Hospitals involve pharmacists in care of indigent patients

Pharmacists' involvement helps improve outcomes, costs

Hospitals that serve populations that traditionally have difficulty affording primary care now are seeing their indigent populations swell as the recession has hit those with hard luck even harder.

Some health care systems have found that including pharmacists in the care of these patients can improve outcomes and help reduce hospitalizations and costs.

"We look at our hospitalizations every month to see if there's anyone from our clinic who has been hospitalized due to any issue," says Sherry Martin, PharmD, the outpatient pharmacy operations coordinator at The Medical Center Inc., which is part of the Columbus Regional Healthcare System in Columbus, GA.

"A patient can be referred to a pharmacist based on their hospitalization if medication therapy is related or due to an uncontrolled disease state," Martin says.

The Medical Center's Outpatient Clinic and Ambulatory Care Pharmacy were established to provide primary care to uninsured patients, and, at the same time, deliver cost-effective therapy while keeping patients out of the hospital, Martin says.

Since these patients have no insurance and no resources to pay for their own care, the Outpatient Clinic and Ambulatory Care Pharmacy are funded through a city-county grant, she adds.

The pharmacy and clinic were established based on the theory that if someone provided preventive services on an outpatient basis to patients, then there would be fewer indigent patients going to the hospital emergency room for primary care, says Lori Hornsby, PharmD, BCPS, an assistant clinical professor with the Harrison School of Pharmacy at Auburn University in Auburn, AL. Hornsby also is an ambulatory clinical pharmacist with the Columbus Regional Healthcare System.

"The thought is that providing these services will help us decrease hospitalizations and ER visits," Hornsby says. "However, we have found this difficult to track as many of these patients transition in and out of our system."

The Family Practice Clinic and Family Health Pharmacy, which also are associated with The Medical Center and Columbus Regional Healthcare System, see some indigent patients, but the clinic's population is slightly more diverse economically, says Jamie Thompson, PharmD, BCPS, ambulatory care clinical pharmacist at the Family Practice Clinic and Family Health Pharmacy.

"The Family Practice Clinic is a medical residency program with 30 medical residents and attending physicians, and it serves as a training site for pharmacy residents and students," Thompson says. "We've had a pharmacist in the clinic for over 10 years."

The clinic's pharmacists help with patient-assistance programs and work to obtain low-cost medications through drug companies and other sources, she says.

"Since a lot of our people can't afford their medications, we work with physicians to assure that they are receiving the most cost-effective medication therapy," Thompson says.

One of the issues with dealing with indigent populations is that funding usually comes from various sources, meaning that not all patients can be seen by one particular site.

For instance, the Family Practice Clinic and Family Health Pharmacy see patients from outside counties because they receive some state funding, but the Outpatient Clinic and Ambulatory Care Pharmacy, funded by the county and city, serve only people who live within Muscogee County, GA, Martin says.

"Each clinic has a separate pharmacy, but the goals of the pharmacy department in both clinics are the same," Martin says.

Here is how the clinics work:

Family Practice Clinic: "There are two pharmacists here in this clinic, and we have patients scheduled to see us every day of the week," Thompson says.

"We see 98% of the patients who come to the clinic for anticoagulation management," she says.

A large portion of what we do is diabetes management, hypertension management, and hyperlipidemia management," she adds. "The other types of physician referrals we receive involve medication compliance and reducing costs of medications."

The pharmacists spend 30 minutes with patients on average, although anticoagulation management visits sometimes are shorter, and diabetes management visits take a little longer, Thompson says.

"For diabetes we talk about whether they're checking their blood sugars and keeping their values in range," she explains. "We make sure they understand what their medications are prescribed for and why it's important to take them and obtain good control of their diabetes."

The pharmacists also will make sure patients know how to improve their overall health and how important it is to lose weight and stop smoking, if appropriate, Thompson says.

"Usually patients bring in their medication bottles with them, and we ensure they're taking their medications correctly," she adds. "We evaluate for any changes needed in their medication therapy and keep them up to date on all their lab work."

With new referrals they keep track of their initial diabetes control and then subsequent testing when they return.

Patients determined to be well-controlled will be seen every 3-6 months to make sure they're receiving regular follow-up, Thompson says.

For patients who have more severe diabetes, the pharmacists will schedule more frequent visits, sometimes even once a week, she adds.

Outpatient Clinic and Ambulatory Care Pharmacy: When patients first are enrolled in the outpatient clinic program they're seen by either a physician or physician extender, Hornsby says.

"Patients found to have certain chronic disease states are automatically referred to us," she says.

Patients are generally referred for diabetes, hypertension, hyperlipidemia, asthma, chronic obstructive pulmonary disease (COPD), hepatitis C, and congestive heart failure. The clinic provides smoking-cessation, weight-management, and anticoagulation service.

The clinic's staff also includes pharmacy residents and fourth-year pharmacy students from surrounding pharmacy schools.

"A lot of what we do is train medical and pharmacy residents and pharmacy students to manage these patients, as well," Hornsby says. "Pharmacy residents conduct a large percentage of our visits with the oversight of the ambulatory clinical pharmacist."

The clinic also has three physicians and a nurse practitioner.

"We work with physicians to assess patients' disease control, their understanding of the disease, and their compliance," Hornsby says.

"We are also able to adjust medication therapy when necessary," she adds.

"We have a very unique setting — a utopian pharmacy — where patients receive their medical care and medications from a clinic and pharmacy located in the same building," she explains. "If there are ever any questions about their medications or medical care, these issues can be easily resolved since all providers are in the same location."

The outpatient clinic's goal is to serve the county's indigent while reducing the hospital's costs in providing care for uninsured patients, Martin notes.

"We're a 340B Disproportionate Share Hospital, and we're always very conscious of cost savings," Martin says. "We've been involved in patient assistance programs sponsored by drug manufacturers for many years, providing medications to patients at little or no cost."

Now the hospital is seeing an increase in the influx of indigent patients, particularly in the Outpatient Clinic and Ambulatory Care Pharmacy.

In the past year, the clinic's patient population has swelled with several new patients each day, she says.

"Our volume has grown because of the economy and people losing their jobs," Martin says.

"We have many people in the community who have found themselves unemployed," she adds. "These were people who previously had health insurance benefits, and now they're here in our clinic for the uninsured."