Making pharmacists part of the multidisciplinary team
Their expertise can help improve outcomes
If your hospital doesn't use pharmacists to collaborate with the multidisciplinary team, review medication during the patient stay, and participate in discharge planning, you might be missing an opportunity to improve patient care and reduce readmissions.
"Medications are one of the most common interventions that patients receive while they are in the hospital. A patient's medication list from admission through discharge and beyond is often complex and sometimes contains discrepancies that need to be corrected, despite everyone's best efforts. Pharmacists have the expertise and knowledge to review the medication and suggest changes," says David Chen, RPh, MBA, director of the American Society of Health-System Pharmacists' (ASHP) Pharmacy Practice Sections and the ASHP's Section of Pharmacy Practice Managers.
Involving pharmacists in the multidisciplinary treatment team is a growing trend, Chen says. "Hospitals are realizing that pharmacists have the expertise to ensure that patients receive the right doses and selection of medication for their disease states, weight, and age as patients prepare for discharge and can be involved in follow-up telephone calls to ensure that patients have filled their prescriptions and are taking their medication correctly," he says.
In addition, pharmacists can improve patient access to prescriptions by eliminating barriers that delay filling prescriptions and managing difficult prior authorization processes, he says. "Pharmacists can help the case managers and social workers deal with complex prescription benefit plans. More and more insurers are requiring preauthorization for prescriptions. Pharmacists can address this issue before discharge and make sure patients have everything they need to get their prescriptions filled," he says.
Pharmacists can advise physicians on choosing medications that are in the patient's insurance company's formulary and those that are affordable, Chen says.
"There are more than 85,000 drug products in the market place and more than 110,000 diagnoses. There's no way a physician can be knowledgeable about everything, and that's why pharmacists are an important part of the treatment team," adds Michael Powell, MS, FASHP, executive director of pharmaceutical and nutrition care at The Nebraska Medical Center in Omaha.
About 40% of patients fail to get their prescriptions filled within two weeks of discharge, and of those, 80% never get them filled; in the vast majority of cases, it's because they can't afford the medication, Powell says. (For details on how pharmacists at The Nebraska Medical Center interact with patients and collaborate with the treatment team, see related article on page 16.)
"Pharmacists have the knowledge to point out when a patient may not be able to afford a medication and suggest a substitute. Cost of medication is something that rarely is on the radar screen of doctors and nurses," adds Amy Boutwell, MD, MPP, president of Collaborative Health Strategies, a healthcare consulting firm based in Lexington, MA.
When case managers and pharmacists work together, everybody wins, says Brenda Keeling, RN, CPHQ, CCM, president of Patient Response, Inc., a Durant, OK, healthcare consulting firm.
She tells of a situation in which a physician gave a patient on IV antibiotics in the hospital a prescription for oral antibiotics to get filled at home. The patient's daughter was savvy enough to ask the hospital pharmacist about the medication and discovered that it would cost the patient $1,500. "There was no way the patient could afford it. Fortunately in this case, the pharmacist was able to consult with the physician and suggest an alternative. If not for the pharmacist, the patient most likely would not have filled the prescription and would have possibly ended up back in the hospital as a readmission," she says.
Multidisciplinary rounds, when the team gathers to discuss the care plan, is the perfect time for pharmacists to review medications and give input into patient care, expressing concerns about doses or potential drug interactions, Boutwell says. Then as discharge approaches, the pharmacist should review the prescriptions the patients will take after discharge.
"Medication management when the patient comes into the hospital and leaves is perhaps the most important medical issue that needs to be attended to, from both a patient safety aspect and from a medical quality standpoint," she says.
Many hospitals use a discharge checklist to make sure that all the recommended tasks are completed before discharge, such as reviewing medication and the patient's ability to pay for it, educating the patient on the medication regimen and discharge plan, determining the patient's support system and needs after discharge, and making sure the patient has a follow-up appointment with a physician and has transportation to the appointment.
"The checklist is overwhelming for any one person, whether it's a nurse, a doctor, or a case manager. It makes more sense to step back and work as a team, assigning the best person to the task. When it comes to medication issues, pharmacists are the experts," she says.
