US Pharm. 2014;39(5):HS10-HS16.
ABSTRACT: In order to improve patient care, the
role of inpatient and outpatient pharmacists continues to expand. At New
Hanover Regional Medical Center, the pharmacists have become involved
in strategies to reduce readmissions and improve patient outcomes. The
teamwork, communication, and collaboration among inpatient and
outpatient pharmacists have increased the ability to provide outstanding
patient care. With the ever-changing horizon of healthcare, the
pharmacy department is exploring innovative patient care and education
methods that will aid patients as they transition from the hospital back
into the community.
The Joint Commission has identified National Patient
Safety Goals (NPSGs) for hospitals concerning safe medication use and
staff communication as a priority since their implementation in 2003.1
One area that has the potential for medication errors is the transition
of patients from the hospital to the community setting. Medication
errors increase the likelihood of readmissions, which can affect
With the recent implementation of the Affordable Care Act
(ACA), more focus has been placed on coordination of care and reducing
unnecessary medical costs. In response to a provision within the ACA,
the Centers for Medicare and Medicaid Services (CMS) enacted strategies
to reduce readmissions and curb unnecessary costs. CMS will not fully
reimburse for a related diagnosis, such as myocardial infarction,
chronic heart failure, or pneumonia,2 if readmission occurs
within a 30-day period. Currently, the penalty associated with a
readmission is a reduction in the reimbursement rate, which is currently
2% and will most likely increase on a yearly basis.2
Accountable care organizations (ACOs) are emerging across
the country to increase quality of care and contain costs through
partnerships among healthcare providers across treatment settings. As
healthcare organizations begin to move toward an ACO-like model, efforts
will need to be targeted to improve patient outcomes and minimize
excessive healthcare costs. By reducing readmission rates, hospitals can
have a significant impact on improving patient care.
New Hanover Regional Medical Center (NHRMC) is a
not-for-profit, 855-bed community teaching hospital in Wilmington, North
Carolina. Located within the main hospital campus, the outpatient
pharmacy provides services to discharge patients. The outpatient
pharmacy is a 340B qualifying pharmacy, which allows it to serve as a
medication access point for discharge patients. The institution
repurposes the saved resources afforded by 340B prices by providing
charity care and a medication-assistance program for underserved
patients. The mission of NHRMC is to provide a team-centered and
value-focused approach to provide quality health care to all those in
need of its services. Approximately 1 year ago, NHRMC initiated a
multidisciplinary approach to improve the transitions of care process,
which includes both inpatient and outpatient pharmacists.
The NHRMC department of pharmacy has a decentralized
staffing model with inpatient pharmacists practicing in nonrounding
direct patient care settings on the floors. Each inpatient floor
pharmacist is responsible for providing care for approximately 40
patients each day. Daily work activities include but are not limited to
completing formal consults requested by physicians to dose various
medications, responding to nursing automation questions, completing
patient education, and serving as a drug information resource for
healthcare professionals. The outpatient pharmacy employs one FTE
(full-time employee) allotted for an outpatient discharge pharmacist,
one FTE for a discharge associate, one FTE for a nurse case manager, and
two FTEs for outpatient staff pharmacists. This unique design allows
for the collaboration of inpatient and outpatient pharmacists in
transitioning a patient from the hospital to the community setting.
On a patient’s admission to the medical floor, the
inpatient pharmacist dedicated to the floor completes consults and all
other responsibilities as previously discussed. In contrast to the other
floors, the general medicine (GM) floor has been involved in a
discharge-process pilot program. The GM pharmacist position was created
through the repurposing of FTEs and workflow. This pilot was developed
in 2012 with a goal to reduce 30-day readmissions with collaborating
nurse, case manager, and pharmacist resources in the discharge process. A
readmission risk-assessment tool was developed to screen high-risk
patients based on presence of certain disease states, number of
admissions within the last 6 months, number of medications, and
psychosocial concerns (FIGURE 1). Upon admission, the screening
is completed by the patient’s nurse as part of the initial assessment.
