Pharmacy Organizations Announce Best Practices in Transitions of Care

Published Online: Friday, October 19, 2012

MMCT, which focuses on identifying and profiling existing best practice models that are scalable in order to facilitate broad adoption, was launched in January 2012 as a joint project between the American Pharmacists Association (APhA) and the American Society of Health-System Pharmacists (ASHP). Eighty-two programs were evaluated through a stringent, competitive process.

The MMCT will highlight key elements from these successful programs, describe implementation barriers and recommend strategies for addressing these barriers in a report that will be available later this year.

“Pharmacists and pharmacy technicians can improve patient outcomes by providing a comprehensive approach to care transitions,” said ASHP CEO Paul W. Abramowitz, Pharm.D., FASHP.  “These models, which address areas ranging from preventing hospital admissions and adverse drug events to improving medication access and adherence, should provide a roadmap for broader implementation of these types of programs.”  

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” said APhA CEO Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and health care providers in different practice settings that leads to improved patient health.”

The eight programs are: 

Einstein Healthcare Network
This transitions-of-care model, the Medication REACH program, is based out of the Department of Pharmacy Services of the Einstein Medical Center Philadelphia (one of several major facilities and outpatient centers of the Einstein Healthcare Network in Philadelphia, Pennsylvania). The purpose of this model is to enhance the patient discharge process by addressing the array of issues associated with medication management of high-risk populations.

The Medication REACH program has an approach that addresses a critical juncture in the continuum of care through direct pharmacist involvement prior to discharge to validate medication reconciliation (R), deliver patient-centered education (E), and resolve medication access (A) issues during transition, through a comprehensive counseling (C) approach. The overarching goal is to achieve a healthy (H) patient at home who is adherent with their medications without adverse outcomes, such as emergency room visits and readmissions within 30 days.

Froedtert Hospital
Froedtert Hospital is part of the Froedtert Health Health System (consisting of an academic medical center, community hospitals, and primary care clinics and providers) located in Milwaukee, Wisconsin. The hospital’s department of pharmacy began its MMCT model in 2010 as a pilot serving a limited number of all patients discharged. As a result of the impact made during that pilot project and other efforts, the transitions-of-care services have been expanded to include all patients discharged from Froedtert. The model’s efforts in medication management in care transitions include embedding its care transitions process into the daily activities of inpatient pharmacists, as well as requiring pharmacists to complete medication reconciliation for every patient at admission, transfer, and discharge. Approximately 600 patients are transitioned through this program monthly.

Hennepin County Medical Center
The Enhanced Discharge Transitions of Care Team is a part of the Health System Pharmacy Services of the Hennepin County Medical Center (a system of primary care and retail clinics operated by Hennepin Healthcare System, Inc.) located in Minneapolis, Minnesota.  The MMCT model began as a pilot in June 2011 and has expanded to include services throughout the community-based medical center and many associated primary care and retail clinics.

This model has implemented a modified patient discharge plan similar to the Project RED model designed by Dr. Brian Jack and colleagues at Boston Medical Center. The model utilizes the deployment of pharmacists to complete medication reconciliation upon discharge and medication therapy management at the follow-up clinic appointment within 5-7 days of discharge. This model focuses on patients that are admitted to the inpatient general medicine service, regardless of diagnosis.

The Johns Hopkins Hospital
The Medication Management Transitions of Care (TOC) Team is a part of the departments of pharmacy, and incorporates services within The Johns Hopkins Health System and Johns Hopkins Medicine in Baltimore, Maryland (a health system consisting of an academic medical center, community hospitals, primary care clinics and providers). The model was developed through the work of a health system wide multi-disciplinary task force in response to the Affordable Care Act (ACA).

The TOC model is a multi-disciplinary approach to enhance care coordination by optimizing acute care management and improving the transition of care from the acute care setting to the ambulatory setting and to reduce preventable readmissions. Since implementation at The Johns Hopkins Hospital, four additional community hospitals in The Johns Hopkins Health System have implemented pilot programs focused on improving the discharge planning process and have tailored these programs to the needs and workflows of those sites.

Mission Hospitals
The Mission Uninsured Safe Transitions (MUST) program is part of the Medication Assistance Program (MAP), a community benefit service of the non-profit Mission Health System that is provided to the citizens of western North Carolina. The MAP was started in 1999 and is now part of the Outpatient Clinical Pharmacy Services at Mission Hospital. This program works collaboratively with many health-system and community partners, including: various hospital departments, care management and discharge planning, medical center pharmacy, community non-profit clinics, the Area Agency on Aging, a county Christian ministries community clinic, two foundations (which provide grant services and financial support) a community health center, and a clinic dedicated to serving the needs of homeless patients.

The health system recognizes the value of reducing both emergency department visits and inpatient admissions of uninsured patients by ensuring that these patients have access to their prescribed medications, access to clinical pharmacist disease management services, and access to staff that are able to connect these patients to additional community resources which will, in turn, enhance their whole-person care.

Sharp HealthCare
The Continuum of Care Network model, which started in 2011, is based at Sharp Memorial Hospital, part of Sharp HealthCare, an Accountable Care Organization (ACO) operating as a regional health care delivery system in San Diego, California. The Sharp HealthCare ACO will receive a grant from the Centers for Medicare & Medicaid Services for the next three years. This model incorporates a Continuum of Care Residency (post graduate year two) that was both started and supported by Touro University College of Pharmacy.

The Continuum of Care Network includes an integrated delivery system to maximize quality of care and prevent unnecessary costs by drawing on the strengths of various Sharp HealthCare entities and community partners, including Sharp Memorial Hospital, primary care clinics and medical offices, a regional community chain pharmacy, pharmacy benefits manager, and home health resources.

University of Pittsburgh School of Pharmacy and University of Pittsburgh Medical Center (UPMC)
The Pharmacist Advocates in Care Transitions model, which began as a pilot program on a single hospital unit, is a partnership between the University of Pittsburgh School of Pharmacy and the UPMC Department of Pharmacy in Pittsburgh, Pennsylvania, has since expanded to other units. The program has also developed an assessment tool, The Medication Access and Adherence Tool (MAAT).

The MAAT was developed by faculty from the University of Pittsburgh School of Pharmacy and tested to identify which patients would benefit from seeing a transitions-of-care pharmacist. Using tablet devices, the MAAT is used with inpatients to assess medication access and adherence. In additional, the MAAT is currently being piloted by the admissions team in the emergency department to screen for patients that would benefit from medication management by a pharmacist.

University of Utah Hospitals and Clinics
Participants in this transitions-of-care model are part of the Department of Pharmacy Services of the University of Utah Hospitals and Clinics in Salt Lake City, Utah. This model began in 2008 as a program on one care unit with two pharmacists and a technician and has since expanded across many services. The model involves a multi-disciplinary approach, which encompasses services within a university health system with multiple specialty hospitals, primary care clinics, a long-term care/assisted living facility, hospital-owned pharmacies, and home infusion services.

Within this model, pharmacists reconcile medications upon admission, during hospitalization, upon discharge, and again in an outpatient clinic setting. In addition to general services, specialized services are provided in the areas of transplant, cardiology, oncology, and thrombosis.

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