Pharmacists: The solution to expanding clinical services

Many Faces of MTM

Hennepin County Medical Center (HCMC) in Minneapolis has a reputation for implementing innovative health system–wide programs that rely on pharmacists as members of a multidisciplinary team to improve patient care. From 2008 to 2010, HCMC conducted 30 different pilot projects to improve patient care. In every instance, pharmacists proved to be an invaluable asset to the team. In addition to promoting the role of the pharmacist, patient care programs such as medication reconciliation at admission and discharge for all patients, expanded medication therapy management (MTM) services, and an ambulatory intensive care unit (ICU) have led to reduced readmissions and reduced hospital costs for the health system.

Trial and error, creativity, and determination are all critical components of innovation. “As we looked for solutions to improving patient care, we were successful in showing the value of the pharmacist,” said Bruce Thompson, BSPharm, Director of Health System Pharmacy Services at HCMC. “We realized that we got better results when pharmacists were part of the solution.”

Health System Administration residents (left to right) Bernadette Aragon, PharmD, and Kristin Showen, PharmD, and Haley Holtan, PharmD, Manager of the Medication Management Team round with Bruce Thompson, BSPharm, and review an inpatient chart to create a transitional care plan.

Evolving care

HCMC is a 462-bed, level 1 trauma center and the largest safety net hospital in Minnesota. The health system includes 16 primary care clinics, 46 specialty clinics, and eight community pharmacies. HCMC currently employs approximately 130 pharmacists and 130 pharmacy technicians. “At Hennepin, we believe [patient care] is about pharmacy [across the entire health system], not just hospital pharmacy,” said Thompson in an interview with Pharmacy Today.

Looking at patient visits from hospital stays to outpatient clinics, Thompson and the group at HCMC implemented numerous programs that target patients who need help the most in order to reduce readmissions, reduce medical costs, and improve care across the entire health system.

In 2008, the organization transitioned the existing decentralized clinical program from a unit-based model to a team-based model, where pharmacists provide clinical services to 16 medical teams, covering 16 hours a day, 7 days per week. “Instead of parking ourselves on the medicine unit and seeing seven or eight different physicians each shift, [pharmacists] round with the same team all day no matter where the patient is located in the hospital,” Thompson explained. “That has helped build a stronger relationship between pharmacists and physicians.”

Left to right: Zachary Stoecker, PharmD, PGY-2 critical care resident, and Holly Christianson, PharmD, PGY-1 resident, take a break from rounding with Bhavin Patel, PharmD, to discuss patients on the renal team.

Medication reconciliation

In addition to rounding with multidisciplinary teams, pharmacists are now responsible for providing medication reconciliation at admission and discharge for all patients. Since pharmacy assumed the responsibility for admission medication reconciliation, compliance has improved across the system by 63%, noted Thompson. Now 100% of all patients admitted to the hospital have medication reconciliation completed within 24 hours.

Changes in medication reconciliation began in late 2008 and early 2009 when two adverse medication events occurred. In one instance, a patient was discharged without oral antibiotics after being on I.V. antibiotics for 36 hours. That patient was readmitted 2 days later with a worsening infection. Another patient was discharged and all of the patient’s home medications were reordered, even though one agent should have been discontinued.

“After those two events, we looked at our approach to discharge and realized that the electronic medical record made it too easy to prescribe discharge medications inappropriately,” Thompson said. A multidisciplinary team conducted several pilot programs that evaluated discharge orders and medication reconciliation and realized that pharmacists and pharmacy interns were most effective at catching discrepancies while performing medication reconciliation. “After months of [evaluation] we discovered that no one did this work better than pharmacists, so we started a program in 2009 with pharmacists doing discharge medication reconciliation for patients discharged to a skilled nursing facility (SNF),” he explained.

The discharge medication reconciliation program has been overwhelmingly successful. According to Thompson, in the beginning, 90% of patients had an error on their discharge orders. These patients were transitioning to long-term care facilities with an average of 15 prescriptions per patient. “These were complex patients to start with, and 30% of the errors found were significant enough that the errors would have caused readmission, corrective action, or some sort of harm,” said Thompson. Today, with pharmacist interventions, the 30-day and 14-day readmission rate for SNF patients has been reduced by more than 40%.

