Pharmacists' role in discharging patients takes center stage in study to increase medication adherence

Key is continuity of care to community

A collaboration of pharmacists, physicians, psychologists, and other researchers have begun a study to see how hospital pharmacists, communicating with patients, community physicians, and pharmacies, might impact patient outcomes post-discharge.1

Public health leaders and researchers have noted in recent years that hospitalized patients often have difficulty adhering to their medication regimens after they're discharged. This problem can lead to increased health care costs as patients rebound to the hospital's emergency room or intensive care units and become "frequent fliers," experts say.

The Joint Commission of Oakbrook Terrace, IL, has recently required hospitals to provide medication reconciliation across various levels of care, partly in response to recognition of medication adherence problems.

"One of the big problems, particularly in the large tertiary hospital, university hospital, is that despite our best efforts there's often times discontinuity as the patient goes home for a wide variety of reasons," says Barry Carter, PharmD, FCCP, FAHA, professor in the division of clinical and administrative pharmacy in the college of pharmacy and a professor and associate head for research in the department of family medicine at Carver College of Medicine, University of Iowa in Iowa City, IA. Carter also is a senior scientist with the Veterans Administration Iowa City Health Care System.

"A patient might have misunderstandings about their new medications and the medications they had been receiving," Carter says. "Many times there's not good communication linkages with the community physician and community pharmacy to help solve this problem of patient misunderstanding."

Previous studies have shown that up to 20% of discharge medications are not filled when patients are sent home, Carter notes.

"So our study is designed not to just educate patients about their medications at discharge and to reconcile them and answer questions," Carter says, "but also to let the patient know what the actual care plan is for each medication."

For instance, a patient might be confused about whether a specific new medication is something they need to take just for two weeks and then be done with it, or whether it's something they'll need to take for the rest of his or her life, Carter explains.

The idea is to show how having a pharmacist assist with discharge planning relates to actual downstream adherence by the patient, says Alan J. Christensen, PhD, a professor in the departments of psychology and internal medicine at the Carver College of Medicine. Christensen also is a senior scientist with the Veterans Administration Iowa City Health Care System.

Downstream adherence issues include medications errors made by patients, failing to fill prescriptions initially, or failing to take them, Christensen says.

"These all are interconnected issues that involve the discharged patient's understanding of the medications he's going home with and how he's supposed to use them," he explains. "We're addressing any barriers that might be evident and impede the patient from understanding the discharge instructions and going home to fill them at the neighborhood pharmacy."

Researchers have identified a clear role for a pharmacist case manager in providing patient education and medication changes during patients' hospital stays and as they are transitioned to the community, says Karen Farris, PhD, RPh, a professor of pharmaceutical socioeconomics at the University of Iowa.

"Anyone enrolled in the study is met daily with a pharmacist," Farris says. "At the first meeting, they'll review the medications the patient has and make sure the patient understands what's going on with their medications, answering any questions."

This daily contact continues throughout the patient's stay, and as medications are changed, the pharmacist case manager continues to educate and inform patients, Farris adds.

Carter, Christensen, and Farris are part of a team of researchers who will be involved in the largest study thus far to address these continuum of care issues. It's funded by a $3.6 million grant from the National Health Lung and Blood Institute (NHLBI), Carter says.

The five-year study, which has begun enrollment, ultimately will enroll 1,000 people, divided into three arms, including the following:

  • One study arm provides usual care in which patients are educated by the nursing staff and given a list of medications at discharge. The usual care group and community physicians will receive a discharge summary from the hospital.
  • A second study arm provides a minimal intervention in which the pharmacy manager works with the patient throughout the hospitalization, providing patients with education along the way, Carter says. Patients in the second arm will receive a wallet card list of their medications.
  • The third group is an enhanced intervention group that receives the same assistance provided in the minimal intervention group, plus additional communication efforts. In this arm, the pharmacy case manager will fax a care plan for medications to the community physician and the community pharmacist, Carter says.

"We hope they'll identify problems as they occur," Carter adds. "We want to identify where there are duplications in medications."

The study's ultimate goals are to see if the intervention reduces adverse drug events, re-hospitalizations, and unexpected visits to the emergency room, Carter says.

The enhanced intervention will be costly, but the study also is addressing whether it will provide long-term economic benefits to the broader health care community.

"This isn't a free lunch, so if you want to do this extra care, we have to realize it costs money," says John Brooks, PhD, an associate professor of the program in pharmaceutical economics in the college of pharmacy at the University of Iowa.

Brooks, who is also among the study's investigators, will be studying how many resources were spent on the intervention and how much these might save the hospital and/or insurance payers.

"It could be that even though the hospital spends money to do this program that it could be a cost savings for the hospital," Brooks says. "Or, if it's not or if it cost a little more, the question is, 'Did we avoid a lot of bad outcomes that we would have had to pay for.'"

If the study's hypotheses are correct and the enhanced intervention ends up reducing adverse events, re-hospitalizations, and repeated emergency room visits, then it would definitely be a money-saver to private health care payers, as well as to Medicare and Medicaid, Brooks says.

"Then the insurers will be very happy about this project," Brooks says.

"We then could demonstrate that it would be very costly for the University of Iowa hospitals and clinics to cover all of its costs," he adds. "So to have an incentive they need to be reimbursed by the insurance company."

The patients who will be enrolled in the study include those with diagnoses of hypertension, hyperlipidemia, heart failure, past heart attacks, diabetes, and other common chronic medical conditions, Carter says.

One key to sending these patients back into the community is to make certain they're taking the medication that's necessary to keep them stable, Carter says.

"So many times these patients are hospitalized because their disease state worsens, and they should have been on a higher dose of medications, but they weren't," Carter explains. "So one big role of the pharmacy case manager is making certain the patient who is diabetic, for example, is taking aspirin so that all the guidelines of concordant therapy are followed."

Also, the pharmacy case manager can help to adjust medication prescriptions as the patient moves closer to discharge and notify the community providers of the patient's situation.

"So the care plan helps to communicate to the community physician and pharmacist what the plan is, and it educates the patient as to what to expect," Carter says. "Many times the patient doesn't realize how the medication will need adjustment and that the patient will continue to need to have his blood levels checked after he goes home."


  1. Carter BL, Farris KB, Abramowitz PW, et al. The Iowa Continuity of Care study: Background and methods. Am J Health-Sys Pharm 2008;65:1631-1642.