Hospital Rx: A pharmacy stop at the patient bedside
Hospital Rx: A pharmacy stop at the patient bedside
The Affordable Care Act is changing healthcare in many interesting ways, and hospital pharmacy practices are no exception. At my hospital, we've decentralized our retail pharmacy by bringing a member of our staff right to the patient's bedside prior to discharge.
This new approach is a direct response to incentives and penalties that ACA uses to improve quality and outcomes, especially the drive to reduce 30-day readmission rates. It's too early to know how much our bedside pharmacy is helping us hit our ACA targets. We should know later this year.
We do know that this "bedside discharge concierge program" - as we fancily (but accurately) call it - has been extremely popular among patients. From a patient's-eye view, it's a model of convenience, simplicity and cost-effectiveness.
The real challenge has been behind the scenes. Nurses, doctors, pharmacists and pharmacy technicians must coordinate a complex series of highly regulated events (paperwork, procedures, products, etc.) and deliver the goods on a very tight deadline.
When patients get approved for discharge, they are ready to get out of the hospital - fast, as in immediately. The discharge process takes perhaps 20 minutes, so that's a bedside pharmacy's deadline. You're dead in the water if you're delaying discharge.
We had the great advantage that our division chief of cardiology Dr. Louis Teichholz initiated the idea. He wanted to reduce the number of patients not taking their medicines properly, a major cause of readmissions. His support gave us great institutional buy-in, so we could focus on technical problems, not cultural ones.
Hackensack University Medical Center is a 755-bed institution spread over a 19-acre campus. I manage the center's two retail pharmacies - one in a medical office building, the other in an outpatient cancer center. Cardinal Health runs both under contract.
Decentralizing a retail pharmacy requires a lot of coordination. We have one full-time pharmacy technician dedicated to the discharge program. She is dispatched in the morning with a mobile pharmacy unit that includes:
- a laptop that has access to our pharmacy system.
- a mobile phone to keep her in contact with the pharmacy.
- a tablet computer that captures payment information and signatures from the patients.
Choosing the right person is a key to success. For our program, we chose Cardinal health employee and certified pharmacy technician Fallon Curry. Fallon has many years of experience at the retail pharmacy and a strong understanding of the pharmacy system and third-party billing. She is outgoing and independent, which made her the perfect person for the job. She works at a desk near the nurse's station Monday through Friday, when most discharges occur. In between discharges, she does a one-week follow-up call to the home of patients who participate in our program to check on health and compliance.
When a discharge is authorized, the technician asks the patient if he or she would like to participate in the bedside pharmacy program. Not surprisingly, 97% say yes. The reason is obvious: a patient gets all medicines on the spot without the hassle of stopping at another pharmacy on the way home. Fallon is able to address insurance issues immediately, such as whether a medication is covered or has a copay that's unaffordable.
Cardiology patients are often discharged with a number of prescriptions. We verify coverage on all medicines before discharge. If a drug isn't covered or is too expensive for a patient, a doctor can substitute another brand or generic before the patient goes home. If a patient is uninsured, we can use patient assistant programs from drug manufacturers and other tools to get medicine to the patient.
The key is putting the right medicines and affordable prescriptions in a patient's hands before a person leaves. By reducing cost and complexity, the odds of a patient complying - and not getting readmitted - improve dramatically.
The challenge is doing all this in less than 20 minutes. The pharmacy technician needs to deliver medicines to the patient's bedside and alert nurses (for discharge dispensing education) with efficiency and precision. I'm proud to say we've never missed a deadline.
Our discharge concierge program started in May 2011 beginning with cardiac services. Last year, we expanded to our mother-baby ward and bariatrics. Now, it's being expanded into our hospital's Hackensack Alliance Accountable Care Organization.
Patients are told they don't have to come back to the hospital to refill prescriptions. The program packet explains how to transfer the prescriptions to a pharmacy of their choice. The goal is to make it as easy as possible for the patient to be compliant. However, one of the great side effects of the program is that 30% to 40% of patients return to the hospital's retail pharmacy to fill their prescriptions after discharge. This, of course, makes a hospital pharmacy more profitable, turning it from a cost center into a strategic asset. It also can become a bridge to Medication Therapy Management (MTM).
I've had lots of calls to ask about our program. My advice is to get buy-in from the top and collaboration from nurses and physicians. Then, start small. Once you have a success story, you can move from floor to floor and deliver a great service to your institution and its patients.