UAMC – UAMC – Discharge Discharge Medication Medication

OptimizationOptimizationLauren Miller, PharmD.Lauren Miller, PharmD.

InstructorInstructorUniversity of Arizona College of University of Arizona College of

PharmacyPharmacyClinical Staff PharmacistClinical Staff Pharmacist

Ambulatory Services, UAMC Ambulatory Services, UAMC HospitalHospital

Pharmacist Pilot Program:Pharmacist Pilot Program:From Discharge to the First From Discharge to the First

RefillRefill One full time pharmacistOne full time pharmacist 2 inpatient units 2 inpatient units

focused on discharges onlyfocused on discharges only Attend daily care coordination Attend daily care coordination

meetings on each floor with nurses, meetings on each floor with nurses, case managers, and social workers to case managers, and social workers to identify high risk patients and plan identify high risk patients and plan safe discharges from admissionsafe discharges from admission

ResponsibilitiesResponsibilities Review discharge medication ordersReview discharge medication orders

DuplicatesDuplicates DDIDDI Missing medications or prescriptionsMissing medications or prescriptions Remove unnecessary medsRemove unnecessary meds

Coordinate prior authorizations ahead of Coordinate prior authorizations ahead of time and assist patients unable to afford time and assist patients unable to afford medsmeds

Assist patients to fill at hospital pharmacy Assist patients to fill at hospital pharmacy so they can leave with all new medications so they can leave with all new medications

Counsel on medications and education on Counsel on medications and education on disease states at bedsidedisease states at bedside

What has worked….What has worked….

Team based transitions of care with Team based transitions of care with nurses, case managers, social nurses, case managers, social workers, and MD all involvedworkers, and MD all involved

All members of the above team now All members of the above team now rely on me to assist more difficult rely on me to assist more difficult discharges and alert me to patients discharges and alert me to patients who need my assistancewho need my assistance

Good response from patients who Good response from patients who like getting their medication like getting their medication problems resolved prior to dischargeproblems resolved prior to discharge

ChallengesChallenges

How to determine when discharge order How to determine when discharge order is inis in Subscribe to discharge pager for both units Subscribe to discharge pager for both units Have nurses contact meHave nurses contact me

Have to wait until discharge is finalized Have to wait until discharge is finalized to review meds for accuracy to review meds for accuracy Multiple patients can be discharged at the Multiple patients can be discharged at the

same time how to see all of themsame time how to see all of them Getting MDs on board with new programGetting MDs on board with new program

Examples of Errors Examples of Errors CaughtCaught

Numerous DDI when home meds restartedNumerous DDI when home meds restarted Discharges with duplicate medsDischarges with duplicate meds Patients discharged without scripts for new Patients discharged without scripts for new

medsmeds New diabetics leaving without Rx for meters or New diabetics leaving without Rx for meters or

syringessyringes Patients leaving without INR follow-up for new Patients leaving without INR follow-up for new

start coumadin start coumadin Provide assistance to patients unable to afford Provide assistance to patients unable to afford

or changing to meds patients can affordor changing to meds patients can afford Incorrect dosing on discharge medsIncorrect dosing on discharge meds

Data Being CollectedData Being Collected Number of patients interacting with Number of patients interacting with

discharge pharmacist including:discharge pharmacist including: Number of meds counseled onNumber of meds counseled on Type of error that was caught and class of Type of error that was caught and class of

medicationmedication If insurance authorization was neededIf insurance authorization was needed Amount of time spent on each dischargeAmount of time spent on each discharge

Readmission rates before and afterReadmission rates before and after HCAHPS scoresHCAHPS scores

Patients ranking of communication about Patients ranking of communication about medications (from hospital survey after medications (from hospital survey after discharge)discharge)