The Role of Hospital Pharmacists in Transitions of Care

In a study of their experiences in a transition of care program, hospital pharmacists had a number of recommendations for improvement.

Patients are frequently discharged from the hospital with changes to their previous medication regimens. As a result, medication discrepancies, nonadherence, and adverse drug events are common during these transitions of care. Indeed, approximately 20% of elderly patients are readmitted within 30 days of discharge.

Pharmacists are poised to play an important role in improving medication management during transitions of care and reducing readmission rates. To help determine how pharmacists can be most effective in this role, researchers at Vanderbilt University carried out a study to characterize pharmacists’ perspectives on their involvement in improving care transitions. Their results were published in the September 2012 issue of the Annals of Pharmacotherapy.

The study involved 11 pharmacists who were involved in the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study, a randomized trial to reduce serious medication errors after hospital discharge. PILL-CVD was carried out at 2 academic hospitals: Vanderbilt University Hospital and Brigham and Women’s Hospital. The pharmacists were interviewed regarding their perspectives on aspects of the PILL-CVD program, including medication reconciliation during admission and discharge, in-hospital patient counseling, use of medication adherence aids, and telephone follow-up with patients.

The results found that the pharmacists experienced medication reconciliation as time consuming, but also as their most important contribution to improving care transitions, especially when it helped correct the admission medication history. “You always find something on there that needs to be changed or clarified,” said one pharmacist in the study.

In addition, the pharmacists noted that detailed medication reconciliation helped clarify medication information for patients, helped patients communicate with their physicians about their medications, made ordering medications at discharge more efficient, and helped prepare for personalized discharge counseling.

The pharmacists reported that the most important question they asked during the initial in-hospital counseling session regarded how many times the patient had missed taking their medications during the week before being admitted to the hospital. (The answer helped them identify and begin to address nonadherence.) Obstacles to carrying out the initial counseling sessions included instances in which sessions conflicted with other medical procedures or when patients were too drowsy to take part. Nonetheless, the pharmacists felt that the initial counseling session helped build rapport with patients and offered an opportunity to encourage patients’ family members to be present during discharge counseling so they would be prepared to help handle the patients’ medications at home.

The pharmacists saw the in-depth review of discharge medications as the most important part of the discharge counseling session. The study protocol called for a complete review of medications with teach-back for all patients, and the pharmacists reported that this seemed unnecessary for some patients, was met with resistance by some, and grew frustrating when dealing with patients who did not understand their medication regimen. During the discharge counseling session, pharmacists reported that some patients were eager to leave and were less receptive to counseling.

As part of the discharge session, pharmacists walked patients through an illustrated medication schedule. This sort of adherence aid was helpful to patients with low health literacy, the pharmacists felt, but less so for those with adequate health literacy. In addition, the pharmacists noted that making the schedules was time-consuming, especially for patients with extensive medication regimens.

Initial post-discharge contact with patients was made by trained administrative staff, which the pharmacists reported was an efficient way to determine which patients needed to follow up with a pharmacist. Approximately 60% of the patients had no medication issues that required follow-up, and the initial contact helped pharmacists focus on the specific problem for those who did require follow-up.

Pharmacists who took part in the study made the following recommendations for how the program could be improved:

• Pharmacists should be integrated into the treating team to help facilitate communication with treating physicians.
• Communication from physicians to pharmacists regarding anticipated date and time of patient discharge should be improved to ensure adequate time for discharge counseling.
• Discharge counseling should be formally scheduled to allow for better planning and adequate duration.
• Patients should be provided with a wallet-sized medication list, which would be easier for them to bring to doctor’s appointments.
• Patients should be better prepared to take part in discharge counseling.
• Patients should be provided with an audio recording of their discharge session.
• Hospital pharmacists should have access to data on whether patients fill their discharge prescriptions to better arm them for follow-up assistance.
• Communication between pharmacists and primary care physicians around patient discharge should be improved to help with discharge planning.