Shannon Reidt

Integrating a pharmacist into a home healthcare agency care model: impact on hospitalizations and emergency visits.

Medication regimens can be complicated during the transition from hospital to home for a variety of reasons. The primary purpose of this retrospective study was to measure the impact of integrating a pharmacist into a model of care at a Medicare-certified home healthcare agency for clients recently discharged from the hospital. The secondary purpose was to describe the medication-related problems among clients receiving services from the model of care involving a pharmacist. Integrating a pharmacist within the model of care demonstrated a positive clinical impact on clients.

Interprofessional Collaboration to Improve Discharge from Skilled Nursing Facility to Home: Preliminary Data on Postdischarge Hospitalizations and Emergency Department Visits

An interprofessional collaborative practice model was established at Hennepin County Medical Center to improve discharge management from the transitional care unit of the skilled nursing facility (SNF) to home. The practice model involves a geriatrician, nurse practitioner, and pharmacist who care for individuals at a community‐based SNF. Before SNF discharge, the pharmacist conducts a chart and in‐person medication review and collaborates with the nurse practitioner to determine the discharge medication regimen. The pharmacists review focuses on assessing the indication, safety, effectiveness, and convenience of medications. The pharmacist provides follow‐up in‐home or over the telephone 1 week after SNF discharge, focusing on reviewing medications and assessing adherence. Hospitalizations and emergency department (ED) visits 30 days after SNF discharge of individuals who received care from this model was compared with those of individuals who received usual care from a nurse practitioner and geriatrician. From October 2012 through December 2013, the intervention was delivered to 87 individuals, with 189 individuals serving as the control group. After adjusting for age, sex, race, and payor, those receiving the intervention had a lower risk of ED visits (odds ratio (OR) = 0.46, 95% confidence interval (CI) = 0.22–0.97), although there was no significant difference in hospitalizations (OR = 0.47, 95% CI = 0.21–1.08). The study suggests that an interprofessional approach involving a pharmacist may be beneficial in reducing ED visits 30 days after SNF discharge.

An interprofessional train-the-trainer evidence-based practice workshop: Design and evaluation

Abstract Evidence-based practice (EBP) is a core skill of health professionals and one that is regularly taught in health sciences programs. This report covers the design and results of an interprofessional EBP workshop at a large university aimed at improving faculty’s confidence in practicing and teaching EBP. The two-day workshop was designed by the University’s Health Sciences Libraries and emphasized small-group work, with the first day focused on critical appraisal and searching and the second on effective teaching strategies. Twenty-five faculty from the schools and colleges of Medicine, Nursing, Pharmacy, Dentistry, and Veterinary Medicine and the Center for Allied Health Programs attended this study. Nine faculty and librarians served as instructors. Attendees rated the workshop and individual lectures highly and reported that it improved their ability to both practice and teach EBP. In addition, they reported a preference for learning in an interprofessional environment. This report suggests that a short EBP workshop can improve faculty members’ self-reported confidence and ability to practice and teach core EBP skills.

The role of a pharmacist on the home care team: a collaborative model between a college of pharmacy and a visiting nurse agency.

Medication-related problems are common among home care clients who take many medications and have complex medical histories and health problems. Helping clients manage medications can be a challenge for all home care clinicians. By partnering with a college of pharmacy at a large university in the community, the agency successfully included a pharmacist as a member of their home care team.

Transitional Care Units: Expanding the Role of Pharmacists Providing Patient Care.

OBJECTIVE To describe two innovative practice models that expand pharmacy services within a nursing facilitys transitional care unit (TCU) to meet the needs of patients transitioning to subacute or community care. SETTING TCU in a hospital-based vs. a community-based facility. PRACTICE DESCRIPTION The two TCUs involved in these practices differ in that one is hospital-owned and the other is community-based and run by a nonprofit organization. Patients involved in the models are those who have been admitted to the TCU from a hospital and will eventually return home to the community. PRACTICE INNOVATION Pharmacy services beyond the federally required, monthly drug regimen review are described, including pharmacist-conducted medication reconciliation, which identifies the drugs the patient is taking on admission and those prescribed before discharge from the TCU. Post-TCU discharge follow-up is also provided via telephone call or home visit. MAIN OUTCOME MEASUREMENTS Description of practice models. RESULTS Timely medication reconciliation and review on TCU admission is key to safe medication use during transitions of care. Incorporating pharmacy students and residents can promote awareness of the service. Partnerships with health systems and colleges or schools of pharmacy can provide financial support of these innovative practice models. CONCLUSION Pharmacist-driven medication reconciliation and review can improve medication safety across transitions of care involving TCUs. Research is needed to evaluate the impact of these models on outcomes before they are replicated.

Drug Therapy Problems Identified by Pharmacists Through Comprehensive Medication Management Following Hospital Discharge

Background: Pharmacists influence health care outcomes through the identification and resolution of drug therapy problems (DTPs). Objective: The objectives of this study were to describe number, type, and severity of DTPs based on clinical significance and likelihood of harm in patients transitioning from hospital to home as assessed during a comprehensive medication management (CMM) visit with a pharmacist. Secondary objectives were to assess intrarater reliability in severity ratings and assess likelihood of harm for adverse drug reactions (ADR) by drug classes. Methods: Retrospective review of 408 patients having a face-to-face, telephonic, or virtual CMM visit within the Fairview Health System. Teams of 3 investigators reviewed each DTP from the electronic medical record for each of the 408 patients and assigned a severity score (0-10) for clinical significance and likelihood of harm. Main Results: The highest severity DTP classes were adherence and ADR. The lowest severity DTP class was unnecessary drug therapy. An average of 2.5 DTPs was found per patient at the index CMM visit following hospital discharge. The most common DTP classes were needs additional therapy and dose too low. There were statistically significant differences in DTP severity scoring between reviewer types, though differences were <5%. Drug classes with the highest severity ADR included diabetes, cardiovascular, and anticoagulant/antiplatelet agents. Conclusions: The DTP severity ratings indicated that reviewers found ADR and adherence DTPs were potentially the most severe. There were differences in DTP ratings between reviewer types, though clinical significance of these differences is unclear.

