Pharmacist pre- and post-discharge medication review equally important

Pharmacists who contacted high-risk patients within 72 hours of discharge from Massachusetts General Hospital, Boston, found more than half of the patients had medication-related issues. In a different group of high-risk patients who had received inpatient interventions, 35% of patients were found to have issues after a pharmacist reviewed their medications just prior to discharge, according to Laura Carr, PharmD.

Carr presented findings from Massachusetts General Hospital’s STAAR [State Action on Avoidable Rehospitalizations] initiative, which occurred between July 2010 and July 2013. Massachusetts General Hospital was one of 20 initial teams to participate in this initiative, which has now increased to approximately 50 hospital teams, said Carr at the American Pharmacists Association annual meeting last month.

Each STAAR hospital team focused on four targeted interventions: performing an enhanced assessment of post-hospital needs [basically a discharge plan], providing effective teaching and facilitating enhanced learning, providing real-time handover communications, and ensuring timely post-hospital care follow-up.

In addition to these four primary efforts under STAAR, the hospital also added two additional interventions, which were the establishment of the discharge nurse care role and the transitional care pharmacist role, noted Carr, who is the senior attending transitional care pharmacist at Massachusetts General Hospital.

The discharge nurse was the main point person on the hospital floor who facilitated communication and worked with all healthcare providers. She encouraged providers to think about how their care would affect discharge and patient length of stay from time of patient admission. She also identified high-risk patients for the inpatient STAAR initiative and was the source of all referrals to the transitional care pharmacist.

High-risk patients were those who were identified to be taking 10 or more medications and have one of the following conditions: heart failure, pneumonia, acute renal failure, atrial fibrillation, cancer pain, dehydration, urinary tract infection, or change in mental status.

The transitional care pharmacist was involved with pre-discharge and post-discharge interventions during the three-year STAAR initiative.

Pre-discharge interventions for high-risk patients discharged to their homes included medication reconciliation, medication review, medication access, and face-to-face counseling. For high-risk patients discharged to a facility, such as a rehabilitation hospital or skilled nursing facility, the pre-discharge interventions involved medication reconciliation and medication review.

Pre-discharge findings

“During the STAAR initiative, 35% of the high-risk patients had medication-related issues of clinical significance,” Carr noted. “These were medication lists that had already been reviewed by their physicians and their nurse. So pharmacists have a big role here.”

In addition, Carr said that the right population of patients had been targeted as pharmacists were involved with approximately 90% of these high-risk patients who need prescriptions filled or other interventions.

“The pharmacist added value in greater than 90% of these patients. Patients on average had 15 medications at discharge. And the average number of medication changes at discharge was six,” Carr said. “This is a huge risk to patients and a big opportunity for pharmacists to decrease drug events.”

Post-discharge follow-up

Another group of high-risk patients were identified for post-discharge intervention by a pharmacist. These patients who had been discharged home had on average about 12 medications and 2.3 discrepancies. That had not been part of the STAAR inpatient interventions at Massachusetts General Hospital.

During the post-discharge follow-up, pharmacists found 52% of the patient calls were associated with medication-related issues. This increase in post-discharge intervention occurred because patients were responsible for their own care and frequently had difficulty following instructions, Carr noted.

“The most common medication-related issues that we found was difficulty following proper dosing instructions, which frequently occurred with anticoagulants,” she said. “Unfortunately, we had a lot of patients going home who were on Lovenox [enoxaparin sodium] with a bridge to Coumadin and didn’t realize proper dosing instructions.

“We also had patients not starting new medications and doses. We were surprised by the number of patients who were called three days post-discharge. They had been in the hospital a week with pneumonia and still hadn’t been to the pharmacy to pick up their antibiotics.”

There were also incomplete medication reconcilations. Medications that patients had at home were not on their medication lists and the doctor was not aware of these drugs, such as over-the-counter agents. “The most common for heart failure patients is that they were taking NSAIDs, and patients who were admitted with a GI bleed were taking aspirin. These OTCs are things that cannot be overlooked.”

There were also medication access issues for this high-risk patient population. “We frequently saw this with Lovenox. Patients would go to the pharmacy and their co-pay was $1,400. Or patients needed prior authorization for medications and were just going without or waiting for their one-week follow-up to get prior authorization or to talk with their physician about prior authorization.

“If we had known that in the hospital, we probably would not have discharged them,” Carr said. “As the pharmacist, we were able to address a lot of these medication access issues.”

During the three-year STAAR initiative, Massachusetts General Hospital was able to demonstrate a reduction in readmission rates with this multidisciplinary team approach for high-risk patients, she said.