As most health professionals have found out the hard way, even thoughtfully conceived treatment plans, painstakingly crafted hospital-discharge instructions and carefully designed drug regimens are of little benefit if patients can't access recommended care or don't adhere to prescribed medication schedules. Outside the hospital, a host of things can thwart the best intentions: Appointments don't get made. Prescriptions go unfilled. Medications aren't taken correctly — or sometimes not at all.
These problems are exacerbated for patients who are medically complex, chronically ill, have limited mobility or have cognitive impairment. Unfortunately, there are inherent limitations in the conventional healthcare delivery system for these types of patients.
Yet, there are ways hospitals and health systems may be able to improve patient compliance. Preliminary data suggests that home visits by pharmacists may increase patient compliance. CareRx, a clinical pharmacy advisory firm based in Irvine, Calif., is utilizing clinical pharmacists "on the ground" to devise timely interventions and ongoing support for patients. As part of its CareRxConnect program, pharmacists make face-to-face residential visits with patients identified as high risk. The objective is to ensure that patients have the correct medications and understand what's supposed to occur, and why.
The visits are making a difference, explains Mark Livingston, PharmD, director of clinical services for CareRx. "In nearly 100 percent of cases, we find that patients need help with planning and scheduling their medications. And more than three-quarters of the time, patients don't understand their drugs or why they're supposed to take certain medications," he said.
Although the program is nascent, preliminary data is showing that the model of embedding a pharmacist as a team member with care-givers and case managers, to conduct face-to-face home visits, is preventing avoidable hospital readmissions. Of 105 patients registered in CareRxConnect through November 2012, there were no readmissions within the first 30 days post-discharge from a hospital or a skilled nursing facility. While such stellar results are unlikely to continue consistently, given the general health status of the patients the pharmacists serve, the numbers bode well for the success of the interventions. The readmission rate between 31 and 90 days post-discharge is also commendable; at 23 percent, it is a 32 percent reduction from the national Medicare average of 34 percent. Mr. Livingston cautions that it "not only takes trained pharmacists, but also systems, communications and teamwork to achieve these types of results."
HMO Health New England, based in Springfield, Mass., has experienced similar results in the wake of implementing pharmacist home visits. In its first six months, the HNE pilot program decreased the 30-day readmission rate for the HMO's Medicare Advantage members from 14 percent to 8 percent.
A study published recently in the Annals of Internal Medicine found that important medication errors were present in up to one half of patients post discharge. Another study found medication discrepancies in more than a quarter of outpatient records, and of those, more than half were missing important medications.
In many situations, home visiting pharmacists improve care transitions by conducting medication reconciliations in the home setting rather than hospitals. "We find a lot of therapy duplications — the medications the patients picked up after discharge and the ones they've got in the cupboard," said Gigi Le-Ta, PharmD, director of pharmacy for Monarch Health Care, a large California IPA with global-risk contracts. "On a recent visit I discovered, for example, that the patient was taking Protonix and Prilosec [both proton pump inhibitors for a gastrointestinal condition]. Other times, I've found that patients are taking herbal supplements that interfere with prescription drugs and could cause serious problems if they continue them."
In the home setting, the pharmacist overcome limitations, such as patients not recalling their medications, or being too distracted or overwhelmed to remember their discharge instructions. "We find that patients are much more relaxed, calm and open to discussions in their home settings," said Mr. Livingston. "We are better able to identify barriers and to come up with plans for patients."
Ms. Le-Ta concurs with Mr. Livingston's view on the importance of seeing high-risk patients in their home environment. Her patients generally are on 10 or more medications and typically have at least three comorbidities. The fact that the pharmacist can spend the requisite time to tease out areas of confusion as well as potentially harmful situations helps to alert patients' physicians and their families to problems in the making. "The more you ask, the more that comes out," she said.
Ms. Le-Ta's organization, Monarch, has created a "high-risk touch team" of clinical pharmacists, nurse practitioners and social workers who figure out what's going on following a hospitalization or significant health-status change that could lead to poor outcomes or readmissions. The clinicians see some patients in a clinic setting, but Monarch added pharmacist home visits when it discovered that some of the high-risk patients couldn't (or wouldn't) make it to the appointment. The home visit is also a good opportunity to identify physical-safety or environmental risks that could compromise the patient's recovery or stability. While in the home, "if we notice there's not enough home support, we send in the social worker to help address what's needed," Ms. Le-Ta explained.
Placing clinical pharmacists in the home setting for these fragile patients is a natural evolution in the general trend toward expanding the overall roles of pharmacists, according to Daniel Cusator, MD, MBA, a vice president at The Camden Group, a California-based healthcare consulting organization. Dr. Cusator, in his previous position, was instrumental in setting up a forerunning clinical pharmacy program within a large California IPA that saved more than $1 million over a single year and improved patient outcomes throughout the standardization of medication management. He thinks that clinical pharmacists remain an under-tapped resource in improving healthcare delivery and safety, regardless of the care setting.
