Frontline Pharmacist

F rontline Pharmacist Pharmacist-led collaborative practice for older adults

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oor quality of care during transitions from one care setting to another and subsequent increases in morbidity, mortality, and healthcare utilization (e.g., hospital admissions, “bounce-backs” to a more-intensive care setting) are increasingly recognized as major public health concerns, especially among older adults.1,2 As a result, there has been a swell of policy change, research, and practice development focused on improving these transitions.1-3 To date, interventions have typically focused on increasing communication among medical teams and often include a component targeting drug therapy problems.4,5 For example, ensuring accuracy of the medication list immediately following transitions has been a cornerstone of many interventions.2,6,7 As a whole, interventions involving a medication-related component primarily include onetime efforts to identify adverse drug effects, determine appropriateness of medications, or use nonpharmacist advanced practice providers to perform medication reconciliation.7-10 These approaches, while important, have failed to address the full scope of drug therapy problems that may occur or recur over time.11 An ideal practice should consider the full clinical and psychosocial needs

of the geriatric patient and facilitate multiple transitions across all types of care settings, minimizing the need for a complete handoff from one provider team to another. Given the contribution

of medications to morbidity during the transition process, the practice should emphasize prevention and resolution of drug therapy problems. Having pharmacists work with other members of the

The Frontline Pharmacist column gives staff pharmacists an opportunity to share their experiences and pertinent lessons related to day-to-day practice. Topics include workplace innovations, cooperating with peers, communicating with other professionals, dealing with management, handling technical issues related to pharmacy practice, and supervising technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601 or [email protected]).

healthcare team while assuming primary responsibility for the patient’s ongoing medication management has several distinct advantages in reaching these goals. First, it takes advantage of the pharmacist’s distinct skill set that complements that of other provider team members. Second, it allows pharmacists to remain involved in their patients’ care over time rather than at a single point during their care transitions. Having the same pharmacist dedicated to medication management at each transition for a geriatric patient offers greater potential for coordinated care transitions and reduces the potential for new or recurrent drug therapy problems. Finally, it maximizes the pharmacist’s ability to provide a personalized approach to medication management based on the patient’s specific needs and living environment. This article describes the development and early-phase implementation of a continuous medication management intervention for geriatric patients to help resolve the medication-related problems in this population associated with transitions of care. Development of the practice. This pharmacy practice is based in a community academic teaching hospital, which includes family medicine residency, geriatric medicine fellowship, and pharmacy residency. Pharmacist–physician collaboration in teaching, patient care, and scholarly activity is embedded within the culture, with pharmacists serving as faculty within the family medicine residency for more than 30 years. In 2004, the institution hosted its second pharmacy resident who had an elective rotation at the hospital’s outpatient geriatric care center. After Continued on page 608

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interacting with the pharmacy resident, physicians of the practice, some of whom had trained within the institution’s family medicine and geriatric fellowship programs, championed the concept of hiring a pharmacist for their practice. That pharmacy resident was hired; 0.2 full-time equivalent (FTE) is dedicated to the outpatient office, and the remaining 0.8 FTE is paid for by the pharmacy department for other unrelated clinical activities. The pharmacist’s reporting structure for the 0.2 FTE was under the department of medical education at the hospital, with a physician serving as supervisor. In 2009, physicians and pharmacists identified an increased patient need for pharmacy services in the inpatient and outpatient areas. At this time, the pharmacist was formally appointed as a faculty member within the family medicine residency and geriatric medicine fellowship programs. After a needs assessment was conducted, a clear role for a pharmacist was identified on the inpatient geriatric teaching service, and her time was increased to include inpatient rounds (1.0 FTE total). The role of the pharmacist was perceived to have a benefit well beyond the clinical impact, as physicians and leadership recognized the role for the pharmacist in the teaching mission of the institution. In 2012, the pharmacy residency program expanded at the institution, and a postgraduate year 2 geriatrics pharmacy resident position was approved by the hospital administration. The opening of a second geriatric outpatient physician office was also planned. With support from the physician champions and the hospital administration and their recognition of the impact of pharmacists in the care of older adults, a second pharmacist was hired. This change resulted in an additional 2 pharmacist FTEs and 1 geriatrics pharmacy resident FTE, all falling under the department of medical education. Overview of current practice. The two pharmacists have specialty pharmacy residency training and are board-

