"PART II" Out-Patient Pharmacist / In-Patient Rounds

Great thought must be put into the planning and implementation of any new service; for once it is begun, it must be regularly continued, monitored and evaluated if it is to succeed.

For those of you that haven't been following, five weeks ago we implemented a new program at the community hospital that I work at.  This program's implementation is described in detail in a previous post titled, "Out-Patient Pharmacist, In-Patient Rounds"; however, it involves a pharmacist from our out-patient clinic pharmacy briefly reviewing 50-70 charts every morning, looking specifically for potential medication discharge issues that would benefit from having a pharmacist help coordinate the process.  During rounds, the case managers, Rn's or MD's will refer at least one patient to the pharmacist who might benefit from a Bedside Medication Therapy Management visit.  This visit is then performed after rounds, before the pharmacist heads back to the out-patient pharmacy for the rest of their shift. 


I am not sure about everyone else; but I find this incredibly interesting stuff.  Us pharmacists have been working for the almighty line item productivity metric for EVER!  Here is an opportunity to break out of the fish bowl, have a positive impact on patient outcome and also help decrease readmission rates.  As the data unfolds, I will continue to take some time to put it into words.  As always, I appreciate feedback on similar programs others have implemented. 

Out-Patient Pharmacist, In-Patient Rounds
Five Week Evaluation

Out-patient pharmacist involvement in the Daily Rounds and Bedside MTM service at our community hospital began five weeks ago.  Subjectively, the service has been a success and is well received by both the rounds team and the patients who have been visited.  Objectively, the data collected from pharmacist involvement is significantly positive; however, the program has not been continuing long enough to gain any significant insight into whether it is making an impact on the 30 day readmission process.

This document will describe the successes and shortcomings of the program thus far. 

Data for first five weeks:
·         32 Bedside MTM consults were received during Rounds Huddle.
o   27 Bedside MTM consults were completed, charted and enrolled in follow up phone call program.
o   5 were not completed because patients were either discharged, sleeping, not in room, in an acute state, or in isolation.
·         40 Appropriate recommendations were made to help coordinate care regarding a medication that may be difficult to fill upon discharge. 
·         31 Verbal orders totaling 50 separate medications to be re-labeled so they may be taken home with the patient when they are discharged from the hospital. 
·         6 Clinical or Med Reconciliation issues were noted by pharmacist during chart review or during huddle and discussed.

Rounds Participation:
Importantly, the pharmacist has been well received on the rounds team.  Comments and suggestions regarding medication discharge planning are well received and definitely fill a gap in the rounding process. 

The efforts regarding coordination of "difficult to fill" discharge medications and the "re-labeling" of inhalers and eye drops makes a significant impact.  These are functions that do not need a pharmacist; however, they were not being done without a pharmacist.   
·         The 40 coordinated prescription interventions for "difficult to fill" medications has been limited to only 10 medications, with 3 medications taking more than 50% of the interventions.
·         The 50 re-labeled inhalers and eye drops was fully coordinated by the pharmacist; obtaining a verbal order from the physician during rounds, obtaining the medication from the unit med cart, taking it to the out-patient pharmacy and labeling it appropriately, then returning it to the appropriate med cart.
In my opinion, these two items alone justify pharmacist participation.  These two processes do not require the presence of a pharmacist in order to complete; however, as seen by the data, there is certainly an opportunity for pharmacist intervention.  Eventually, with some training, it is possible that these items might be performed without the presence of a pharmacist.

Bedside Medication Therapy Management:
Interestingly, the Bedside MTM visits are very well received by patients.  Our goal is to help educate patients about the management of their medications so they may be more prepared to manage their own medications when they return home.  As stated, during the first five weeks of the program, 27 Bedside MTM visits have been completed and all of them enrolled in 3 and 21 day follow up phone call service from the pharmacist.

It is too early for the objective data; however, subjectively, patients very much appreciate the opportunity to discuss medication management with a pharmacist at their bedside.  I believe this process will not only decrease the potential for readmission, it will also increase our patient satisfaction scores.

As a pharmacist, the difficulty we face is that we realistically only have time to visit one patient per day.  Rounds are complete at 11:30, at which time we need to return to the pharmacy office in order to print and review the med list for the patient we will see that day.  After our 20 minute Bedside MTM visit with a patient, we then need to document our visit in the patients electronic health record while also documenting our participation in rounds for the day.  Our time is complete at 12:30, at which time lunch begins, so we may be back at our out-patient post by 13:00.

Analysis:
Five weeks ago, this position didn't exist.  Today, there is more work than we are able to complete in our 3.5 hour shift.  The process of coordination of discharge prescriptions and re-labeling of bulk items has been a success.  The implementation of Bedside MTM visits is even more of a success.

Over the next few months I believe we will see that the greatest value comes from providing Bedside MTM visits to patients.  This is specifically a pharmacist driven process; coordinated and implemented by pharmacists.  Ideally, our daily flow will need to be evaluated so that we are able to see more than one patient/day.

Initially, we could potentially increase our participation time by 30 minutes so that we have until 13:00 (an even 4 hours) to complete our daily process.  Presumably, this would allow us time to see two patients each day which would significantly increase our presence.

Secondarily, in the future, we may look at training the case managers to recognize which meds will require special discharge coordination so they may follow up on these at least a day prior to discharge.  We may also be able to develop a process where charge nurses or respiratory therapists take  verbal order to re-label inhalers which may then be forwarded to the out-patient pharmacy for appropriate discharge labeling.  This may free up the pharmacist to see many more patients.

Conclusion:
The pharmacist involvement in Daily Rounds and Bedside MTM program has been received well and is a functioning program thus far.  Over the next two - three months we will be training a couple more pharmacists who will be available to cover this shift.  Time will tell if the provision of these services eventually leads to a decrease in 30 day readmissions as an objectively driven, outcome oriented, pharmacist delivered program.

Thanks
Steve
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