Iowa COC project seeks to prove importance of discharge planning

Goal is to show safety, health benefits

Discharge planners know intuitively that what they do matters to patients' health and safety and to reducing the public health costs of repeated hospitalizations.

The problem is convincing hospital executives of these benefits when there is inadequate literature to offer as evidence.

Researchers involved in a new study hope to find evidence of better outcomes when a thorough discharge planning intervention is used. This huge study, which now is underway, could provide the answers that discharge planners and other health care professionals seek.

The Iowa Continuity of Care study will investigate outcomes among 1,000 patients post-discharge to compare the typical discharge process with both a minimal intervention and an enhanced intervention.1

"Often the hospital discharge is a quick and chaotic event," says Barry Carter, PharmD, FCCP, FAHA, a professor in the division of clinical and administrative pharmacy in the college of pharmacy at Carver College of Medicine in Iowa City, IA. Carter also is a professor and associate head for research in the department of family medicine at Carver College and a senior scientist with the Veterans Affairs Iowa City Health Care System in Iowa City.

Patients are worried about how they'll return home and may find it difficult to concentrate during the discharge planning meeting, he notes.

Carter and co-investigators are testing an intervention that provides enhanced discharge planning throughout a patient's hospital stay.

"So, the medication education is not provided in that alarming way it sometimes is during the last few minutes as a patient walks out the door," Carter says.

A pharmacy case manager meets with patients daily during shorter stays and less frequently during long hospitalizations.

"The pharmacy case manager tries to meet with patients daily and walks through the medications they'll be taking when they return home," Carter explains. "Then the pharmacy case manager calls the patient three-to-five days after discharge and asks the patient if there are any questions or problems and if they were able to fill all medications at discharge."

If there are issues to address, the pharmacy case manager works with the patient until these are resolved, Carter adds.

Also, the case manager sends detailed reports to each discharged patient's community physician and community pharmacist.

This enhanced intervention will be compared with two other study arms for adverse drug events, re-hospitalizations, and unexpected visits to the emergency room, Carter says.

The intervention also will address health care costs.

"The study could show that if we looked at this strictly from the hospital's perspective, it is a money-losing proposition, because they've expanded all of these resources in getting information out to the community providers," says John Brooks, PhD, an associate professor in the program in pharmaceutical economics in the college of pharmacy at the University of Iowa.

"It might turn out that the benefits to society are accruing outside the hospital," Brooks says. "We'll look at both society's perspective and the hospital's perspective."

If the study shows substantial cost savings to payers because of the intervention, then its findings could be used to have a discussion with payers and policymakers about reimbursing hospitals for this service, Brooks explains.

An insurer could say it's willing to reimburse for the service, and it would save money even if it paid the hospital more up-front, Brooks says.

"If the study shows there are a lot of benefits to patients and payers, meaning Medicare, Medicaid, or Blue Cross/Blue Shield, then a wise payer would turn to the hospital and say, 'We need you to provide extra services to us before patients check out,'" Brooks says.

Funded by a $3.6 million grant from the National Heart Lung and Blood Institute (NHLBI), this is the largest study of its kind, he notes.

"Our study is not only larger, but it's more encompassing in collecting adverse event data," Carter says.

The hospital in which the study will take place currently provides discharge planning through having a nurse on the patient's floor give the patient a list of medications before the patient is sent home, Carter says.

If the Iowa study shows positive outcomes for the enhanced discharge planning arm, then it's possible it will influence a change in how that hospital and others do discharge planning, Carter says.

"I would hope the hospital would switch to using the intervention," he says. "If it works, then it will encourage hospitals to do the same, and we could make presentations to The Joint Commission and other organizations."

Improving communication is a central theme of the project, 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 VA Iowa City Health Care System.

"Our central issue is recognizing that someone drops the ball at discharge," Christensen says.

"Either information is not conveyed in a manner adequate to the patient's understanding, or the patient doesn't hear it because of some barrier in communication," Christensen adds. "Or, the patient hears it, but when he goes home there's some other barrier, such as financial, structural, or cognitive that prevents him from following through."

These barriers, whether psychological, behavioral, social, or financial, can be overcome if discharge planners recognize them and educate patients about coping strategies.

Pharmacy case manager Cindy Webber, PharmD, who has been meeting with patients enrolled in the study, says the interventions take time.

Webber provides discharge planning for patients enrolled in either the minimal intervention or enhanced intervention arms. But for patients in the enhanced intervention arm, she also writes a detailed discharge care plan that is faxed to community physicians and pharmacists, she says.

"When they're going home after I've done the discharge teaching with them, the study manager tells me whether they're in the minimal group or the enhanced intervention group," Webber explains. "Then I make a discharge care plan, which goes out to the enhanced only."

The discharge care plans inform physicians and community pharmacists about the patient's medical status and discuss any problems that need to be monitored, says Karen Farris, PhD, RPh, a professor of pharmaceutical socio-economics at the University of Iowa. Farris is a co-investigator with the study.

Pharmacy case managers lay the groundwork for patients' discharge education through the daily meetings and medication teaching, Farris says.

"At discharge we talk about new medications, how to take them, and why they're important," Farris says. "We try to identify any situation where we have a patient on a loading dose and maybe have to change it, or if they need to get in the lab in a certain time-frame or have a particular symptom to address."

For the enhanced intervention arm of the study, the pharmacy case manager will make the post-discharge phone calls to see if patients are having any new symptoms or problems with their medications, Farris adds.

"And if there's an issue ,then the care providers, depending on the situation, will contact whoever needs to be contacted to manage that situation," she says.

For example, if a patient returns home with a diagnosis of heart failure, and while home the patient's breathing worsens, the pharmacist case manager will find out this symptom change when she contacts the patient in a follow-up call, Farris explains.

"If it looks like the drug isn't helping, then the patient might need to see his doctor, and the pharmacy case manager would talk to the primary care physician," Farris says. "Or if the patient has a complication arising from the discharge, then the case manager would talk with the inpatient physician to discuss what's going on."

Reference

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(17):1631-1642.

Sources

For more information, contact:

• John Brooks, PhD, associate professor, Program in Pharmaceutical Economics, College of Pharmacy, University of Iowa, Iowa City, IA. Email: john-brooks@uiowa.edu

• Barry Carter, PharmD, FCCP, FAHA, professor, Division of Clinical and Administrative Pharmacy, College of Pharmacy; professor and associate head for research, Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA; senior scientist, Veterans Affairs Iowa City Health Care System, Iowa City. Phone: (319) 335-8456

•Alan J. Christensen, PhD, professor, Departments of Psychology and Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA. Email: alan-christensen@uiowa.edu.

• Karen Farris, PhD, RPh, professor, Pharmaceutical, Socio-economics, University of Iowa, Iowa City, IA.

• Cindy Webber, PharmD, pharmacy practice specialist, University of Iowa College of Pharmacy, Iowa City, IA.