OBJECTIVES: In our previous work, providing medications in-hand at discharge was a key strategy to reduce asthma reutilization (readmissions and emergency revisits) among children in a large, urban county. We sought to spread this work to our satellite hospital in an adjacent county. A key initial barrier was the lack of an outpatient pharmacy on site, so we sought to determine if a partnership with community pharmacies could improve the percentage of patients with medications in-hand at discharge, thus decreasing reutilization.
METHODS: A multidisciplinary team partnered with community pharmacies. Using rapid-cycle improvement methods, the team aimed to reduce asthma reutilization by providing medications in-hand at discharge. Run charts were used to display the proportion of patients with asthma discharged with medications in-hand and to track 90-day reutilization rates.
RESULTS: During the intervention period, the median percentage of patients with asthma who received medications in-hand increased from 0% to 82%. A key intervention was the expansion of the medication in-hand program to all patients. Additional changes included expanding team to evening stakeholders, narrowing the number of community partners, and building electronic tools to support key processes. The mean percentage of patients with asthma discharged from the satellite who had a readmission or emergency department revisit within 90 days of their index admission decreased from 18% to 11%.
CONCLUSIONS: Impacting population-level asthma outcomes requires partnerships between community resources and health providers. When hospital resources are limited, community pharmacies are a potential partner, and providing access to medications in-hand at hospital discharge can reduce asthma reutilization.
- CCHMC —
- Cincinnati Children’s Hospital Medical Center
- ED —
- emergency department
- EMR —
- electronic medical record
- HM —
- Hospital Medicine
- QI —
- quality improvement
The World Health Organization 2003 report on medication adherence1 quoted Haynes that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.” An obvious, yet critical, component to medication adherence is access to medications; consequently the failure either to fill new prescriptions or to refill existing ones is a critical point of failure in the postdischarge care of patients.1,2 Previous work at our institution has demonstrated a sustained reduction in hospital and emergency department (ED) reutilization in part due to efforts to discharge patients with asthma with their medications in-hand.3
In 2008, Cincinnati Children’s Hospital Medical Center (CCHMC) began an asthma-improvement initiative focusing on reducing 30-day and 90-day reutilization, defined as readmissions or revisits to the ED for asthma after an index asthma admission for Medicaid patients from our primary service county, Hamilton County. The medications in-hand intervention was a critical piece of the initiative and had 2 main components: relabeling the inhalers (rescue and controller) the patient used during admission for home use, and using our institution’s outpatient pharmacy to fill the patient’s oral steroid, rescue inhaler, and controller medication prescriptions.3 From 2007 to 2013, a median of 86% of patients left with relabeled inhalers, and 71% left with their oral steroid medication in-hand. The asthma 30-day reutilization rate from the county Medicaid population was reduced from 11.1% to 5.4%.3 This work originally focused on Medicaid patients, then expanded to include all patients discharged after an asthma exacerbation, including those from our 8-county primary service area.
CCHMC opened a satellite facility, Liberty Campus, in the northern Cincinnati suburbs in August 2008. Although discharged patients could receive their relabeled inhalers at this satellite facility, no outpatient pharmacy existed on site to fill the oral steroids or inhalers. Initial efforts at establishing medications in-hand at discharge from Liberty Campus included relabeling inhalers and encouraging families to fill their prescriptions at nearby pharmacies before discharge. However, interim analysis of 30- and 90-day readmission outcomes from our 8-county service area revealed we had not yet improved outcomes for children from the second most populous county, Butler County, where the Liberty Campus is located. Further, most asthma discharges among children living in Butler County were from the Liberty Campus. With guidance from our CCHMC outpatient pharmacy colleagues, we worked to form a partnership with 2 local, family-owned pharmacies located near the satellite facility with existing home medication delivery programs. After feedback from families and primary care providers, we planned to build a process to deliver discharge medications directly to patients at our satellite facility before discharge.
With a global aim of decreasing 90-day reutilization, beginning in August 2013, the specific aim of this study was to increase the percentage of patients with asthma admitted to the satellite facility who receive medication delivery from 0% to 80% by December 2014.
CCHMC’s Liberty Campus, a satellite facility of CCHMC’s Burnet Campus, is a 12-bed, suburban hospital located in Butler County, OH, with an on-site ED, approximately 40 surgeries per day, many multispecialty outpatient clinics, but no ICU or outpatient pharmacy. The Hospital Medicine (HM) Service admits ∼800 pediatric medical patients per year to Liberty compared with about 5000 HM pediatric admissions per year at the base Burnet Campus. Patients at the Liberty Campus differ significantly from patients at the Burnet Campus with respect to race, insurance, and age (Table 1). Typically, the Liberty Campus inpatient unit is staffed by an HM provider, with intermittent resident or medical student presence. During most of this study period, ∼40% of weekend shifts were staffed by non-HM moonlighters.
