There are often gaps in care as patients transition from hospital to home. Mission Health System’s Matthew Ransom, PharmD, leads an innovative endeavor called the Medication Assistance Program (MAP), which provides medication access and education as well as chronic disease management to senior and low-income patients after they are discharged from the hospital.
Located within the Outpatient Clinical Services Department, the MAP relies on a collaborative and interdisciplinary approach to ensure that patients know how to get their medications, navigate a complex health care insurance system, and take their medications properly. “There has been an amazing shift in the way we think about providing care within a hospital system,” said Ransom. “The care we provide during this transition phase links inpatient services and outpatient services. It’s a collaborative effort among the different [health professions] in the continuum of care.”
In addition to improving markers of clinical care, such as A1C (glycosylated hemoglobin) and blood pressure, the MAP program has reduced the number of hospitalizations and decreased hospital length of stay for uninsured patients at Mission Health.
Matthew Ransom, PharmD, BCACP, checks prescriptions and prepares to demonstrate proper injection technique.
With as many as 44 million Americans without insurance and as many as 17.1 million Americans underinsured, there is a critical need to help patients obtain the medications they need after hospital discharge. Based in Asheville, NC, Mission Health’s MAP began in the late 1990s as a way to help seniors with medication access. The program evolved and expanded to include patients discharged from the hospital with no prescription coverage. Around 2006, the program’s focus evolved once again to where pharmacists and other health professionals help patients aged 18 to 64 years who are uninsured gain access to medications. The MAP team most often counsels patients with depression, diabetes, chronic obstructive pulmonary disorder, heart failure, hypertension, and hyperlipidemia.
Uninsured and underinsured patients who need medication assistance or are at high risk for readmission based on their medication history are referred to the MAP after hospital discharge. These patients often face complex situations and barriers to accessing health care, such as transportation challenges and low health literacy. The multidisciplinary MAP team includes two pharmacists, two pharmacy technicians, a licensed clinical social worker, two prescription assistance coordinators, and administrative support. Ransom has been with the MAP program for the past 6 years and has held a leadership role for the past year. He meets with patients one-on-one after they were recently discharged. He also helps with chronic disease management, supports pharmacy operations, and maintains grant application and tracking processes.
MAP pharmacists obtain a comprehensive medication history, reconcile the medication lists, and provide personalized education (medication and self-management, navigating the physician visit) during an initial visit with the patient. To get a clear picture of a patient’s health care story, pharmacists may need to call multiple physician offices and hospitals. Next, pharmacists create a plan for each patient that outlines how the patient will not only access medications long term but also how they plan to stay connected to the primary care provider. In some cases patients may be choosing between buying food and seeing their doctor, so by coaching patients on how to talk about their medical concerns, patients see the doctor visit as useful and productive.
The MAP team meets weekly to discuss patient care issues and medication access.
“Everyone in the MAP has a critical role to play,” said Ransom. “There are a lot of crisis moments, so having a social worker on staff who is trained in handling these types of situations is really important.” Wendy Billingsley, the MAP’s licensed clinical social worker, supports patients by connecting them with appropriate mental health services and helping them navigate the insurance application process.
Prescription assistance coordinators are integral to the drug retrieval process. “It can be confusing [for patients] to figure out how to access medications through various pharmacy programs, so the coordinators spend a lot of time researching and collecting the appropriate documents and keeping up with resources that are available to help patients access free medications,” said Ransom.
Anita Peek, CPhT, helps patients navigate resources to help them identify the least expensive options for obtaining medications. As part of a Disproportionate Share Hospital, the MAP can purchase medications through the 340B drug pricing program. These medications are used to fill prescriptions. “Our technician spends a lot of time helping people prioritize how they are going to continue to get their medications in a reliable, long-term way,” said Ransom. The challenge is that there is no one source for all medications, so the technician “helps patients understand how to use multiple sources, coordinate medication use, and figure out when and how to refill prescriptions,” he added. This information is then communicated back to the patient’s primary care physician.
Lacey Presnell, CPhT, focuses on the postdischarge follow-up phone calls. Patients are called within 72 hours of discharge, within 1 week of the first medication refill, and after the patient’s first visit with a primary care provider to help ensure adherence and access to medications. Depending on the patient’s needs, pharmacy support may continue beyond 30 days.
At Mission Health, a fundamental shift has occurred in the way the health system approaches the care process. The focus is around what it means to provide excellent care to an individual patient and growing it from there, noted Ransom. The MAP started with meeting individual patient needs and following each of those patients to a point of completion. “Now, the MAP is evolving into a large system of care that is more than just our program—it spans our entire hospital system to include discharge planning and care maintenance,” said Ransom. “It shows how traditional pharmacy roles are being expanded to include a transition of care focus.”
Even with an emphasis on transitions of care, the challenge of medication access remains. “It has intensified our sense of trying to understand what resources are there for patients and pointing patients toward opportunities they may have to get access to medications,” said Ransom.
Ransom and his team are also in the process of developing a health literacy class series. Launching this fall in a pilot phase, the classes are designed to help patients understand health care basics and learn skills for navigating the health care environment. Experts from different health professions will educate patients about various aspects of their health care. “We’ll have a physician come in to talk about how patients can have a conversation with their doctor, and we’ll have a pharmacist talk about medications, how to get a prescription refilled, and what it means to transfer a prescription,” said Ransom.
Ransom and Lacey Presnell, CPhT, review the proper technique for measuring blood pressure and discuss counseling tips for weight management.
Some patients are used to living without insurance and scraping by with free medication samples. A specialist will discuss insurance and what it means to have a deductible, a premium, and a copay. “Once someone gets insurance, we want to educate them about the opportunities for them to access care,” said Ransom. “Some of this is being driven by inpatient need because how effectively you provide inpatient care minimizes unnecessary hospital readmissions.”
For Ransom, the success of the MAP always comes back to providing an exceptional health care experience to his patients. “Patients need their medicines, so having a pharmacist there in that moment of recognition when a patient understands that they need to consistently take their medications is important,” he said.
It is also important to have the entire MAP team on hand because each patient is in a unique situation with individual challenges or barriers. Pharmacists help the patient understand the clinical reasoning behind the choice of taking the medication, pharmacy technicians identify medication resources available to the patient, a social worker helps them overcome barriers, and prescription assistance coordinators help patients fill out the right documents and paperwork.
“It comes down to getting the best outcome for patients despite the barriers they encounter,” said Ransom. “The MAP shows a complete picture of what it looks like to give an individual a medication and how this affects the overall health system and continuity of care.”