Hitting the Target

A recent American Hospital Association Annual Survey reveals that there were approximately 35 million hospital stays in the United States in 2015. As many as one in five patients is readmitted within 30 days of his or her discharge, according to the Agency for Healthcare Research and Quality (AHRQ). With an aging population, increased life expectancy and about half of adults suffering from one or more chronic conditions, hospital visits and medication use are increasingly common. Expenditure projections from the Centers for Medicare & Medicaid Services (CMS) indicate that the U.S. healthcare system is the most expensive in the world, accounting for 17 percent of the gross domestic product. Pharmacists are among the many healthcare stakeholders exploring interventions that will lead to healthier patients, thereby lowering costs.

The Institute for Healthcare Improvement, for example, is one organization pursuing initiatives with these goals in mind. The IHI Triple Aim is a framework that describes an approach to optimizing health system performance. The Triple Aim includes improving patient care, improving health and reducing costs. IHI suggests that when communities achieve the Triple Aim, patients can expect less complex and more coordinated care. Reducing the per-capita cost of care for populations will lessen the pressure on publicly-funded healthcare budgets. To put the Triple Aim into action, IHI recommends broadening the role of primary care and other community-based services.

AHRQ, part of the U.S. Department of Health and Human Services, is another entity that is focused on interventions that improve care. AHRQ partnered with researchers at the Boston University Medical Center to develop the Re-Engineered Discharge toolkit to assist hospitals, particularly those with diverse populations, with reducing readmissions and post-hospital emergency department visits. The toolkit helps patients prepare to care for themselves when they leave the hospital. Hospital staff and patients review the steps to take upon discharge, such as which medications to take and when to follow up with medical appointments. Pharmacists play a key role in ensuring that patients have the necessary information to keep their recovery on track.

Other examples of the increasing use of evidence-based interventions illustrate the heightened focus on making the Triple Aim goals a reality. Million Hearts, a national initiative co-led by the Centers for Disease Control and Prevention and CMS, set a goal in 2012 to prevent a million cardiovascular events in five years. The initiative successfully aligned disease prevention efforts around a select set of evidence-based public health and clinical goals and strategies. Involving community pharmacists in such interventions “fosters a true collaboration between these pharmacists and researchers such that the nature of the intervention can be transformed and better account for the practicalities of implementing the intervention sustainably,” said Dr. Meagen Rosenthal, assistant professor of pharmacy administration, at the University of Mississippi’s department of pharmacy administration. “These kinds of considerations can also improve our ability to scale up interventions from single clinics and pharmacies to larger communities and health systems.”

Smooth Moves

While researching transitions of care during her sabbatical three years ago, Dr. Judith Kristeller, professor of pharmacy practice at the Wilkes University Nesbitt School of Pharmacy, realized that pharmacists could play a bigger role in reducing hospital readmissions. “I saw an opportunity for pharmacists to improve care during transitions and I saw a lot of problems with medication management as patients transition from hospital to home,” Kristeller said. “I thought that pharmacists could have a positive role during that transition, and even beyond that, for patients with chronic disease to optimize medication management and keep them out of the hospital.”

Last fall she and Dr. Dana Manning, a fellow pharmacy professor at Wilkes, received a three-year, $150,000 grant from the Cardinal Health Foundation to help improve patient medication use and ease the transition from hospital to home. They are developing a model where hospital and community pharmacists can work together to provide care as patients experience this transition. “We are exploring ways to develop a process that is efficient, effective and sustainable,” she noted.

Kristeller said that she believes pharmacists are highly underutilized. “If [pharmacists] had information about the patient and knew what medications were being used and why we are using them, they could provide ongoing assessment and could counsel patients on adherence issues, non-pharmacological treatment strategies, self-care issues and could encourage them to talk about potential medication-related problems.” She added that giving pharmacists regular access to patients allows them to talk directly to patients’ primary care physicians. She encourages pharmacists to do continuous patient education and counseling to keep patients with chronic conditions from having to return to the hospital.

Some of the grant money is devoted to technology-related aspects, but some goes into building the project’s sustainability. “We have pharmacy students that do a lot of the clinical work in terms of evaluating patients, meeting with patients, developing an assessment and plan and communicating with the patients,” she said. She assesses how the model is working from the patients’ perspective by collecting patient satisfaction surveys and tracking the success of the interventions. “We also want to evaluate from the perspective of the community pharmacist to identify opportunities and barriers to bringing them into this collaborative practice with hospital pharmacists to provide continuity of care,” Kristeller added. “We want to survey the community pharmacists to find out what we can do to make that process better.”

