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

Setting

JHH is an 1192-bed academic teaching hospital located in Baltimore, Maryland. At JHH, the department of pharmacy has 4 inpatient divisions that service the medication needs of different patient populations: medicine, critical care/surgery, oncology, and pediatrics. The adultinpatient pharmacy division covers medicine units in addition to obstetrics, neurology, and surgery units. It is responsible for 486 inpatient beds on 22 units and was the first division to provide the pharmacy bundle of services described below. Currently, 11 rounding and 5 operational pharmacists provide care coordination and order verification support, respectively, for the division during day shift.

Program Overview

Rounding pharmacists on care coordination teams address acute care medication issues and provide a bundle of services that includes targeted patient education, medication reconciliation, post-discharge follow-up phone calls, and discharge prescription planning. The full details of these services have been described [1]. Briefly, patients newly initiated on medications deemed ”high-risk” (eg, anticoagulation, insulin, metered dose inhalers, dual antiplatelets) receive education by a member of the pharmacy team (ie, pharmacist, pharmacy resident, or pharmacy student) prior to discharge. Those patients who receive education are offered a post-discharge follow-up phone call to assess for any questions or issues. Patients who accept this service are contacted 48 to 72 hours post-discharge. Specific patient populations (eg, patients with congestive heart failure, diabetes) are also targeted for completion of medication reconciliation. If patients are being discharged with prescriptions, they are offered our “Meds for Home” service. Patients who accept this service have their prescriptions filled at one of our outpatient pharmacies and delivered to the unit prior to discharge. Highly trained certified pharmacy technicians, called “Meds for Home” coordinators (MHCs; previously known as transitions pharmacist extenders), facilitate this process.

Challenges Faced

Care Coordination Team Coverage

One challenge to implementation of the pharmacy bundle of services was providing consistent team coverage with adequately trained pharmacists. It was not feasible to hire a pharmacist to cover each of the care coordination teams. To address gaps in coverage, we initially utilized postgraduate year 1 and 2 (PGY1 and 2) pharmacy residents on an internal medicine rotation to cover care coordination teams without a rounding pharmacist. However, this method proved unreliable as a pharmacy resident was not scheduled for an internal medicine rotation each month. In the beginning, our division had 3 rounding and 9 operational pharmacists during day shift. To provide sufficient clinical coverage while still adequately addressing order verification needs, a major restructuring of our pharmacy model was necessary. We increased the bed-to-pharmacist ratio for order verification, which allowed the number of operational pharmacists to decrease from 9 to 5. Those 4 remaining pharmacists were now available to serve as rounding pharmacists. Along with hiring 2 additional rounding pharmacists with funding from the CMS innovation grant, we were able to increase the number of care coordination teams consistently covered from 3 to 9.

Although we expanded pharmacist coverage of care coordination teams, time constraints prevented all patients who met criteria for patient education or medication reconciliation to have these services completed in a timely manner or at all by a pharmacist. Our rounding pharmacists’ responsibilities also included participation in high-level activities such as order set reviews for a new provider order entry system, ambulatory clinic time, stewardship activities, and quality improvement projects. In order to increase our scope, we utilized pharmacy technicians, students, and residents to assist with completing these tasks. All pharmacy students and residents on rotation within our division participated in a daily huddle Monday through Friday. Rounding pharmacists whose unit had patient education needs that could not be met by that pharmacist submitted requests by a set time. Those patient education tasks were then divided amongst the pharmacy learners at the huddle for completion. Prior to being allowed to independently counsel patients, pharmacy learners’ patient education skills were evaluated by preceptors. To facilitate timely completion of medication histories, technicians were hired. These medication history technicians are available Monday through Friday to complete medication histories for patients admitted to specific medicine units, ideally within 24 hours of admission. Rounding pharmacists are notified of completion of medication histories via our electronic medical record and reconcile that list with the patient’s inpatient medication list. Any clinically relevant discrepancies are communicated to providers. Pharmacy learners may also collect medication histories.