Reinventing the pharmacist role in a hospitalist model of care
Eric Maki, PharmD, BCPS, and Melissa Nelson, PharmD, collaborate to proactively identify issues to streamline patients’ transitions of care.
According to Erik D. Maki, PharmD, BCPS, transitions of care can be like a game of telephone, in which a teacher whispers something to a student, who whispers the same phrase to the next student, and by the time the phrase goes around the room, it’s turned into something completely different.
“The same thing can happen when a patient enters a health system,” said Maki. “They might have one medication list from their primary care provider, another list from their pharmacist, and upon hospital admission, there might be a different list entirely.”
At Mercy Medical Center in Des Moines, IA, Maki, who is a Clinical Specialist, works with hospitalists to make sure transitions of care are as accurate as possible.
“We know that when a patient enters the hospital from a clinic, more often than not the person obtaining the medication list and medication history takes the path of least resistance,” he said. “Instead of contacting multiple sources, we often get a list without any verification of accuracy.”
That’s why Maki and his group of student pharmacists are on a mission to work with the care team to improve the accuracy of medication lists and increase the quality of care.
Mercy Medical Center follows a model that uses hospitalists, board-certified internists, or family practice physicians to care for patients. Using hospitalists enables a patient’s primary care physician to be more available to patients in the office, rather than having to travel back and forth between seeing patients in the office and in the hospital. At Mercy Medical Center, a hospitalist is assigned to each patient, following patients throughout their entire hospital stay.
Hospitalists are valuable additions to health systems because they are more available to inpatients, have more hospital experience and expertise than primary care providers, and have an increased commitment to hospital quality improvement.
However, one challenge of the hospitalist model is continuity of care. That’s where Maki and his team enter the picture.
“The hospitalist model makes the process of transitions of care a little more disjointed because the hospitalists don’t intimately know the patients, they only know why they’re here, and they don’t necessarily have a strong relationship with the clinic where the patient came from,” Maki explained. “It’s not impossible to get information, but it’s not easy and it takes time.”
Nelson and Maki collaborate with the bedside medication delivery and patient education programs to ensure patient access to medication and improve medication understanding for patients and their caregivers.
When Maki began working with the hospitalist group at Mercy Medical Center in 2008, there were about 20 hospitalists on staff comprising physicians and nurse practitioners. The hospitalists saw almost every patient admitted to the hospital, “so there were lots of patients with lots of different disease states,” said Maki. He paired up with a hospitalist and rounded with one each day, offering medication suggestions and disease state education.
“After I did that for a few years, I realized that it wasn’t the most efficient use of my time or my students’ time, mostly because there was a lot of downtime and waiting for physicians,” said Maki, who is also an Associate Professor at Drake University College of Pharmacy and Health Sciences.
About 3 years ago, Maki began focusing his efforts on transitions of care. “This was mostly born out of frustration at how poorly we do it,” he said. Today Maki and his team of students pull reports on each of the 20 to 30 patients who are assigned to hospitalists each day. “We divvy the patients up among the students and look for disease states or medication interactions that might be a problem,” he said.
Maki often lets the students choose the patients they want to work with and the disease states they want to learn about. “I give the students a few hours to collect all the information I need to make my assessment,” said Maki. “Students talk to patients or the nurses and research medications or disease states.” He then sits down with the students to discuss each patient. “By leveraging the students, I’m able to see and touch a lot more patients than if it was just me running around trying to do all these things alone,” Maki explained.
After talking about the patients for several hours and discussing their disease states and medications, Maki and his student pharmacists “go out and chase down the hospitalists to offer recommendations to optimize care.”
“For simple interventions, we use text messaging, but others need dialogue that can only be accomplished face to face,” he said. “Fortunately, our hospitalists are very receptive, and we have a strong collaborative relationship.”
Although Mercy Medical Center recently implemented an electronic medical record system with computerized physician order entry, pharmacists are still needed to verify and track down a patient’s medication list. “There isn’t a single system where everyone talks to each other, and not everyone has access to pull the medication lists from various sources,” Maki said.
To further improve transitions of care, Maki is currently in the early stages of launching a collaborative project between one of the health system’s cardiology specialty clinics, a family practice clinic, and a pharmacist from a community pharmacy.
“We’re working on empowering the pharmacist to have access to all of a patient’s medication lists, so when the pharmacist performs medication therapy management, they don’t have to spend time making a records request—they can just access the electronic medical record system,” explained Maki.
It’s a win–win situation for the pharmacist and the physicians. The pharmacist will keep patients’ medication lists up to date when a new prescription is added or a medication is no longer needed, and the pharmacist will have instant access to the patient’s records at the various clinics.
“It’s not a perfect solution because a patient might visit a mail-service pharmacy, but it’s a great start, and it allows the pharmacist to avoid jumping through hoops to get medication information,” said Maki.
Maki believes that pharmacists play a valuable role at Mercy Medical Center, and the more that pharmacists become integrated into the culture, the more opportunities there will be to improve patient care.
“Pharmacists are one of the most underutilized [professions] in the health care system, and we are such a small group compared to the doctors and nurses, so it is important that our voice is heard when policies or new initiatives are being created,” he said.
It is also important for pharmacists to be recognized for the important work they do.
“When a pharmacist is taking a medication list or talking to a patient about allergies, we ask more in-depth questions and more follow-up questions to get at what the real issues are,” said Maki. “For many providers, the medication list is a small piece of the puzzle, but for pharmacists, the medication list is the puzzle.”
Maki and Nelson use the expertise of the pharmacist in both the inpatient and ambulatory environments to increase the quality of care their patients receive.
Connecting with patients
In addition to expanding the role of the pharmacist and collaborating with hospitalists to improve patient care, Maki believes that pharmacists truly make a difference in patients’ lives.
“We get the chance to sit down and talk to patients about questions they have about their medications,” said Maki. “You can tell that patients truly appreciate the time you took to talk to them, and you can see the joy on their faces. It’s that connection with the patient that I enjoy the most.”