Cleveland Clinic improves HCAHPS performance with pharmacist interventions

Improvement in HCAHPS scores is possible with pharmacists’ involvement in patient education efforts, according to a report at the 2014 ASHP Midyear meeting in Anaheim, Calif.

The pharmacy department at the Cleveland Clinic undertook a pilot study to see if implementation of a pharmacy service-first-dose education and/or discharge education for neurology patients-could have a positive effect on HCAHPS performance, said Erick Sokn, PharmD, manager of Transitions of Care/Emergency Department Services at the Cleveland Clinic, Cleveland, Ohio.

In the fall of 2013, some physicians approached the neurology pharmacy team to see if they could help improve the HCAHPS scores in terms of patient education about their medications. Some initiatives driven by nurses and physicians had not made a large impact on these performance scores, Sokn said.

“We were really excited about the initiative,” he said. “The opportunity to use this as a pilot program to test our involvement was something we were very interested in.”

First-dose vs. discharge education

The pharmacy team reviewed the literature and settled on first-dose and discharge counseling as services to concentrate on. First-dose counseling aligns with some of the HCAHPS questions that pharmacists are trying to impact, such as did someone within the hospital inform you of a purpose and possible side effects of your medications before you received your first dose. In addition, first-dose counseling provides multiple counseling opportunities with the patient.

However, first-dose counseling has certain limitations, including timeliness-the pharmacist can’t always speak with the patient before the medication is administered, as the pharmacist’s workload is too heavy. In addition, there was no existing means of identifying new medications for the pharmacists in the electronic medical record.

Discharge counseling by the pharmacist offers more lead time for the pharmacist than occurs with first-dose counseling. “So procedurally, it is more convenient for the pharmacist to intervene [before the patient is discharged],” Sokn said. However, the limitation with discharge counseling is that if it doesn’t occur, there is not a second change like there is with first-dose counseling.

“We decided, after reviewing the evidence, that doing both [first-dose counseling and discharge counseling] would probably be our best chance at impacting HCAHPS scores,” Sokn said. However, because of the volume of work, the counseling had to be prioritized to specific patients-those who were going home with new medications. These medications usually were started in the hospital and would be continued after discharge.

The discharge medications were in the pilot study. Both psychotherapeutics and CNS drugs were determined to require pharmacist counseling services, and automated alerts were set up in the EMR to warn the pharmacist that certain patients may need counseling.

The impact of pilot study

“We decided that we should evaluate the average capture rate for these processes-medication reconciliation, discharge counseling, and first-dose education,” Sokn said.

Discharge medication reconciliation had an average capture rate of greater than 90% on the weekdays and discharge counseling also was high with a 66% average capture rate during the week. First-dose counseling was fairly low. “The majority of the time spent by pharmacists was spent on discharge counseling, not first-dose counseling,” he noted. The average time spent counseling each patient was approximately 10 to 15 minutes.

The first month after the patient education initiative by pharmacists the HCAHPS score reached the 90^th percentile for the first time, but then declined the following months. After evaluating possible reasons for the decline in HCAHPS performance, a review identified possible causes: a lack of pharmacy student help, less lead time for medication reconciliation, and the capture rate varied dramatically, depending on the day of the week.

Stakeholders of the pilot program decided to re-emphasize the need for early medication reconciliation, and student pharmacists were employed again to help the pharmacist. The results were positive.

“This program gave us a good opportunity to experiment a little and how to focus pharmacists’ efforts to see if they have an impact,” Sokn said. “Our pilot showed that discharge counseling in our experience may offer a procedurally simpler means of improving HCAHPS scores than first-dose education.”