US Pharm. 2009;34(8):49-57.
Various studies have focused on evaluating the impact of pharmacist-provided discharge counseling on patient outcomes.1-5 A recent literature evaluation showed benefits from interventions by clinical pharmacists in both inpatient and outpatient settings. Services included medication reviews and reconciliations, therapy recommendations, and medication discharge counseling. Pharmacist-provided discharge counseling continues to grow with an increased clinical role for pharmacists in the health care field.1-5 In addition to providing background information, this article will focus on a pilot study where pharmacy students, with the supervision of clinical pharmacists, provided medication discharge counseling to patients at a hospital in Pennsylvania.
A randomized study was conducted involving 178 patients being discharged from a teaching hospital.1 The intervention group received discharge counseling provided by pharmacists, which included a review of medications, side effects, indications, directions, and barriers to compliance, as well as a telephone follow-up 3 to 5 days later. The control group was discharged without comprehensive counseling by pharmacists. Pharmacists reconciled the discrepancies between preadmission and discharge medications. During the follow-up, pharmacists reviewed compliance, adverse effects, and adherence with the medication schedule. Thirty days after the discharge, preventable adverse effects, which were the primary outcome of the trial, were found in 1% of patients in the intervention group and in 11% of patients in the control group, which was statistically significant (P = .01). The rate of preventable, medication-related hospital readmissions was 1% in the study group and 8% in the control group (P = .03). The article concluded that patient discharge counseling provided by pharmacists, along with medication review and follow-up, were directly associated with a lower rate of preventable adverse effects.
A study of 165 elderly patients was conducted to evaluate the benefits of patient medication counseling.2 Sixty patients were counseled by a clinical pharmacist on name, purpose, and administration of medications before discharge. They were asked to repeat the information until satisfactory answers were given. Forty-five patients were given the same type of counseling plus memory aids to help them with drug administration at home. Sixty patients did not receive counseling or memory aids but just brief description of the tablets. All patients were assessed for compliance, medication errors, dose schedule, and administration at 7 days, 6 weeks, and 12 weeks after discharge. The results showed that medication errors were approximately three times more common in the group of patients who did not receive counseling. This suggests that clinical pharmacists should provide medication counseling prior to discharge and that counseling reduces medication errors.
Another study analyzed a specific implementation of discharge counseling provided by pharmacists in a Veterans Affairs (VA) hospital.3 Pharmacists staffed various patient care units where they conducted admission interviews, verified physicians’ orders, participated in patients’ rounds, and provided medication discharge counseling. Pharmacists educated patients on all of their medications, including administration, side effects, interactions, precautions, and compliance. Preliminary results of this study suggested a decrease in the number of unnecessary medications, a significant reduction in costs, and an increase in patient satisfaction with the hospital, indicating that pharmacists’ counseling prior to discharge should be an established practice.
In many hospitals, health care providers other than pharmacists perform patient counseling prior to discharge, which mainly consists of providing a list of medications and how to take them. Given the fact that pharmacists are experts in pharmacotherapy and pharmacology, they are poised to provide the most comprehensive and efficacious education to patients prior to their discharge from institutional settings. The studies previously described demonstrate the effectiveness of discharge counseling conducted by pharmacists that includes a thorough explanation of side effects, overdose, storage, contraindications, drug interactions, and safety procedures. Pharmacists and students possess the knowledge and skills to be involved in more in-depth pharmacotherapy counseling. Thus, patient medication discharge counseling provides an opportunity for students and pharmacists to improve patients’ therapeutic outcomes.
Pilot Student Study
Lake Erie College of Osteopathic Medicine (LECOM) School of Pharmacy conducted a pilot study with a pharmacy student on a 6-week Advanced Pharmacy Practice Experience (APPE) that concentrated on hospital medication discharge counseling. The pilot was completed in 2008 and the purpose was to determine if counseling by a pharmacy student was beneficial to patient care. The site of the study was Millcreek Community Hospital in Erie, Pennsylvania, a 200-bed teaching facility affiliated with LECOM School of Pharmacy.
Objectives: The primary objective of the study was to determine if counseling by pharmacy students with the supervision of clinical pharmacists would enhance patients’ care services. Specifically, potential benefits of medication discharge counseling by pharmacy students and clinical pharmacists were evaluated in this research study.