"Any health professional should be positioned to practice at the highest level of their expertise as often as they can," Dr. Cusator said. "Clinical pharmacists are well positioned to identify medication issues and handle drug side effects and interactions because they keep up on the rapidly changing pharmaceuticals — which is something that's very difficult for physicians to do these days." Pharmacists can play an important role in the ongoing management of patients with chronic conditions, he adds, "because they've got both the time and the expertise to look at the drugs and prescribing patterns and can make appropriate recommendations."
Randy Fedorchuk, MD, a palliative medicine physician with Outreach Care Network in Pasadena, Calif., who works collaboratively with the CareRxConnect pharmacists, finds that the pharmacists help with a number of challenging situations.
"The clinical pharmacists are an important resource for me, when I am working with very complicated patients — those who have, for example, advanced renal failure and painful neuropathy or concurrent dementia. I consult them to figure out cost-efficient ways to meet these patients' needs, and they go onsite to set up adherence plans or to educate." He cited a recent case in which the pharmacist helped come up with a sophisticated pain-management plan using a subcutaneous drug, enabling the patient to remain at home far longer than he would have under other circumstances. "I know the team approach has saved a lot of urgent care and ER visits," Dr. Fedorchuk said.
Bonnie Darves is an independent writer, editor and communications consultant based in the Seattle area. She began her career as a copy editor for Reader's Digest (Canada) and has since worked as an associate editor, contributing editor and managing editor for several publications. She is a regular contributor to several healthcare publications and news services and her articles have appeared in numerous general-interest publications.
Managing Population Health: Where Should Hospitals Begin?
These problems are exacerbated for patients who are medically complex, chronically ill, have limited mobility or have cognitive impairment. Unfortunately, there are inherent limitations in the conventional healthcare delivery system for these types of patients.
Yet, there are ways hospitals and health systems may be able to improve patient compliance. Preliminary data suggests that home visits by pharmacists may increase patient compliance. CareRx, a clinical pharmacy advisory firm based in Irvine, Calif., is utilizing clinical pharmacists "on the ground" to devise timely interventions and ongoing support for patients. As part of its CareRxConnect program, pharmacists make face-to-face residential visits with patients identified as high risk. The objective is to ensure that patients have the correct medications and understand what's supposed to occur, and why.
The visits are making a difference, explains Mark Livingston, PharmD, director of clinical services for CareRx. "In nearly 100 percent of cases, we find that patients need help with planning and scheduling their medications. And more than three-quarters of the time, patients don't understand their drugs or why they're supposed to take certain medications," he said.
Targeting readmissions — and making a difference
The patients with whom the home visiting pharmacists consult are identified by medical groups, hospitals or payors as high risk for poor compliance, poor outcomes or readmissions — and as it often happens, all three. A typical patient receiving the intervention has multiple chronic and progressive diseases, nine-plus medications, two or more prescribing physicians, medication adherence problems and is likely to be non-compliant with the medication regimen.Although the program is nascent, preliminary data is showing that the model of embedding a pharmacist as a team member with care-givers and case managers, to conduct face-to-face home visits, is preventing avoidable hospital readmissions. Of 105 patients registered in CareRxConnect through November 2012, there were no readmissions within the first 30 days post-discharge from a hospital or a skilled nursing facility. While such stellar results are unlikely to continue consistently, given the general health status of the patients the pharmacists serve, the numbers bode well for the success of the interventions. The readmission rate between 31 and 90 days post-discharge is also commendable; at 23 percent, it is a 32 percent reduction from the national Medicare average of 34 percent. Mr. Livingston cautions that it "not only takes trained pharmacists, but also systems, communications and teamwork to achieve these types of results."
HMO Health New England, based in Springfield, Mass., has experienced similar results in the wake of implementing pharmacist home visits. In its first six months, the HNE pilot program decreased the 30-day readmission rate for the HMO's Medicare Advantage members from 14 percent to 8 percent.
What goes wrong — and why
The literature is replete with evidence that many things go awry with medications in the post-discharge arena — and often even before discharge. Incomplete information from patients or the inability to access medication data among disparate systems often translates into incomplete medication reconciliation in the hospital. This, in turn, can lead to incorrect instructions or inappropriate prescriptions.A study published recently in the Annals of Internal Medicine found that important medication errors were present in up to one half of patients post discharge. Another study found medication discrepancies in more than a quarter of outpatient records, and of those, more than half were missing important medications.
