discharge counseling/continuity of care
At St. Francis Hospital and Medical Center in Hartford, Conn., pharmacists work closely with discharge planners to make sure inpatients undergo a smooth transition to an outpatient setting. The health-system pharmacists are involved in everything#151;making sure patients know what drug to take, when to take it, and what adverse effects to watch out for when they leave the hospital. They will even communicate with community pharmacists about complex new drug regimens.
Discharge planning and continuum-of-care matters are not limited to pharmaceutical issues. However, a large component of successfully moving patients from the inpatient to the outpatient setting clearly includes patient education regarding drugs and contact with caregivers who work with patients once they leave the hospital.
Discharge planning and continuum-of-care instructions are nothing new for pharmacists and other healthcare professionals. However, new standards issued in 2001 by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) made involvement in these areas mandatory. JCAHO's new language specifies that hospitals need to have discharge planning mechanisms in place for patients. The standards also require that the patient be informed in a timely manner of the need to plan for the discharge or transfer to another organization. Under the standards, the hospital should provide for referral, transfer, or discharge of the patient to another level of care, health professional, or setting. The discharge process should also provide for continuing care based on the patient's assessed needs at the time of discharge.
According to health-system experts, pharmacists are performing pretty well in the area of discharge planning and continuum of care in facilities that have the pharmacy manpower to devote to those initiatives. JCAHO doesn't stipulate that a particular discipline be involved in this area, but Kurt Patton, executive director of accreditation services for JCAHO, made it clear that "the function must be performed."
Many health-system pharmacists believe their group is the best qualified for the task. "We're the drug experts," noted Kathi Salmon Lucas, inpatient operations manager in the department of pharmacy at Stanford Hospital & Clinics in Stanford, Calif. She said postsurgical care patients discharged from Stanford on painkillers or antibiotics interact regularly with pharmacists charged with making sure the patient or post-hospital caregiver is aware of potential food interactions and side effects of certain agents.
Lucas said that, for bone marrow transplant patients, who are often discharged on multiple medications, pharmacists prepare a calendar/ schedule listing all the different medications a patient is taking#151;complete with dosing times and comments about indications. "So patients leave here with a fairly comprehensive picture of their medications," she said.
Mary Inguanti, St. Francis' director of pharmacy, said R.Ph.s are members of the discharge planning rounding teams. It's important, she asserted, to have pharmacists play a role in discharge planning because inpatients don't necessarily go home with the same drugs they took in the hospital. In some instances, she noted, patients are prescribed a drug that's difficult to get at a community pharmacy. For example, the antiarrhythmic agent Tikosyn (dofetilide, Pfizer) is available only in retail pharmacies registered to provide it. "Pharmacy has an opportunity to make sure that a lot of that kind of planning is in place for the patient," she said.
At Shands Hospital in Gainesville, Fla., pharmacists are charged with making sure patients being released on high-risk drugs understand their drug regimen and experience an orderly transition to an outpatient setting. In addition, pharmacists play an active counseling role in the hospital's ambulatory pharmacy and also monitor adverse drug events (ADEs) at Shands' anticoagulation clinic, which pharmacists helped set up. According to director of pharmacy Alan Knudsen, R.Ph.s facilitate proper anticoagulation procedures including overseeing drug therapy as well as the monitoring of patients as they make the transition out of the hospital.
One of the best examples of how health-system pharmacists participate in discharge planning and continuum of care is in organ transplant programs. "A transplant program is built on continuum of care," said Troy Somerville, Pharm.D., clinical specialist in solid organ transplant at the University of Utah Hospitals and Clinics in Salt Lake City.
Because transplant services are medicine-driven, pharmacists follow transplant patients from the time they're admitted to the time they leave, Somerville explained. After surgery, a transplant patient's care is turned over to a pulmonary physician, a cardiologist, or a nephrologist, because ultimately they're seen long term in an outpatient clinic. The person who needs to be in the middle to translate all the information back and forth is the pharmacist, said Somerville.
"At the time of discharge, pharmacists make sure the patient schedules an appointment in our clinic, and pharmacists go with them on their first appointment," said Somerville. Pharmacists bring the entire clinic staff up to speed on the patient's in-hospital experience. In addition, a pharmacy resident presents each patient, on a weekly basis, to a quality assurance-style team. "It's a good model. The pharmacist takes care of transplant patients on all levels, in- and outpatient, from the day they enter the system." Pharmacists also manage an immunosuppression service for transplant patients. "Immunosuppression will be affected in some way, and pharmacists are the perfect choice to work in this area," he said.
Somerville commented that pharmacists also helped develop a computer-assisted Web tool that teaches patients about complex medications they have to take when they leave the hospital. The site, Medplanner, provides end users with a life-size picture of medications as well as dosing and adverse drug reaction information.
Despite JCAHO's mandate to provide discharge planning and continuum-of-care services, not every hospital is in a position to assign a pharmacist to perform in that role. "We'd like to," noted Anne Niemiec, Pharm.D., clini- cal coordinator at Community- General Hospital in Syracuse, N.Y. "But we don't have enough pharmacy staff, the workload is too much." She said that for now discharge planning and continuum- of-care duties are left up to nurses and done only for a select patient group, such as oncology.
Community-General isn't alone. Industry observers point out that many hospitals that want to involve pharmacy in that area are having a difficult time because of a pharmacist shortage. "It's no secret that there is a nationwide shortage of pharmacists," said Shands' Knudsen. It just so happens that there's more of a nursing shortage than pharmacy shortage at Shands, so pharmacy was able to step up to the plate and meet the discharge planing and continuum-of-care requirements. "We're very fortunate," he said.
But Knudsen was realistic about the tenuous nature of the manpower situation facing health systems. "Do I have an open checkbook from the CFO to meet all requests for pharmacy services that I have out there?" he asked. "No, I don't."
Tony Vecchione. Discharge planning standards draw mixed response from R.Ph.s.