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

Lessons Learned

The time of transition from one level of care to another is a vulnerable time for patients, as it is a time when medication-related problems often arise. In an elderly patient population, one study demonstrated that contributing factors for medication discrepancies following hospital discharge included unintended nonadherence and inadequate discharge instructions, and patients experiencing a medication discrepancy were at a significantly higher risk of readmission [4]. Hospital readmissions have also been linked to a lack of adequate follow-up in the outpatient setting [5]. Pharmacists should become more involved in preventing medication-related problems during the times of transition by performing activities such as medication reconciliation, patient education, and assessment of patient outcomes post-discharge [6,7]. Studies have demonstrated that pharmacists are able to reduce medication-related adverse events during and after hospitalization by completing these activities [8–10]. Residency-trained pharmacists are well-equipped to provide these services and are needed to create new processes and models to meet the ever changing demands of health care payers and accrediting bodies. ASHP recommends pharmacists entering into careers in health systems be at least PGY1-trained while the American College of Clinical Pharmacy (ACCP) envisions all pharmacists involved in direct patient care complete residency training [11,12]. Health systems will continue to be challenged with transforming pharmacy models to allow for this influx of highly trained individuals in a time of budget constraints. Below, we describe the lessons we learned while implementing our pharmacy bundle of services and think are essential for other institutions to consider when initiating their own services.

Rethink the Role of the Pharmacist

As health systems acquire smaller hospitals, the role of the pharmacist may need to be redefined and reinvented. The responsibilities of a pharmacist in a large academic hospital may be different than those of a pharmacist with the same skill set in a community hospital. However, despite the difference in practice setting, the same core pharmacy services around medication use can still be deployed. Participation in transitions of care activities is a relatively new concept for many pharmacists as residency training programs traditionally focused on caring for patients within a defined setting such as the intensive care unit or ambulatory care. The pharmacy profession should define the role of the clinical pharmacist in order to make the incorporation of transitions of care responsibilities into job expectations easier for all. The ACCP outlines this need and sets forth recommendations for clinical pharmacists’ responsibilities within the health care team to include assessing patients and medication regimens, developing and implementing medication-related therapy plans, and evaluating clinical outcomes [13]. Pharmacy leadership organizations, including ASHP and ACCP, offer resources providing the vision of pharmacy practice and expectations for which institutions should be reaching. Pharmacy departments should use these resources to complete gap analyses of current processes and those envisioned for the future to help guide efforts for change at their own institutions.

Obtain Support Within Your Institution

Gaining support from hospital leadership for advancing pharmacists’ involvement in patient care is instrumental. Without leadership support at both the institutional and department of pharmacy levels, pharmacists with advanced training may be hindered from practicing at the top of their license. Furthermore, support by leadership of pharmacy residency programs and experiential student learning sites at the institution is also important. Pharmacy residents and students became indispensable in our model and allowed us to expand our reach to more patients. We used residents to cover additional teams that were previously uncovered by a rounding pharmacist and, along with students, provide medication reconciliation, patient education, and follow-up phone calls to more patients. Requiring participation in the pharmacy bundle of services for rotations also allowed us to train these individuals about the value of transitions of care and see the challenges patients face in gaining access to medications. In a survey of academic medical center executives, pharmacy directors, and pharmacists at 8 institutions, residents were noted to add value to the institution through decreasing drug-related errors and drug costs, expansion of clinical services, and enhancing opportunities for research [14].

Support from other disciplines is also essential. Collaborating with other disciplines should occur prior to, during, and beyond implementation. We collaborated with providers, nurses, case managers, social workers and many other disciplines during all phases of the process. Being inclusive during the planning process allowed everyone to understand each other’s role and to provide input on how we could work together to best utilize everyone’s resources. This multidisciplinary approach to developing pharmacy services also allowed an opportunity to collaborate on research and evaluate our processes with other disciplines.

Tracking interventions will demonstrate the value of pharmacists, technicians, and other pharmacy team members participating in these advanced roles. This information will be useful when justifying the practice model to hospital leadership and for recruiting new pharmacists, residents, and technicians to the institution. Additionally, defining both outcome (eg, 30-day readmission rates, HCAHPS scores) and process (eg, number of patient education sessions performed, number of medication discrepancies reconciled) measures upfront is important in order for those involved to understand how their work will be assessed. These data will be useful in determining whether the intervention is making an impact early on and allow for restructuring of the process if not.

Create Depth in Your Team While Engaging Current Resources

We spent a significant amount of time planning the implementation of our pharmacy bundle of services, collaborating with other disciplines, and training our pharmacy team members. We hired highly trained and competent people into new positions and ensured every-one clearly understood their responsibilities. This was a critical step in order to ensure we were providing optimal care to our patients and integrating leaders into our team. We also utilized our current workforce to fill new clinical rounding pharmacist or technician roles. For those pharmacists who had not completed a residency, we required the pharmacists to complete a compact training program similar to that required of our residents [1]. This training ensured that important services were being performed adequately by each rounding pharmacist. Similarly, technicians transitioning from a primarily medication dispensing role to a MHC or medication history role received extensive training to assist with developing their new skill set.

Creating relationships with an outpatient pharmacy is essential to ensure patients are discharged from the hospital on medications they can afford long-term. We are fortunate to have 5 outpatient pharmacies on the JHH campus that are under the Johns Hopkins Health System umbrella, which made collaboration between the inpatient and outpatient teams seamless. However, many hospitals may not be directly affiliated with an outpatient pharmacy with which to collaborate or may contract with a retail chain pharmacy. In the latter case, inpatient and outpatient pharmacies must work together to define roles around transitions of care and how to best serve the patient in a collaborative manner. If no onsite outpatient pharmacy exists, dedicated resources should be acquired to serve as a liaison between the inpatient team and the outpatient pharmacy. These resources may work through issues such as formulary preferences, prior authorization requests, and connecting the patient to the medication either through bedside delivery or filling at the patient’s community pharmacy. Community pharmacies recognize the cost benefit they could gain through 340B pricing and specialty drug dispensing when working in collaboration with healthcare systems. However, health systems must be aware that collaborating with outpatient pharmacy partnerships will create further challenges as providers ensure patient preference for use of a particular pharmacy is honored and cost-sharing is incorporated into models.