Planning the Intervention
Because Liberty Campus did not have an outpatient pharmacy on site to provide medications in-hand to discharged patients, a strong partnership with local pharmacies was necessary to provide this service. We had kickoff phone calls with 2 local pharmacies chosen due to close proximity to the satellite facility and preexistence of home delivery programs. On the kickoff call, we explained our goals for the program, discussed ways to facilitate communication regarding the program, and designed initial tests to share insurance information needed to fill prescriptions for eligible patients. The improvement team, consisting of a project manager, nurse manager, 2 physicians, and a floor nurse, met weekly to discuss tests of change and program feedback.
Eligible patients for the program were identified by weekly census lists for the unit, with patients with asthma eligible if they were discharged on the asthma care pathway. The nurse manager collected data on success rate from nurse process stickers and the electronic medical record (EMR). Before the beginning of the intervention, the patients included in the reutilization data were taken from system-wide data, which only included patients between 2 and 18 years old. Once we began the intervention, we began tracking reutilization outcomes for all patients included in the medication delivery program.
Two primary methods were used for evaluation of the ongoing performance of the program. The percentage of patients with asthma receiving medication delivery was shown on a monthly run chart. Run charts display data in a timed sequence to help detect special causes of variation.4 Special cause is reached when there are 8 points above or below the median line. Finally, weekly phone calls were used for qualitative feedback from the improvement team, to assess success of tests and plan for next steps. Three main outcomes were tracked: the percentage of patients with asthma who received their medications in-hand, the percentage of patients with asthma discharged from the satellite who had an asthma reutilization (at a CCHMC hospital, ED, or urgent care) 90 days after an index admission, and finally, the percentage of patients discharged within 2 hours of meeting medically ready criteria, used as a balancing measure. Our institution has been working on improving discharge efficiency since 2012, by tracking when patients meet medically ready for discharge criteria and assessing if patients are discharged within 2 hours of meeting that goal.5 One of their primary failure reasons was due to medications/pharmacy, so efforts were made to ensure our medication delivery program did not delay discharge.
Human Subject Protection
The CCHMC institutional review board reviewed the project and considered it to be a local quality improvement (QI) initiative and not research involving human subjects. Informed consent beyond the standard consent for treatment of all inpatients was not required.
The median percentage of patients with asthma who received medication delivery increased from 0% to 82% by December 2014 (Fig 1). The mean percentage of patients with asthma discharged from the satellite who had a readmission or ED revisit within 90 days of their index admission decreased from 18% to 11% (Fig 2). During the study period, the median percentage of patients discharged within 2 hours of meeting medically ready criteria ranged from 88% to 95%, although only 2 patients (2% of all failures) had delayed discharge due to medications.
The improvement team, consisting of a project manager, nurse manager, 2 physicians, and a floor nurse, met weekly to discuss tests of change and program feedback. Early on, the team identified providers forgetting or being confused about the program as the main reason for failure, especially with the high number of weekend moonlighters. The team believed that if we expanded the program to all conditions, we would increase reliability for patients with asthma. We worked with our local pharmacy colleagues, as well as Liberty staff and providers to determine a spread plan, and expanded the program to all conditions in April 2014. Although the median of patients with asthma who received their medications in-hand had already begun to increase, it was stabilized at or above 80% after the program expansion (Fig 1). We also tracked the median percentage of all eligible patients who received medication delivery, and it was 64% in December 2014. After the program expanded to all conditions, the 90-day asthma reutilization rate mean decreased to 11%. We believe this is likely due to increased reliability for patients with asthma.
To better engage the night staff and further educate the providers at the Liberty Campus regarding the expansion of this program, the team was expanded to include the unit medical director, 2 evening nurses, the evening unit clerk, and 2 additional physicians. The night staff in particular was essential to the team, because often they started the process on admission. We tested having the admitting nurse complete the demographic form containing weight, allergy, and insurance information for all patients on admission, which allowed for necessary information to be sent to the delivery pharmacy as soon as medications were decided. This test improved the process, increased reliability, and was adopted.
There were a few interventions that used the EMR. We added a reminder about the medication delivery program to the Liberty-specific Asthma History and Physical Admission Note template. This document was used previously in our institution to increase referrals to a community program.6,7 By reminding the physicians on admission, it ensured that the process started early in the patient’s stay. A reminder was also built into the EMR-based attending handoff tool. Finally, the staff began documenting the process in the EMR. This let all providers and staff know if the family had elected to use the medication delivery program, if the prescriptions had been sent, and if they had been delivered to the family. A description of the remaining tests can be found in Table 2.
