Transcript Pharmacist-led Discharge Education

PHARMACIST-LED
DISCHARGE EDUCATION
Outcomes of a Pharmacist-Driven Education Program
For Residents Discharged from a Skilled Nursing Facility
Michela C.C. Fiori, Pharm.D.
PGY1 Pharmacy Resident, Penobscot Community Health Care
Presentation Overview
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Introduce and discuss Maine Veterans’ Home
Pharmacies four-step pharmacist-driven discharge
counseling program (NavigatoRx)
Review current program data for issues identified
by pharmacy during medication reconciliation
Discuss the benefits of pharmacist-led discharge
education on quality of patient care
Background
• Each year, patients nationwide are cared for in skilled
nursing facilities (SNF) following a hospital stay and
subsequently discharged.
• Many of these patients are readmitted to a hospital
within 30 days due to medication-related preventable
causes.1,2
• Medicare patient readmission rates have been
observed as high as 20 percent with costs nearing
$17.4 billion per year.3
• Pharmacists can make a profound impact by
identifying risk factors for readmission and making
interventions during discharge counseling to help
prevent readmissions and reduce costs.1,2
Background
• There is a paucity of research available
specifically regarding pharmacist discharge
counseling in SNF settings.4
• Elderly patients are particularly high risk for
hospital readmissions resulting from medicationrelated issues, so the population within the SNF
could benefit greatly from pharmacist-driven
discharge counseling.4
Maine Veterans’ Home Pharmacies
NavigatoRx Program
Step 1: Medication Review on
Admission
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Performed by pharmacist, then documented and
communicated to nursing home staff via fax
Immediate issues are communicated via phone to
nursing staff and/or MD staff
Documentation: Medication Regimen Review Form
Step 2: Medication Reconciliation within
48 hours of Admission
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Performed by pharmacists and trained interns
Nursing home provides as much history as possible,
ideally one or both of the following:
Home medication list
 Hospital discharge summary
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MVH Pharmacy in-house staff provides current
medication list
Medication reconciliation is performed with any issues
raised via phone communicated to nursing staff and/or
MD staff
Documentation: Medication Reconciliation Form
Step 3: Review and Counseling
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Performed by pharmacists/pharmacy residents and trained
interns
Home staff provides final/pending discharge medication list
Home staff works with pharmacy team and resident to
schedule face-to-face meeting
Widely recognized Indian Health Service medication
counseling methodology is used to provide effective and
efficient review of medications
Follow-up phone call is arranged and discharge counseling
session information is provided to central fill pharmacy
Documentation: Counseling Review Form
Step 4: Follow-Up Phone Call within
48-72 hours Post-Discharge
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Performed by pharmacist at central fill pharmacy
Recognizing that outpatient care providers are now part of the
picture (i.e. PCP and outpatient pharmacist), the purpose of this call
is to quickly follow up to be sure that the now discharged resident
has no lingering questions or problems with medications.
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Review discharge medication list and address discrepancies
Assess for side effects
Answer questions
Triage and recommend (when appropriate) involving additional
caregivers. (Example: “Please call your primary care physician about
this” or “I think that you should talk to your current pharmacist about
this.”)
Documentation: Follow-up Review Form
Reducing 30-Day Hospital Readmissions
through Pharmacy Intervention
Step 2: Medication Reconciliation
Medication Issues Identified
By Type
10.00%
5.70%
5.70%
47.10%
11.40%
15.70%
4.30%
Medication List
Discrepancy
Therapeutic
Duplication
Discharge Instructions
Unclear
Drug-Drug
Interactions
Lab Result requires
Medication Change
Inappropriate
Medication or Dose
Other
Step 3: Discharge and Counseling
Review and counsel with patient/family
Provide written, patient-friendly education
materials for medications
Focus discussion on critical medications (e.g.
cardiac, hematologic) and adherence
Facilitate understanding
Speak slowly and clearly
Utilize teach-back method
Involve all members in the discussion
Encourage questions
Provide 72-hour follow-up phone call
Review important counseling points
Assess adherence
Clarify discrepancies
During a post-discharge follow-up phone call, the
pharmacist has the opportunity to:
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D.
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Correct medication dosing discrepancies which may
have occurred post-discharge.
Review and discuss the discharge medication list
with the patient.
Assess the patient for any medication-related side
effects.
Discuss any concerns/questions the patient may
have about their medications.
All of the above.
References
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4.
Pal A, Babbott S, Wilkinson ST. Can the Targeted Use of a Discharge Pharmacist
Significantly Decrease 30-Day Readmissions? Hosp Pharm. 2013; 48(5):380-388.
Wilkinson ST, Pal A, Couldry RJ. Impacting Readmission Rates and Patient Satisfaction:
Results of a Discharge Pharmacist Pilot Program. Hosp Pharm. 2011;46(11):876-883.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in Medicare feefor-service program. N Engl J Med. 2009;360:1418-1428.
Chinthammit C, Armstrong EP, Warholak TL. A Cost-Effectiveness Evaluation of Hospital
Discharge Counseling by Pharmacists. J Pharm Pract. 2012;25(2):201-208