The pharmacy team at Lehigh Valley Health Network (LVHN)-Muhlenberg kept seeing the same problem: Too many discharged patients from the Bethlehem, Pennsylvania, facility were failing to get their outpatient prescriptions filled — and landing back in the hospital.
Nowhere was the problem more apparent than the cardiac unit, so the pharmacy team in 2020 launched a pilot transition of care (TOC) program to closely track and monitor medication management for those patients at discharge.
“There were a lot of patients that went home on high-cost medications, and the regional cardiac unit is the largest in the network, so we felt like a pharmacy presence there would really be able to help the unit with rounding and make sure that patients were going home on plans that were safe for discharge,” said Sidney Fries, pharmacy supervisor at LVHN-Muhlenberg.
Physicians, nurses, and patients gave such high marks to the program that LVHN expanded it to two other hospitals in the network. Today, LVHN’s TOC team is credited with driving a striking increase in the number of prescriptions filled in-house and contributing to a decrease in hospital readmissions.
System-wide, the TOC team increased the share of prescriptions filled in-house from about 9% to more than 60% over the last five years and contributed to a decrease in 30-day hospital readmission rates for enrolled patients. What’s more, the pharmacy has been able to use revenue generated by the increased prescriptions to cover salaries for the TOC team. Some 20% of patients who opt into the program continue to use the pharmacy for refills and other medications following their discharge.
“It’s unbelievable how impactful this program is,” said pharmacist Lauren Grantz, administrator of outpatient pharmacy for the health network. “It’s so helpful for patients, because in our area, there have been a lot of pharmacy closures. It’s really a struggle for patients in our community to get medications in a timely manner, let alone the ones that they need at discharge. It’s a huge patient satisfier because they don’t have to stop and get anything on the way home.”
The pharmacy team says patients praise individual pharmacists by name in patient surveys, “which is pretty good for pharmacy, because a lot of times we’re behind the door or in the back of the pharmacy, not patient-front,” said Fries.
Nearly 20 full-time pharmacists and pharmacy technicians — most assigned to specific hospital floors or services — work in tandem to help with rounding and case management, enroll patients in the TOC program, and ensure that when it’s time for discharge, patients are prepared with medications in hand, understand how to take them correctly, and know how to monitor potential side effects.
Before the project began, most patients were discharged with prescriptions in the hope they would have them filled at an outside retail pharmacy, Fries said. But due to the cost of the medications or inability to get to the pharmacy, patients often were readmitted or nonadherent in taking their medications, she said.
Providers were sometimes discharging patients on medications without knowing their insurance status, or without considering that prescriptions from mail order pharmacies would take several days to arrive.
During the pilot on the cardiac unit, the nurses and nursing director expressed how happy they were with having a pharmacist on the unit to help with the automatic medication dispensing machine and intravenous line capability, for example, said Fries. The pharmacy team also noted an increase in patient satisfaction related to medication use, she added.
Pharmacy technicians with the team are referred to as TOC coordinators. While pharmacists handle the clinical work, the technician coordinators assist with case management; review patients’ prescription insurance coverage; complete prior authorizations; collect copays; and relay information to the appropriate colleagues. Together, the pharmacists and coordinators attend rounds and track metrics on discharges, prescriptions filled, and readmissions.
“All of these items are done proactively to make sure that the patient has a safe and effective discharge plan,” Fries said.
When patients indicate they want to enroll in the TOC program at discharge, the hospital pharmacy fills their discharge medication prescriptions and sends the medications to the floor, where coordinators deliver the medications to the patients and arrange for the pharmacists to review instructions and answer questions. Coordinators then conduct follow-up calls with patients after discharge.
At LVHN-Muhlenberg, the TOC program covers most of the campus, including the intensive care unit, inpatient rehabilitation, same-day discharges from the operating rooms and post-anesthesia care unit, all medical-surgical floors and labor and delivery. The health system plans to expand to additional units, and the system wants to establish hand-offs to the health network’s population health pharmacy team.
“We’re trialing that right now with some of our heart failure patients,” said Grantz. “If the TOC team sees a complex heart failure patient, they’ll do a referral to our population health pharmacy team so that patient can continue to be followed after discharge by pharmacy. It’s working really well.”
Other pharmacists can start something similar in their own health systems by identifying units like the heart service where many patients are sent home on medications. The biggest challenge in the beginning was being able to track data, Grantz said, so the team worked with the chief medical information officer to build a dashboard to track prescription capture and readmission rates.
“Pharmacists and pharmacy coordinators play a vital role in the hospital discharge process,” said Fries, “by ensuring patients are prescribed guideline-directed therapies that are affordable, safe, and effective.”
