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Improving Transitions of Care

Published on 01 April 2014

At the Core: How Pharmacists are Improving Transitions of Care

Story by Stacy Austerman
Illustrations by Peter & Maria Hoey


Whether a person is moving from operating to recovery room, hospital to home, or home to skilled-care facility, each transition of care can become a complicated, intricate process. Pharmacists, physicians, nurses, and other health care team members may interact with patients at each transition, and new information, including tests, scans, lab results, and medication changes, may occur and needs to be shared.

Each care transition requires every member of the health care team to correctly communicate and properly educate each other and the patient to ensure that the patient receives the best possible care. Yet, when breakdowns in care occur, a patient’s transition of care can be mishandled and a person’s health and well-being are at risk. In an effort to save lives and stop a sometimes endless cycle of readmission rates, pharmacists are searching for ways to improve transitions of care. As the critical link between health care systems and patients, they are medication managers who are transforming the spectrum of health care.

The Affordable Care Act Effect

While transitions of care can take place in any health care setting, significant attention is currently focused on a patient’s transition of care from hospital to home or out­patient facility. An alarming number of patients, especially Medicare patients, are being readmitted to the hospital not long after they are released. On average, nearly 20 percent of Medicare beneficiaries who were discharged from the hospital were readmitted within 30 days of their release, and 34 percent were readmitted within 90 days. “The elderly are the most common population to be readmitted into the hospital,” says Tricia Berry ’94/’95, Pharm.D., interim senior associate dean of pharmacy, interim chair of the pharmacy practice department, and professor of pharmacy practice. She and Terry Seaton, Pharm.D., professor of pharmacy practice, along with other College faculty, have proposed researching transitions of care models, especially those that focus on pharmacists’ roles in improving care. “Also, patients with certain medical conditions are more likely to have recurring hospitalizations,” Berry says.

Currently, the staggeringly high rate of readmissions is costing the United States health care system about $25 billion annually. In an effort to improve readmission rates, especially in Medicare and Medicaid patients, the federal government added a provision to the Affordable Care Act. The Hospital Readmissions Reduction Program requires the Centers for Medicare and Medicaid Services (CMS) to reduce payments to acute care inpatient prospective payment system hospitals with excess readmissions. Beginning in October 2012, hospitals whose readmission of patients within 30 days of release were higher than the national average saw withholdings of reimbursements from CMS. “The penalties from the federal government are costing some health systems millions of dollars,” Seaton  explains. “They have started searching for ways to avoid the penalties by improving transitions of care.”

The Critical Link

In order to improve transitions of care, the causes for the high number of readmission rates must be identified. According to the Joint Commission, a nonprofit organization that accredits health care systems nationwide, three types of breakdowns occur when a patient is discharged from the hospital: communication, patient education, and accountability.

“While a patient is in a hospital, it’s a routine process for members of a care team to communicate issues, but we have not had that same mindset when it comes to a patient’s discharge,” Seaton says. “We need to rethink our paradigm of communication. We’re usually talking with patients who may not be the best communicators because of their environmental situation. They may still be sick and possibly overwhelmed or scared. We may try to communicate instead with a caregiver, but not every patient has one.”

To Berry, a key breakdown in communication comes from inadequate information available to long-term providers in the outpatient setting. “If information, especially information about a patient’s medication regimen, isn’t properly communicated to the patient’s primary care physician or community pharmacist, a mistake could occur that sends the patient spiraling back into the hospital. The community pharmacist needs to be aware of any medication changes, so they can update the patient’s medication records and help him or her understand what the medication regimen should be.”

Amy Drew, Pharm.D.Amy Drew, assistant professor of pharmacy practice, agrees with Berry’s assessment. “Picture yourself as a patient in the hospital. You’ve been seen for a recent illness, and your entire medication list can change dramatically. You’re given a sheet of paper that says which medications to start, continue, and stop. That’s assuming it is the most current piece of paper because that is what the patient will rely on.” Drew, who works at Mercy Clinic Family Medicine, a physician-based clinic, often follows up with patients on medication reconciliation and adherence. “When I call a patient to review his medications, I’m using that same sheet of paper. As I go through it, the patient may just read off the paper. But what he really needs to do is go through his medication bottles and tell me what he’s actually taking and why he’s taking it. If that isn’t happening, it is potential for serious breakdowns and health risks.”

Just as proper communication with a patient is important, so is patient education and health literacy. “Not enough time is spent educating patients,” Seaton says. “It can be a lengthy and costly process, especially when patients have unique educational needs. That is why pharmacists are key, especially in the medication reconciliation process. Patients enter and leave the hospital with complex medication histories and medical problems and need the expertise of pharmacists.”

Jamie Pitlick, assistant professor of pharmacy practice, further explains the critical role of pharmacists. Pitlick, who works at Mercy JFK Clinic, a hospital-based clinic that serves patients who are uninsured or covered by Medicare and Medicaid, has seen firsthand the adverse effects caused when patients don’t understand the medications they are prescribed. “I work with a low socioeconomic and low health literacy population,” she explains. “Many times a practitioner makes a medication decision, and the patient is told about the decision, but she may not understand it. When I make follow-up calls with patients, they may tell me they were prescribed something, but they don’t know why. My role is to help them understand, so they can get proper treatment and get better.”

“In a number of conversations I’ve recently had,” Drew says, “patients share that they don’t understand why they are or are not taking a certain medication. For instance, a patient told me he started taking a new cholesterol medication. He didn’t know why, especially since he didn’t have a cholesterol problem. What he didn’t understand was that the medication doesn’t just treat high cholesterol. There may be additive benefits for him outside of lowering cholesterol. Pharmacists are in a great position because we have the understanding not only about the drug, but why it is the best choice for the patient. We can provide that linkage for the patient, which can make the difference between them taking it or not taking it.”

