Bringing Out the Best with Less: The Health-System and Integrated Delivery Network

Departments of pharmacy in the hospital will be called upon to work within existing budgets while providing additional services such as medication reconciliation and patient education.

As a recent first-time homeowner transitioning from city apartment life to a suburban house, my husband and I faced the challenge of heading out to shop for furniture to make our new house a home. When shopping for these items, of course each item had a monetary value (one that we attempted to bargain down when the opportunity presented itself), and each piece of furniture also had potential sentimental value as it would be the backdrop for holiday parties, family dinners, game nights with friends, and many other milestone events. I provide this example as the first thing that comes to mind for many when thinking of value as being “cost savings.” However, there is a fine balance between ensuring the affordability of items or services and making sure the final product is of high quality and sustainable in nature.

Doing More with Less

Today, health systems across the country are constantly being asked to do more with less. Medical training programs have cut back on the hours trainees can be in-house, but the expectations for quality and quantity of care provided have not changed. Recently at our institution, our nurse case managers and social workers were asked to care not for just 1 team of patients, but for a whole unit; in most cases this increased their workload by 33% to 50%, yet the expectation for scope of services provided did not change.

Within the department of pharmacy we are being asked for more pharmacists to attend multidisciplinary rounds and provide medication reconciliation and patient education as a part of our institution’s readmissions preventions efforts. While these direct patient care services are increasing in demand, we must find a way to balance this with the fundamental need to provide safe and effective order verification.

Efficient Division of Labor

It is certainly a positive reflection on our profession that pharmacy involvement in these efforts is not just being requested, but required. In order to meet these demands and provide value-added services all around, we cannot proceed in a “business as usual” fashion. If we do, team members most certainly will quickly become overworked and frustrated with trying to fit extra tasks into a schedule that was already full. Old models, practices, and habits simply won’t lead to success in this new environment. This calls for taking a good look at current practices. What work can be eliminated altogether? What can be redistributed to other staff members—especially to our pharmacy technician colleagues? How can we leverage our pharmacy learners to help support the pharmacy team? These are not simple questions to answer, and some staff members are going to be more willing than others to think outside the box.

At our institution, better incorporation of pharmacy learners into our practice models has brought a lot of value to our department. On the first day of their rotation, pharmacy students and residents are provided with our criteria by which patients are targeted for certain services. By equipping our learners with the skills they need to perform medication reconciliation and patient education, we have increased the number of patients that interact with pharmacists during their hospital stay. For students who are just learning the ropes of making interventions, performing medication reconciliation gives them a defined role with the team and it is a structured avenue through which they can contribute to patient care. Delivering these services is a valuable educational experience for learners, while at the same time expanding the clinical services of the department in a cost-neutral fashion.

From Order Fulfillment to Pharmaceutical Care

For health-system pharmacy, providing value means tackling all of these questions, while always keeping our end goal in mind: providing safe and effective medications to our patients. Our patients will not know that there are now fewer pharmacists verifying orders through advances in technology and redistribution of work, but with increasing expansion of pharmacist involvement in direct patient care, patients will remember that it was a pharmacist who took the time to discuss their medications with them during their hospital stay. When they go home they will be able to share with their family and friends what a valuable resource their hospital pharmacist was. They will leave the hospital feeling more empowered to manage their own medications and with greater knowledge of how their medicines work to maintain their health.

These concepts carry tremendous value to those patients who have these interactions with their hospital pharmacist. Some of these same patients will get discharged from the hospital, perhaps after having had their prescriptions delivered at bedside, and then go to a clinic to get longitudinal care from a pharmacist. These are all things that are happening across the country because the value of such services has been proved through research, and individuals pioneering these services have shared their successes at conferences and in literature.

At our institution, for example, in order to expand services we developed training programs for our pharmacists who historically had order verification responsibilities only. We structured these programs like a rotation, and we gave the pharmacist a chance to round with the medical team, participate in topic discussions, and review patients with a preceptor each day in an effort to expand their clinical skills.

I had the opportunity to “precept” one of my colleagues during her rotation in internal medicine. Very soon into the training experience, this pharmacist realized that there was a whole different realm of pharmacy practice that she had a strong desire to be a part of. Most of our days ended with her sharing with me how much she was enjoying her work despite the much longer hours. This pharmacist got so much out of this 1-month experience that she was inspired to apply for our nontraditional postgraduate year 1 residency to further her clinical skills. I have my fingers crossed that she will be selected for this program and I will get to see her realize her own goals, while also helping to expand our department’s ability to take care of patients. This example of value was very heartwarming for me.

Just like starting out fresh with a new home and being faced with the challenge of selecting the perfect items to furnish this home, departments of pharmacy need to face the challenge of cleaning out the house head on. New models of service need to be brought in that will not only work with existing budgets, but will also stand the test of time as we are asked to provide more direct patient care services while continuing to provide the same high caliber of medication distribution.

During our furniture shopping, we spent the most time selecting our family room sofa. After spending several weeks of long nights and weekend days in the furniture store making our decision, we were disappointed to find out that we would have to wait 8 to 12 weeks for delivery. However, when the sofa finally arrived, it was a perfect fit for our family room—and it was definitely worth the hours of agonizing over shape, fabric, and color.

Value is not something that can develop overnight, but with the right amount of thought and with the end goals in mind, it becomes very clear what matters the most. With that vision in mind, excellent models can be developed that will persevere through resource-limited times.

Emily Pherson, PharmD, BCPS is a clinical pharmacy specialist in adult internal medicine at The Johns Hopkins Hospital in Baltimore, Maryland. In this role, she is responsible for overseeing both acute care pharmaceutical needs and care coordination services post discharge for her team of internal medicine patients. Dr. Pherson also serves as the coordinator for a pharmacy resident rotation focusing on post discharge pharmacist home visits.

Dr. Pherson earned a bachelor of science degree in biology and psychology from the University of Maryland, College Park, and received her doctor of pharmacy degree from the University of Maryland, Baltimore. She completed a 2-year pharmacotherapy residency at The Johns Hopkins Hospital in 2013, and she is a board-certified pharmacotherapy specialist.

Involvement with the American Society of Health-System Pharmacists (ASHP) has been central to Dr. Pherson’s career: she served as chair of the Pharmacy Student Forum Executive Committee from 2010 to 2011, and was a member of the New Practitioners Forum Professional Practice Advisory Group from 2011 to 2013. She currently serves on the ASHP Ambulatory Care Practitioners Section Advisory Group on Compensation and Practice Sustainability.