Walgreens pharmacist Austin Mudd, PharmD, stands at the bedside of Lewis Broughton, 49, and explains the instructions for Broughton’s antibiotics. “Make sure you take all of them even if you start feeling better,” said Mudd, who is Manager of the Walgreens on campus at DeKalb Medical in Atlanta. Broughton can now go straight home after discharge without making a stop at the pharmacy. “This is a blessing,” the patient told Pharmacy Today. “A lot of times you have to catch a bus or take a cab, and it costs money to get there. And then when you get there, you have to wait in line.”
Mudd delivers prescriptions to patients’ bedsides through Walgreens’ partnership with DeKalb Medical; the partnership became a hospital-wide program in July. Under the program, medication reconciliation is carried out by the attending physician, and Walgreens fills the attending’s final prescription for patients who choose to use the service. The program aims to ease the transition from hospital to home and increase patient adherence and satisfaction while lowering readmissions.
“One of the main reasons patients come back to the hospital is that they don’t follow their medication instructions correctly. This program will help cut down on that and improve medication [adherence], which results in better patient outcomes,” said Solomon Tafari, MD, MPH, DeKalb’s Hospitalists Medical Director.
Taking medications correctly means beginning the prescription promptly, and bedside delivery makes that more likely. “After discharge, many patients go straight home and don’t get their prescriptions filled right away. Delays in taking prescribed medicines or missing a dose can result in slowed recovery or even a return to the hospital,” said Tom Sweeney, RN, MBA, FACHE, Vice President and Chief Nursing Officer at Washington, DC’s Adventist Hospital, which also partners with Walgreens.
Before delivering prescriptions bedside, pharmacists complete any insurance authorizations, work with physicians to prescribe brands or generics that their patients can afford, and ensure that specialty items are in stock at community Walgreens pharmacies after discharge.
“If they take the prescription to the pharmacy and find out it’s not covered, they’ve got a problem, whereas if you know right now, while they’re still in the hospital, we can swap this antibiotic for one that’s covered and know they’re getting the medication,” Mudd said. Many partnering pharmacists also make follow-up phone calls to patients 48 to 72 hours after discharge to review instructions for medications and to make sure patients have adequate supplies.
“We’ll ask more than just yes-or-no questions. If it’s Lovenox [enoxaparin] they’re taking, we’ll ask how many syringes they have left just to make sure [adherence] is there,” Mudd said.
Over the past 5 years, Walgreens partnerships have launched at most of the approximately 100 hospitals with on-campus or nearby Walgreens stores, including those in Washington, DC, Chicago, and Atlanta, and cities in Florida, California, and Arizona.
At some hospitals, such as Florida’s Sarasota Memorial, Walgreens pharmacists continue to follow up with patients 7 and 28 days after discharge. They may also call community pharmacists outside the hospital at Walgreens and elsewhere on the patient’s behalf. Some programs, like DeKalb Medical’s, include the pharmacists in regular meetings with the rest of the health care team.
More than satisfied patients
In October 2012, CMS will begin penalizing hospitals with the highest 30-day readmission rates by cutting their reimbursements. Readmissions cost Medicare $26 billion in a decade, according to estimates from the U.S. Department of Health & Human Services, and many of those readmissions are medication-related. Bedside drug delivery may look simply like a major added convenience for patients, but hospitals hope the program will improve patient outcomes and their bottom line.
Medication adherence ranks as the number one reason for readmissions, so hospitals are taking an interest in patients long after discharge. “A percentage of patients never get [their] prescriptions filled, some drop it off but never pick it up, and some pick it up but don’t take it correctly, so we’re trying to close that gap,” said Mudd.
Poor medication adherence costs the U.S. health care system an estimated $290 billion per year, according to the National Association of Chain Drug Stores. Some studies have shown that as many as half of prescriptions written in hospitals go unfilled. Other research reveals that only 15% to 20% of those prescriptions filled are dispensed exactly as prescribed.
