How the Iowa continuity of care plan works

Intervention begins at admission

The Iowa Continuity of Care study's intervention arm includes extensive work on the part of a pharmacist case manager to make certain a chronically ill patient is discharged with the education and support needed to remain stable.

Investigators hope this time-consuming intervention will result in study patients having fewer drug adverse events and fewer returns to the hospital or emergency room.

Pharmacist case managers fax information to community physicians and pharmacists and follow-up with them to address any patient issues that arise, says Karen Farris, PhD, RPh, a professor of pharmaceutical socioeconomics at the University of Iowa in Iowa City, IA. Farris is one of the team of investigators involved in the continuity of care study.

Here's how the pharmacist case manager process works:

1. A pharmacist case manager takes the patient's medication history on admission. "We take an inpatient history," says Cindy Webber, PharmD, a pharmacy practice specialist with the University of Iowa College of Pharmacy in Iowa City, IA. Webber is one of two pharmacy case managers who has been working with the first enrolled patients in the five-year study.

"We try to go over every medication they're taking," Webber adds. "And we call their pharmacy to make sure we have the right doses and strengths."

Webber discusses over-the-counter (OTC) medications, mentioning specific names of drugs the patient might not think to mention, and she reviews the patient's symptoms and the possible OTC treatments for these.

"We have a lot of problems with this," Webber admits. "Patients don't consider those [OTC drugs] as medications, and they don't list them or tell their doctor of the medications they're taking."

For instance, a patient might forget that she's taking ibuprofen or ginseng.

Or the patient might be reluctant to mention herbal remedies because he has heard that doctors won't like hearing about these supplements, Webber says.

So Webber's strategy is to ask specific questions, such as the following:

  • What do you take for pain that you can buy without a prescription?
  • Do you use anything for your sinuses or colds or flu?
  • We've talked about most of the things you can buy without a prescription, but what about herbal things like ginseng and echinacea, teas and other herbals for treating colds?
  • Do you take any vitamins or multivitamins?

These admission interviews will take from 15 minutes to 45 minutes, depending on the complexity of the patient's case, Webber says.

Also, Webber spends an additional 5-10 minutes on calling the patient's community pharmacist to verify the prescribed medications.

2. The pharmacist case manager provides daily patient education. The average length of stay for the hospitalized patients is 3-5 days, and Webber makes it a point to visit the patient each of those days.

Occasionally there will be a patient who is admitted for an extended period of time, and so the daily visits are not necessary, she notes.

"We had one patient who was here for a liver transplant," Webber says. "She was here for five weeks, and I didn't visit her every day, but after a while, it was maybe twice a week."

Also, the daily visits vary in length of time depending on the patient's educational needs.

"For patients who are newly prescribed warfarin, they need a great deal of medical teaching," Webber says. "We try to teach them early on in their stay and then answer any questions that come up because it takes patients time to digest the information."

The idea for the daily visits is to reinforce medication use education that was taught the day before, or to teach patients about changes in their medication regimen and about the drugs they'll be prescribed when they are discharged, Webber explains.

3. Create care plan that will be faxed to community providers. The care plan is a 3-4 page document that lists all discharged medications and gives a summary of what happened in the hospital, as well as providing information about any monitoring and follow-up care that is needed, Farris says.

For example, the care plan might include information about monitoring a symptom, monitoring a lab value, medication dosing, timing for discontinuing medications, liver tests, etc., Farris explains.

"We make recommendations that are more long-term than the usual care plan," Webber says.

Since Webber's role includes obtaining a detailed medication history and daily meetings with patients, she learns of potential drug interactions or risks that most providers would never anticipate.

For instance, Webber might have worked with a diabetic patient who has not been using aspirin. If she hadn't done the extensive medication review at admission, she or the patient's physician might have assumed that the patient would be taking aspirin when discharged home.

Since aspirin use is recommended in the national guidelines, Webber will include a recommendation in the care plan that the community physician start the patient on aspirin.

"Or we could recommend a long-term strategy of having the physician consider advising the patient to take aspirin at a later date, in the event that the hospital physician did not want the patient on aspirin for a period of time," Webber explains.

In another example, there might be a patient with hypertension that was treated with a particular medication during the patient's hospitalization.

"We will recommend to the outpatient provider that they monitor the blood pressure, and we'll give the range the blood pressure was in while the patient was in the hospital," Webber says. "We'll provide the patient's blood pressure goal and explain why a particular medication was withheld and how the provider still should perform monitoring after discharge."

If it's warranted, the care plan then will provide a recommendation for an additional choice of medication if the patient still is hypertensive, Webber adds.

The pharmacist case manager has the skills necessary to detect the most subtle potential medication problems.

"We might have an older patient, a 75-year-old, who had been using Tylenol PM, which is inappropriate for the elderly," Webber says.

"Obviously, they're not using Tylenol PM while in the hospital and the hospital physician wouldn't write a prescription for that," Webber adds. "But the patient could go home and buy that medication again."

So the care plan will note that the patient had been using the OTC drug prior to being admitted into the hospital and that the patient had been counseled not to continue using it, Webber says.

"Then we'll recommend to the community physician that she prescribe a low dose of trazodone as a prescription for helping the patient with sleeping," Webber adds.

4. The pharmacist case manager provides follow-up care. The pharmacist case manager will call the patients about 3-5 days after they've returned home, Farris says.

The calls will ask about new symptoms, medication problems, and any other obstacles to their medication adherence, she adds.

If there are problems, then the pharmacist case manager will contact the community physician and/or pharmacist and provide them with an update.

Hospitals could adopt the continuity of care and medication reconciliation model used for the Iowa study, but it would require some financial and time investment.

The most challenging part of the educational efforts for hospital pharmacists would be to find time for it, Webber notes.

"On some days the hospital pharmacist has dedicated time to complete these activities, and that's critical," she says. "Any hospital pharmacist is going to be capable of making recommendations and explaining things to the community physician about why things were done a certain way in the hospital."

But finding time to talk with patients and discuss any medication issues with inpatient physicians takes time that hospital pharmacists often do not have, Webber says.

There is another potential drawback that the Iowa study might identify when it's complete, Webber notes.

Community physicians and pharmacists might not read through the care plans as carefully as is needed for them to be useful in producing the positive outcomes of reducing adverse events and improving safety.

"I have a feeling that the care plans are sort of long and physicians might gloss over the medication list," Webber says. "So we make the main recommendations at the very top."

So far, the only feedback Webber has received from community pharmacists who received the care plans involved one pharmacist asking if these were supposed to be medications that should be filled and another one inquiring about a dose change and deactivating an old prescription, she says.

"We haven't had a lot of feedback from community pharmacists," Webber says. "They're very busy."