How Sustainable Are 'Meds-to-Beds' Programs?

NOVEMBER 30, 2017
The delivery of patient care is changing. It always has, and it always will. As health care providers, we are working amid change from our first day in practice until we retire. As a pharmacist, I must have practiced 25 years before I first heard the term, “transitional care." Now, 5 years later, providing a smooth and efficient transition of care from one setting to the next is the primary focus of many health care institutions.
 
The transition of care with which pharmacists are concerned is the move from the hospital bed to home. Often, a patient is stabilized on a specific new medication while in the hospital. Traditionally, when a patient is discharged, he or she is prescribed a continuation of the therapy that was started in the hospital. The doctor may electronically send the prescription to the patient’s pharmacy of choice, with the expectation that the patient will stop by the pharmacy, pick up the medication, and continue an uninterrupted cycle of therapy.
 
Unfortunately, barriers regularly get in the way of patients receiving medication from the community pharmacy. Most commonly, either the medication is not covered by insurance or the copay for the medication is too expensive for the patient. Depending upon the pharmacy or pharmacist, a phone call may be placed to the hospital that discharged the patient. The trouble is, the person who wrote the order may be off shift or unavailable, and the situation is left unresolved. When this happens, it is common for the patient to leave the pharmacy without medication. 
 
Medications that fall into this category are usually critical. They most commonly include antiarrhythmic medications, antibiotics, anti-diabetic medications, blood thinners, and a host of other possibilities. Patients may be referred back to their primary-care doctors. However, chances are that the patient may go untreated for many days. Commonly, these patients end up back in the emergency department of the hospital from which they were just discharged.
 
I practice in an out-patient pharmacy for a mid-sized community hospital. Over the past 2 years, we have begun to address this issue with increased lines of communication between the hospital and pharmacy staff. Throughout the day, we are in regular communication with the care coordination team members and help coordinate “difficult-to-fill” prescriptions. Regularly, the care-coordination team will come by the pharmacy, pick up the discharge prescriptions, and deliver the medications to the patient’s room.
 
On any given day, we may have up to 5 or 6 patients for whom we process discharge medication orders, totaling between 20 and 30 prescriptions. Throughout this process, we work on the phone with a host of different care-coordination workers, unit nurses, family members, and often the discharging hospital staff member. Our system is thorough, yet fragmented and cumbersome. Often, much more effort goes into completing the entire process than is necessary. 
 
Ideally, this should be a pharmacy-driven program, with a single technician interfacing with the care-coordination team, the patient, and family members, and the outpatient pharmacy. Unfortunately, in our institution, a pharmacy-driven scenario is not sustainable. Our team of 2 pharmacists and 2 technicians is busy from open to close managing all the functions involved with running a small community pharmacy. We do not have the manpower to interface with all the stakeholders necessary to manage a full-service so-called meds-to-bed program. 
 
With our staffing and productivity model, we would need to generate an additional 30 prescriptions in a 4-hour timeframe to sustain a 4-hour-per-day meds-to-bed technician. These additional 30 prescriptions per day would be on top of the 20 to 30 discharge orders we are already filling with the help of the care-coordination team. 
 
Perhaps if the productivity/labor metric was shared between departments, this could be a much more sustainable venture.
 
I am writing a proposal for the development of a new meds-to-bed technician position in our institution. This position would work 4 hours each day, Monday through Friday. For this to become a sustainable position, we would need to share 1 hour per day from 4 separate departments to make up the 4-hour shift. 
 
Which departments in the hospital would benefit most if we were able to get patients' prescriptions in their hands prior to walking out the door? These are the departments that will be asked to come up with the hour of shared labor.
 
The meds-to-bed technician does not necessarily need to be a pharmacy technician. In our institution, we have many capable case managers who may also be adequately trained to manage this position. The meds-to-bed technician would need to have an excellent understanding of all the workings that are involved in the discharge process. This position would also need to understand all that goes into evaluating, processing, filling, and delivering prescription medications. As well as the technical fundamentals, this position would require a self-empowered personality, a strong understanding of hospital navigation, and the proven ability to follow through on task completion.
 
One individual, rather than a host of different care-coordination team members, would be responsible for managing the flow of discharge prescription orders. 

This would involve:
  1. Communicating with the discharge planning team about which patients are candidates for the meds-to-bed program
  2. Assuring that all team members, including the patient’s hospitalist, are aware of the patient’s choice to participate in the meds-to-bed program
  3. Visiting the patient’s room to explain what to expect, as well as coordinating prescription insurance and payments.
  4. Alerting the outpatient pharmacy to expect orders and demographic information on specific patients, as well as discussing any insurance or payment issues that need to be resolved.
  5. Delivering the medications to patient in their rooms, collecting any appropriate payments and signatures, and coordinating a phone or Skype consultation with the pharmacist.
Every hospital has a vested interest in helping patients achieve the best possible outcome. One way of helping discharged patients stay discharged is to assure that they have their difficult-to-fill prescriptions in their hands when they leave the hospital. But doing this has proven elusive. 
 
In my opinion, if all the involved departments came together to share the productivity of the increased workload, a sustainable meds-to-bed program could be developed. This program, managed on a daily basis by a meds-to-bed technician, would provide such a valuable service, we would wonder how we ever managed without it.
 
Reference
West L. Ambulatory pharmacy as the hub of transitional care. Knowledgedriven, AmerisourceBergen.
knowledgedriven.com/articles/health-systems/ambulatory-pharmacy-as-the-hub-of-transitional-care.aspx#.WgkO61tSyUk
Published October 31, 2017. Accessed November 26, 2017.
 
 
 
 
 
 
 
 
 
 


Steve Leuck, PharmD
Steve Leuck, PharmD
Steve Leuck, PharmD, has been practicing both hospital and community pharmacy for over 30 years. He founded AudibleRx, in 2011, which provides Consumer Medication Information which is both Useful and Accessible. Content designed to meet health literacy guidelines. Format designed to "read along" with the audio presentation in a simple to use web application. More information at AudibleRx.org.
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