Delivering Confidence

 

By Eunice Moore

During the transition from hospital to home–or a skilled nursing or long-term care facility–patients with complex medical needs are at risk for sub-optimal outcomes due to issues with medication adherence and errors. Of particular concern are patients who, once discharged, do not obtain the medications prescribed for them during their hospital stay. There are many possible reasons why: some patients lack transportation to visit the local pharmacy–or experience other barriers, such as fatigue or lethargy–and don’t have friends or family members who can do the errand for the. The pharmacy may not have the appropriate medications in stock. There may not even be a pharmacy nearby. In addition, high insurance co-pays pose a financial barrier for some patients. Others may not understand the critical need of the medications, so they won’t bother filling the prescriptions.

A hospital-based concierge medications program can make it simple for patients to obtain medications and learn how to take them properly before leaving the hospital. In addition, medication reconciliation education can help ensure that a new prescription does not interact negatively with medications that the patient is already taking. By ensuring that patients have the medications they need upon discharge, the hospital can:

• Improve adherence. Patients who leave the hospital with their medications are more likely to take them properly.
• Ensure medication reconciliation. Among complicated patients, complete agreement between the medication list and what the patient is actually taking occurs only 5% of the time (Barnsteiner, 2005). Medication reconciliation education can help mitigate this risk.
• Increase patient satisfaction. Improved adherence and medication reconciliation can lead to better outcomes.
• Help reduce 30-day readmissions. With value-based models grading hospital performance, avoiding readmissions is a critically important goal for hospitals as well as patients.

Two ways a concierge medications program can work

Hospitals can implement a concierge medications program in two basic ways: Deliver medications from the ambulatory pharmacy to the patient’s bedside or have the medications available for pharmacy pickup as the patient exits the hospital.

At Mercy Health System in Philadelphia, Pennsylvania, medications are delivered to the patient’s bedside. “Patients love it! There’s no need to stop anywhere for medications after discharge,” says Lorraine Micheletti, nurse manager of same-day surgery and the short-procedure unit at Mercy Fitzgerald Hospital. “And we can be confident that they’re going home with the right medications and instructions on how to take them.”

Saint Vincent Hospital in Worcester, Massachusetts, asks discharged patients to pick up their medications at the pharmacy. “Because our pharmacy is located right next to the hospital’s main exit, patients can conveniently pick up their medications right there,” says Jason Poquette, Saint Vincent’s pharmacy manager.

While their approaches differ, both organizations are seeing strong results from their programs.

Reducing 30-day admissions in the real world

At Mercy Health System, the concierge medications program may help decrease 30-day readmissions. “Having medications in hand before patients leave the hospital can decrease readmissions by helping to ensure they take medications without delay,” says Prashanth Ramachandra, MD, chair of the surgery department at Mercy Fitzgerald and Mercy Philadelphia Hospitals. “It’s a big plus that inpatients and outpatients can ask any questions about their medications while they are still at the medical facility.”

Convenience also plays a critical role. “It has a huge impact on compliance, of course, and having our own pharmacy means that medications prescribed frequently by Mercy physicians are likely to be in stock,” Ramachandra says.

“Mercy Pharmacy prepares prescriptions quickly and efficiently for our patients, ensuring that patients leave our unit in a timely fashion with the medications they need,” Micheletti adds.

A further benefit is having the time to identify and address any pharmacy benefit coverage issues before the patient is discharged. And for patients who don’t have a convenient way to pick up medications after leaving the hospital, Mercy’s concierge medications program alleviates that barrier as well.

A logical extension of the ambulatory pharmacy

A concierge medications program has proven to be a successful addition to the ambulatory pharmacies of both Mercy Health System and Saint Vincent Hospital. In addition to improving patient care, both pharmacies have benefited from increases in prescriptions and revenue optimization.

“The concierge service delivers medications to patients in their rooms at the time of discharge and also in the emergency room; this adds a fair number of patient visits on a monthly basis, which also increases the number of prescriptions filled,” says Don Shenk, CFO of Mercy Catholic Medical Center, which comprises Mercy Fitzgerald and Mercy Philadelphia Hospitals.

Micheletti adds, “As a result of making the concierge service available to same-day surgery and the short-procedure unit, Mercy Pharmacy has seen a 48% increase in outpatient pharmacy revenue.” The reason is simple: “When patients are presented with the convenience of having medications delivered to their bedside, 98.5% of them want the service.”

Results have been strong at Saint Vincent Hospital as well. “Our prescription capture rate is 80% to 100% in some departments,” Poquette says. “In others, we’re at 25% to 50%, with plenty of room for improvement.” The variation in capture rates can be attributed to varying levels of patient acuity and length of stay, as well as the time of discharge. If patients leave the hospital when the pharmacy isn’t open, there’s no opportunity to fill their prescriptions. So the pharmacy sets its operating hours to most closely align with when the greatest number of discharges typically occurs. “We’re increasing capture rates in every department, and there’s still room to grow,” Poquette says.

Implementation: Laying the foundation

Micheletti cites several steps that Mercy Health System follows to obtain physician buy-in to the concierge medications program and to help ensure its smooth implementation. To make the program work, surgeons write prescriptions in the recovery room instead of waiting until later.