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certified pharmacotherapy specialists. Both pharmacists’ responsibilities include direct patient care and education of staff, pharmacy residents, and physician residents. Both pharmacists are faculty within the pharmacy residency, family medicine residency, and geriatric medicine fellowship. The pharmacists’ and resident salaries are funded through the department of medical education. Each pharmacist has designated areas of clinical practice but is trained to cover any of the practice areas in the other’s absence. One pharmacist practices in one of the outpatient physician offices located on a senior living campus. She provides direct patient care to outpatients living independently in the surrounding community and residents of the senior living campus, which includes skilled nursing, personal care, and personal care–dementia care facilities. The other pharmacist practices in another outpatient physician office, located on the hospital campus, and attends rounds five mornings per week on the inpatient geriatric teaching service. The service has an average daily census of 12 patients. The shared location of the outpatient offices with the senior residential and inpatient facilities allows for increased efficiency, flexibility, and time for patient care. In addition, most of the residents on the senior living campus are triaged to the main hospital if inpatient care is required. The close working partnership between the two pharmacists within a broader interprofessional team, representing geriatric medicine, geriatric psychiatry, nursing, and licensed clinical social work, allows for the provision of coordinated, continuous care as patients transition across these settings. As the intensity of each patient’s care needs changes over time, the team provides continuous care to the patient across all care settings, including the outpatient physician practice, personal care facilities, skilled nursing facility, and hospital. Patients are given the opportunity to be admitted to the hospital, skilled nursing facilities, and personal care facilities where the interdisciplinary team of physicians and pharmacists

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hold privileges, making transitions seamless. In each nonhospital care setting, there is a designated pharmacist–physician pair that directs the team-based care for each patient. When the patient transitions to the hospital, this pharmacist–physician pair communicates the patient’s history, acute problems, and medications to an inpatient pharmacist–physician pair. Because each pharmacist–physician pair is a part of the same geriatrics care team, the outpatient pair can remain peripherally involved and is consulted regularly. The interdisciplinary Pharmacist-led Interventions on Transitions of Seniors (PIVOTS) team at our institution is currently studying the effectiveness of this effort. Innovative integration. Our practice is innovative in integrating the pharmacists into the healthcare team across all three levels of geriatric patient care: inpatient care (249-bed community academic teaching hospital), outpatient care for independently dwelling seniors (20 hours per week), and senior campus care (skilled nursing, 199 beds; personal care, 89 beds; and personal care–dementia care, 37 beds). The pharmacists are responsible for the patient’s care and coordinate the identification, prevention, and resolution of drug therapy problems across all geriatric healthcare and living settings. This is a role currently unfulfilled in contemporary pharmacy practices caring for older adults, where the community pharmacist, nursing home consultant pharmacist, and inpatient clinical pharmacist lack standard avenues to communicate. An integral aspect of the comprehensive care pharmacists provide is initiating communication and relationships with the site-specific pharmacist (e.g., community pharmacist and skilled nursing facility consultant pharmacist). The pharmacists document a variety of activities in the permanent medical record at each of the three levels of care (inpatient care, outpatient care, and senior campus care). That same documentation is copied into a standalone database (Assurance Medication Management Systems, Golden Valley, MN) that phar-

Frontline Pharmacist

macists share to track drug therapy problems for all levels of care. Our practice has four distinct advantages compared with traditional practices: (1) the pharmacist provides prospective, direct patient care in real-time with the interdisciplinary team across all care settings in which the patient may reside, rather than retrospective recommendations communicated through the health record at one location during the patient’s care, (2) the pharmacist is responsible for all medication therapy needs and provides actionable and timely follow-up, (3) the pharmacist– physician pair has continuous communication with all members of the care team, including those caring for the patient while in the hospital, and (4) the practice instills a comfort and confidence for the patient and family knowing that the same group of providers is continuing to care for the patient, regardless of the level of care needed. Future directions. The PIVOTS team has received funding from the American Society of Health-System Pharmacists Research and Education Foundation, the Jewish Healthcare Foundation, and the Pennsylvania Pharmacists Educational Foundation to support an outcomes evaluation of this practice. The geriatrics practice has received generous support from the St. Margaret Foundation. Results will be used to inform future practice improvements and assist with ensuring the pharmacists’ practice sustainability, replicability, and scalability. The evaluation will include multiple components, assessing how the pharmacists’ practice is being implemented as well as its effectiveness on patient and practice outcomes. We are currently completing a workflow analysis that details how each pharmacist spends his or her time. A longitudinal survey of pharmacists’ patients and caregivers is underway to assess the impact of the practice and the pharmacists’ efforts on their self-efficacy in managing medications and perceptions of care coordination. Focus groups with physician providers and staff are currently undergoing thematic analysis to gather detailed information on how the phar-

