Evaluation of a discharge medication service on an acute psychiatric unit

Pharmacist interventions in medication adherence in patients with mental health disorders: a scoping review

OBJECTIVE

Mental health patients struggle with medication adherence, providing opportunities for pharmacists to have a critical role in implementing key interventions for this patient cohort. This scoping review aimed to identify and evaluate evidence of pharmacists' involvement in medication adherence interventions in mental health patients.

METHODS

Three databases were searched from January 2013 to August 2022: PubMed, Embase and CINAHL. The first author independently performed screening and data extraction. Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) was utilized to report this review. Themes related to the pharmacist's role in improving medication adherence for mental health patients were identified and the strengths and weaknesses of these studies were evaluated.

KEY FINDINGS

A total of 3476 studies were identified and 11 studies met the selection criteria. Study types included retrospective cohort studies, quality improvement projects, observational studies, impact studies, service evaluations and longitudinal studies. Pharmacists worked primarily in community pharmacies, hospitals, or interdisciplinary mental health clinics, and improved medication adherence within these settings, at transitions of care, and by utilizing digital health. The patient perspective was valuable in identifying barriers and enablers to medication adherence. Pharmacists had varying levels of education and training, with studies highlighting the importance of completing extended training programs and partaking in expanded roles such as pharmacist prescribing.

CONCLUSIONS

This review highlighted the need for expanded pharmacist roles within multidisciplinary mental health clinics and further training in psychiatric pharmacotherapy, to aid pharmacists in confidently improving medication adherence for mental health patients.

Impact of Pharmacist Counseling at Discharge for Older People

Objective To examine the evidence surrounding how the implementation of pharmacist discharge counseling affects the number of readmissions. Data Sources A search was conducted using EBSCOhost and the National Library of Medicine databases for articles published through December 2020 with the keywords "discharge counseling," "discharge teaching," "discharge education," "patient education," "patient teaching," "medication reconciliation," "pharmacist," and "readmission rates." The authors independently screened citations and applied inclusion and exclusion criteria. Study Selection A total of 32 articles were reviewed and analyzed. Inclusion criteria included articles published in the English language with human subjects, and adults (18 years of age and older) involving pharmacist-led discharge counseling and assessment of readmission rates were included. Data Extraction Study characteristics, intervention type, and outcomes with statistical significance where reported were included in the literature analysis. Data Synthesis Studies examined reported varying health care improvements postdischarge with the implementation of pharmacist services in the discharge process. Not all results were significant for reduction in readmission rates, but a downward trend was observed. Conclusion Implementation of pharmacist discharge counseling may decrease the number of hospital readmissions, particularly in older people.

Implementation of nurse navigation for behavioral health inpatient services to divert early readmissions: A pilot program

OBJECTIVE

Inpatient behavioral health units across the United States have high readmission rates. The Centers for Medicare and Medicaid Services (CMS) as well as healthcare organizations are focused on reducing readmission rates, especially those readmissions that occur within 30-90 days. Behavioral Health Nurse Navigation was implemented at St. Luke's University Health Network's Sacred Heart Campus to investigate, address, and divert early behavioral health readmissions through evidence-based discharge calls and problem-solving methods.

METHOD

Following approval for Behavioral Health Nurse Navigation, workflow and discharge call screens were developed for behavioral health discharge calls. Discharge call screens populated at specific intervals and calls were made at those times. Data was maintained on those patients who participated in calls. Increased collaboration and dissemination of information ensued.

RESULTS

613 patients participated in discharge calls from March 2020 to October 2020 as 98% of patients liked receiving calls. 56% of participants used substances; the most commonly used substance was THC. MDD was the most common diagnosis among participants and most patients utilized St. Luke's Psychiatric Associates for outpatient mental health care. Participants most often required assistance in the areas of medication, community coordination, and support/reassurance. The Behavioral Health Nurse Navigation diversion rate ranged from 81% to 96%.

CONCLUSION

Behavioral Health Nurse Navigation promotes patients' successful adherence to discharge plans through increased collaboration, communication, and skillful problem-solving in the areas of medication, community coordination, and therapeutic reassurance/support. The outcome of Behavioral Health Nurse Navigation is increased patient satisfaction, compliance with treatment, and diversion of patients at high risk for early readmission.

