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Service Delivery Innovation Profile

Pharmacist Provides Telephone-Based Medication Reconciliation and Education to Recently Discharged Patients, Leading to Fewer Readmissions


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Summary

Novant Health's Safe Med Program uses pharmacists to telephone recently discharged patients to educate them about their medications and reconcile their medication list, with the goal of preventing readmissions related to adverse drug events. During the call, the pharmacist asks the patient to review all prescription and over-the-counter medications currently being taken and provides educational information about each. The pharmacist reconciles the patient-reported list with the list documented at discharge and updates the medication list within the electronic medical record, addressing any discrepancies. The patient receives a copy of the reconciled list along with additional relevant information and adherence aids. As necessary, the pharmacist arranges for prompt followup on any medical or disease management needs identified during the call. Certified pharmacy technicians also call high risk patients 30 days after the initial pharmacist call to conduct further followup. The program has significantly reduced overall readmissions and those related to adverse drug events and has generated high levels of patient satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of 30- and 60-day readmission rates (both overall and those related to adverse drug events), along with qualitative feedback from post-implementation patient satisfaction surveys.
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Developing Organizations

Novant Health
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Date First Implemented

2007

Problem Addressed

Medication errors remain common and preventable, with many such errors occurring during the prescribing and administration process.1 Improved medication reconciliation systems, including those that occur postdischarge, can play a critical role in preventing these errors; yet, many hospitals do not have effective systems in place.
  • A common, preventable problem: Some experts estimate that more than 1.5 million adverse drug events occur each year in the United States.1 These errors often result from confusion caused by similar drug names and from a lack of patient understanding about dosing and other medication changes made by their physicians. The aging of the patient population will likely exacerbate this problem, due both to cognitive difficulties faced by many older adults and to the increasing number of older patients taking multiple medications from multiple providers.
  • Unrealized potential of medication reconciliation processes: Most medication errors can be prevented,1 particularly the numerous errors that occur during prescribing and administration.2 Medication errors stemming from such failures frequently occur at transition points, such as admission (responsible for 22 percent of reconciliation errors), transfer (22 percent), and discharge (12 percent).2 Although effective medication reconciliation can greatly reduce the risk of such errors,3 and hospitals have developed medication reconciliation processes that occur while the patient is still in the hospital, many hospitals do not have systems in place to fully reconcile medications following patient discharge.

What They Did

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Description of the Innovative Activity

