Lost Between the Cracks: Transitions of Care
Pharmacists play an important role in bridging care between hospital and home
It’s finally time to go home. After weeks in the hospital getting patched up by doctors and cared for by nurses, it’s finally time for our patient (let’s call him JD) to resume the normalcy of his life outside of the hospital. We can imagine that during those final hours of his stay, he is preoccupied with work that needs to be caught up on: a garden neglected, errands that need to be run, etc. With his mind in multiple places at once, JD is distracted when his nurse or pharmacist enters the room and begins explaining his discharge medication instructions to him, a potential area of confusion that may cause great harm.
Approximately 20% of 30-day readmissions to the hospital are results of medication errors. In other words our failure to ensure that patients are receiving appropriate therapies once they get home is causing significant patient harm and decreasing funding to our health systems. So what can we do? Involving pharmacists in the discharge process inside the hospital can dramatically improve patient safety.
There are multiple points that may introduce error in the patient discharge process. From language and educational barriers to errors made by team members, the steps necessary to ensure a safe patient discharge requires a truly interdisciplinary approach where communication and sound protocol are necessary. Pharmacists can play important roles in this process by providing checks on the discharge medication reconciliation, educating on medication instructions, ensuring any barriers to medication adherence are addressed, and being a resource for any potential questions from both the patient and the healthcare team.
Medication reconciliation is central to the discharge process. In this step providers go over the patient’s medication history in the hospital and input the medicines they want the patient to continue at home. The pharmacist ensures that the medication reconciliation is addressed, makes sure that therapy choices are appropriate and adequate, and makes recommendations to team members if they are not. This is the most crucial step as it determines the road-map for every decision afterwards.
Pharmacists can play the role of educator as well. Patients often have little awareness about changes to their medicines while in the hospital and need to understand those changes now that they (or their caretaker) will be managing their regimen at home. Pharmacists are trained specifically in medication education and can fill this gap by not only providing medication specific counseling, but also answering any questions the patient may have.
There are many barriers that often interfere with patient treatment during this time. Insurance barriers exist for medications that may not be on their formulary. Financial barriers may exist due to patient funding. Supply barriers exist if the medication is not available at the patient’s pharmacy of choice (specialty medications for example). Pharmacists can help address insurance issues by getting the necessary paperwork to responsible parties (for example prior authorizations). Help with funding is another issue where discount programs/cards are areas pharmacists are familiar with. If alternative recommendations are needed, pharmacists may be able to offer those recommendations. Finally, pharmacy can play a role in directing patients to where they can fill their medicines specifically.
At the end of this process, it’s important to remember that patient’s must agree and be on-board with the decisions made. They must be the primary stakeholder and without their buy-in the chance for medication errors will increase regardless of interventions.
Thanks for reading,
Stephen W