Methods: Pharmacists, nurses, and physicians notified the pharmacy student when a patient would be discharged. The pharmacy student would immediately review the patient’s medical record to identify any drug–drug or drug–disease related problems. Any problems or pharmaceutical interventions needed were immediately brought to a pharmacist’s attention. If there were no problems, the discharge counseling process continued. Next, the home medication discharge list was obtained from the patient’s medical record. Patient information leaflets were gathered from MedlinePlus, a free site provided by the U.S. National Library of Medicine and National Institutes of Health. Once the patient gave consent for counseling, a pharmacist and the pharmacy student would begin the counseling session. A discussion was held between the pharmacy student and the supervising pharmacist prior to the session to ensure that correct information would be provided to the patient.
During the counseling session, the pharmacist would stand outside the patient’s room and let the pharmacy student go into the room alone and counsel the patient. The pharmacist would be in close proximity in order to see and hear the counseling session being performed. At the end of the session, the pharmacist would walk into the room and correct or verify any information. However, in some instances there was no need for the pharmacist to do so because the pharmacy student performed adequately.
The patient received verbal and written information on each medication, including new medications the patient was to start on after discharge from the hospital. A basic counseling session covered the following points: the name and description of the medication, the route of administration, dosage form and duration of drug therapy, administration and use by the patient, common severe side effects or interactions, therapeutic contraindications that may be encountered (including their avoidance), and the action required if they occurred. In addition, techniques for self-monitoring drug therapy, proper storage, prescription refill information, and action to be taken in the event of a missed dose were discussed with the patient. After every medication was explained, the patient was prompted to repeat the information to state verbal understanding of the information given. After a short question-and-answer period at the end of the counseling session, the patient was given printed instructions on his or her medications from MedlinePlus, and the patient was permitted to leave the hospital.
When the counseling session was completed, the pharmacy student documented the session in the patient’s medical record and in the pharmacy computer system, which were both cosigned by a pharmacist. A short telephone quality assurance survey was completed following the patient’s discharge. The survey evaluated the patient’s understanding of the counseling information given, satisfaction, and opinion about the value and benefits of the counseling session (TABLE 1).
Results: The pharmacy student counseled a total of 18 patients during the 6-week rotation. The average number of medications was 5.33 per patient, with two patients counseled on only one medication. Patients varied in disease states, including heart failure, hypertension, gastro esophageal reflux disease, hypercoagulable states, coronary artery disease, depression, hyperlipidemia, anemia, pneumonia, stroke, and knee and hip surgeries. Eight patients completed the phone survey, with the majority of them agreeing or strongly agreeing that counseling by a pharmacy student was beneficial (TABLE 2).
Discussion: Many patients were not aware of some of the side effects or interactions of the medications they were taking, and all the patients expressed satisfaction immediately after the counseling session and really appreciated the knowledge about their medications. One patient had been readmitted to the hospital as a result of poor understanding of medications due to a lack of prior discharge counseling. The counseling session provided by the pharmacy student clarified the patient’s wrong interpretation of therapy. In this case, the counseling clearly made a difference and improved the patient’s understanding of the therapy. Many counseling sessions lasted 30 to 40 minutes depending on the number of discharge medications. On one occasion, the session lasted 1 hour. Patients asked questions during the counseling sessions, and attention was paid to avoiding conversation that would steer away from focusing on medications. The survey results indicated that a great majority of patients agreed or strongly agreed that the counseling was beneficial for them. Counseling appeared to give clear instructions on administration and side effects, and improved overall understanding of therapies.
In Pennsylvania, pharmacy students are unable to counsel patients on medications without the supervision of licensed pharmacists. In many hospitals, other health care professionals are given the task of providing discharge counseling to patients because of the current pharmacist shortage. Pharmacy students in their final year have more training than other health care professionals on medications, and this study may be an indicator that pharmacy students, an untapped resource, can provide effective patient discharge counseling in a hospital setting. Future research needs to be conducted to assess the effectiveness of pharmacist- and student-provided discharge counseling among a larger patient population and the impact of implementing a specific protocol to include pharmacist-provided discharge counseling as part of the discharge process.
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2. MacDonald ET, MacDonald JB, Phoenix M. Improving drug compliance after hospital discharge. Br Med J. 1977;2:618-621.
3. Saunders SM, Tierney JA, Forde JM, et al. Implementing a pharmacist-provided discharge counseling service. Am J Health Syst Pharm. 2003;60:1101,1106,1109.
4. Steinman MA, Rosenthal GE, Landefeld CS, et al. Conflicts and concordance between measures of medication prescribing quality. Med Care. 2007;45:95-99.
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6. Kramer JS, Hopkins PJ, Rosendale JC, et al. Implementation of an electronic system for medication reconciliation. Am J Health Syst Pharm. 2007;64:404-422.
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