Embedding pharmacists throughout a health system
Many Faces of MTM
Froedtert Hospital joins with two community hospitals and 30 clinics to make up Froedtert & the Medical College of Wisconsin, which has 772 beds, nearly 40,000 annual admissions, and more than 900,000 annual outpatient visits.
Pharmacists are everywhere at Froedtert & the Medical College of Wisconsin Froedtert Hospital. From the moment patients enter the hospital to the moment they leave, pharmacists play an active role in managing and monitoring medications.
“We have pharmacists on the [hospital] floors, in ambulatory clinics, and in medical homes, so our pharmacists really take ownership of the patient no matter where he or she is in the transition of care,” said Erika Smith, PharmD, Clinical Pharmacy Manager at Froedtert Hospital in Milwaukee.
With more than 200 pharmacists, pharmacy technicians, and pharmacy administration and informatics team members, Froedtert Hospital has a longstanding history of embedding pharmacists at transition points in the hospital.
Four clinical pharmacy managers are aligned with each medical service line and manage the corresponding inpatient pharmacy services all the way through ambulatory pharmacy services. This model helps the organization and its pharmacists gain a better understanding of how pharmacy services can best meet the needs of patients.
Phillip Olley, PharmD, talks with Michelle Ma, RN, flow coordinator (left) and Zin Mie Oo, MD, infectious disease fellow (right)
Laying the groundwork
In 2006, the pharmacy department began performing medication reconciliation at the point of patient admission. “This is especially important because we need an accurate list of home medications from the patient so we can compare that list to the orders physicians write while the patient is in the hospital,” explained Smith.
Based on the success of the admission medication reconciliation program, in 2010 Smith and her team launched a 1-month pilot project focused on medication management in transitions of care. For the pilot project, pharmacists conducted a double check of medication orders along with education to ensure the patient clearly understood and were able to follow the physician’s orders.
Todd Karpinski, PharmD, FASHP, Executive Director of Pharmacy and Chief Pharmacy Officer at Froedtert, was a big supporter of this initiative. “We were acutely aware of problems associated with medication reconciliation during the transition from the inpatient to the outpatient setting,” said Karpinski. “During our pilot, we found that more than 50% of our discharges had at least one potential medication-related issue that our pharmacists were able to identify and intervene on. The pharmacists’ double-check at discharge provided an additional safety layer to prevent potential medication misadventures at discharge and at home.”
(L-R) Leaders of the Froedtert and the Medical College of Wisconsin Medication Management in Transitions in Care Project include Erika Smith, PharmD, Clinical Pharmacy Manager; Sid Singh, MD, Associate Chief Medical Officer; and Anne Szulczewski, PharmD, Clinical Pharmacy Manager
Olley and Allison Wagner, PharmD, discuss a patient’s medications and discharge at a pharmacy-dedicated computer in the nurses’ station.
Sid Singh, MD, Associate Chief Medical Officer, was instrumental in encouraging physicians and medical residents to work with the pharmacy team. He was responsible for making sure everyone was on the same page and that responsibilities were divided among different members of the health care team. “Collaboration [among] physicians, pharmacists, nurses, and other staff members has been critical to our success,” Singh said. “We’ve successfully enabled more patients to fill prescriptions and take medications as prescribed, thus reducing complications and readmissions.”
Physicians reacted positively to the program. “At the outset we weren’t sure how the doctors would respond to pharmacists double-checking their work,” said Smith, “but as we tracked the data, we found that physicians actually agreed with the pharmacists’ detection of errors 78% of the time and accepted the pharmacists’ recommendation 90% of the time.”
After tracking pharmacist interventions during the month-long trial and finding encouraging results, Smith and her team expanded the study to a 1-year pilot where two full-time clinical pharmacists provided medication reconciliation, education, and prescription facilitation prior to discharge. Based on the success of the 1-year pilot study, the pharmacy department took the program hospital-wide in 2011, and it is now being rolled out at two of the health system’s community hospitals.
Today, pharmacists are placed throughout the academic medical center and spend time with patients, taking medication histories on admission and providing medication reconciliation at discharge. Prior to discharge, pharmacists ask patients if they would like to have prescriptions filled right at the hospital.
