1. Boles, Nicholle MSN, RN
  2. Gowac, Anne MSN, RN, CNOR

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Q: Despite medication reconciliation being completed at the start of care, our agency has had several recent readmissions related to medication adverse events. What else can we do to ensure medication safety for our patients?


Healthcare today has generated a new focus toward the improvement of care for patients in the community. The transition from the acute care setting to home is a time of many challenges, frustrations, and anxiety. For many older adults and those with a chronic disease, these challenges can be magnified with each hospitalization. Patients and families often struggle to understand the progression of their disease and the ongoing changes to their plan of care, especially their medication regimen. Medication-related issues are critical to the outcomes and the management of the chronically ill and elderly population and can lead to hospital admissions and readmissions. Your agency is not alone. As many as 17% of Medicare patients are readmitted within 30 days of their initial hospitalization and it is estimated that 76% of these admissions were avoidable (Fera et al., 2014). Such statistics begs the question, what can we, as healthcare providers do to improve this process?


Medication safety should become a priority not only at the time of discharge, but throughout the transition home. At discharge, an interdisciplinary team develops a plan that most often includes the primary care physician and home care services. Although the nurse is continuously monitoring, assessing, and educating patients and families on proper medication use, continued discrepancies and errors are often noted, especially after subsequent physician visits. Introducing the role of a pharmacist, not only throughout the hospitalization, but at the time of discharge, and into the transition to home, as part of the interdisciplinary team, is an innovative approach to enhancing the continuity of care, medication safety, and improved patient outcomes, while supporting the nurse and other clinicians in complex cases.


The role of the pharmacist in transitional care is rarely discussed (Fera et al., 2014), yet it is an essential component to the process. Although physicians and nurses are trained in pharmacology, pharmacists bring their own skill sets and expertise that can enhance the care provided to the patient returning to the community. Although most organizations complete medication reconciliation and education at both the time of admission and discharge, there continues to be no standard practice. Despite increased efforts to educate and ensure that patients and families understand all information provided, the underlying problem still remains. Discharge instructions can be complicated and confusing for patients with a chronic illness and their families. Oftentimes, for this population, multiple drugs are prescribed to manage their health, and in turn, this leads to a higher risk for errors, nonadherence, and adverse reactions (Jones et al., 2015).


Utilizing the pharmacist post discharge has not been widely studied, but it is an intriguing concept to consider (Fera et al., 2014). Pharmacists bring a unique perspective to the interdisciplinary team, especially for this high-risk population. In a recent study that examined the role of the pharmacist in the home setting, "only 8% of patients who received the services were readmitted within 30 days. This compares favorably to the average historical same-hospital readmission rate of similar patients of 16-17%" (Pherson et al., 2014, p. 1,581). Such results, along with readmission penalties, should motivate healthcare organizations to investigate the possibility of including a pharmacist's skills in the transition process.


The addition of a pharmacist in the home setting would bring a new perspective to the care of the patient in the community. These highly qualified professionals would focus not only on the reevaluation of the patient's knowledge of his or her medications, but would allow further assessments of any barriers leading to nonadherence and any potential adverse drug-drug or drug-food interactions. Home visits by both nursing and pharmacy personnel provide an opportunity for different perspectives in the evaluation of the patient in his or her natural environment, and their ability to safely manage their medications. This in turn may lead to the prevention of duplicated medications, evaluation of potential medication interactions, and increased collaboration with the providers involved in the patient's care. These interventions may identify unforeseen needs that should be addressed such as urgent concerns requiring follow-up and/or the necessity of supplementary services for safe care. Pharmacists can assist to ensure that patients understand how to take their medications and the side effects related to such mediations, while allowing the nurse to focus on symptom management and disease-specific interventions to meet the patient's goals of care.


Expanding the role of the pharmacist from the acute care setting into the community is a new and promising idea. Although there are limited studies to support this change, this may be an innovative approach to improving the quality and safety of patient care, while decreasing readmissions and healthcare costs. Currently, pharmacy services are not reimbursed in the home care setting, but home care agencies are beginning to consider the benefits of improved patient outcomes and costs when utilizing these services (O'Connor et al., 2016). Although nurses are trained in medication reconciliation and educating patients to recognize possible side effects, the utilization of a pharmacist in the community for a more comprehensive assessment is beneficial. As healthcare continues to focus on value-based purchasing and readmission penalties, expanding the practice of pharmacists from the acute care setting to the community should be further considered with the ultimate goal of enhancing patient care.


Obamacare's Medicaid Expansions May Be Improving Care

HealthDay News: Low-income adults in Arkansas and Kentucky experienced significant improvements in care after their states expanded Medicaid under the Affordable Care Act, a new study reveals. The gains were not immediate. But after the second year of coverage, patients had better access to primary care, lower out-of-pocket spending, and less reliance on hospital emergency departments for care, compared with low-income adults in Texas. Texas didn't expand Medicaid coverage. Medicaid expansions under the Affordable Care Act, or Obamacare, have resulted in health coverage for millions of low-income Americans in 30 states. Kentucky and Arkansas differed in their approaches to extending health coverage to low-income residents. Kentucky opted for a traditional Medicaid expansion, whereas Arkansas pursued a hybrid approach using Medicaid funding to enroll low-income people in private health insurance plans. Despite the differences, the study found that low-income residents in both of those states enjoyed similar health improvements. It doesn't seem to matter how states expand coverage; what matters is "whether or not you expand coverage" at all, explained Dr. Benjamin Sommers, the study's lead author. The uninsured rates dropped in Arkansas, from 42% to 14% from 2013 to 2015. In Kentucky, those rates dropped from 40% to 9%. Texas saw only a modest decline, from 38.5% to 32%. The study authors noted that the research wasn't designed to prove a cause-and-effect relationship. Still, compared with Texas, both Arkansas and Kentucky saw sharp improvements by 2015.


The study was published in JAMA Internal Medicine.




Fera T., Anderson C., Kanel K. T., Ramusivich D. L. (2014). Role of a care transition pharmacist in a primary care resource center. American Journal of Health-System Pharmacy, 71(18), 1585-1590.[Context Link]


Jones G., Tabassum V., Zarow G. J., Ala T. A. (2015). The inability of older adults to recall their drugs and medical conditions. Drugs & Aging, 32(4), 329-336.[Context Link]


O'Connor M. A., Pike A., Ambrefe M. M., Greenberg E. L. (2016). Reducing readmissions through a targeted geriatric pharmacy program. Home Healthcare Now, 34(2), 112-113. Retrieved from[Context Link]


Pherson E. C., Shermock K. M., Efird L. E., Gilmore V. T., Nesbit T., LeBlanc Y., ..., Swarthout M. D. (2014). Development and implementation of a postdischarge home-based medication management service. American Journal of Health-System Pharmacy, 71(18), 1576-1583.[Context Link]