Assessment of Perceived Barriers to Herpes Zoster Vaccination among Geriatric Primary Care Providers

The herpes zoster vaccine is recommended for use in adults 60 years of age and older to reduce the incidence and morbidity associated with infection. Its limited uptake has been attributed to logistical barriers, but uncertain efficacy and safety in subsets of this patient population could also be contributing. The purpose of this study was to evaluate the current vaccination practices, barriers to vaccination, knowledge of vaccination reimbursement and strategies to evaluate for insurance coverage among an urban, safety net, teaching hospital, geriatric primary care provider group through a survey administered via paper and online platforms. Survey participants (n = 10) reported lack of availability of the vaccine in their practice settings (6/10), with half of providers (5/10) referring patients to outside pharmacies or to other practice settings (2/10) for vaccine administration. Reimbursement issues and storage requirements were perceived as major barriers by 40% (4/10) of providers, whereas 80% (8/10) of providers reported that concerns about safety and effectiveness of the vaccine were not major barriers to vaccination. Logistical barriers, rather than concerns about safety and effectiveness of the vaccine, were reported as major barriers to vaccination by a significant portion of providers. Lack of availability and reimbursement problems for practice sites allow for gaps in care. Partnership with community and long-term care pharmacies could serve as a possible solution.

Integrating home-based medication therapy management (MTM) services in a health system

OBJECTIVES To describe the integration of home-based Medication Therapy Management (MTM) into the ambulatory care infrastructure of a large urban health system and to discuss the outcomes of this service. SETTING Minnesota from September 2012 to December 2013. The health system has more than 50 primary care and specialty clinics. Eighteen credentialed MTM pharmacists are located in 16 different primary care and specialty settings, with the greatest number of pharmacists providing services in the internal medicine clinic. PRACTICE INNOVATION Home-based MTM was promoted throughout the clinics within the health system. Physicians, advanced practice providers, nurses, and pharmacists could refer patients to receive MTM in their homes. A home visit had the components of a clinic-based visit and was documented in the electronic health record (EHR); however, providing the service in the home allowed for a more direct assessment of environmental factors affecting medication use. EVALUATION Number of home MTM referrals, reason for referral and type of referring provider, number and type of medication-related problems (MRPs). RESULTS In the first 15 months, 74 home visits were provided to 53 patients. Sixty-six percent of the patients were referred from the Internal Medicine Clinic. Referrals were also received from the senior care, coordinated care, and psychiatry clinics. Approximately 50% of referrals were made by physicians. More referrals (23%) were made by pharmacists compared with advanced practice providers, who made 21% of referrals. The top 3 reasons for referral were: nonadherence, transportation barriers, and the need for medication reconciliation with a home care nurse. Patients had a median of 3 MRPs with the most common (40%) MRP related to compliance. CONCLUSION Home-based MTM is feasibly delivered within the ambulatory care infrastructure of a health system with sufficient provider engagement as demonstrated by referrals to the service.

Clinical research that matters: Designing outcome-based research for older adults to qualify for systematic reviews and meta-analyses

Though older adults are more sensitive to the effects of medications than their younger counterparts, they are often excluded from manufacturer-based clinical studies. Practice-based research is a practical method to identify medication-related effects in older patients. This research also highlights the role of a pharmacist in improving care in this population. A single study rarely has strong enough evidence to change geriatric practice, unless it is a large-scale, multisite, randomized controlled trial that specifically targets older adults. It is important to design studies that may be used in systematic reviews or meta-analyses that build a stronger evidence base. Recent literature has documented a gap in advanced pharmacist training pertaining to research skills. In this paper, we hope to fill some of the educational gaps related to research in older adults. We define best practices when deciding on the type of study, inclusion and exclusion criteria, design of the intervention, how outcomes are measured, and how results are reported. Well-designed studies increase the pool of available data to further document the important role that pharmacists have in optimizing care of older patients.

Supporting formative peer review of clinical teaching through a focus on process

BACKGROUND The professional need for development of clinical faculty is clear. Previous scholarship provides insight into the formative potential of peer review in both didactic and experiential settings. Less information exists on a comprehensive peer review process (PRP) designed to support faculty change. EDUCATIONAL ACTIVITY AND SETTING A clinical faculty PRP was developed and implemented based on input from the literature, stakeholders, and field experts. The process included: 1) self-reflective pre-work, 2) a peer-observation component, 3) self-reflective post-work, and 4) creation of a specific action plan via meeting with an educational expert. The process was assessed by collecting evaluative data from peer reviewer and clinical faculty participants. FINDINGS Eight of 26 faculty members participated in a pilot of the PRP and formed four clinical faculty-peer dyads. When surveyed, all participants unanimously reported that they would participate in the PRP again. Aspects perceived among most helpful to clinical teaching included peer observation, self-reflection, and meeting with an educational expert. Challenges related to the process included anxiety of peer observation, burden of pre-work, and logistics of scheduling meetings. DISCUSSION While instruments are important in guiding and documenting the evaluation of clinical teaching during an observation period, this initiative focused on the process supporting the observation and evaluation, in order to optimize the formative feedback received by participating faculty and encourage professional development actions. SUMMARY A PRP that incorporates preparation, reflective practice, and a meeting with an educational expert may support meaningful faculty development in the area of clinical teaching.