Health system pharmacists telephone recently discharged patients to provide complete medication reconciliation and medication-related education. The pharmacist asks the patient to review all prescription and over-the-counter medications being taken and provides educational information about each. The pharmacist then reconciles the patient-reported list with the list documented at discharge and updates the electronic medical record, addressing any discrepancies. The patient receives a copy of the reconciled list along with additional relevant information and adherence aids. As necessary, the pharmacist arranges for prompt followup on any medical or disease management needs identified during the call. Certified pharmacy technicians also call high risk patients 30 days after the initial pharmacist call to conduct further followup. (Updated January 2014). Key elements of the program include the following:
  • Prioritizing patients to be called: While the program tries to contact all patients discharged from a Novant hospital (the program team currently has the capacity to telephone approximately 97 percent of such patients), a team of seven pharmacists and two pharmacy technicians conducts a weekly review to identify those at highest risk of readmission so they can be given top priority. Each Monday and Thursday, the team receives a report that identifies all patients discharged from every Novant hospital the previous week who are patients of a Novant primary care provider. Pharmacy technicians review the summaries and highlight those patients at the highest risk of readmission due to an adverse drug event. At-risk patients include those age 65 and older; those taking eight or more medications; those who experienced a prolonged hospital stay; those with cognitive impairment; those who suffer from high risk conditions such as congestive heart failure (CHF), diabetes, pneumonia, myocardial infarction (MI); and those taking certain medications with high risk of an adverse drug event (e.g., anticoagulants, digoxin, potassium, and sedatives). Novant physicians can also refer patients seen in their offices that require medication management to the Safe Med program. (Updated January 2014).
  • Pharmacist preparation for call: Before phoning the patient, the pharmacist accesses the patient care summary in the electronic medical record to review the patient's condition(s), laboratory test results, and medications recommended at discharge. The pharmacist considers potential problems and challenges the patient may face and determines what education to provide. The pharmacist also reviews the medication list to identify whether accepted standards of care have been followed. For example, if a patient admitted for congestive heart failure also has diabetes, the pharmacist will review the patient's diabetes medications to determine whether all recommended medications (e.g., a statin) have been prescribed.
  • Pharmacist–patient interaction: The pharmacist telephones the patient or caregiver, introduces himself/herself, describes the purpose of the call, and conducts a 30- to 90-minute interaction (depending on the complexity of the case); the program typically reaches 60 percent of all patients who are identified. The pharmacist leaves a message if the patient does not answer; if the timing of the call is not convenient for the patient, the pharmacist will call at a later time. Calls generally proceed as follows:
    • Assessment of medications: The pharmacist asks the patient to gather all medication bottles, including nonprescription medications and herbal supplements. (If the patient needs significant time to complete this task, the pharmacist will call back later at a designated time.) The pharmacist asks the patient to read the information from the medicine bottles over the phone and inquires whether the patient knows the purpose of each medication and the directions to properly administer the medication.
    • Education regarding medications: As necessary, the pharmacist provides education about each medication, such as its purpose, dosage, timing, and side effects. He/she also ascertains whether the patient faces any barriers to adherence (e.g., high cost, bad taste) and, if so, attempts to address those barriers.
    • Medication reconciliation: The pharmacist checks for discrepancies between the patient care summary and the patient's medication list. For example, the pharmacist will inquire about any medications listed in the patient care summary that the patient has not mentioned and then reinforce the importance of filling the prescription. The pharmacist also documents use of medications not initially noted in the patient care summary.
  • Documentation in database: For each patient, the pharmacist enters information on each medication (e.g., name, dosage, precautions), performs medication reconciliation, enters pharmacist progress notes and patient education materials, and identifies medication related issues in the electronic medical record along with a summary of the interaction, including his or her assessment and recommendations for the patient's physician (updated January 2014).
  • Followup with physician and disease management program: The pharmacist routes the full report from the electronic medical record to the physician. If the pharmacist identifies an immediate need, he/she will telephone the physician directly to resolve the issue or arrange for a prompt follow up appointment for the patient. If the patient appears to be facing meaningful challenges related to disease management, he/she will refer the patient to the Novant disease management program, which provides chronic disease patients with education, regular phone followup, and/or referrals to home health and other needed services.
  • Mailing of patient educational materials: The pharmacy technician mails the reconciled medication list (printed in large font) and relevant educational materials to the patient, along with a pill box, pill splitter, and refrigerator magnet with the Safe Med toll-free telephone number. The patient can use this number to call a pharmacist with follow up questions at any time.
  • Technician followup: Certified pharmacy technicians call high risk patients 30 days after the initial pharmacist call to ensure that the patient received the educational materials, had a follow up appointment with their physician and has no questions about their medications.
  • Program enhancements: According to information provided in January 2014, pharmacists now contact patients referred by a primary care provider, hospitalist, or inpatient pharmacy. Pharmacists also contact patients admitted for high risk conditions including CHF, pneumonia, MI, and newly diagnosed diabetes, regardless of age.

