Katharine Gammon

April 05, 2013

When patients move from a hospital to home, it is a challenge to maintain a consistent level of care and manage their medications. A new report describes ways for pharmacists to collaborate with medical teams to deliver the best possible care.

With millions of Americans taking multiple medications for chronic conditions, the cost of poor medication management at hospital admission and discharge runs into the billions of dollars, according to the report, which was presented at American Pharmacists Association (APhA) Annual Meeting and Exposition in Los Angeles, California.

"Pharmacists are in a unique position to serve as patient advocates during care transitions and to optimize the use of health technology," said James Owen, PharmD, BCPS, senior director of professional practice at the APhA.

The current situation is alarming. Approximately 1.5 million preventable adverse drug events occur annually as a result of medication errors, at a cost of more than $3 billion per year. Nearly half of all hospital-related medication errors and 20% of all adverse drug events have been attributed to poor communication at the transitions and interfaces of care, and the average hospitalized patient is subject to at least 1 medication error per day.

These preventable adverse drug events account for an estimated 2.5% of emergency department visits for all unintentional injuries and 6.7% of those leading to hospitalization.

The data also show that pharmacists can do something about the problem. In one large academic medical center, medication reconciliation — regimented documented review to avoid drug errors during patient transfers within hospitals — decreased medication errors from 90% to 47% on a surgical unit and from 57% to 33% on a medical unit.

In 2011, the Centers for Medicare and Medicaid Services Innovation Center launched its Partnership for Patients program. Its goal is to reduce preventable and costly hospital readmissions by 20% (6.5 million fewer readmissions) by the end of 2013.

The report, part of a larger joint project by the APhA and the American Society of Health-System Pharmacists, profiles 8 institutions that are solving the problems of care transitions. "They are using creative ways to reorganize their staff, and use support and technical staff to support the actions of pharmacists," said Dr. Owen.

Creative Problem Solving, Technology, Data

One place reportedly doing it right is the University of Pittsburgh Medical Center in Pennsylvania. The team there developed a survey tool, which can be accessed on a tablet, to identify patient problems with medication access, affordability, and adherence to drug regimens at home. The tool enables pharmacists to reach out to inpatients about their medications. It can also be used to determine which patients will benefit most from follow-up with a pharmacist after discharge.

When the center crunched the numbers, they found that the tool helped to identify 774 medication discrepancies in 216 patients. That led to much lower readmission rates in the group that used the tool than in the group that did not (10.5% vs 23.7%).

Dr. Owen explained that technology is critical to creating better systems for care transition management. "Technology is key, but so is developing standardized tools and processes to create a predictable situation so everyone on a team knows what they'll be doing," he noted.

Another institution that has implemented a system to improve the discharge process, and profiled in the report, is Johns Hopkins in Baltimore, Maryland. In the pilot program, nurses screen inpatients using validated discharge-readiness tools, such as the Early Screen for Discharge Planning, to determine the risk for readmission. On the basis of risk category and discussions during rounds, each patient receives tailored multidisciplinary interventions, including postdischarge phone calls, follow-up appointments, and personal health coaching.

The readmission rate was lower after the program was implemented than before (11.7% vs 13.7%). In addition, the average length of stay on the unit dropped from 4.52 days to 4.48 days, according to the report.

Dr. Owen noted that using team members — including students and pharmacy technicians — creatively is a good way to improve care transitions. "Improvements can be made...and the impacts are very significant. We are seeing places where readmission rates are in the order of 50%," he said.

Angela Cassano, PharmD, a pharmacy consultant and coauthor of the report, added that there is another element to a successful care-transition program: data. It is enormously helpful to have data, whether from a single institution or multiple institutions. "The larger a group's partnership data network — whether within their own system or with community partners — the more likely they were to be successful," she said.

Each institution solves problems in its own way. "There's a need to be creative from a resource standpoint," said Dr. Cassano. "Practitioners should be encouraged by the fact that others are doing this. There's no one-size-fits-all solution."

American Pharmacists Association (APhA) Annual Meeting and Exposition. Presented March 1, 2013.