macists have affected their practice and to generate ideas for improving patient care going forward. The impact on patient clinical outcomes (hospitalizations), financial outcomes (economic analysis), and practice management (drug therapy problem evaluation) also will be evaluated using an interrupted time series design.

Heather Sakely, Pharm.D., BCPS, Director Geriatric Pharmacotherapy UPMC St. Margaret Pittsburgh, PA [email protected]

1. American Geriatrics Society. Prevention is the foundation of geriatric care, March 2013. www.americangeriatrics.org/files/ documents/Adv_Resources/Preventive_ Medicine_Fact_Sheet.pdf (accessed 2015 Jan 15). 2. Steurbaut S, Leemans L, Leysen T et al. Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home. Ann Pharmacother. 2010; 44:1596-603. 3. Patient-Centered Primary Care Collaborative. The patient-centered medical home: integrating comprehensive medication management to optimize patient outcomes, June 2012. www.pcpcc.org/sites/ default/files/media/medmanagement.pdf (accessed 2015 Jan 15). 4. Naylor M, Brooten D, Campbell R. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004; 52:675-84. 5. Budnitz D, Shehab N, Kegler S et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007; 147:755-65. 6. Crotty M, Rowett D, Spurling L et al. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother. 2004; 2:257-64. 7. Centers for Medicare and Medicaid Services. Initiative to reduce avoidable hospitalizations among nursing facility residents. http://innovation.cms.gov/ initiatives/rahnfr/ (accessed 2015 Jan 15). 8. Boockvar KS, Carlson LaCorte H, Giambanco V et al. Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother. 2006; 4:236-43. 9. Vegda K, Nie JX, Want L et al. Trends in health services utilization, medication use, and health conditions among older adults: a 2-year retrospective chart review in primary care practice. BCM Health Serv Res. 2009; 9:217. 10. Duffy J, Hoskins L, Dudley-Brown S. Improving outcomes for older adults with heart failure: a randomized trial using a theory guided nursing intervention. J Nurs Care Qual. 2009; 25:56-64. 11. Sinvani LD, Beizer J, Akerman M et al. Medication reconciliation in continuum of care transitions: a moving target. J Am Med Dir Assoc. 2013; 14:668-72.

Kim Coley, Pharm.D., FCCP, Professor Department of Pharmacy and Therapeutics University of Pittsburgh School of Pharmacy Pittsburgh, PA

Jason Corbo, Pharm.D., BCPS, Clinical Pharmacy Specialist Geriatrics UPMC St. Margaret

Melissa McGivney, Pharm.D., FCCP, Assistant Dean for Community Partnerships and Associate Professor of Pharmacy and Therapeutics University of Pittsburgh School of Pharmacy Carolyn Thorpe, Ph.D., M.P.H., Core Investigator Center for Health Equity Research and Promotion Veterans Affairs Pittsburgh Healthcare System Pittsburgh, PA Assistant Professor of Pharmacy and Therapeutics University of Pittsburgh School of Pharmacy Patricia Klatt, Pharm.D., BCPS, Director Advanced Pharmacist Practice UPMC St. Margaret Loren Schleiden, B.S., Research Assistant University of Pittsburgh School of Pharmacy John Zaharoff, M.H.A., N.H.A., Executive Director and Administrator Presbyterian SeniorCare, Willows Oakmont, PA Lora Cox-Vance, M.D., Director Geriatric Fellowship UPMC St. Margaret Vincent Balestrino, M.D., Medical Director Presbyterian SeniorCare, Willows Associate Director, Family Medicine Residency UPMC St. Margaret

Partially funded by a research grant from the ASHP Research and Education Foundation. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp140228

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