The American Pharmacists Association (APhA) calls medication-related problems and medication mismanagement “a massive public health problem.” APhA estimates that 1.5 million preventable adverse events cost the U.S. healthcare system $177 billion each year, but improved medication management shows potential to improve care and lower readmission rates. Getting patients to both access and adhere to medications with fidelity, however, is an ongoing challenge.

Daniel J. Cobaugh, PharmD, vice president of the American Society of Health-System Pharmacists’ (ASHP’s) research and education foundation, says the causes of patient noncompliance are “multifactorial,” including regimen complexity, health literacy or patients’ ability to manage their disease. Patients also tend to cease taking their meds when symptoms improve.

Johns Hopkins Medicine in Baltimore and Froedtert Hospital in Milwaukee are two providers trailblazing patient-centered medication management practices to keep patients compliant, healthy and out of emergency rooms and the hospital.

Two systems

Both organizations position the pharmacist to orchestrate coordination of care within a provider team.

Froedtert launched its medication management program in 2011 following a successful pilot in 2010. All patients have their medications reconciled by a pharmacist and are counseled at discharge regardless of request, with medications delivered to the bedside. The inpatient pharmacist resolves any discrepancies with the provider and, if needed, can change medications with physician co-signature in the EHR.

Post pilot, the discharge reconciliation led to 800 interventions, preventing errors including improper dosage, unnecessary medications and duplicate therapies. The hospital also saw an improvement in patient satisfaction scores.

Johns Hopkins uses a multidisciplinary team to coordinate follow-up care and plays an active role in patient medication management, according to Meghan Davlin Swarthout, PharmD, MBA, BCPS, division director, ambulatory and care transitions, department of pharmacy.

The pilot “brought down our readmission rates, did not negatively impact length of stay, and we had improvement in our HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] scores related to the patient experience,” she says.

Access, education & adherence

Many people don’t even get their first prescription filled, Cobaugh says, because of time constraints, affordability and lack of understanding of the importance of adhering to medication therapy.

Institutions like Froedtert and Johns Hopkins proactively tackle financial concerns that prevent patients from filling prescriptions by seeking out programs available through pharmaceutical companies, optimizing the use of their own insurance and providing convenient access to the patient pharmacy, he says.
“About 25 percent don’t fill prescriptions when they leave the hospital. We make sure patients are able to,” says Ann Szukzewski, clinical pharmacy manager at Froedtert Hospital.

At Johns Hopkins, care transition teams target interventions for patients taking 10 or more medications, or with known issues of non-adherence. Patients with moderate or high risk for readmission receive post-discharge phone calls within 72 hours to review the patient’s medication regimen to assess proper use; access issues; effectiveness of therapy; and potential adverse effects. This interaction is documented into the EHR.

Based on the patient’s individual needs, the pharmacist may facilitate interventions through collaboration with the discharging physician or triage patient needs to the appropriate member of the multidisciplinary team.

Extra support also is given to those on high-risk medications such as anticoagulants, insulin and meter-dose inhalers. The provider supplies education within 24 hours of initiation of the high-risk medication to ensure understanding of key concepts. Some methods used include teach-back techniques, motivational interviewing and behavioral counseling.

For example, Swarthout says patients are asked directly to explain their medication management plan. “At first, you get a few deer-in-the-headlights looks, and they say ‘no one has ever asked me that before.’ It has been an ‘aha’ moment on both sides, and we have a better understanding if they do get it.”

Contextualizing the patient

Experiences at Froedtert and Johns Hopkins show that good medication management must be highly individualized to the patient.

Swarthout tailors medication education to her patients. By asking patients what they like to do, providers can individualize concerns. For example, “You like to play basketball with your grandson? If your heart is not in good shape, it will prohibit you from being able to do that.”

Swarthout shares the story of a patient who never went to dialysis and always ended up back in the hospital. It wasn’t until he was asked directly why he failed to go that the physician learned he was bored during the treatment. When offered access to an iPod, he began showing up for dialysis every time, she says.

“We need to start asking the right questions to allow patients to share that with us, and not feel embarrassed or in any way create barriers to understand their motivations.”

Making the economic case  

Economic studies showing the impact of integrated medication management practices are difficult to conduct, Cobaugh says, but Froedtert was able to boost its bottom line due to the increase in prescriptions. The revenue supported six additional pharmacists and three technicians, and contributed to the overall sustainability of the program, Szukzewski says.

Cobaugh cautions that increased revenues from prescriptions should not be the only metric to judge the economic impact of a program. “The return on that investment probably shows up in other areas critical to system, like lower readmissions, patient satisfaction and [better] healthcare outcomes.”
“We are trying to do more with less as healthcare expenditures continue to decrease,” says Swarthout. Johns Hopkins has “had to take strategic looks at what our pharmacists are doing every day and whether that is the most appropriate use of their time.”

Nevertheless, the pilot did enable Johns Hopkins to successfully apply for and receive a $19 million CMS innovation grant to allow for full deployment at the hospitals by the end of 2013 and within all adults units by 2014.

Froedtert and Johns Hopkins represent best practices right now, and as their successes bear fruit, surely more providers will follow.