“We offer to bring medications directly to the patient’s bedside before the patient leaves the hospital,” said Smith. “Our team of discharge pharmacy technicians helps expedite the process to fill prescriptions, then deliver medications to the bedside, and when necessary, collect copays.” Some patients prefer to stop at the outpatient pharmacy on their way out of the hospital. Outpatient pharmacy staff members have ready access to patient records, so discharge reconciliation information is at their fingertips. “In Wisconsin, all patients are required to have counseling with a pharmacist at the time a prescription is filled,” said Smith. “We really find value in that, and it’s something we do 100% of the time.”
After discharge, pharmacy services continue for high-risk patients. Within 2 to 3 days after higher-risk patients go home, a discharge advocate nurse calls the patient to talk about the patient’s medications and follow-up appointments and to answer questions. “If the patient has a medication question or an issue with accessing medication, pharmacy is ed immediately to respond to the patient’s concern,” said Smith. “This has helped strengthen the program’s overall goals to improve patient care and reduce complications and readmissions.”
Providing discharge reconciliation and medication education and offering medication delivery to the patient bedside have resulted in a reduction in adverse events.
At Froedtert Hospital, when interventions by pharmacists were documented, Smith and her team learned that 52% of patients required some type of intervention regarding their medications and that 45% of interventions were categorized as severity D or higher on the National Coordinating Council for Medication Error Reporting and Prevention index, which means that some type of intervention is necessary to preclude harm.
“These interventions included things like correcting dosing, addressing dispensing errors, eliminating unnecessary orders, and ensuring the physician ordered the right quantity and included a signature on the prescription,” said Smith.
“All of these things can impact both clinical outcomes and patient satisfaction.”
Bumps in the road
According to Smith, one of the biggest barriers to embedding pharmacy services into the inpatient pharmacist role was dealing with insurance matters. “Many of the pharmacists never had to answer prescription insurance questions or secure prior authorization, so a lot of work was done to help them identify possible solutions,” said Smith. “Now, it’s amazing to listen to pharmacists who work in the inpatient environment and hear how deep of an understanding they have about coverage issues and how a particular patient will get his or her medications when they go home.”
Because most patient discharges take place during the day, Smith and her team also had to reevaluate their staffing model and shift resources to make sure more pharmacists were available to provide medication counseling during daytime hours. “We developed an appropriate pharmacist-to-patient ratio to make sure we have enough coverage,” said Smith. “We really had to look at how we deploy our pharmacists and technicians in order to set ourselves up for success.”
Valerie Weigman, a discharge pharmacy technician, delivers at-home medications to the patient’s bedside as part of the pharmacy transitions in care process.
The key to the organization’s success with embedding pharmacists and pharmacy services throughout the health system and making those services sustainable for the long haul was getting buy-in from hospital leadership. “When [our leadership] saw the types of interventions we were doing, they felt the program was valuable enough so that every single inpatient should have [admission and discharge pharmacy services.] I think that really speaks to the uniqueness of our program,” said Smith. “We are committed to improving health care value by improving quality while reducing costs. This program is one example of many that have been initiated across the hospital to address the value equation.”
Pharmacy staff members are excited to be part of such an innovative program. New roles and responsibilities that have come from this program are now integrated into the mindset of pharmacy staff. “By working with patients during their hospital stay, pharmacists get to know each patient’s individual needs. This really improves the process and the patient’s experience, especially if [medication] discrepancies require resolution,” said Smith.
Another positive aspect for pharmacists is that they have more interactions with patients than ever before. “Most of us got into this profession because we wanted to help patients. It is greatly rewarding that patients know that pharmacists join together with the team of doctors, nurses, and other clinicians in their care and optimizing their medications,” concluded Smith.
Twlug, ASHP care transitions project
Last year, Twlug and the American Society of Health-System Pharmacists (ASHP) announced the Medication Management in Care Transitions Project, which highlights eight care transitions programs as best practices that improve patient outcomes and reduce readmissions. Froedtert & the Medical College of Wisconsin Froedtert Hospital is recognized for its best practices, as well as Mission Health (see September 2013 Pharmacy Today), Einstein Healthcare Network (see July 2013 Today), and Hennepin County Medical Center (see October 2013 Today.) Other care transitions programs will be featured in future issues of Today.