Finally, accountability for both practitioners and patients need to be improved. “Prior to the recent implementation of CMS penalties, accountability for patient safety and quality really focused on inpatient care,” Berry says. “But with the new regulations, you see the accountability shifting. The primary care provider is no longer the one who is solely responsible for what’s happening in the outpatient environment. Now the hospital also has an interest in outpatient care. We’re seeing the formation of accountable care organizations to bring together multiple providers across a health system, so they can work and communicate more successfully.”

Transforming the Spectrum of Care

Several transitions of care models are being implemented across health systems nationwide to reduce readmission rates and improve the quality of patient care. Many involve the critical role of the pharmacist as the health care professional who links the patient from hospital discharge to outpatient recovery and who can best educate patients on medication adherence.

Berry and Seaton have partnered with several health care and research institutions to create a transition of care model to improve readmission rates and overall patient care. At the center of the model are pharmacists, both in the hospital and in the community. “The most important feature of our research is to connect the hospital pharmacist and the community pharmacist,” Seaton says. “Right now, those two entities don’t communicate at the time of transition of care from the hospital to home and vice versa.” He continues, “When a patient is admitted to the hospital from home, the community pharmacist has this wealth of drug information about the patient that doesn’t get shared with the hospital pharmacist. It’s really the initial medication reconciliation. Our second most important feature is patient education and empowerment. Both in the hospital and also in a repetitive sequence in the outpatient setting there would be education focusing on different aspects of care.”

Jamie Pitlick, Pharm.D,Berry and Seaton’s model includes a unique aspect for improving communication. “Many hospitals are shifting to electronic records,” Berry says. “However, they are not connected across health care systems yet. So an electronic health record, while visible at the hospital, may not be viewable at the physician’s office or the pharmacy. We are proposing the use of a platform that would connect those systems, so inpatient and outpatient providers can communicate. This platform is critical in helping community pharmacists be better informed and provide the best possible support to their patients.”

Berry and Seaton are collaborating with Barnes-Jewish Hospital, Walgreens, and the Missouri Pharmacy Association and its Missouri Pharmacists Care Network. “This way, any pharmacist in Missouri could participate,” Berry says. “Both retail and independent pharmacies could take part in the education and training.” In addition, Essence and Aetna health insurance companies joined the collaboration to provide data analysis of health care costs.

Both are confident that their model can elevate the role of the pharmacist in patient care and improve readmission rates. “We are talking about a systematic change,” Berry says. “We are transforming patient care.”

Drew and Pitlick are also collaborating on a transitions of care model. As pharmacists through Mercy health system, they are working together to research and analyze readmission rates connected to their respective clinics. “Jamie and I both practice in ambulatory care clinical pharmacies,” Drew says. “We’re in the position to catch and correct medication errors with the primary purpose of improving patient care and the quality of care for patients.”

Both pharmacists took a proactive approach to being involved in collaborative efforts. “We saw an important role we could play on our health care teams,” Pitlick says. “We took the initiative and created these roles in our respective clinics. I learned a resident physician at my clinic was beginning a scholarly project on ways she could improve the way patients are cared for. She mentioned transitions of care, and I asked her what I could add. Together we agreed on what she and I would focus on when we counseled patients at the clinic.”

“I was in a unique position where I had an inpatient clinical pharmacist as the counterpart to my outpatient role,” Drew says. “When that person left and the position hadn’t been filled, we noticed that those patients who were in the hospital were missing out on the benefits of having an inpatient pharmacist who could counsel or talk to them about medications they were being prescribed at discharge. Since I work  in the same health system as the physicians and patients, I realized I could step into that medication management role. I could speak to patients on the phone or talk to them in the office when they come for their follow-up appointment. I speak to them about any medication changes or questions or concerns they may have, and then I forward that information to the physicians before their appointments.”

Together Drew and Pitlick are evaluating results from both of their clinics. “We are analyzing our readmission rates within 30 days and 60 days prior to when we started our collaboration,” Pitlick says. “Then we’ll evaluate readmission rates from a few months into the collaboration. We’ll also look at how many patients were contacted and how many discrepancies were found.”

“We’re using readmission rates as one of the drives to show the importance of pharmacists’ involvement,” Drew says.

Both pharmacists agree they have seen positive results from acting as liaisons between patient and physician. “I was working with a patient who recently started on two types of insulin in the hospital,” Pitlick says. “She was on a very small dose, so one packet of medication lasted more than one month. About a month after being discharged from the hospital the patient came to the clinic with blood sugars in the 300s and 400s, and the week before her sugars were in the upper 100s. The providers were brainstorming on reasons why the sugars changed so quickly, and they asked me to speak with the patient.” Pitlick spoke with the patient, asking her what medications she was currently taking, when she used them, and where she stored them. “She was storing all of her medications on her kitchen table, and since most medications only last for 28 days at room temp­erature, her insulin lost its ability to work. She came back the next week to clinic and her blood sugars were back down to the upper 100s. This is not only a great example of how talking with patients and helping them to under­stand their medications helps but also how pharmacists can work alongside medical providers to help in the problem solving.”

The Best Team Member

Models for transitions of care are constantly evolving, and new data is being developed each day to offer solutions to avoid patient re-hospitalizations. “The role of pharmacists in these new health care models is as medication managers,” Seaton says. “There are standards for medication management, and pharmacists need to be recognized for providing a consistent and dependable level of care.” There is a growing opportunity for recognition through transition of care improvement models. “The future of health care is team-based care,” Seaton says. “Pharmacists have to be a part of the team because they are the most qualified team members to manage drug therapy. If a pharmacist isn’t integrated within a health system in some way, now is the time to do it.”  

This article originially appeared in the Spring, 2014 issue of Script.

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