Pharmacists at Heart of HF Program

Heart failure readmissions slashed via patient outreach efforts

by Carol Milano


When the Centers for Medicare & Medicaid Services (CMS) announced a substantial new penalty for hospitals with high readmission rates among heart failure (HF) patients aged 65 years or older, Thomas Jefferson University Hospital took a proactive approach to lower its numbers. In November 2010, the Philadelphia institution launched a pilot program that uses the clinical skills of pharmacists to keep patients healthy and at home.


Although outcomes data from the initial 436 patients are still being analyzed, the HF program already has proven to be enough of a success that it has triggered the development of pharmacist outreach programs in several other disease states, according to Patrice Miller, MSN, MBA, vice president for clinical resource management, who oversees the program.


“It’s unique for the extent of our pharmacists’ involvement,” said Ms. Miller, who did extensive research before planning began. Impressed by Boston University Medical Center’s RED (Re-Engineered Discharge) program, in which pharmacists call patients after discharge to discuss their medications, she recommended borrowing and building on RED’s concept. (The RED program reduced readmissions by 30%; Ann Intern Med 2009;150:178-187).

Immediately, Ms. Miller recruited another Jefferson executive to the multidisciplinary planning group—Brian G. Swift, PharmD, MBA, vice president/chief of pharmacy and accreditation. “When Jefferson’s leadership called on the pharmacy department to support the program, we were ready,” Dr. Swift said. “I knew that our pharmacists were well trained to provide services beyond their usual team roles.”


The low-cost program emphasizes educating patients and caregivers about each aspect of their condition and treatment, especially medications. Inpatients keep a medication log and learn which prescriptions they should be taking and the correct time to take them. At discharge, a pharmacist reviews medications the patient will take at home, who to contact if they run out, how to reorder and which signs and symptoms should trigger a call to the physician.


“We always encourage patients to take ownership of their treatment,” Ms. Miller said. “We stress the risk of not taking a medication exactly as prescribed, and what problems can occur.” The family is alerted to possible side effects and reactions.


Jefferson’s pharmacists make five follow-up calls during the patient’s first 30 days at home, an unusually high number. “Involving our pharmacists in not only inpatient care but in postdischarge communication utilizes their expertise well,” Ms. Miller said. “With their clinical knowledge, pharmacists are able to further educate patients and reinforce their understanding about their medications. Another big benefit of pharmacists making these calls is that they review meds and address any clinical symptoms related to heart failure.”


Joanne Heil, PharmD, RN, BCPS (AQ Cardiology), director of Thomas Jefferson’s Advanced Practice Heart Failure/Transplant Pharmacy department, said that pharmacists in the HF outreach program take an early and aggressive role in patient care. “Our approach is very different [from other programs] because we provide much of the initial education to patients and their caregivers,” she said. “Up front, we see doctors’ orders to enroll the patients and we activate them into the program. We’re able to enroll patients into the program ourselves.” The pharmacists assess patients’ medication regimens, lab values, chest x-ray results and echocardiogram results. Based on these assessments, “we determine if the patient qualifies for our program. Our pharmacists are also making the follow-up calls and intervening on behalf of the patient, if need be. Most programs have nurses doing all of this, except for medication education.”


Pharmacist Activities


During discharge sessions, pharmacists discuss diet, activities and other at-home factors. Each patient gets a seven-day pillbox. After discharge, pharmacists call each patient on days 2, 7, 14, 21 and 30. They confirm upcoming scheduled doctor’s visits, review all discharge instructions and check patients’ understanding of their current medication regimen, including adherence to time and dosage instructions.


Dr. Heil coordinates pharmacists’ calls and questions to patients. “We all learned how to do a proper medication history and standardize our approach,” she said. “Jefferson pharmacists have substantial patient contact, so they’re comfortable with that aspect.” But for the HF program, a more challenging goal needed to be achieved—“attaining uniformity about how and at what level we provide medication education, so that patients understand,” she explained.


Dr. Heil updates her team on any changes to the program and provides training if any further education is needed. Additionally, she is the liaison between pharmacists and pharmacy/hospital administration.


Four rotating pharmacists work with the HF patients, full-time, for a week. Three others rotate the weekend shift. Since 2010, approximately 600 patients have enrolled. During a typical week, in late October, Dr. Heil’s team was covering 35 patients throughout enrollment, discharge and follow-up.


Program responsibilities are time-consuming for pharmacists, she conceded. Postdischarge calls average three to 15 minutes, followed by documentation and evaluation of the phone discussion. Assessing and enrolling a patient can require 45 minutes.


