Pharmacists see patients through discharge
They call those at-risk for readmission
At the Nebraska Medical Center in Omaha, pharmacists interact with patients from admission through discharge and beyond, conducting medication reconciliation and education, and working with the multidisciplinary team on the treatment plan.
Pharmacists see many patients in person, starting on Day 1. "They don't see all of the patients with stays of a short duration, but they do review the medical history taken by nurses and, based on their experiences, follow up with patients who need it. Every patient history is either taken by a pharmacist or approved by a pharmacist, who uses the information to work with the multidisciplinary team to build a treatment plan," says Michael Powell, MS, FASHP, executive director of pharmaceutical and nutrition care at the medical center.
The pharmacists visit patients throughout their visit, checking on what has been prescribed and the potential for interactions. As discharge approaches, the pharmacists review the discharge prescriptions, conduct medication reconciliation, and educate the patients on their medications and the importance of taking them as directed. Pharmacists make follow-up calls to certain high-risk populations within two to three days of discharge to patients with conditions that are at risk for medication mismanagement. They make sure the patients have filled their prescriptions, understand their medication regimen, and answer any questions.
"When patients are admitted, we get a complete record of what a patient is taking before admission and determine what, from a pharmaceutical standpoint, might have contributed to the admission, such as therapeutic failure or drug interactions," Powell says.
At The Nebraska Medical Center, pharmacists collaborate with all disciplines as part of the treatment team, making rounds and attending multidisciplinary team conferences. Instead of just reacting to medication orders from a physician, pharmacists at The Nebraska Medical Center give physicians advice on how to build a treatment plan. "When the pharmacist collaborates with the physician, it decreases the likelihood of an adverse event or a medication reaction. Pharmacists can help physicians avoid using an IV drug or an injectible drug when an oral drug will be just as effective," Powell says.
When the pharmacists assess patients, they evaluate their financial position, find out if they have insurance, and if it includes drug benefits. The pharmacists can call on the hospital's pharmacy financial counselors to help patients without insurance or drug coverage access pharmaceutical assistance plans to get the medications they need.
"Many of the patients who don't fill their prescriptions can't afford them. Our pharmacists help physicians plan a medication regimen that patients can afford and try to head off any problems that would interfere with the patients following their treatment plans," he says.
The hospital is beginning a discharge medication program that delivers medication directly to the patient at bedside. "This assures us that the patients have the medication they need when they leave the hospital," he says.
The pharmacists collaborated with the case managers to develop a medication instruction sheet that includes the name of the drug, a picture of the drug, and the times it should be taken. They work with the case managers to identify patients who are at high risk for readmissions. In those cases, the pharmacists help with patient education and in some cases, teach patients how to set up a medication container to schedule doses.
"We know that when patients don't take their medication properly, it can have a significant impact on their health, so try to make sure patients understand the importance of taking their medication. Frequently, when they are about to be discharged, patients are anxious to get home and don't listen carefully to their discharge instructions. That's why we make follow-up calls and give them an opportunity to ask questions," he says.
The hospital has assigned pharmacists as pharmacist coordinators for patients with conditions that put them at risk for treatment failure, including heart failure, organ transplant, and pain management. "The pharmacists are experts in therapies for the diagnoses and provide extensive education to the patients as well as working closely with the treatment team to plan the discharge and the medication regimen. Our involvement with the organ transplant team is very intensive. We have three pharmacist coordinators who work with all disciplines, including case management," Powell says.
The hospital is developing a staffing model redesign so pharmacists can expand their ability to initiate a pharmaceutical case management program. The goal is to develop a pharmacotherapy program for every patient. The initiative includes patients with high-risk diagnoses including heart failure, diabetes, and other chronic diseases with high readmission rates. Once the patient is admitted, the pharmacist completes an assessment and suggests a medication treatment plan for the duration of the inpatient stay. "The pharmacist interventions help avoid adverse events caused by interactions and potential therapeutic failure," Powell says.