Context of the Innovation

Novant Health, an integrated health system serving patients in North Carolina, South Carolina, and Virginia, includes 14 hospitals with 2,700 total beds, more than 450 outpatient locations, and 1,100 physicians. In 2012, Novant had more than 3.7 million physician visits and 122,000 hospital admissions. A member of the Voluntary Hospital Association (VHA), Novant participated in a VHA research project that involved tracking and analyzing adverse drug events. Results showed that many recently discharged Novant patients—particularly those on certain high-risk medications such as anticoagulants (blood thinners) and digoxin (used to treat congestive heart failure and atrial fibrillation)—ended up being readmitted due to an adverse drug event triggered by a lack of patient understanding about his or her medication regimen. To address this problem, Novant leaders decided to develop an initiative focused on reducing adverse drug events and associated admissions and readmissions.

Did It Work?

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Results

The program significantly reduced overall readmissions and those related to adverse drug events and has generated high levels of patient satisfaction.
  • Fewer readmissions overall: Between January 2007 (before program implementation) and October 2008, the 30-day readmission rate decreased from 13.1 to 6 percent, while the 60-day rate decreased from 7.7 to 2.7 percent.
  • Fewer readmissions related to adverse drug events: The 30-day rate for readmissions related to adverse drug events decreased from 3.4 to 2 percent, while the 60-day rate decreased from 2.5 to 0.6 percent.
  • Cost avoidance resulting from reduced readmissions: An analysis conducted by Novant Health indicates that in 2009, Safe Med contacted 3,694 patients to provide medication reconciliation and education after discharge from an acute care facility, which translates to an estimated 305 readmissions prevented; assuming an average cost of a Medicare hospitalization of $11,000, a conservative estimate of potential cost avoidance is $3.4 million per year.
  • High patient satisfaction: Surveys of patients contacted by a Safe Med pharmacist found high levels of satisfaction with the program, with most patients expressing gratitude for the service.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of 30- and 60-day readmission rates (both overall and those related to adverse drug events), along with qualitative feedback from post-implementation patient satisfaction surveys.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Steering committee review of alternatives: Novant leadership formed an adverse drug event steering committee, based in the health system's Clinical Improvement Division, to identify patients at highest risk of preventable readmission related to adverse drug events. The committee, which included the medical director of clinical improvement, physicians, nurses, and pharmacists, performed a literature search to identify different options for an initiative focused on reducing adverse drug events. Many articles emphasized the pharmacist's potential to serve as a medication expert by directly consulting with patients during the medication reconciliation process.
  • Hiring and training pharmacists: The steering committee hired four pharmacists to partner with physicians and serve in a direct consulting role with patients. At first, the pharmacists did not receive additional training; however, as the program progressed, it became clear that the pharmacists needed training on patient engagement. An outside consultant who was a pharmacist provided the pharmacists with brief training on patient counseling, motivational interviewing, and other strategies for engaging with patients, particularly older adults.
  • Identifying and tracking target patient population: The committee determined parameters for identifying patients at highest risk of readmission, and the information technology department developed a weekly report of discharged patients that included these parameters.
  • Pilot testing and feedback: Initial pilot testing involved patients from six primary care practices during a 3-month period. To prepare for the pilot, the pharmacists visited these practices to explain the program as an extension of current services designed to improve patient outcomes (not an effort to review or question their care decisions). After the pilot, physicians offered feedback about the service and the reports.
  • Expanding to all practices: After the pilot test, the Safe Med program expanded to all Novant practices. Program leaders mailed a packet of information to each practice describing the program and its goals, the nature of the pharmacist–patient interaction, and the high risk of readmission associated with certain medications. The materials noted that patients would be proactively contacted after hospital discharge but also invited physicians to refer nonhospitalized patients who might need medication management. The pharmacists also attended various medical team meetings to describe the program and placed "advertisements" in Novant's physician newsletters.
  • Hiring pharmacy technicians: After program developers realized that pharmacists spent too much time reviewing the weekly report and managing patient mailings, they received approval to hire two part-time pharmacy technicians to handle these tasks.
  • Ongoing testing and evaluation: In July 2013, the Safe Med program received a Cardinal Health grant to improve medication adherence and reduce readmission rates by using electronic medication reminders (updated January 2014).

