Hybrid Models Can Transform Team Chemistry

Morristown Medical Center, a member of Atlantic Health System, is a 735-bed community teaching hospital located in New Jersey.

The pharmacy department of Morristown Medical Center operates 24 hours a day and has 165 employees verifying about 1.6 million medication orders per year. The area-based pharmacist (ABP) model, which was reviewed and approved by pharmacy leadership as the future state of pharmacy services, was designed to transition a traditional staff pharmacist to a hybrid, clinical/staff pharmacist.

Pharmacy models within an institution may be centralized (within the main pharmacy or satellite), decentralized (directly on the nursing units themselves), or a combination of the 2.

The first steps were to identify the main goals of the model, measurable outcomes, and staff scheduling logistics for implementation. A 2-day proof-of-concept trial took place, which was followed with a 6-week pilot on the nursing units. The working team comprised assistant managers, an educator, a manager, pharmacist supervisors, and the transition-of-care clinical pharmacist. A targeted positive outcome was to improve communication, as 70% of adverse events can be attributed to poor communication in health care. Nursing leadership was instrumental during the ABP model design and was supportive of its implementation.

The ABP pharmacist was primarily responsible for discharge counseling, medication history reconciliation when possible, order entry and clarification(s), patient education, and participation in multidisciplinary patient care rounds. Training competencies and manuals were created to provide clinical training, whereas positions and responsibilities were redistributed to use the current staffing resources. These goals were to be accomplished while maintaining order entry turnaround time and routine pharmacy operations.

The team selected 2 units, adult general medicine and neurology, which were selected based on their lower-than-hospital-average Hospital Consumer Assessment of Healthcare Providers and Systems Scores, manageable volume of patient beds-to-pharmacist ratio (combined 104 beds: 1 pharmacist), and proximity to each other. The pharmacy reviewed the current staffing model and reallocated a position with existing resources, designated as the new ABP.

A 2-day proof-of-concept trial confirmed that the locations, patient volume, and workload were manageable for 1 pharmacist. For the 6-week pilot, 3 pharmacists with interest in being directly involved volunteered to optimize the overall model structure and provide real-time feedback. A list of responsibilities was created, including discharge counseling, medication education, medication history collection and review, order clarification, and prioritization of order entry. In real time, the pharmacist addressed urgent missing medications, optimized therapy recommendations, and provided answers to drug information questions during morning huddles. Staff pharmacists expanded their roles to increase direct patient care involvement (see Table 1).

Clinical competencies were developed based on the patient populations. In addition to reviewing clinical resources, patient counseling and education were not performed by staff pharmacists. Therefore, training was provided to ensure that pharmacists were comfortable speaking with the patient and/or family members and handling the corresponding documentation. Shadowing sessions were scheduled with a transitions-of-care clinical pharmacist to observe patient assessment, education, and history and to sign off on a patient counseling checklist. In addition to training and collecting feedback, medication inventories were optimized for the units’ automated dispensing cabinets.

FINDINGS AND RESULTS

Collaboration between the ABP and the multidisciplinary team led to an increase in direct patient contact and opportunities for interventions. The average interventions from pre-ABP and post-ABP increased from 5 to 16 per shift. During the 6-week pilot, there were 257 interventions made, and 87 (34%) were only made possible with the pharmacist present on the unit.

Nursing satisfaction surveys were distributed pre-, mid-, and 1-month post implementation using a 5-point Likert scale, ranging from very poor to excellent. Favorable was defined as a good or excellent rating. The survey results showed a favorable increase in all questions, including satisfaction of the availability of STAT medication orders within 30 minutes (61% increase), as shown in Table 2.

A noteworthy finding within the nursing survey was the reported 67% improvement in medication tracking and delivery. Although the automated dispensing cabinets were optimized before the pilot, changes were not made to the delivery process. Rather, through communication and acknowledgement of where the medications were and having a pharmacy point of contact for these needs, the perception of delivery timeliness was improved.

With pharmacist presence on the nursing unit, there was an increase in value-added patient encounters (VAPEs). Examples of VAPEs include allergy review, discharge counseling, medication history clarification and collection, patient education, and the patient’s own medication processing. With each VAPE, the ABP use reduced unnecessary phone calls, minimized interruptions to nursing and delays to medication verification and administration, and overall improved efficiency. Often, problems were resolved before the medication order was entered into the electronic system.

With resource and time limitations, collecting medication histories for about 100 patients was not possible. Therefore, members of the nursing department identified and flagged complex patient cases for the pharmacist. There were instances requiring more resources and time than the ABP could offer because of continued operational priorities. These situations were escalated to the care of a clinical pharmacist or pharmacy leadership. In addition to resource limitations, a call-out contingency plan was developed.

CONCLUSION

The ABP model is a progressive strategy aligning the interdisciplinary team at the bedside to improve communication, pharmacist access, patient education, and outcomes.

Using this platform, the pharmacists developed stronger communication and interpersonal skills with patients. Strong relationships were built with nurses, prescribers, and other health care professionals. The availability of the ABP allowed for on-demand in-service training based on the clinical need of the nursing units. And ultimately, the ABP model empowered pharmacists by giving them opportunities to further develop and use their clinical skills. By being at the forefront of patient care, there was an observed sense of job satisfaction and pride.

Clinically focused programs such as the ABP have tremendous potential in improving patient care. Through the collaboration, communication and information challenges decreased, interruptions to nursing workflows were minimized, and proactive pharmacy recommendations were made before order entry. A pharmacist was made available during emergency situations, turning the focus on patients and their care.

In March 2019, 3 additional nursing units were selected to deploy a second ABP with a focus on cardiology. The deployment of 2 ABPs had been done in a full-time equivalent-neutral manner by reallocating positions and roles from the main pharmacy into these roles. The ABP model was well-received, and nurses have shown their support of the model. We look forward to the continued expansion of the ABP program with the goal to roll out this program system-wide, providing more global and individual improvements in patient care.

Nicole Nazy, PharmD, is pharmacy supervisor of operations at Morristown Medical Center in New Jersey.Brittney Daley, MSN, RN, CCRN, is a nurse manager at Morristown Medical Center in New Jersey.Nina Elk, PharmD, BCPS, is a clinical pharmacist in transitions of care at Morristown Medical Center in New Jersey.James A. Gensch, MSN, BSN, ASN, is the in-patient coordination manager at Morristown Medical Center in New Jersey.Douglas Bloomstein, PharmD, is manager of pharmacy services at Morristown Medical Center in New Jersey.

REFERENCE

Gilligan C, Outram S, Levett-Jones T. Recommendations from recent graduates in medicine, nursing and pharmacy on improving interprofessional education in university programs: a qualitative study. BMC Med Educ. 2014;14:52. doi: 10.1186/1472-6920-14-52.