Shortly after the initial phase, CCHMC decided to select 1 community pharmacy to continue with. This community pharmacy was willing to deliver medications at any time during their delivery hours (even if it was just 1 medication), offered to reformulate medications for specific patients (ie, making a liquid formulation, cutting pills for ease of use), and engaged in communication with the study team.
By leveraging an existing community resource to provide a service that was lacking at a satellite hospital, we were able to parallel a service that had shown success at an urban, academic pediatric hospital. We were able to increase the percentage of patients discharged with their medications in-hand, which was associated with a reduction in the percentage of patients with asthma with a 90-day reutilization. Although we showed limited success when this work was just focused on patients with asthma,5 once we expanded our eligibility criteria to all patients being discharged with medications, we were able to increase awareness and adherence to the programs by staff and physicians. Our primary reason for expansion to all patients was to increase reliability and improve outcomes; however, there was also strong willingness from staff, providers, and our pharmacy partners to offer this service to all patients.
The involvement of other key stakeholders, such as front-line nurses, unit clerks, nurse managers, hospitalists, and hospitalist leadership, was also instrumental to our success. They led each testing cycle and provided weekly feedback on what needed adoption and what needed to be abandoned. Staff input is known to be highly valuable in the use of QI in the health care setting, as many QI projects involve active participation and buy-in from a multidisciplinary staff.8–10 By engaging night staff when we expanded the program to all patients, we were able to begin the process on admission. During the asthma-only phase of the program, we were relying primarily on the daytime staff, which caused us to miss patients who were admitted late in the day and ready to be discharged the following day. As the night staff began discussing the program with families on admission, and completing the demographic form to be sent to the pharmacy after they agreed, we were using the most appropriate staff to complete necessary steps of the process.
By engineering key interventions into the EMR, such as the reminders in the Liberty-specific Asthma History and Physical Admission Note template and the attending handoff, as well as documentation of the process in the nursing notes, we were able to increase the reliability of the process. Increased reliability due to utilization of the EMR has been shown in both the inpatient setting6,7,11 and the outpatient setting.12–14 Although the prescriptions themselves were also sent through the EMR, limitations of that system still required staff to send the demographic form, containing relevant demographic information, such as weight and allergies, as well as the patient’s insurance information, via fax. As the process of e-prescribing expands, there may be further efficiency gains.
Other studies have shown success leveraging community partnerships in unique ways,7,15,16 although to our knowledge no previous study has partnered with a community pharmacy to ensure that patients are discharged with their medications in-hand. Having an engaged community partner in one pharmacy was essential to our success. The study team communicated with the owner frequently to discuss challenges, potential interventions, and study progress. The pharmacy team showed incredible flexibility and willingness to help our patient population.
Along with an active pharmacy partner, buy-in from other key stakeholders was important. Early staff and provider adopters were essential to getting the program started. Throughout the project, by focusing our efforts on patients willing and able to use the program, as opposed to expending effort on families ineligible for the program due to insurance reasons or unwilling to participate, we were able to increase staff buy-in. Family participation and buy-in are also essential, and overall qualitative feedback solicited from families was positive.
This study was not without limitations. It was conducted at 1 satellite hospital of a larger, academic institution, where a robust culture of QI exists. The local pharmacies we chose had existing home medication delivery programs, so this program was an expansion of their existing process and not a new program. Although we started with 2 local pharmacies, we eventually chose to focus on the partnership with the one that had been an active member of the improvement process. Previous work has shown that there are likely willing partners in many communities and identifying them is the first step to success.
Impacting population-level asthma outcomes requires partnerships between community resources and health providers. We were able to mirror a process from our main hospital of ensuring patients have medications in-hand before discharge at a satellite hospital by partnering with local pharmacies. Providing access to medications in-hand at hospital discharge may reduce reutilization for children with asthma. Community pharmacy partnerships have strong potential, as providers and health systems are increasingly held accountable for population health outcomes.
We thank the members of our improvement team: Michael Faller, Claudia Lares, Shawna McKinney, Julie Mullaney, and Elizabeth Wright. We could not have succeeded with this work without the staff and providers at the Liberty Campus. We thank Dr Andrew Beck for his statistical assistance, Ms Allison Loechtenfeldt for her data assistance, and Dr Patrick Brady for reviewing the revised manuscript. Preliminary data from this work was presented at the Pediatric Hospital Medicine Conference, July 25, 2014 (Orlando).
- Accepted August 11, 2015.
- Address correspondence to Hadley S. Sauers-Ford, MPH, Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medicine Center, 3333 Burnet Ave, MLC 7035, Cincinnati, OH 45229. E-mail:
FINANCIAL DISCLOSURE: Mr Yost is the owner of Yost Pharmacy. The other authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: Mr Yost is the owner of Yost Pharmacy. The other authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2016 by the American Academy of Pediatrics