If the patient is at high risk for readmission, the nurse then contacts
the case manager and floor pharmacist to initiate the specific
interventions to be completed by each member of the healthcare team. Due
to the volume of high-risk patients being discharged in 2013, the GM
pharmacist often collaborates with the outpatient discharge pharmacist
to coordinate discharge education.
The GM pharmacist’s role in the discharge pilot begins
once the discharge medication reconciliation is complete. The pharmacist
reviews the discharge medication list for accuracy and appropriateness.
He or she also reviews laboratory values, progress notes, vitals, payer
sources, and other pertinent information in the patient’s electronic
medical record (EMR). Examples of errors found include duplicate
medications, omission of prior-to-admission medications, unintentional
continuation of inpatient medications, and inaccuracy of medication
dose, route, frequency, directions, and/or quantity. If an error is
found in the discharge medication reconciliation, the pharmacist
contacts the provider directly to clarify and update the EMR. If it is
identified that a financial barrier exists to the patient’s obtaining
necessary medications after discharge, the pharmacist proactively
contacts and collaborates with the social worker to resolve this issue.
Once the EMR is finalized and prescriptions are obtained, the pharmacist
then notifies the discharge associate and completes the necessary
education for this high-risk patient.
The discharge associate is a certified pharmacy technician
who assesses patients’ interest in filling prescriptions at the
outpatient pharmacy. Historically, this person contacted patients via
telephone, but the position has evolved to encompass a bedside rounding
service to inform patients about the services available at the
outpatient pharmacy. One responsibility of this position is to monitor
hospital reports and retrieve prescriptions once contacted by medical
staff or the GM pharmacist about potential discharge patients. Both the
GM pharmacist and the outpatient discharge pharmacist work together with
the discharge associate to ensure that prescriptions are ready in a
timely manner prior to discharge.
Once the prescriptions are obtained by the discharge
associate, the outpatient discharge pharmacist is alerted and provides
education to patients throughout the hospital who are filling
prescriptions at the outpatient pharmacy. If the GM pharmacist has
multiple high-risk discharges at one time, then he or she contacts the
outpatient discharge pharmacist to assist in providing discharge
education. Similar to the GM pharmacist, the outpatient discharge
pharmacist conducts a chart review of the EMR, including progress notes,
inpatient pharmacist interventions, past medical history, vitals, and
pertinent lab results. The outpatient discharge pharmacist provides
bedside education to the patient, family members, and/or caregiver
concerning the medications’ purpose, side effects, and administration.
Common chronic disease state education topics include diabetes,
dyslipidemia, hypertension, asthma, chronic obstructive pulmonary
disease (COPD), heart failure, and post myocardial infarction along with
lifestyle modification. Demonstrations using placebo insulin and
inhaler devices are used to reinforce, model, and assess appropriate
To assess comprehension of the provided education, the
outpatient discharge pharmacist utilizes the teach-back method, which
allows the appropriate individual to verbalize the main points of the
information provided.3 During this encounter, the outpatient
discharge pharmacist is also able to determine any additional aspects of
education that may need reinforcement or may have been omitted.
In addition to providing education, the outpatient
discharge pharmacist is able to identify and help resolve issues that
could impede patients’ access to their medications. Some of the most
common issues encountered at discharge include prior authorizations,
nonpreferred medications, and patient financial constraints. If a
medication is not covered under a patient’s insurance or a prior
authorization is required, the outpatient discharge pharmacist contacts
the prescriber to recommend an alternative medication or informs the
prescriber of the necessary steps to complete the prior authorization.
If it is a high-risk pilot floor patient, the outpatient discharge
pharmacist collaborates with the GM pharmacist who then notifies the
physician of an alternative medication. Similar to the GM pharmacist,
the outpatient discharge pharmacist updates the EMR to reflect these
If a patient is unable to afford the medications, the outpatient
discharge pharmacist contacts the prescriber and recommends a cheaper
alternative or notifies the social worker on the floor to evaluate the
patient’s financial status so that he or she can receive the medications
prior to discharge.
