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 reimbursement rates.

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.

Current Practice

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 patient use.

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 changes.
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 months.

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.


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