Implementing Meds-to-Beds in a Community Hospital

This article was collaboratively written with Tyler B. Clay, PharmD, BCPS; Brian A. Gallagher, RPh, JD; Robert B. Stanton MBA; PharmD, BCPS; Heidi N. Romero, PharmD; and Janet Wolcott PharmD.

The American Association of Colleges of Pharmacy cites “the increased complexity, number, and sophistication of medications and related products and devices” as some of the major factors contributing to the growth of the pharmacist’s role,¹ which now includes bedside delivery of discharge medications. Meds-to-Beds is highly effective in improving outcomes and deceasing cost. In one study, only 5% of patients who participated in a bedside delivery program with a follow-up call were readmitted, compared with 9.5% of those who received usual care.²

Background

Implementing Meds-to-Beds in a hospital can enhance perception of pharmacy services. Building this service requires planning and collaboration with stakeholders outside the pharmacy department. This process can be overwhelming and problematic to the pharmacy department if it’s not implemented correctly. When a program is inappropriately introduced, and adequate resources haven’t been allocated, the result is a lack of consistency in service delivery, which creates difficulties within and outside the department and leads to frustration throughout the system for both providers and patients.

The key to successfully establishing a Meds-to-Beds program is careful consideration and planning for initiation and expansion. A critical element before and during initiation is buy-in from the executive suite, pharmacy director, nurses, physicians, information technology (IT), social workers, and those whose approval is needed to permit the program.

This article proposes a logical approach to initiation and expansion of a hospital-based Meds-to-Beds program by outlining the processes needed to be addressed.

Investigation

The initial step in developing the program’s logistics was visiting functioning sites to understand their dynamics and workflow. Before the first visit, a questionnaire was developed to serve as a guide to ensure all key topics and questions were addressed. When making site visits, the goal wasn’t to learn every minute detail about their program, but to gain general understanding of how they were handling daily operations and observing the various options available to operationalize a Meds-to-Beds program.

When analyzing other programs, it was quickly apparent there was no “one size fits all.” Thus, it’s essential to outline the workflow of each institution, compare and contrast them, and ascertain which elements of each would fit well within your existing structure and which would need to be modified to your specific needs. It’s vital to ask the right questions, and then make note of the array of potential solutions and select those that best suit the needs and circumstances or your particular institution.

Collaboration

A multidisciplinary team consisting of physicians, pharmacists, social workers, technicians, nurses, IT specialists, and upper level administration was formed to begin outlining the workflow of the program within our institution. The team dissected the information gathered from the site visits and began addressing key issues relevant to operationalizing the program. The following table summarizes the questions addressed and corresponding answers at our institution:

Question & Answer

Question: Where is the program being initiated?

Answer: The outpatient surgery department.

Question: Who will be eligible for the program?

Answer: Any patient not in any form of isolation.

Question: Who will propose the program to patients?

Answer: The admitting nurse now informs patients of the program and offers enrollment.

Question: How will enrollment information be relayed to the pharmacy?

Answer: In collaboration with IT, software was developed to link the hospital and pharmacy computer system.

Question: Will the inpatient or outpatient pharmacy fill the prescriptions?

Answer: Currently, the outpatient pharmacy is filling the prescriptions.

Question: How will orders be relayed to the pharmacy for filling?

Answer: Prescriptions are either e-scripts or hard copies faxed to the pharmacy.

Question: Who will deliver the prescriptions to patients?

Answer: Typically, APPE students or employed interns deliver prescriptions, but technicians deliver if needed.

Question: How will the pharmacy department know when patients were to be discharged?

Answer: A “Facesheet” was developed to be faxed to the pharmacy with total number of prescriptions and nurse name and extension before the anticipated time of discharge.

Question: How long before discharge can prescriptions be delivered to patients?

Answer: Prescriptions can be delivered to patients 1 hour before discharge or to family in the patient’s room any time before discharge.

Question: How will patients be counseled?

Answer: If APPE students or employed interns do the delivery, they’re able to provide patient counseling. However, if technicians are used, they make the offer and have a pharmacist return to the room if needed.

