Pharmacists Are Essential in Managing Transitions of Care for Patients

In an interview with Pharmacy Times® at the American Society of Health-System Pharmacists Summer Meetings and Exhibition, Aimee Banks, PharmD, BCPS, MSCS, clinical pharmacist in the Multiple Sclerosis Clinic at Vanderbilt University Medical Center, discusses the role of the pharmacists in patient care, improving outcomes, and managing transitions of care.

Q: What is the role of pharmacists in caring for these patients and how can they help to improve outcomes?

Aimee Banks: So many ways that pharmacist play an impactful role in patient care. I think, initially, my first thoughts revolve around education, communication, and setting expectations, specifically with the patient, but even with the care team. Pharmacists to have oftentimes a little bit more room and time to spend with patients, whether it's in clinic and an in person visit, or on the phone as a follow up to an appointment. So one of the roles that I play in my day to day practice is really education upfront, and then regular check ins and follow ups with patients to try to help identify barriers later.

Just a couple of the barriers to hopefully mitigate upfront, and then to resolve if they do occur are financial barriers. These medications are very expensive, and the high cost of the medications can be a really big barrier for access. So, understanding having an awareness of the different types of insurance companies and the different types of financial assistance that's available based on not only the medication, specifically, but even just based on the type of insurance plan that a patient has and what they might be eligible for, that's really important. We can play a really big role in just reducing the financial barrier for patients. That's not as fun, I guess, in the world of clinical pharmacy, but it's really important because if a patient can't access their treatment due to high cost, then that treatment that may be the most ideal for them. If they don't have access to it, then we may have to make therapy adjustments.

So there's the financial piece of it, which is oftentimes a barrier to treatment, and then also maintaining adherence to treatment, but also from a clinical perspective setting expectations is really big for patients, helping them understand not only their therapy, but even sometimes their diagnosis and kind of putting everything together and making it make sense in their own terminology that they understand, which I think pharmacists have a really important role in that area

So, setting expectations, and then coordinating care for all of the different people involved. There's the prescriber, and there's the nursing staff, and there's insurance companies, and there's specialty pharmacies, oftentimes which are mail order, that are only available if that phone call,manufacturer support programs, and third-party financial grant programs. So, just kind of playing like traffic controller in a way and coordinating that care is really important to improve outcomes, and even more clinical from there anytime that a pharmacist can be involved in collaborating with the providers of an interdisciplinary team to make a therapy selection, that's really valuable for the patient, but it also helps promote us as clinical pharmacist and really prove our value and are in our place on the team. Helping providers identify the therapies that are most appropriate for a patient based on not only their diagnosis, but maybe there are other comorbidities, there concomitant medications, and things like that.

So collaborative practice is a hot topic and a key word helping make specific patient treatment plans based on all of the different variables that go into that decision. I think is a place that pharmacists really can play a big role and help the clinic staff and the providers and make a big impact in patient care and outcomes as well.

Q: How can pharmacists help manage patients through transitions of care (such as inpatient to outpatient)?

Aimee Banks: It’s hard, transitions of care and management through that is really difficult actually, because there's so many different parties involved. I think it's good to look at it is just an extension of routine care. So, for one, being just present and involved is really important, and really understanding what the different levels of care are, and remembering there's so many different types of transitions of care. I think my default is to think about a patient who is in the hospital being discharged to go home or maybe a patient who's being admitted. I'm trying to coordinate those home medications, and so I'll start kind of with those with those specific transitions.

One thing to consider for an inpatient who's being discharged to an outpatient setting, maybe they need to be initiated on a new therapy during the inpatient stay. One process to be aware of and have an understanding and really know who the primary stakeholders are and how to coordinate conversation and communication among those parties is thinking about discharge planning ahead of time, so rather than waiting until the patient is ready to go home and trying to figure out how they're going to connectmedication that they just started in the hospital.

Discharge planning in advance and starting that benefits verification and investigation for the preparation for the discharge and trying to be proactive and helping the patient access that therapy, even before they're actually discharged to go home is really important.

When we talk about outpatientpatients on the outpatient setting that are admitted to the hospital, we have to try to find a way for them to continue their home medications, and oftentimes, these specialty medications are not on the hospital formulary. So having an understanding of and being aware of the hospital systems nonformulary review process is important.

That's an area that I'm just recently becoming involved in and realizing how complicated it can be, but also so very important to help those patients in that continuation of care process, and then also, most likely, the hospital systems usually have a pathway for helping patients continue home medications within the hospital, so even if the hospital is not able to provide the medication during that stay, there may be a process to have an approval for the patient or a family member to bring in those home medications so that they can continue those throughout the hospital stay, of course, when they're appropriate.

Another important transition of care though, and this is really what I'm involved in more on a day-to-day basis is transitions from one medication to the other for maybe the same diagnosis. So that can be all in an outpatient setting. In my day-to-day, it's in our multiple sclerosis (MS) center, patients may switch from an oral medication that they've been taking at home every day, and they may need to switch to an IV infusion therapy that would be given in an infusion center. Helping coordinate all of those things and making sure that the patient is able to continue their current therapy up into the point that it's no longer appropriate. Always considering wash out period, so there does there need to be a lapse in between maybe an oral to an IV therapy or an IV to a subcutaneously administered at home medication? Sometimes we intentionally have washouts in between those therapies, but also especially within MS and some other disease states, we have to consider that if there is a lapse in therapy that's too long, it can actually increase disease activity. Patients with MS for example, can have sort of like a rebound phenomenon. We have to be really careful so that we don't allow them to have too long of a gap in between those therapies.

I think pharmacists really especially are more aware, I think, of that piece of it, even sometimes in the providers are and we can really be involved in the day-to-day details of coordinating the care with, again, the prescriber, the nursing team, the infusion center, the insurance company, financial assistance programs, and all those things to make sure that patients transition appropriately from one medication to the other.

I mentioned communication and setting expectations earlier, I am so passionate about that I can't emphasize that enough, it is so important to keep the patient at the center of the conversation, either the patient or their family member or their caregiver or their representative. It's really great if everybody on the care team knows what's going on, but if no one remembers to update the patient on where we're at and what needs to happen next, and any steps that they might need to take along that journey, then we've missed a really important piece. I practice it day-to-day or I try to practice it day-to-day and I teach strongly that patient centric decision making and communication is so important. I think that's important on the pharmacist role and how we can improve outcomes for patients, but also in any transition of care whether it's health care settings, or even just medication switches.