According to Micheletti, convincing physicians to change the time they write prescriptions is easy once they’re presented with the benefits. A key advantage is that patients can take their medications right away—instead of having to wait for a local pharmacy to fill them—because the outpatient pharmacy is on-site at the hospital. Plus, physicians can be confident that their patients will receive the proper instructions for taking their medications before they leave the facility.

Physicians also hope their offices will receive fewer follow-up calls from patients or family members who have questions or concerns about their medications, as those issues are handled before patients go home. That has a substantially positive impact on patient satisfaction, which increases physician satisfaction as well.

“We started with the health system’s owned physician practices, beginning with the GI physicians,” Micheletti says. “We explained that our outpatient pharmacy is right next door to their offices, and if they write their prescriptions in the recovery room instead of later, they could be certain their patients were leaving the hospital with the right medications and instructions. Once the physicians see the value of the concierge medications program, they’re willing to participate.”

At Saint Vincent Hospital, Poquette also focuses on the “other” customer for the concierge medications program. “Patients aren’t our only customer,” Poquette explains. “Our hospital staff members are customers as well. They’re under tremendous stress already, and now more than ever, they are being pressured to do more with less. They need solutions to help them improve patient care, and that’s what our concierge medications program is all about.”

Poquette cites several principles he followed to successfully introduce the program to the hospital staff:

• Remember who matters most. The No. 1 reason to implement a concierge medications program is to improve patient care. Keeping the patient as your primary focus will remind everyone on your hospital staff why the program should become part of your culture.
• Get the right people involved, in the right order. Begin with your C-suite and demonstrate the value of a concierge medications program, both in terms of economic return and improved patient outcomes—particularly related to reducing 30-day readmissions and their penalties. For example, Saint Vincent Hospital has achieved average revenue per patient of $400, with a gross profit of nearly 300%. Most importantly, there have been no readmissions among patients that use the service.
• Work closely with your outpatient pharmacy to develop an implementation plan. Engage with your clinicians to demonstrate how easy the program is to use and how beneficial it will be to patients. Above all, remember that collaboration and education are critical to success.
• Track your results. Get your IT department involved. If you can track, measure, and share your success, the program will grow.
• Be patient. Success won’t happen overnight. Clinicians will naturally be skeptical, and there will be bumps in the road. Give the program some time to become part of your institution’s culture.

Implementation: Best practices

Following the program launch, Mercy Health System followed these six steps to ensure ongoing success:

• Once the surgeon writes the prescription in the recovery room, it’s faxed to Mercy Pharmacy.
• Attached to the prescription is a patient demographic information sheet, which includes the patient’s name and address, insurance information, and local pharmacy contact information.
• Mercy Pharmacy contacts the local pharmacy to review the patient’s history, including other medications, to ensure there will be no negative interactions with the new drug(s) being prescribed.
• Mercy Pharmacy fills the prescription, and it’s delivered to the patient’s bedside before discharge.
• The nurse discusses the new medications with the patient and family members, if present. The goal of medication reconciliation at discharge is to make sure the patient thoroughly understands how to take the medications properly, to help ensure adherence.
• The patient goes home with the new medications, with no need to stop at the local pharmacy.

 

At Saint Vincent Hospital, Poquette follows his own series of best practices to promote and grow the concierge medications program. The first best practice is to educate patients. For those having elective surgery, the pharmacy can engage in the preadmission education process and obtain patient data, including insurance information. That way, filling prescriptions at discharge will be faster, easier, and more convenient for both pharmacy and patient. Saint Vincent Hospital also distributes leaflets to all inpatients to inform them about the concierge medications service.

The next best practice is to network with and educate your staff. Everyone is a potential ambassador for the concierge medications program. That includes not only clinicians, but also secretaries, case managers, and even the transportation staff members who push the wheelchairs down the halls. In addition, the hospital educates pharmacy school students who make patient rounds. The more your staff knows about the program, the more opportunities you’ll have to gain patient participation.

It’s also critical to customize your approach by department. Telemetry, ICU, elective surgery, inpatient psychiatry, and pediatrics all have unique workflows—for example, some may electronically deliver prescriptions to the pharmacy, while others send faxes—and your concierge medications program must accommodate each department’s process. “Our goal is to make it easy to work with us,” Poquette says. “And flexibility is the key.”

Above all, remember that great service is contagious. Patients are happy to go home with their medications. As your staff sees patient satisfaction scores rise, they’ll naturally discuss how the concierge medications program is contributing to the success, and that will increase program awareness and participation.

Into the future

While they take different approaches to concierge medications, both Mercy Health System and Saint Vincent Hospital are seeing the benefits—and so are their patients. Their programs improve the health of patient and hospital alike, increasing medication adherence, improving outcomes, raising pharmacy revenue, and lowering 30-day readmissions.

In a world where hospitals are charged to do more with less, a concierge medications program is more than just a good idea. It’s an essential strategy whose time has come.

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Reference:

Barnsteiner, J. J. (2005). Medication reconciliation: Transfer of medication information across settings – keeping it free from error. American Journal of Nursing, 105(Suppl 3), 31–36.