Medication-related characteristics of a high-utilizer psychiatric population

OBJECTIVE

To identify medication-related and nonmedication-related characteristics and risk factors for readmission in a high-utilizer psychiatric population.

METHODS

In this retrospective cohort study, patients were identified through the institution's electronic medical records as high utilizers if they had 5 or more psychiatric admissions or at least 1 30-day psychiatric readmission from July 2012 through March 2014. The primary outcome was to identify medication-related characteristics. Secondary outcomes were to identify if medication- and nonmedication-related factors were related to number of and time to readmissions.

RESULTS

A total of 170 patients and 497 readmissions were included. Up to 89% of patients had 30-day readmissions, and 12% had 5 or more readmissions. A total of 52% of patients were discharged on 6 or more medications, with 54% discharged with at least 3 psychotropic medications. A total of 31% of patients had documented medication nonadherence, with adverse effects or cost reported as the most common reasons. Only 32% of patients filled a prescription at the hospital's outpatient pharmacy with 44% doing so within 7 days of discharge. Adherence and use of outpatient pharmacy were unrelated to the number of readmissions and time to readmission, but having a diagnosis of major depressive disorder was related to shorter time to readmission.

CONCLUSIONS

Low outpatient pharmacy utilization, multiple psychotropic discharge medications, and unknown or documented nonadherence are common traits of this population. Future studies to determine what medication factors influence readmissions and whether targeting those specific medication-related factors would decrease the risk for readmission are needed.

Bedside medication delivery programs: suggestions for systematic evaluation and reporting

PURPOSE

Several factors lead to medication non-adherence after hospital discharge. Hospitals and pharmacies have implemented bedside medication delivery (BMD) programs for patients, in an attempt to reduce barriers and improve medication adherence. Here, we provide a critical review of the literature on these programs.

DATA SOURCES

We conducted a literature search on BMD programs in PubMed, Google Scholar, Scopus and a general Google search using these keywords: 'medication delivery bedside', 'discharge medication delivery', 'meds to bedside' and 'meds to beds'.

STUDY SELECTION

We identified 10 reports and include data from all reports.

DATA EXTRACTION

Data on study characteristics and settings were extracted along with four outcomes: medication error, patient satisfaction, 30-day hospital readmission and visits to the emergency department.

RESULTS OF DATA SYNTHESIS

Of the 10 reports, only 4 were peer-reviewed publications; others were reported in the lay press. Outcomes were reported in both qualitative and quantitative terms. Less than half of reports provided quantitative data on 30-day readmission and patient satisfaction. Others suggested qualitative improvement in these outcomes but did not provide data or specific details. None reported outcomes of their programs beyond 30 days.

CONCLUSION

We highlight the need for increased use of optimal program design and more rigorous evaluations of the impact of BMD programs. We also provide guidelines on the types of evaluations that are likely needed and encourage improved reporting.

Influence of Psychotropic Medications on Readmission Rates of Patients Receiving a Pharmacist Discharge Medication Reconciliation

BACKGROUND

Current literature suggests that patients with psychiatric disorders are at an increased risk for inpatient readmission. This study evaluated the impact of pharmacist-driven discharge medication reconcilliation (DMR) on readmission rates of patients discharged with one or more psychotropic medications.

METHODS

This study was a retrospective review of patients receiving a pharmacist-driven DMR. The primary outcome was to compare the prevalence of 30-day readmission rates among patients who had a pharmacist DMR between patients who had at least one psychotropic medication upon discharge versus those without psychotropic medications. Secondary objectives were to (1) compare the number of medication discrepancies and pharmacist interventions prior to discharge and (2) compare prevalence of medical comorbidities between patients who had at least one psychotropic medication upon discharge versus those without psychotropic medications.

RESULTS

A total of 151 subjects were included who had a DMR and either at least one psychotropic medication at discharge (n = 69) or no psychotropic medications at discharge (n = 82). The 30-day readmission rates were similar between both groups (P = .609). The mean number of discrepancies (P < .001) and number of pharmacist interventions (P = .005) were significantly greater in patients who had at least one psychotropic medication upon discharge compared to those without psychotropic medication.

CONCLUSIONS

The prevalence of 30-day readmissions was similar between the two groups; however, patients discharged with at least one psychotropic medication had a greater number of discrepancies requiring significantly more discharge interventions during a pharmacist DMR.

