Transitions of Care Pharmacy: Analysis of Pharmacy Interventions to Improve Clinical Outcomes

West Virginia University Medicine is a 500+ bed academic teaching hospital located in Morgantown, West Virginia. Services offered include a level I trauma center, a level III NICU, and a state of the art cancer center. The hospital has an outpatient pharmacy onsite and in 2012 launched a Transition of Care Pharmacy to offer a bedside consulting service and postdischarge prescription service to any patient within our facility. Since its inception, our program has reached more than 20,000 patients in 2 years and had up to a 50% capture rate.¹ From 2007 through 2011, the national 30-day, all-cause, hospital readmission rate averaged 19%. During the calendar year 2012, the readmission rate averaged 18.4%.² These data show the need to implement strategies to lower patient readmissions and focus on improving the health care system wide. The hospital is looking forward to continuing to enhance and improve this service. One avenue is to look within the program to evaluate and audit the pharmacy to explore better ways of accomplishing our goals.

The pharmacy staff worked with many health care staff and was an integral part of the multidisciplinary team to lower the all-cause readmission rates. The focus was on disease states of high readmission as determined by the Center for Medicare and Medicaid services (CMS). Pharmacists can be an important key in reducing readmissions when they are involved in the discharge process. A problem affecting hospitals countrywide is unplanned readmissions. Nearly three-quarters of these readmissions—costing an estimated $12 billion annually–are in categories of diagnoses that are potentially avoidable. Failures of care coordination can increase costs by $25 billion to $45 billion annually, which puts financial stress on the health care system.³

Background

The discharge process we found can be a complicated, multifaceted process. Just on the pharmacy side, many factors affect the successful completion of filling a patient’s medication in a timely fashion prior to discharge. Our pharmacy noticed the difference in these factors, some being internal to the pharmacy program and many being external. With the development of an APPE (Advanced Pharmacy Practice Experience) pharmacy externship program, we used the entire pharmacy health care team and 2 pharmacy externs to conduct a study and research program to explore these factors. The internal factors ranged from insurance billing, staffing, and pharmacy hours to reach as many patients as possible. The external factors included insurance issues (eg, prior authorization), drug selection, and communication from the different services and units we serve. Our hope was to identify root causes and learn to improve the pharmacy procedures for discharge to aid in efficiency and safety for our patients.

Program Overview

The transition of care pharmacy audited prescriptions to explore the extent, time, and logistics of interventions made. Our focus was to gather information on the cause behind the interventions as well as the service or location from which the interventions were coming. Our goals were to reduce medication errors stemming from these intervention, improve availability of outpatient prescriptions and streamline the discharge prescription process by efficiently reducing the pharmacistand technicians time. One of our performance goals is to adhere to an “out by noon discharge” for most of our patients. The goal takes different dynamics due to patient’s ability to leave the facility and patient’s destination (facility, hospice, home, etc.).

Study Design

In order to audit the discharge pharmacy process, pharmacist, pharmacy students, and technician interventions were tracked over a period of a month. These interventions were collected on a standardized data form and entered into a secure excel spreadsheet each day. Data collection included: date of intervention, prescription number of intervention, location of patient within the hospital, type of intervention made, number of phone calls made, time spent on the phone, and monetary savings when patients qualified. Observed interventions were grouped into 11 categories: insurance issue, prices issue, prior authorization, direction clarification, therapy duplication, missing/unwritten prescription, drug change, strength change, quantity error, drug interaction, and miscellaneous (eg, worker’s compensation, transfers, out of stocks, compounding issues, delivery issues). Cost savings were represented separately in dollar amounts. Phone data from July 2015 were obtained from WVU Medicine’s Department of Process Improvement and was extrapolated forward to our data in August.

Results

Altogether, a total of 278 interventions and 588 intervention-related phone calls totaling 3411 minutes were reported by staff over the sampled 25 days. Phone data were accessed to determine the amount of telephone calls the discharge pharmacy received and made. The average time in minutes was also recorded to attain the total time the pharmacy was on the phone. Extrapolating from the interventions in the study, approximately two-thirds of phone calls made and received were intervention related. Data on average showed that 11 interventions were made each day, requiring 13 minutes per intervention. Approximately 55% of all interventions made fell into the insurance issue, price issue, and prior authorization categories.

There were 11 categories in relation to time spent in minutes. Some important notes about this data showed insurance problems, price issues, and appropriate directions allocated the most time for the pharmacy. “Missing prescription” referred to retrieving of the printed prescriptions that were written for the patient and left on the hospital floors. These prescriptions were at times given to the patient, the nurses or still in possession of the physician. On some occasion the patient’s family intercepted the prescriptions of which some were taken offsite. Quantity error both referred to an incorrect amount written for duration of prescription as well as no quantity written at all.

Regarding financials $4772 was reported as the savings patients received through co-pay and free trial cards, financial assistance programs, price matching, and hospital assistance funding on eligible patients.

It’s interesting to note that approximately 11% of prescriptions were returned to stock after the verifying process was completed due to several external factors. Some of the factors included the patient’s changing a desire to use the pharmacy, payment problems, and external communication with the program.

Conclusions

The study demonstrates the enormous amount of time technicians and pharmacists spend on interventions over the course of a few weeks. Furthermore, this data can be used to streamline the discharge pharmacy workflow process, to improve interdisciplinary coordination and communication, and to reevaluate the full-time equivalent budget with regard to technician and pharmacist hours. Pharmacists, pharmacy technicians, and interns can play important roles in transitions of care by improving the efficiency of the intervention process.^4,5 As this transition of care pharmacy continues to evolve the data shows the value of pharmacists in the health care team.

References

1. Calemine L, et al. Reduction in 30 day readmissions through implementation of medication to beds and reconciliation at discharge. Poster presented at: ASHP Midyear 2014. The 49th ASHP Midyear Clinical Meeting and Exhibition. Dec 6-10, 2014; Anaheim, CA.

2. Gilmore V, et al. Implementation of transitions-of-care services through acute care and outpatient pharmacy collaboration. Am J Health Syst Pharm. 2015;72(9):737-744.

3. Burton R. Reducing waste in healthcare. Health policy brief. September 13, 2012. healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_76.pdf.

4. L'Hommedieu T, et al. Utilizing pharmacy students in transitions-of-care services. Am J Health Syst Pharm. 2015;72(15):1266-1268.

5. Burton,R. Improving care transitions. Health Affairs website. healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76.