A pharmacist-focused model. Similar research is underway at the University of Hawaii at Hilo Daniel K. Inouye College of Pharmacy. Dr. Karen Pellegrin, the college’s director of continuing education and strategic planning, also wanted to explore what happens with care transitions when patients are moved from one place to the next in the healthcare system. While there have been many models that attempt to improve that transition, she explained, none had really focused on the unique expertise of the pharmacist. Funded by a CMS Innovation Center Health Care Innovation Award, the Pharm2Pharm model focuses on reducing medication problems after hospital discharge.

“That’s a common place for problems to arise, so why not put a medication expert on that to prevent subsequent hospitalizations?” she said. The model works like this: Hospital pharmacists screen newly admitted patients with evidence-based criteria. They start working with patients while they are in the hospital and then do a handoff to the community pharmacist. From that point forward, the community pharmacist handles the patient post-discharge for up to a year.

The inspiration for the Pharm2Pharm model came from Les Krenk, independent pharmacy owner, who wanted to better utilize community pharmacies. Pellegrin and Krenk realized that the hospital setting would allow them to identify high-cost, high-risk patients. “It started with an interest in getting community pharmacists better positioned in the broader healthcare system,” she explained. “That’s what we did by creating a medication management system that really leverages that expertise. We thought that if we could do a better job taking care of medications, we could reduce hospitalization rates.”

With three years of baseline data showing the stable medication-related hospitalization rate among those 65 and older, the Pharm2Pharm model was implemented in about half of the general acute care hospitals in the state and yielded a significant decrease compared to those hospitals without Pharm2Pharm. The model was associated with an estimated 36 percent reduction in the medication-related hospitalization rate for older adults. Pellegrin’s data reveal that the avoided cost of those hospitalizations was about $6.6 million. The cost of the pharmacists delivering those services was $1.8 million, a robust return on investment. These results were published this past year in the Journal of the American Geriatrics Society.

“We surveyed pharmacists and patients and tried to get everyone’s perspective on the model,” she noted. “The patient ratings were through the roof. They were so happy to have these services. These patients typically have multiple chronic conditions. Having that expert pharmacist who was able to take the time to sort through to get them on the best medication regimen and work on adherence…that’s the most attention many of these patients had ever had.”

In a population-level project such as this one (as opposed to a clinical trial), the team was constantly working to improve the model. “We had a systematic outreach program with physicians.” Pellegrin said. “We implemented really novel health information technology. That was phased in to give the pharmacists more efficient and timely access to clinical information, which is so critical to doing medication management properly. It was all continuously developed. We had mandatory training that was updated as we made changes. That allowed us to refine the model over time.”

While Pellegrin said she is confident that Pharm2Pharm is a scalable model, she is still working to drill down to see which factors predicted better success and where it had the biggest impact. “These follow up analyses will help health plans, ACOs and others adapt the model within their unique setting. We have standard operating procedures, training, and tools, such as a more user-friendly pharmacist recommendation template based on physician feedback. People can adapt these tools as much as they would like. Our online training (a six-hour continuing pharmacy education program) ensures each learner knows the concepts before they complete the program.” As people live longer and rely more on medications, she said, pharmacist involvement will be crucial to reducing hospital readmissions and helping with medication management. “If we really want to improve quality of care and be more cost effective, we have got to get pharmacists better positioned and compensated across all healthcare settings.”

Immunization Revelation

At the University of Wisconsin-Madison University Health Services, an idea for an M.P.H. research project turned into an intervention that focused on keeping students healthy by promoting immunization. Angela Long, an independent public health professional, was looking for a project to pursue when she thought about her two college-age daughters and the struggle around getting the HPV vaccine. Of the 14 million new HPV infections in the United States annually, more than 50 percent are estimated to occur in persons age 15–24.

“Immunization is one of a number of things that have brought clinical pharmacists closer to patients,” said Long, who approached the University of Wisconsin about taking on the project in 2014. She had observed nursing students administering influenza vaccines and wanted to get pharmacy students involved in the same way. The university was looking for a quality improvement program to increase HPV vaccination rates. Long connected with Dr. Mary Hayney, a professor with the School of Pharmacy, and they decided to target the international student population because those students had insurance that covered vaccines administered at University Health Services, which simplified billing.