Several times a week, pharmacists encounter a medication problem. “For example, someone may skip a water pill when they’re out all day at a social event, or say, ‘I’ll take it at night—I’m at work all day,’” Dr. Heil said. “We educate them about diuretics, explaining what can happen when they miss a day, the danger of fluid gain, that taking it near bedtime interferes with needed sleep, and the risk of taking one outdoors in hot weather: If they suddenly pass out, they’re back in the hospital! We help patients find a specific time of day when they’ll have enough hours at home to take that water pill.”


A pharmacist following up discovered that a patient started on furosemide by her cardiologist in the hospital had previously been taking bumetanide, prescribed by her nephrologist. “We called to verify exactly what the cardiologist wanted the patient to take,” Dr. Heil recalled. “It wasn’t so much lack of communication between doctors—it’s the patient not understanding to stop a previous medication after getting home.”


Several elderly patients on diuretics live in two-story homes, with the only bathroom on the upper floor. Pharmacists arranged for commodes, through consulting with caseworkers.

Pilot study data are still being analyzed, according to Ms. Miller. Among the outcomes being tracked are number and type of pharmacist interventions and the impact of the program on hospital readmission rates. Initial results are “promising,” she noted—so much so, that the HF program’s approach to reducing hospital readmissions is being rolled out to patients diagnosed with pneumonia and with myocardial infarction.


Other Programs Document Success


Other health-systems already have documented success with similar outreach programs. Wishard Health Services in Indianapolis, for example, documented the value of having pharmacists on the HF team in a study published in the Annals of Internal Medicine (2007;146:714-725). In the National Institutes of Health–funded trial, low-income patients with HF were randomly assigned to a pharmacist intervention group (n=122) and a “usual care” group (n=192) that did not see a pharmacist targeting HF. The most marked effect was observed in emergency department visits and hospital readmissions—both occurred 19.4% less frequently (incidence rate ratio, 0.82; 95% confidence interval, 0.73-0.93) in patients seen by pharmacists.


Jim Young, PharmD, CPHQ, quality assurance/process improvement pharmacist for Wishard Health and a co-author of the Annals study, praised the Thomas Jefferson University Hospital program. “It’s great to see a hospital integrate pharmacists into a heart failure program and use their strengths to follow up on patients’ pharmaceutical care,” Dr. Young said.


The American Society of Health-System Pharmacists (ASHP) will feature Jefferson’s pharmacist outreach efforts in HF and other disease states in its online Practice Spotlight section. The hospital is being profiled because its clinical programs illustrate the type of innovation promulgated by the Pharmacy Practice Model Initiative (PPMI), a joint effort by the ASHP and the ASHP Foundation to promote practice change. The HF program was cited as an outstanding PPMI example at the Pennsylvania Society of Health-System Pharmacists’ 2011 meeting, where Jefferson showed a slide presentation about its efforts.


“Expanding pharmacist involvement in the transition of care is evolving here, as at many other institutions,” said Dr. Swift. “I’m happy to report that our pharmacists are playing an important role in our enterprise-wide efforts to improve patient care and reduce hospital readmissions. Pharmacists are uniquely qualified to provide much-needed services like the ones in our heart failure program.”


Colleagues concur. “Multidisciplinary programs, such as Jefferson’s Heart Failure Readmission Reduction Program, are essential to improving patient outcomes and the overall efficiency of health care,” said Cynthia Reilly, BSPharm, ASHP’s practice development division director. “Medication-related problems, including errors and nonadherence, are common as patients transition between care settings. Pharmacists are ideally suited to work with patients and other health care providers to prevent these drug therapy issues.”


The ASHP featured a story on another HF outreach program in the Dec. 1 issue of its AJHP News. The program, known as Steward Healthy Transitions, employs clinical pharmacists who conduct home visits and telephone follow-up calls to patients who are diagnosed at discharge with HF, acute myocardial infarction or pneumonia. Before the program began, hospital readmission rates for these conditions ranged between 5.56% and 32.5%. Post-rollout, “we’ve seen re-admission rate for enrolled patients hold steady at about 5%,” Ernest R. Anderson Jr., MS, RPh, system vice president of pharmacy at Steward Health Care System, Boston, said in an interview with Pharmacy Practice News. Moreover, “patient survey data show a high acceptance rate of the pharmacists’ recommendations (100% agreeing) and a 90% rate of changed behavior.”


Although the Healthy Transitions program “is still in its infancy,” Mr. Anderson added, “the data are encouraging and should have a positive financial impact.”


For Dr. Heil, although such financial considerations are important, it is the clinical benefits of these outreach programs that truly resonate. “We’re getting much more involved in the full spectrum of a patient’s care, which is what we’re trained to do: assess, listen, talk, and educate,” she said. “I want more [clinical] involvement and gratification. My attitude is ‘let’s move ahead and see what else we can do.’ Machines can count pills!”