Implementation

The first step was identifying a physician champion who supported the service. This was imperative as the pilot program was being implemented in a single unit within the hospital, and needed to be in affiliation with a collaborative physician who was willing to accept the growing pains the program would likely face in its infancy. Before any physicians were approached, however, ideal units were selected where that physician should be located.

Acute myocardial infarction, heart failure, and pneumonia have particularly high readmission rates,³ so units with a high prevalence of these disease states were specifically avoided for initiation. Stakeholders at our institution decided the program should be well-established before units servicing high levels of complex and difficult patient populations were incorporated. Instead, the program sought units with typically low readmission rates and common discharge order sets to help minimize the complexity of the process while it was in its early stages.

Once the program identified the target unit to be piloted, the participating physician, an order of operations, and the process of training personnel began. Since pharmacy technicians would be a key component of the filling process, senior technicians who posed 2 key qualities were sought to pilot the program:

• Those who were well-seasoned in communication with other health care professionals, since the program’s success was largely contingent on effective communication among an interdisciplinary team.
• Those possessing leadership skills, as they would likely become the trainers for additional staff as the program grew and staffing needs expanded.

Once staff was trained, the program was launched. Following a trial period, the original interdisciplinary team reconvened to discuss aspects that were working well and those that needed improvement. The team reverted back to the original information gathered from site visits for possible answers to logistical issues, as well as expanding to those involved in daily operations for input. Changes to the workflow were then employed and another trial period was used in the pilot unit to ensure smooth operations.

Expansion

The program was expanded by a single unit location at an adequate time to adjust pharmacy staffing to meet increased demands. The number of new patients added with the addition of each unit was an unknown, making staffing predictions difficult. There were concerns that if the program expanded too rapidly, there was potential for inability to meet the staffing requirements necessary for daily functioning in a practical time frame. This would lead to a considerable delay in the discharge process, which would ultimately lead to failure.

With this in mind, the interdisciplinary team carefully selected the order in which the hospital units would be included in the program, saving the areas for the greatest potential impact, like those treating patients with cardiovascular and respiratory issues, for last. This allowed the program to mature to a fully functional stature before the incorporation of these units. The slow expansion of the program also allowed for resolution of issues that were unforeseen in their entirety and ample time to make accommodating adjustments before new issues related to extended expansion arose.

As the program continued to grow, frequent and regular meetings of participants were essential to share issues, interpret how the actions of one participant might adversely impact other participants, and find common ground and workable solutions. These meetings not only identified issues, but also proved critical to cross-functional problem-solving. Our team in its entirety encompassed diverse backgrounds that generated synergistic solutions from an array of experiences that couldn’t have been paralleled had it only consisted of pharmacy staff.

Conclusion

Overall, an effective hospital-based Meds-to-Beds program was developed to meet the needs of both patients and the hospital while benefitting both. Bringing key stakeholders together to address pertinent issues and meeting regularly to address specific concerns was critical to its success. The program was rolled out in a deliberate step-by-step systematic process, but it must continue to adapt as the health care industry evolves to maintain smooth and effective functioning. The collaboration among physicians, nursing staff, and a dedicated pharmacy team assures patients have their medications at discharge and receive personalized counseling aimed at increasing adherence, reducing hospital readmissions, and increasing patient satisfaction, leading to overall cost savings.

References

1. American Association of Colleges of Pharmacy. Job outlook for pharmacists. aacp.org/resources/student/pharmacyforyou/Pages/joboutlook.aspx. Published July 8, 2013.

2. Kirkham HS, et al. The effect of a collaborative pharmacist-hospital care transition program on the likelihood of 30-day readmission. Am J Health-Syst Pharm. 2014;71(9):739-745.

3. Cardinal Health. Changing the standard of care: bedside discharge prescriptions improves patient care. cardinalhealth.com/content/dam/corp/web/documents/brochure/Cardinal-Health-CaseStudy-Hackensack-Bedside.pdf. Published 2013.