Kitchen Table Consults: Shifting the Point of Care

In-home consultation programs provide one-on-one patient care.

Philosophers have, for some time, pondered the following: if a tree falls in a forest and no one is around to hear it, does it make a sound?

Pharmacists, however, may find themselves wondering: if patients fill their prescriptions and no one is around to check up on them, are they taking their medicine as prescribed? Too often, the answer is no. Poor adherence is not only detrimental to patients, it places a significant financial burden on the health care system. A 2009 report by the New England Healthcare Institute estimated that nonadherence and other drug-related problems result in approximately $290 billion in avoidable medical costs each year.¹

The true focus of pharmacy is not merely filling prescriptions, it is making sure patients understand what their regimen entails and that they are taking their medications as prescribed. Pharmacists are in the unique position of being able to identify nonadherence and utilize their expertise to benefit patient outcomes.

Placing greater focus on certain pharmacy services, such as medication therapy management (MTM) programs, may help to reduce medication errors, improve adherence, and allow patients to take on a more active role in their health care. These services, however, have limitations, especially in vulnerable populations (eg, the elderly) where nonadherence is perhaps most pronounced.

MTM programs are typically conducted within the pharmacy, and many patients are unwilling or unable to visit the pharmacy or lack the transportation or equipment necessary for an in-person discussion. Pharmacy programs that deliver care to the home can tap into harder-to-reach community members. In-home or “kitchen table” consult programs can shine a light on potential problems by seeing patients in their unique home environments.

Programs that boost adherence will also be worthwhile for pharmacists, as quality measures within Medicare—especially surrounding adherence—become more aligned with payment. With the help of programs that place pharmacists and certified pharmacy technicians inside the homes of members of vulnerable populations, the pharmacist can become an invaluable player on the health care team in achieving adherence. Moreover, as medication experts, pharmacists are increasingly being held accountable for meeting certain quality measures, several of which are centered on medication adherence.

Identifying and Overcoming Barriers to Adherence

Pharmacists can equip patients with the tools to improve adherence through MTM programs, but there may be several barriers to surmount. First and foremost, patients must engage with their pharmacists. Some patients, including those who suffer from vision problems and cannot drive, homebound elderly patients, or individuals who lack transportation resources, may not be able to visit their pharmacy. Further, certain practices, such as telemedicine and mail order service for 90 days’ worth of supplies, increase the physical distance between patients and members of their care team.

Programs that provide in-home consultations with pharmacists and/or pharmacy technicians have the opportunity to make a significant impact in the health care of patients. In-home visits provide pharmacists with the unique opportunity to see how their patients live in their own day-to-day environment and identify and assess challenges to adherence. Moreover, because many patients feel safe and comfortable in their home, they may have a more open dialogue with the pharmacist.

One of the challenges to addressing medication nonadherence is obtaining an accurate list of patients’ current medications. In-home consultations allow a pharmacist to review all the medications or supplements a patient is taking by having them laid out on a kitchen table or common area. This is especially important as patients may fill their prescriptions at multiple pharmacies and they may forget to tell their pharmacist that they are taking certain supplements.

This medication review may serve as a safeguard against additional medication problems that may arise. For example, some patients may be taking OTC products, unbeknownst to their physicians, which could negatively interact with other medications they are taking. Similarly, if a patient was recently diagnosed with a new condition, some medications may now be contraindicated or increase the risk of adverse effects (AEs). In-home consultations may also identify cases of duplicate therapy, whereby patients are unnecessarily taking more than 1 medication that has the same effect.

In-home pharmacist consultations provide an opportunity for patient education on the purpose of each medication and its possible AEs. For those who struggle with literacy, the pharmacist can find ways to help them better understand their medications. Simple sticky notes detailing in laymen’s terms what each medication is for can help patients understand their importance.

The in-home consultation also allows pharmacists to assess medication storage conditions, the organization and ease of accessing medications, and the complexity of the regimen. Pharmacists can optimize adherence by finding a personalized system for patients to take their medications. Some patients, for example, may benefit from a system in which they have daytime medications placed in an envelope marked “day” and nighttime medications in a separate envelope marked “night.” Others may prefer to keep pills in their bottles but place pictures on the label to better understand each medication. Developing a system for taking medications may have to include the patient’s caregiver, as well. Pharmacists can aid patients in finding what works for them personally; a one-size-fits-all solution should not apply to medications or medication regimens.

Lack of insurance or prescription drug coverage or a limited income can be additional barriers to adherence. Patients may need someone to help in finding financial assistance. Pharmacists can be this support system; they can help chronically ill patients find programs like manufacturers’ patient assistance programs, which have made medication accessible to patients who are uninsured or who need financial assistance. Once a relationship has been established, follow- up calls to see if the patient is taking his or her medications as prescribed can be another way pharmacists help patients achieve adherence.

Hospital and Pharmacy Collaboration: Setting a Plan in Motion

Pharmacists interested in setting up inhome consultation programs may benefit from forming collaborative agreements with local hospitals.

Our South Carolina-based program, Winyah Home Rx (WHRX), originated from a meeting with hospital administrators in July 2014. A plan was put in place to have referrals from the hospitals’ 14 physician practices sent to the hospitals’ outpatient pharmacy, which would fill discharge medications through their concierge service and follow up on prescriptions. Once a referral came in, WHRX would deploy a medication coach to the patient’s home. These medication coaches, often medical assistants or pharmacy technicians, would enter the home and examine all the patient’s medications on the kitchen table and begin a dialogue with the patient and his or her caregivers. Then, WHRX would address any issues or concerns and set the patient on a path to adherence (see Case Studies).

A similar program could be implemented in which pharmacies are contracted through the hospital to fill patients’ discharge prescriptions in addition to providing medication management services.

These programs also provide a financial benefit to hospitals. Under the Affordable Care Act, penalties are levied against hospitals that readmit Medicare patients for the same condition within 30 days of discharge. Pharmacists who can help boost adherence may be able to prevent patients from reentering the hospital. In-home consultations represent an important service that can make a significant impact in the care of patients, especially vulnerable populations who are unable or do not have the means to visit their pharmacy.

A key remaining challenge is that the financial incentives need to be more aligned with this type of value-based care so that pharmacists are compensated for such services. As payments are increasingly linked with quality, new mechanisms will have to be put in place to enable pharmacist reimbursement for these kinds of services that could lead to fewer hospital readmissions and improved outcomes.

After graduating from the Medical University of South Carolina, Christy Whitlock, RPh, returned to her family’s community and long-term care pharmacy business where she took a position as pharmacy director. Her work history includes providing staff pharmacy services, managing pharmacy operations and consultant pharmacy services, and serving as the director of market development for a large long-term care pharmacy. She has served as a member of several local and state advocacy groups and governmental agencies, and is nationally recognized as a leader in incorporating evidencebased medicine in the long-term care pharmacy environment. Christy is a founding partner of Evidence-Based Solutions, LLC, and Winyah Home Rx, LLC. She co-founded and owned Palmetto Infusion Services, a specialty pharmacy company providing outpatient infusion services. In addition, she and her husband currently co-own 3 long-term care pharmacies in Georgetown, SC; Charlotte, NC; and Atlanta, GA, with Guardian Pharmacy Services. They also own a medical equipment company, Winyah Home Medical in Georgetown, SC.

Reference

• New England Healthcare Institute. Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. Cambridge, MA; New England Healthcare Institute; August 2009. www.nehi.net/writable/publication_files/file/pa_issue_brief_final.pdf.