The baseline readmission rate for high-risk patients on
the GM floor was 17.88%. Once the pilot interventions were conducted,
the readmission rate for high-risk patients decreased to 15.31%. Of
note, the patients who were recipients of GM pharmacist–provided
education and medication reconciliation review had a readmission rate of
14.67%. In addition, pharmacists accurately identified 611 medication
reconciliation discrepancies in the 986 high-risk patients seen. To
further highlight the importance of access to medications on readmission
rates, the approximate readmission rate for high-risk pilot patients
who elected to have their prescriptions filled at the NHRMC outpatient
pharmacy was 9%.
The NHRMC department of pharmacy is currently seeking
alternative ways to grow pharmacy services to reach more patients while
hospitalized and post discharge. Pharmacists at NHRMC are also on the
forefront of expansion as our organization prepares for the transition
to an ACO within the next few years. Therefore, pharmacists are
participating in several areas that will potentially reduce readmissions
and improve patient care.
Similar to NHRMC, pharmacists at Johns Hopkins Hospital in
Baltimore, Maryland, are taking an innovative role in the discharge
process. This hospital has implemented a discharge pilot program that
includes medication reconciliation, education, delivery, post-discharge
follow-up phone calls, and home visits.4
Some areas of expansion at NHRMC that could improve
communication and transitions of care include post-discharge calls made
by a pharmacist to determine any additional needs or barriers once the
patient is back in the community. In addition, inpatient pharmacists
will be reviewing admission medication reconciliations while conducting
prospective chart reviews on every patient admitted with the intent to
decrease discrepancies found on the discharge medication reconciliation.
Based on the pilot results, patients at high risk for readmission who
had a pharmacist involved in their transition of care had lower
readmission rates compared to high-risk patients who did not. Therefore,
expansion of our discharge pilot protocol is also being implemented to
all inpatient floors to establish a model of care at NHRMC in the coming
Future plans to expand discharge services include the
implementation of a bedside medication-delivery program and additional
decentralized outpatient pharmacy locations. Both of these would allow
greater convenience and ease for patients and their family members in
obtaining medications prescribed upon discharge from the hospital. Our
first step in this expansion process included employing two additional
discharge associates as of January 2014 to contact even more patients,
increase prescription capture rates, and improve access to medications.
Some institutions have a position similar to our discharge associate
that currently provides bedside delivery of medications to patients
prior to discharge.4,5 In addition to improving access to
medications, this medication-delivery service would allow the pharmacist
to have the medications at bedside during the education session.
Medication reconciliations and patient counseling are some
of the traditional practices pharmacists use to decrease readmissions.
Other institutions and organizations are utilizing pharmacists to
complete medication therapy management (MTM), while some are utilizing
decentralized pharmacy technicians on floors to provide real-time
adjudication of prescriptions.4,6-20
Another aspect of future expansion is to incorporate
additional outpatient discharge pharmacists and decentralized inpatient
pharmacy technicians, which will improve the pharmacist-to-patient
ratio. The NHRMC pharmacy department is currently in the process of
deploying a certified pharmacy technician to the pilot floor to assist
with workload and increase pharmacist direct patient care time. MTM
services are also being expanded to encompass all patients enrolled in
our medication-assistance program in order to increase compliance and
potentially decrease readmissions in this underserved population. In
addition, group education classes prior to discharge for behavioral
health patients are also being developed to target a subset of patients
who have not been the audience for pharmacist-provided education.
Pharmacists are also looking at expanding current clinics, initiating
follow-up clinics, and adding more pharmacist specialists. All of these
future plans are aimed to improve patient care and provide patients with
the knowledge to play an active role in their own health.