Ambulatory ICU

A multidisciplinary team at HCMC also created and implemented a program to help patients who need better health care management. “We have an indigent population that uses the emergency department [ED] as their primary care clinic, so we created an ambulatory ICU designed for those higher risk patients,” said Thompson. “About 46% of this population takes 10 or more medications.”

In the ambulatory ICU program, a pharmacist meets with the patient 3 to 5 days after discharge to evaluate the patient’s pharmacy literacy. “If the patient has no clue about their medications, then the pharmacist will meet with the patient every week to provide education and to fill pill boxes with a goal to have the patient manage their medication therapy independently,” explained Thompson. The multidisciplinary team at the ambulatory ICU includes pharmacists, nurses, physicians, and social workers. “We focus on their health care needs, but if housing is a major problem, then the team helps them find housing too,” said Thompson.

Left to right: Tom McDonald, BSPharm, Thompson, and Brian Finstad, BSPharm, discuss serving high-risk patients using the integrated community pharmacy system with the electronic health record at HCMC.

MTM growth

Over the past few years, HCMC has made significant strides in expanding MTM services to patients. In 2008, there were 0 MTM patient visits; now there are around 900 patient visits per month. Five years ago, the hospital had four pharmacists dedicated to providing MTM services to patients. “Today, we have 24 pharmacists providing MTM services. The value we bring to the [health system] by reducing readmissions and preventing adverse events allows us to continue to expand that program by about 30% each year,” said Thompson.

All MTM practitioners are part of multidisciplinary teams embedded in 15 primary care and specialty clinics within the health system, including family practice clinics, internal medicine, and specialty areas such as HIV, oncology, senior care, pain management, and cardiology. “We have been able to demonstrate a reduction in hospital readmissions when a pharmacist sees a patient in an outpatient setting,” Thompson added.

In 2012, HCMC developed a pharmacy technician position to support the MTM program and to help collect data, answer insurance questions, call  patients, and communicate with the patient’s health care team.

Emergency services

Another area where HCMC bolstered the pharmacist’s role started in 2010 with ED coverage. According to Thompson, in early 2011 only 11% of ED physicians felt that pharmacists were essential to their practice. Today, 70% of ED physicians feel that pharmacists are essential in the ED.

Pharmacists demonstrated their value as members of the ED team by providing dose recommendations, order verification, code response, and patient education. The role of pharmacy interns was also expanded to include ED admission medication reconciliation under the supervision of ED pharmacists. “We did a [study] and realized that 87% of patients in the ED had an error in medication reconciliation when this was performed by nurses,” said Thompson. “Now when pharmacists and interns do medication reconciliation, we get more accurate results.” Based on the success of the program in the ED, the intern service has expanded to the medical–surgical units each evening and on weekends.

Thompson and Showen discuss a medication management improvement project.

Advancing care

HCMC also recently added two additional programs that expand pharmacists’ roles. A pharmacist was added to the transitional care unit to work with providers, patients, and family members with a focus on reducing errors during transitions of care with discharge medications and home MTM visits. A transitional care residency was also added. The resident splits time between current MTM providers, clinic providers, and the community pharmacy to provide patients with continuity of care. This role also facilitates improved communication among the patient, providers, and the pharmacy.

For the past 5 years, Thompson and the team at HCMC have worked tirelessly to revolutionize patient care. Pharmacists, pharmacy technicians, and pharmacy interns are at the heart of this endeavor. The success of HCMC’s best practices in pharmacy is a health system–wide effort to advance care to help patients where they need it the most. “I have been fortunate to have such a great team to work with at HCMC. Both the pharmacy team and the leadership at our facility allow and promote new ideas that provide better quality care,” Thompson said.

APhA, ASHP care transitions project highlights best practices

Last year, APhA and the American Society of Health-System Pharmacists (ASHP) announced the Medication Management in Care Transitions Project, which highlights eight care transitions programs as best practices that improve patient outcomes and reduce hospital readmissions. Eighty-two programs were evaluated through a stringent, competitive process. Hennepin County Medical Center is recognized for its best practices, as well as Mission Health (see September 2013 Pharmacy Today) and Einstein Healthcare Network (see July 2013 Today). Other care transitions programs will be featured in future issues of Today.