Next Generation is a BWH Clinical & Research News (CRN) column penned by students, residents, fellows and postdocs. This month’s column is written by Jillian Dempsey, PharmD, BCPS, and Christine Gillis, PharmD, BCPS, second-year pharmacy residents, specializing in transitions of care.

Christine Gillis (left) and Jillian Dempsey (right)

More than 100 patients are discharged from BWH each day. What happens to these patients when they leave the hospital? What types of issues and challenges might they face? Throughout our pharmacy curriculum, we were taught about these challenges, including gaps in medication access, comprehensive medication education and timely follow-up with outside providers; however, when we began working at BWH, we recognized the true impact that care transitions can have on patients and their families. We identified a need in the area of transitions of care (TOC), and we were confident that a streamlined comprehensive plan for patients being discharged – including provider follow-up, referrals and arranging appropriate blood draws for monitoring drug response – would have a tremendous impact on patient quality and safety. We decided to continue our training by beginning a novel six-month postgraduate year two (PGY-2) pharmacy residency program with a focus on TOC.

A large part of our residency training has been centered around our longitudinal pilot project, developed in collaboration with BWH’s Cardiology Division, called Project PURPOSE (Pharmacist Utilized Resources to ImProve CardiOvascular CarE). The goal of our six-month quality improvement initiative was to evaluate the role of a pharmacist intervening with cardiovascular patients who are at an increased risk for readmission and medication side effects.

We met with patients and their families during their hospital admission or afterward, and prior to their Watkins Clinic cardiologist outpatient appointment . We reconciled patients’ home medication lists, assessed medication adherence, provided medication education, triaged and resolved issues surrounding medication access and offered recommendations for drug therapy optimization. Medication reconciliation involved reviewing medications listed in the patients’ electronic health record, interviewing patients and/or caregivers and clarifying medications regimens with phone calls to the patients’ pharmacies.

For hospitalized patients, we also offered medication bedside delivery and completed post-discharge phone calls to the patient and/or caregiver 48 to 72 hours following discharge. These patients were identified based on pre-specified high-risk criteria for readmission via daily Epic reports. We targeted patients over the age of 65who had either a history significant for congestive heart or acute coronary syndrome.

We knew that taking on this project would require a large time commitment, coordination with many different departments and other logistical complications. What made us want to start this pilot program and take on the challenge of being involved in an innovative initiative? With the passing of the Affordable Care Act, there is now an increased focus on avoiding unnecessary readmissions, and there are fiscal incentives tied to that. Our hospital leadership saw an opportunity to expand the role of pharmacists to be more extensively involved in the TOC process. Lastly, we believed pharmacists could contribute to the multidisciplinary efforts aimed at bridging the gap between ambulatory and inpatient care. As we thought about how many patients are admitted because of an adverse drug event or because of limited access to medications, or because they didn’t understand how to correctly take their medications, we felt empowered to find ways to improve care for patients through our involvement in medication management and follow up.

From the outset, we knew that starting a pilot initiative would not be an easy task. It required a lot of trial and error in program design from both an operational and clinical perspective. We must have redefined our high-risk population for readmission about a half dozen times, and we re-worked our daily tasks on several occasions to align with existing infrastructure in both the inpatient and ambulatory settings. We were fortunate to have the Watkins Cardiovascular Clinic staff supporting us and mentors within the pharmacy department who pushed us to be creative when altering our design. Given that it was just the two of us managing the pilot project and we both had additional job responsibilities, it was important that we maintained a balance between the two. This was our greatest challenge throughout the pilot.

As our pilot wraps up, we reflect on the number of patients we came into contact with through our work and the differences we feel we have made in the care they received. To date, 117 high-risk cardiology patients have participated in the pilot. We have identified and corrected an average of four medication discrepancies per patient, for example, patients taking a different dose of a medication than prescribed. We have made 156 recommendations for drug therapy optimization, 83 percent of which were accepted and acted upon by a physician. In addition, we were able to provide 22 patients with significant medication cost savings, of up to $1,200 per year. Some of the ways we brought about this cost savings included providing drug coupons for patients with commercial prescription insurance, recommending less expensive medication alternatives with lower co-pays and performing Medicare Part D reviews during open enrollment for Medicare patients. Our patients have been overwhelmingly satisfied with our services: we had 100 percent patient satisfaction among the 50 patients who filled out our survey. Thirty-day hospital readmission rates among our patients decreased at least 10 percent, compared to BWH-specific readmission averages for our specified patient populations.

Our pilot project wraps up this month, and we plan to use the data to support funding for additional pharmacist involvement in TOC. We have learned a great deal from this experience, remain excited about the success of our pilot and hope to continue our TOC work at BWH.