The Crisis in Psychiatric Hospital Care: Changing the Model to Continuous, Integrative Behavioral Health Care

Inpatient psychiatric hospital services, as they currently exist, have little to no evidence base. Deficits in the current system represent a critical missed opportunity to improve the trajectory of patients' lives and long-term outcomes. The authors posit that a fresh approach to hospitalization is needed, one that incorporates distinct, measurable goals tied to a comprehensive, individualized treatment plan tailored to address a patient's lifetime course of illness. A structured approach can ultimately improve care quality and continuity by allowing for rigorous testing of each aspect of the assessment and care provision process, improving patient outcomes and care engagement while shortening average lengths of hospital stays, and accelerating the movement of care to cost-effective, need-specific settings. In an effort to move the field toward establishing a systematic, evidence-based protocol for hospital-based psychiatric care, the authors describe a new model, called the S.E.T.U.P. approach.

Impact of discharge medication bedside delivery service on hospital reutilization

PURPOSE

To evaluate the impact of a medication to bedside delivery (meds-to-beds) service on hospital reutilization in an adult population.

METHODS

A retrospective, single-center, observational cohort study was conducted within a regional academic medical center from January 2017 to July 2017. Adult patients discharged from an internal medicine unit with at least one maintenance medication were evaluated. The primary outcome was the incidence of 30-day hospital reutilization between two groups: discharged patients who received meds-to-beds versus those who did not. Additionally, the incidence of 30-day hospital reutilization between the two groups was compared within predefined subgroup patient populations: polypharmacy, high-risk medication use, and patients with a principal discharge diagnosis meeting the criteria set by the Centers for Medicare and Medicaid Services 30-day risk standardized readmission measures.

RESULTS

A total of 600 patients were included in the study (300 patients in the meds-to-beds group and 300 patients in the control group). The 30-day hospital reutilization (emergency department visits and/or hospital readmissions) related to the index visit was lower in the meds-to-beds group, but the difference was not statistically significant between the two groups (8.0% in the meds-to-beds group versus 10.0% in the control group; odds ratio, 0.78; 95% confidence interval, 0.45-1.37). There was no significant difference in the 30-day hospital reutilization related to the index visit between the control and meds-to-beds groups within the three subgroups analyzed.

CONCLUSION

There was no difference in 30-day hospital reutilization related to the index visit with the implementation of meds-to-beds service in the absence of other transitions-of-care interventions.

Using Discursis to enhance the qualitative analysis of hospital pharmacist-patient interactions

INTRODUCTION

Pharmacist-patient communication during medication counselling has been successfully investigated using Communication Accommodation Theory (CAT). Communication researchers in other healthcare professions have utilised Discursis software as an adjunct to their manual qualitative analysis processes. Discursis provides a visual, chronological representation of communication exchanges and identifies patterns of interactant engagement.

AIM

The aim of this study was to describe how Discursis software was used to enhance previously conducted qualitative analysis of pharmacist-patient interactions (by visualising pharmacist-patient speech patterns, episodes of engagement, and identifying CAT strategies employed by pharmacists within these episodes).

METHODS

Visual plots from 48 transcribed audio recordings of pharmacist-patient exchanges were generated by Discursis. Representative plots were selected to show moderate-high and low- level speaker engagement. Details of engagement were investigated for pharmacist application of CAT strategies (approximation, interpretability, discourse management, emotional expression, and interpersonal control).

RESULTS

Discursis plots allowed for identification of distinct patterns occurring within pharmacist-patient exchanges. Moderate-high pharmacist-patient engagement was characterised by multiple off-diagonal squares while alternating single coloured squares depicted low engagement. Engagement episodes were associated with multiple CAT strategies such as discourse management (open-ended questions). Patterns reflecting pharmacist or patient speaker dominance were dependant on clinical setting.

DISCUSSION AND CONCLUSIONS

Discursis analysis of pharmacist-patient interactions, a novel application of the technology in health communication, was found to be an effective visualisation tool to pin-point episodes for CAT analysis. Discursis has numerous practical and theoretical applications for future health communication research and training. Researchers can use the software to support qualitative analysis where large data sets can be quickly reviewed to identify key areas for concentrated analysis. Because Discursis plots are easily generated from audio recorded transcripts, they are conducive as teaching tools for both students and practitioners to assess and develop their communication skills.

