1. Bracken, Janice MN, RN, PHN


A hospital addresses barriers to postdischarge treatment.


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As a case manager in a busy ICU-cardiac ICU, I hear a lot about the use of "bundles" for particular conditions, such as sepsis and ventilator-associated pneumonia. A bundle is a protocol that employs a number of interventions to treat or prevent a specific cluster of symptoms (the combination produces better outcomes than any one intervention can). Bundles are usually created to address specific physiologic aspects of acute, life-threatening conditions, but recently I began to wonder whether the bundle concept could be used for critically ill patients who have socioeconomic barriers to postdischarge treatment. Might we also "bundle" interventions to solve problems that impede access to care?


I work in a 483-bed, not-for-profit hospital in Portland, Oregon. More than 6% of our patients are uninsured; many of them are unemployed and homeless. Providing "compassionate service" to "the poor and vulnerable" is part of our mission statement. Every patient who comes through our doors is given the best care possible, regardless of insurance status.


A few months ago, I was screening a patient whom a bedside nurse had identified as "unable to afford his medications." In talking with him, I discovered that he had had a cardiac stent placed within the past year. He had been discharged with a prescription for clopidogrel (Plavix), which he was to take for at least one year to prevent clotting and stent thrombosis. Having no insurance, he couldn't afford the drug and was readmitted for stent failure.


Later, I screened another patient with a postdischarge prescription for clopidogrel who had similar access difficulties. A case manager had enrolled him in our hospital's medication assistance program, and a physician in the community had agreed to receive the patient's prescription by mail (a requirement of the program). But because the patient had to gather and submit various financial data to establish eligibility, it would be 40 to 45 days before the physician received the medication from the program-and the patient needed a supply of free medication to bridge that gap.


Of the nearly 35 patients a month who receive cardiac stents in our hospital, two to four are underinsured, uninsured, or homeless. Colleagues on other units have told me they care for many such patients as well. So I decided to develop a "medication access bundle" for underinsured patients requiring cardiac stents and postdischarge clopidogrel. The bundle addresses a cluster of social symptoms-little or no insurance; an inability to buy medication; undocumented immigration status; and such obstacles to follow-up as homelessness, transience, or the lack of a phone-and presents solutions to fit the circumstances.

Figure. Janice Brack... - Click to enlarge in new windowFigure. Janice Bracken

The bundle involves four interventions. First, case managers work with attending physicians to find physicians in the community who will see low-income patients on a sliding scale and accept clopidogrel shipments for them in 90-day increments for a year. Second, the case managers use the protocol I developed to fill out the necessary paperwork and fax it to our hospital's medication assistance program, which forwards it to the drug's manufacturer. (Applications for more than 400 medications are also available at Third, we give patients a free 30-day supply of clopidogrel and, through the manufacturer's representative, arrange for the patient to receive an additional 14-day supply-thus providing adequate coverage until the mail-ordered prescription arrives. Fourth, upon discharge, we give the patient the medication, follow-up physician information, and written instructions.


This bundle was put into action in the discharge planning department. After approval from the director, I gave the department an in-service training and became the point person for this particular bundle.


There are scores of medical conditions complicated by socioeconomic issues. Perhaps the bundle concept can be used to open up more avenues of care to these patients.