"The pressure on the healthcare system to improve care helps us identify who on the healthcare team is trained and well suited to do various jobs. In the old model of hospital care, doctors and nurses divided discharge planning tasks. We weren't very thoughtful about who was the best professional on the team to perform this work," she says.
Involving pharmacists in patient care not only results in using the best professionals to do the job, it helps break down the silos in which healthcare professionals often operate, Boutwell says.
"It makes so much sense to engage the pharmacist as part of the healthcare team. Pharmacists have the opportunity to help coordinate care as they work with the rest of the treatment team to ensure that the patients receive the care they need while they are in the hospital and are fully informed about their medication, how to take it, and the importance of following their treatment plan," says Patrice Sminkey, chief executive officer for the Commission for Case Management Certification.
There is a huge opportunity to improve patients' medication adherence, and pharmacists have the knowledge and expertise to do so, Sminkey says.
Patients often are discharged with numerous oral medications and a complicated and confusing medication regimen, she points out. Some medications have to be taken with food, some on an empty stomach. Some are taken twice a day, others every other day. "When my mother was discharged with multiple medications, I felt a little overwhelmed, and I have years of experience in healthcare," she says. Having an expert spend time at the bedside educating the patient is a simple solution that could vastly improve outcomes, she says.
Pharmacists are the best-equipped members of the team to educate patients about the importance of taking their medication and to help them understand a complex medication regimen, Chen says.
Interventions by pharmacists in addition to the regular discharge teaching help patients feel more confident in following their medication regimen, Chen says. "Pharmacists recognize the complexity of the medication regimen and have the knowledge to help patients understand it," Chen says. In some hospitals, pharmacists contact patients after discharge to discuss their medication regimen and help patients navigate the issues with medication they may be having, he adds.
Pharmacists are invaluable when it comes to medication reconciliation, Chen adds. When patients are in the hospital, the treatment team focuses on the reason for the hospitalization, but many patients have chronic conditions or comorbidities and take medication for that as well. "The way our healthcare system operates, each specialist may be looking at his or her particular piece," Chen says. Pharmacists look at how all the medications fit together—those that patients were taking when they came in and those they take in the hospital, as well as those prescribed upon discharge. They can review the medications as they change during the inpatient stay and make sure patients are taking the right medication and right dosage, he adds.
For instance, many seniors are taking six to 10 medications and seeing different specialists. The pharmacist has the ability to step back and look at the patient's situation in its entirety, focusing on the medications and how they fit together, Chen says.
"There is tremendous value in having a pharmacist review all medications at the time of discharge," Keeling says. "Often, patients don't understand their medication instructions and a thorough medication reconciliation review is not completed, so patients don't follow their plan and end up back in the emergency department or the hospital," she says.
Hospitals are expanding the role of pharmacists as one of several new strategies to use the workforce they have in a better way, Boutwell says.
"Pharmacists and the allied professionals that support them are well suited for this job. It provides job satisfaction for pharmacists as well as providing a service to other clinicians and patients," she says.
Some hospitals are developing pilot programs that move pharmacists from the pharmacy to the floor for a few hours a day. They attend multidisciplinary rounds to help with medication reconciliation and to review medication lists for interactions and dosages, Boutwell says.
Sminkey tells of one model in which a retail pharmacist comes to the hospital bedside and reviews the discharge medication with the patient. "This is a small model with outcomes yet to come, but it's logical to think this would improve outcomes. A pharmacist can help patients understand the need for medication adherence, identify compliance issues, and review the medications for duplications and interactions," she says.
In some hospitals Keeling has worked with, pharmacists are involved in discharge planning rounds every day. In others, pharmacists are assigned to specific units and work closely with the case managers to review every order the patient receives.
"The only problem is that it's difficult to find enough pharmacists for the job," she adds.
Some hospitals are using pharmacy residents to help facilitate education and discharge planning, Chen says. Others are using the revenue generated from their outpatient pharmacy to hire additional pharmacists.
As hospitals recognize the value of pharmacists in supporting the prevention of readmissions and improving care, they are beginning to reassess where they allocate resources and are investing in increasing efficiency in patient treatment and the discharge planning process, he says.