopkins Hospital, Baltimore, MD.

The project described was supported by grant # 1C1CMS331053-01-00 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented was conducted by the awardee. Findings may or may not be consistent with or confirmed by the findings of the independent evaluation contractor.

Abstract

• Background: Medication management is becoming more complex, with new medications entering the market, drug prices increasing, and patients transferring into and out of the hospital. Transitions of care services are being implemented to prevent readmissions and increase patient satisfaction. Pharmacists play a key role by expanding clinical services provided to patients around medication management.
• Objective: To describe a pharmacy transitions of care model at a large academic teaching hospital and lessons learned during implementation.
• Methods: A pharmacy bundle of services was initially developed in a medical patient population and included medication reconciliation, patient education targeting high-risk medications, post-discharge follow-up phone calls, and bedside discharge prescription delivery. This bundle was expanded to other patient populations through the use of residency-trained pharmacists, pharmacy residents, pharmacy students, and certified pharmacy technicians.
• Results: Challenges were faced when implementing our transitions of care services, including expanding care coordination team coverage with existing resources, training pharmacy staff in new roles, determining the needs of patients cared for by teams we had not previously been integrated into, and creating our discharge prescription delivery program. During this process, we learned to rethink the role of pharmacists on our team, value the support within our institution to create change in order to improve patient care, and continuously evaluate this process.
• Conclusion: We are at an opportune time to expand the scope of the inpatient pharmacist to provide advanced medication-related services to patients. Residency training is creating individuals who will thrive in these new models.

Medication management around the acute care inpatient stay is a challenging but crucial task to ensure patient safety and desired clinical outcomes. The first step in successful medication management is to understand the patient’s medication regimen in the home environment. Patients may take medications differently than prescribed; skip medication doses intentionally to make a supply last longer; use over-the-counter medications, herbal supplements, or someone else’s medication based on the recommendation of family or friends; or discontinue medications based on side effects or media influence. Over the course of the inpatient stay, medication management involves adjusting doses based on changes in organ function, detecting side effects and potential drug interactions, and monitoring clinical outcomes to ensure appropriate drug therapy is being prescribed. As the patient approaches discharge, ensuring the patient understands the indications for his/her medications, has self-monitoring techniques to recognize efficacy or adverse effects, and has access to discharge medications is important. Lastly, long-term medication management includes patient access to pharmaceutical expertise over time. Pharmacists’ involvement in medication therapy management services and patient-centered medical homes is key to ensuring safe and effective medication use over time.

In 2009, the Johns Hopkins Health System Readmission Prevention Task Force developed strategies to reduce preventable readmissions and improve transitions of care. In 2011, a new multidisciplinary approach to patient care was implemented at the Johns Hopkins Hospital (JHH) to optimize care coordination and improve acute care management. Using this approach, care coordination teams composed of physicians, nurses, pharmacists, nurse case managers, social workers, physical/occupational therapists, nutritionists, and home care coordinators meet on a daily basis to discuss the inpatient and discharge care needs of patients in order to improve care transitions and reduce preventable readmissions. In 2012, JHH was awarded a 3-year innovation grant from the Centers for Medicaid & Medicare Services (CMS) that would assist with expansion of these care coordination teams to every unit of the hospital. Prior to implementation of the care coordination model at JHH in 2011, there were 3 pharmacists who consistently rounded on 3 inpatient medicine teams (one pharmacist also had operational responsibilities). Pharmacists were deemed by the task force to be key providers of medication management and, thus, essential members of the care coordination team. Due to an inability to hire a new pharmacist for every care coordination team, the department of pharmacy needed to determine how to provide consistent pharmacist coverage utilizing current resources. This report describes the challenges faced and lessons learned by our adult inpatient pharmacy division when implementing a pharmacy bundle of services to improve care transitions for an adult patient population.