Using 340B drug discounts to provide a financially sustainable medication discharge service

The 340B Drug Pricing Program was intended to stretch federal resources by providing significant discounts to covered entities providing care to underserved populations. Program implementation and evidence of expanding services to higher income patients has brought more scrutiny and calls for elimination of the program. While additional review and reform may be warranted, profitability from 340B discounts enables covered entities to provide additional services that may not be feasible in absence of the program. This case report demonstrates one institution's use of 340B discounts to financially justify providing bedside medication delivery services for patients at the time of discharge from an inpatient admission. A simple financial model was developed using hospital data and inputs from available literature to estimate gross profit and earnings before interest, taxes, depreciation, and amortization (EBITDA) with and without 340B discounts. Without the 340B drug price discounts, the service would operate at a financial loss, and further investigation must be done to determine whether other clinical or economic benefits would warrant discharge medication delivery at the institution.

Assessment of Pharmacists Experiences and Attitudes Toward Professionalism and its Challenges in Pharmacy Practice

Nowadays pharmacists should be involved in patients care and providing pharmaceutical care more than before, but still there is a gap between standard of care and pharmacy practice in pharmacies. In this study we aimed at evaluating the pharmacists experiences and attitudes about ethical professional practice in pharmacies. The study was conducted in the Tehran University of Medical Sciences, Tehran, Iran. This study performed as a mixed method study including 12 semi-structured interviews and two focus group discussions (FGDs). All interviews and FGDs were recorded verbatim. The study evaluates the pharmacy practice based on the Code of Ethics for National Pharmaceutical System requirements. Our study presents the pharmacists ethical challenges in 14 areas of practice such as lack of proper pharmacists-patients and inter and intra-professional relationship; poor management of medication error; lack of pharmacists awareness about their responsibilities, professional rules and regulations; non-OTC drug dispensing without prescription; no collaboration with custodian organizations; dissatisfaction from profession; financial problems; mismanagement in confronting with ads and offers of pharmaceutical companies, and conflict of interest; and uneven drug distribution during shortage. For providing standard pharmaceutical care modification of infra structures, educational system and regulations in pharmaceutical system is highly recommended.

Integrative Review of Mobile Phone Contacts and Medication Adherence in Severe Mental Illness

BACKGROUND

Poor medication adherence is a significant problem in individuals with severe mental illness (SMI). About 50% of people with SMI become nonadherent to treatment in the first month following discharge from the hospital.

OBJECTIVE

This study examined literature in the past decade (2006-2016) on the use of mobile phone contacts in individuals with SMI to improve medication adherence post hospital discharge.

DESIGN

This integrative review used the search terms texting, text messaging, SMS, cell/mobile phone, medication adherence, medication compliance, and mental illness. Databases (CINAHL, PubMed, PsycINFO, and Scopus) and manual searching of reference lists were done. The main inclusion criteria were the use of mobile phone contacts on medication adherence in individuals with SMI. Adults 18 years and older, studies conducted from 2006 to 2016, and studies conducted in English were also criteria for inclusion. Only five studies met criteria for inclusion.

RESULTS

Outcomes from the review showed that mobile phone contacts have been used to improve medication adherence in individuals with SMI and able to provide the four types of social support (instrumental, informational, emotional, and, appraisal). When phone contacts especially text messaging was used as an adjunct to other interventions, it yielded better medication adherence than when used alone. However, results on medication adherence rates were mixed in participants on both psychiatric and nonpsychiatric medications.

CONCLUSION

Although mobile phone contacts are a promising tool to enhance medication adherence after hospital discharge, its effectiveness to increase medication adherence in this population remains inconclusive.

Emergency Department Asthma Medication Delivery Program: An Initiative to Provide Discharge Prescriptions and Education

Background

Prescription fill rates for children being discharged from the emergency department (ED) after asthma exacerbations are low, placing the child at risk for additional ED visits or admissions for asthma. This article describes the implementation of an ED asthma prescription delivery service designed to improve pharmacy prescription capture and decrease ED revisit rates.

Methods

A core group developed a service to provide asthma prescriptions and education to patients in their ED room before discharge. The project assessed the percent of ED asthma patients who filled ED asthma prescriptions at the hospital outpatient pharmacy, 7-, 14-, and 30-day ED revisit rates, and patient satisfaction.