“That transition into the community is where some things get lost, which is why we do have some readmissions. You need a whole team, pharmacists, doctors, nurses, everybody on board,” said Spencer Hudon, RN, BS, CNML, who is Clinical Manager of the heart failure unit at Sarasota Memorial Hospital.
While there aren’t yet data to show how community pharmacy partnerships with hospitals specifically affect readmission rates, health professionals agree that ensuring that patients leave the hospital with their medications and clear instructions is a step in the right direction. Health care providers are finding additional education and counseling to be key in improving adherence. “We have some of the lowest readmissions rates in the country. We have a very comprehensive heart failure program that involves a lot of education, and I think Walgreens is a piece of that,” Hudon said.
“We hope that if patients leave the hospital with their medications that [adherence] will be better,” said Nicole Bernardo, PharmD, Cardiology Team Leader at Chicago’s Northwestern Memorial Hospital. There, Walgreens pharmacy technicians deliver prescriptions to patients’ bedsides and hospital staff—preferably pharmacists—counsel patients about the medications.
Patient satisfaction with medicationrelated communication has improved greatly, as seen in rising scores on the CMS-administered Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS).
At DeKalb Medical, patient satisfaction with medication-related communication rose from 50% to 63% in the first 90 days of the Walgreens program, and it continues to trend upward. Sarasota Memorial saw a 14% rise in scores in this category after the Walgreens partnership and several other initiatives to improve communication were put in place. Other hospitals are seeing similar results as DeKalb Medical, according to Ron Weinert, Walgreens Vice President of Health Systems Services. “We’re seeing great results in the HCAHPS scores because this program fills a big gap. Patients can now say, yes, they did get the medication and they did speak with somebody about the medication’s [adverse] effects,” Weinert said.
Improved patient satisfaction means improved patient retention for hospitals. “It means you’re creating loyal customers [who] come back. Buyers buy from people they like,” Tafari said. DeKalb’s Mudd is seeing more patients return from far-flung Atlanta suburbs for their follow-up visits. “They love the service enough that they are actually making the drive back to get follow-up care,” Mudd said.
More time for patients
More than simply bringing pills to the bedside, pharmacists are providing patients with a commodity in short supply in health care today: time. Where physicians would send patients away with a prescription and hope the community pharmacist would make all the instructions clear, the in-house Walgreens pharmacists are answering all the patients’ and family members’ questions without any apparent restriction on their time. “The physicians are all excited about this. We always wonder when we write the prescription, if they will actually get it, but at least we know now that they are getting their medications here. That gives us a lot of comfort,” Tafari said.
After Mudd explained Broughton’s antibiotics, he confirmed that Broughton knows how to use his new inhaler. “Now after you shake it, how do you normally hold it?” Mudd asked the patient, handing him the inhaler. “I shake it up like this; then I put it in my mouth like this,” Broughton demonstrated. “You got it,” Mudd said. All along, Mudd kept his eyes on the patient, never glancing at any papers, his watch, or the door.
Later Mudd knelt by the bedside of 84-year-old Frances Black. “Just sitting down tells the patient you have time to talk to them,” Sarasota’s Hudon said. Mudd doesn’t leave the room until Black is sure she understands exactly how much she needs to eat each time she takes her medication.
“This kind of partnership is vital. Nurses and doctors can’t do it alone. And the Walgreens pharmacists have the ability to spend more time because they don’t have every patient in the hospital,” Hudon said.
Looking to the future
As the health care reform law pushes for care delivery to be coordinated across the allied health professions, Walgreens’ hospital partnerships may be offering a glimpse of pharmacists’ future role. Several participating hospitals have plans to further integrate community pharmacists into care delivery. Sarasota Memorial, for example, is exploring how to allow partnering pharmacists access to patients’ electronic medical records so community pharmacists can make notes to patient records about possible problems after follow-up phone calls.
Under health care reform, Tafari says, “Everyone involved in the care of the patient has a collaborative approach. This is going to be the future of patient care.”