In many situations, home visiting pharmacists improve care transitions by conducting medication reconciliations in the home setting rather than hospitals. "We find a lot of therapy duplications — the medications the patients picked up after discharge and the ones they've got in the cupboard," said Gigi Le-Ta, PharmD, director of pharmacy for Monarch Health Care, a large California IPA with global-risk contracts. "On a recent visit I discovered, for example, that the patient was taking Protonix and Prilosec [both proton pump inhibitors for a gastrointestinal condition]. Other times, I've found that patients are taking herbal supplements that interfere with prescription drugs and could cause serious problems if they continue them."
At-home interview delivers value
Medicare and healthcare organizations have been experimenting for years with alternative care management models, Mr. Livingston observed, noting that the industry "is awaiting a verdict" as to which works best. "We believe there is not one workable model for all patients. Telephonic support can suffice for coherent and mobile patients, whereas a more intensive intervention is needed for others," he commented. "We believe the high-risk patient is best seen in the home."In the home setting, the pharmacist overcome limitations, such as patients not recalling their medications, or being too distracted or overwhelmed to remember their discharge instructions. "We find that patients are much more relaxed, calm and open to discussions in their home settings," said Mr. Livingston. "We are better able to identify barriers and to come up with plans for patients."
Ms. Le-Ta concurs with Mr. Livingston's view on the importance of seeing high-risk patients in their home environment. Her patients generally are on 10 or more medications and typically have at least three comorbidities. The fact that the pharmacist can spend the requisite time to tease out areas of confusion as well as potentially harmful situations helps to alert patients' physicians and their families to problems in the making. "The more you ask, the more that comes out," she said.
Ms. Le-Ta's organization, Monarch, has created a "high-risk touch team" of clinical pharmacists, nurse practitioners and social workers who figure out what's going on following a hospitalization or significant health-status change that could lead to poor outcomes or readmissions. The clinicians see some patients in a clinic setting, but Monarch added pharmacist home visits when it discovered that some of the high-risk patients couldn't (or wouldn't) make it to the appointment. The home visit is also a good opportunity to identify physical-safety or environmental risks that could compromise the patient's recovery or stability. While in the home, "if we notice there's not enough home support, we send in the social worker to help address what's needed," Ms. Le-Ta explained.
Tapping pharmacists' expertise where it's needed
The important role that clinical pharmacists play in preventing readmissions by interacting directly with high-risk patients is being increasingly recognized. The National Transitions of Care Coalition, for example, recently recommended that pharmacists should have "direct contact with patients and other healthcare providers to ensure medication information is transferred accurately and completely." The coalition stressed that pharmacists are beneficial in any care setting but are especially optimal in the home setting, when patients have multiple medications and medical conditions, and when patients take medications that must be adjusted based on their clinical status.Placing clinical pharmacists in the home setting for these fragile patients is a natural evolution in the general trend toward expanding the overall roles of pharmacists, according to Daniel Cusator, MD, MBA, a vice president at The Camden Group, a California-based healthcare consulting organization. Dr. Cusator, in his previous position, was instrumental in setting up a forerunning clinical pharmacy program within a large California IPA that saved more than $1 million over a single year and improved patient outcomes throughout the standardization of medication management. He thinks that clinical pharmacists remain an under-tapped resource in improving healthcare delivery and safety, regardless of the care setting.
"Any health professional should be positioned to practice at the highest level of their expertise as often as they can," Dr. Cusator said. "Clinical pharmacists are well positioned to identify medication issues and handle drug side effects and interactions because they keep up on the rapidly changing pharmaceuticals — which is something that's very difficult for physicians to do these days." Pharmacists can play an important role in the ongoing management of patients with chronic conditions, he adds, "because they've got both the time and the expertise to look at the drugs and prescribing patterns and can make appropriate recommendations."
Randy Fedorchuk, MD, a palliative medicine physician with Outreach Care Network in Pasadena, Calif., who works collaboratively with the CareRxConnect pharmacists, finds that the pharmacists help with a number of challenging situations.
"The clinical pharmacists are an important resource for me, when I am working with very complicated patients — those who have, for example, advanced renal failure and painful neuropathy or concurrent dementia. I consult them to figure out cost-efficient ways to meet these patients' needs, and they go onsite to set up adherence plans or to educate." He cited a recent case in which the pharmacist helped come up with a sophisticated pain-management plan using a subcutaneous drug, enabling the patient to remain at home far longer than he would have under other circumstances. "I know the team approach has saved a lot of urgent care and ER visits," Dr. Fedorchuk said.
Bonnie Darves is an independent writer, editor and communications consultant based in the Seattle area. She began her career as a copy editor for Reader's Digest (Canada) and has since worked as an associate editor, contributing editor and managing editor for several publications. She is a regular contributor to several healthcare publications and news services and her articles have appeared in numerous general-interest publications.
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