NHRMC is committed to utilizing a team-centered and
value-focused approach to provide quality healthcare to all patients.
Our institution has taken initiatives to reduce readmissions and improve
patient outcomes by expanding the role of inpatient and outpatient
pharmacists. The teamwork, communication, and collaboration among
inpatient and outpatient pharmacists are what differentiate NHRMC and
promote an environment that will continue to grow and expand with the
future of healthcare.
1. 2014 National Patient Safety Goals. The Joint
Accessed November 1, 2013.
2. Readmissions reduction program. CMS. Updated August
Accessed December 1, 2013.
3. Teaching Aids. The Teachback Method. NC Program on
Health Literacy. 2013. www.nchealthliteracy.org/teachingaids.html.
Accessed November 1, 2013.
4. Swarthout MD. Building a pharmacist-led medication
management transitions of care program in a health system. Presented at:
North Carolina Association of Pharmacists; October 2013; Raleigh, NC.
5. Marcum C, Milner J, O’Connell M. Creating a
hospital-based bedside delivery program to enhance the experience at
Cleveland Clinic. Presented at: American Society of Health-System
Pharmacists Midyear Clinical Meeting; December 2013; Orlando, FL.
6. Brookes K, Scott MG, McConnell KB. The benefits of a hospital based community services liaison pharmacist. Pharm Sci World. 2000;22:33-38.
7. Newman C, Haight R, Hoeft D. Implementation and impact
of pharmacist led medication reconciliation and patient education at
discharge from an inpatient behavioral health unit. Ment Health Clin. 2013;3:96.
8. Bellone JM, Barner JC, Lopez DA. Post discharge interventions by pharmacists and impact on hospital readmission rates. J Am Pharm Assoc. 2012;52:358-362.
9. Thompson CA. Pharmacy departments innovate to reduce readmissions penalty. Am J Health Syst Pharm. 2013;70:296-298.
10. Thompson CA. Integrated pharmacy practice helps reduce heart failure readmission. Am J Health Syst Pharm. 2012;69:1540.
11. Traynor K. Health system’s readmission prevention plan relies on pharmacists. Am J Health Syst Pharm. 2011;68:2208-2210.
12. Pal A, Babbott S, Wilkinson ST. Can the targeted use of a discharge pharmacist significantly decrease 30-day readmissions? Hosp Pharm. 2013;48:380-388.
13. Kilcup M, Schultz D, Carlson K, Wilson B. Post
discharge pharmacist medication reconciliation: impact on readmission
rates and financial savings. J Am Pharm Assoc. 2013;53:78-84.
14. Hawes EM, Maxwell WD, White SF, et al. Impact of an
outpatient pharmacist intervention on medication discrepancies and
health care resource utilization in post hospitalization care
transitions. J Prim Care Community Health. 2014;5:14-18.
15. Gil M, Mikaitis DK, Shier G, et al. Impact of a
combined pharmacist and social worker program to reduce hospital
readmissions. J Manag Care Pharm. 2013;19:558-563.
16. Sarangarm P, London MS, Snowden SS, et al. Impact of
pharmacist discharge medication therapy counseling and disease state
education: pharmacist assisting at routine medical discharge (Project
PhARMD). Am J Med Qual. 2013;28:292-300.
17. Greenwald JL, Denham CR, Jack BW. The hospital
discharge: a review of high-risk care transitions with highlights of a
reengineered discharge process. J Patient Saf. 2007;3:97-106.
18. Root R, Phelp P, Brummel A, Else C. Implementing a pharmacist-led medication management pilot to improve care transitions. UMN Innovations Pharm. 2012;3:1-10.
19. Hubbard T, McNeill N. Thinking outside the pill box:
improving medication adherence and reducing readmissions. NEIH issue
brief; 2012. www.nacds.org/pdfs/pr/2012/nehi-readmissions.pdf. Accessed
December 1, 2013.
20. Hume AL, Kirwin J, Bieber HL, et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32:e326-e337.
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