Resources Used and Skills Needed

  • Staffing: The program includes five full-time pharmacists, two part-time pharmacists, and two pharmacy technicians. Each full-time pharmacist can perform a complete telephone consultation with approximately 100 patients per month.
  • Costs: The primary program costs consist of salaries and benefits for the pharmacists and technicians; other expenses include printing and photocopying of educational materials, postage, and production of the pill boxes and refrigerator magnets.
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Funding Sources

Novant Health
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Tools and Other Resources

A medication reconciliation toolkit from the Institute for Healthcare Improvement is available at: http://www.ihi.org/knowledge/Pages/Tools/MedicationSafetyReconciliationToolKit.aspx

Adoption Considerations

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Getting Started with This Innovation

  • Emphasize quality when seeking physician buy-in: Physicians may initially be reluctant to allow pharmacists to contact patients directly. To address this concern, pharmacists should communicate the value of the program to physicians, emphasizing its team approach and potential to improve outcomes. They should also note that the program is not intended to monitor, approve, or question physician decisions regarding medications but to serve as an added resource for patients and physicians.
  • Hire pharmacists who enjoy patient contact: Pharmacists will be most effective if they enjoy working closely with patients (to a much degree greater than typically required of a pharmacist).
  • Train pharmacists in patient communication: Pharmacists will likely need training on how to engage patients in their medication issues; teaching motivational interviewing can be particularly helpful. Training efforts should include communication strategies specifically geared toward the population being targeted.
  • Include pharmacy technicians: During the initial implementation of the program, (highly-paid) pharmacists reviewed discharge lists and created mailing packets for patients. Pharmacy technicians can perform these tasks more efficiently, saving money and allowing time for pharmacists to interact directly with patients.

Sustaining This Innovation

  • Focus on patient and physician service: Although the program has "built-in" customers (i.e., the patients identified each week from the discharge summary list), pharmacists can build ongoing support and additional patient referrals by focusing on providing excellent, timely service to both patients and physicians. Also, because many adverse drug events occur at transition points such as transfer and discharge, partnerships with primary physicians are critical. For example, at Novant, the Safe Med program is directed by the physician group to achieve such integration.
  • Integrate pharmacists into system-wide medication safety activities: Elevate medication reconciliation as a strategy to be encouraged across the organization, focus on care coordination both inside and outside the hospital setting, and allow the program's pharmacists to participate on committees and initiatives focused on medication safety. This approach will enhance pharmacists' exposure, professional capabilities, and contributions, while simultaneously increasing physicians' comfort level with the pharmacists and the program.

More Information

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Contact the Innovator

Terri B. Cardwell, RPh, Pharm D
Senior Director, Clinical Improvement
Novant Health
2000 Frontis Plaza Blvd., Suite 200
Winston-Salem, NC 27103
(336) 277-2417
E-mail: tbcardwell@novanthealth.org

Rebecca Bean, BS, PharmD 
Safe Med Manager
Novant Health
2000 Frontis Plaza Blvd., Suite 200
Winston-Salem, NC 27103
(336) 718-8494
E-mail: rabean@novanthealth.org

Innovator Disclosures

Dr. Cardwell and Ms. Bean have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Tilyou S. Strong Medication Reconciliation Effort Lowers ADE Readmissions. Pharmacy Practice News. 2009 August;36(8). Available at: http://pharmacypracticenews.com/index.asp?section_id=50&show=dept&issue_id=553&article_id=13661 (Note: Free site registration is required.)

Footnotes

1 Institute of Medicine. Preventing Medication Errors. Washington, D.C.: National Academies Press; 2006.
2 Joint Commission on Accreditation of Healthcare Organizations. Using medication reconciliation to prevent errors. Jt Comm J Qual Patient Saf. 2006;32(4):230-2. [PubMed]
3 Santell JP. Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: January 19, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 29, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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