Intervention

Patients/families who chose to participate in the service received asthma prescriptions and education at the ED bedside. Within 1-3 days, ED outreach nurses obtained patient satisfaction survey responses via telephone.

Results

There was a statistically significant increase in the number of patients who filled ED asthma prescriptions at the hospital outpatient pharmacy (22.2% versus 33.8%; P < 0.0001). The decrease in 7-, 14-, or 30-day ED revisit rates for patients who received the medication delivery service compared with standard of care was not statistically significant. Patients were satisfied to very satisfied with the service.

Conclusion

Postimplementation of a medication delivery program within the ED, there was an increase in the percentage of patients who filled ED asthma medication prescriptions at the hospital outpatient pharmacy. There was no difference in ED revisit rates for patients who enrolled in the prescription delivery service versus standard of care.

Examining hospital pharmacists' goals for medication counseling within the communication accommodation theoretical framework

BACKGROUND

Medication counseling opportunities are key times for pharmacists to speak to patients about their medications and any changes made during their hospital stay. Communication Accommodation Theory (CAT) posits that an individual's goals drive their communication behavior. The way in which pharmacists communicate with patients may be determined by the goals they set for these medication counseling sessions.

OBJECTIVES

To examine hospital pharmacists' goals in patient medication counseling within the CAT framework.

METHODS

Hospital pharmacist focus groups were held in two teaching hospitals. Interested pharmacists attended a focus group designed to elicit their goals in patient medication counseling. Focus groups were audio recorded and transcribed verbatim. NVivo(®) software was used to assist in coding and organization. The codes were reviewed for reliability by pharmacists independent of the focus groups. An inductive thematic analysis was applied to the data.

RESULTS

Six 1 h focus groups were conducted with a total of 24 pharmacists participating. Saturation of information was achieved after four focus groups. Greater than 80% consensus was achieved for reliability of the identified codes. Patient-centered themes constructed from these codes were to build rapport, to empower patients and to improve patients' experience, health and safety. Exemplars provided by pharmacists for the goals of building rapport and empowering patients were aligned with five CAT communication behaviors (approximation, interpretability, discourse management, emotional expression and interpersonal control).

CONCLUSIONS

Patient-centered goals described by hospital pharmacists for medication counseling aligned well with CAT behaviors necessary for effective communication. Further research using the CAT framework to examine the effectiveness of hospital pharmacist-patient exchanges that include both participants' perspectives is required to better understand how well pharmacists communicate with patients.

Hospital pharmacists' perceptions of medication counseling: A focus group study

BACKGROUND

Medication counseling sessions are key times for a pharmacist to speak to patients about their medications and the changes made to their therapies during their hospital stay.

OBJECTIVES

To explore hospital pharmacists' perceptions of their roles and goals in patient medication counseling, and perceived barriers and facilitators to achieving their goals.

METHODS

Hospital pharmacist focus groups were held in two tertiary referral hospitals. Eligible pharmacists had provided medication counseling within the previous six months in inpatient and/or outpatient settings. Interested pharmacists attended a focus group designed to elicit their opinions and perceptions of patient medication counseling. Focus groups were audio recorded and transcribed verbatim. Inductive thematic analysis was applied to the data to identify initial patterns (codes) which were then organized into common overarching themes using NVivo(®) software. The codes were reviewed for reliability by pharmacists independent of the focus groups.

RESULTS

Six, 1-h focus groups were conducted with a total of 24 pharmacists participating. Saturation of information was determined after four focus groups. Greater than 80% consensus was achieved for reliability of the identified codes. A number of themes emerged from these codes around the goals, roles, and the barriers and facilitators to meeting these goals. Pharmacists' patient-centered goals in medication counseling were to build rapport, to empower patients and to improve patients' experience, health and safety. These goals would be accomplished through specific roles such as being an assessor, educator and problem-solver. Pharmacists frequently cited time pressures caused by systemic (hospital), and pharmacy specific processes as key challenges to achieving their goals. Factors that enabled pharmacists to meet their goals were those related to effective interprofessional collaboration and the quality of professional practice (such as training, expanded roles and advanced planning for discharge).

CONCLUSIONS

Hospital pharmacists emphasized patient-centered goals in medication counseling and outlined the challenges to meet those goals. The findings from this study will be used to develop strategies for effective communication and inform pharmacy practice changes to improve patient care.