Using the American Pharmacists Association national program Operation Immunization—which allows pharmacy students to brainstorm ideas they have to promote immunization in the community—as a framework, Long and Hayney set out to increase HPV immunizations on campus. “The pharmacy students helped with outreach in 2015,” Long noted. “In 2016, Mary was able to arrange for pharmacy students to actually administer the HPV and flu vaccines. We wanted to showcase pharmacy student involvement.” By piggybacking the HPV intervention on the flu shot clinic, the university saw a 37 percent increase in HPV vaccinations in 2015 and a 76 percent increase in 2016 during the months of September through November each year, resulting in a 140 percent increase in HPV vaccination from 2014 to 2016.

Long did not formally evaluate the immunization campaign, but she said the key to the program’s success was targeting a specific population. “We really tapped into the Chinese student population by way of two pharmacy students who spoke Chinese,” she said. “They were able to reach out on social media. We felt that the second year we were able to reach further into that community because we had done it the previous year.”

Long, Hayney, and their third collaborator, Craig Roberts, M.S., PA-C, are helping other campuses replicate the campaign by providing the methodology via presentations and professional interactions. “Each school will have a unique approach to increasing HPV vaccination,” Long continued. “Mary had to work through the Wisconsin Pharmacy Examining Board to gain a waiver to the supervisory rule; each state has different rules in terms of student pharmacist immunization. Insurance coverage is different at every school. The main concept of piggybacking with the fall flu campaign is to reach an immunization-ready audience, which is a common thread we feel can be successful in any situation.”

Added Hayney, “Any time health professions students get the opportunity to practice with their peers, it benefits the whole community. Students gain experience. Pharmacy students get to practice in a setting where they are supervised. It also gives them some exposure to emergency preparedness.” She said that another benefit of involving pharmacy students is that undergraduates who hadn’t thought about pharmacy school might reconsider when they see their fellow students in action.

“Peer-to-peer outreach is key,” she noted. “Have a champion and make sure that champion can relate to students who might be ready to get the vaccine but need a recommendation from a peer.”

A Valuable Relationship

Another professor at the UW–Madison School of Pharmacy is also exploring how pharmacists can use their interactions with patients to promote lasting healthy habits. Dr. Betty Chewning teaches a required class for Pharm.D. students that involves them collaborating with community pharmacies to plan services that will raise patient expectations about pharmacist roles. “In addition to teaching students program planning methods, the goal is to help the pharmacies offer new, high-quality sustainable services to enhance the health of their patients,” explained Chewning. Her research aims to support and promote an active partnership between pharmacists and patients.

Recently, she and her students worked with community pharmacies to help individuals orchestrate their regimen schedule to take medication doses safely and efficaciously at the fewest unique times per day. “The individual identifies his or her ‘typical day’ and preferences for best times to take medications, and in partnership with the pharmacist, determines the best schedule,” she said, noting that this simplifies medication management. In another example, a one-question assessment at the pharmacy provided smokers with the opportunity to connect with telephone tobacco Quit-Lines. Chewning also worked with physician and pharmacist dyads to refer individuals with complicated regimens to a community pharmacist for MTM consultations. This referral process reinforced the legitimacy of the pharmacists’ delivery of MTM.

Chewning teaches students to follow planning steps when developing interventions. These include conducting SWOT analysis, comparing options, identifying relevant literature, writing objectives, describing the intervention, flowcharting the preparation process preceding implementation, conducting a cost/benefit analysis, developing a quality improvement plan, testing the service and summarizing what revisions are needed.

Deciding which interventions are needed is based on pharmacy experiences and reviews of the research literature on patient needs. The dose orchestration approach originated in part when Chewning had to help her husband manage his complicated medication schedule. One of her students undertook the Quit Line referral study as part of her dissertation, which involved a randomized controlled trial with 16 Walgreens pharmacies. “Each year the student pharmacists in my course plan and pilot tests of services with about 20 community pharmacies,” she noted. “Pharmacists are an important, underused resource that patients need to help them manage their medications effectively. The challenge is to help patients understand what pharmacists can offer, and to help pharmacists understand how grateful patients would be to receive this help.”

Jane Rooney is a
freelance writer based in Oakton, Va.