SAN FRANCISCO, CA 27 August 2012—Deploying pharmacists to where the patients and health care teams are at North Shore University Hospital is reaping benefits for the New York facility, according to a poster presentation at the American Hospital Association’s recent Leadership Summit in San Francisco.

Readmissions within 30 days for patients with heart failure are on the decline.

So are errors in medication orders.

Toward an integrated model. Clinical Coordinator Susan Lee, who presented the poster in San Francisco, said her department is transitioning to a patient-centered integrated model of pharmacy practice.

Of the department’s 50 full-time pharmacists, 10 provide clinical services on the patient care units, Lee said in mid-July.

Three years ago, the hospital’s health system had unit-based pharmacists only in the critical care and pediatrics areas, according to the health system’s website.

The vision for 2013 and beyond, Lee said, is for most of the 40 pharmacists now in the central pharmacy to work out of the units.

From the units, the pharmacists will continue to provide clinical services, such as evaluating medication regimens and laboratory test results, she said. But they will also educate patients about their medications and diseases and perform rounds with the interdisciplinary health care teams.

With an eye on metrics. Like most other acute care hospitals in the country, North Shore faces the possibility that Medicare will soon penalize the facility for excess readmissions.

The federal Hospital Readmissions Reduction Program, established in 2010 by the Patient Protection and Affordable Care Act, is the reason. Under the program, the Centers for Medicare and Medicaid Services will reduce payments to hospitals that exceed the average national rate at which Medicare beneficiaries with heart failure, myocardial infarction, or pneumonia are readmitted to the hospital within 30 days of a prior hospitalization for those disorders. This program starts with discharges on October 1, 2012.

Readmissions of patients with heart failure, in particular, are a "big hitter" for North Shore, Lee said.

According to the federal Hospital Compare website, for the three-year period ending June 30, 2011, the hospital performed worse than the national average for two outcome-of-care measures:

• 30-day readmission rate for Medicare beneficiaries with heart failure, and
• 30-day readmission rate for Medicare beneficiaries with myocardial infarction.

The estimated risk-adjusted rates for both measures exceeded the national rates by 3.5 percentage points.

But heart failure was more commonly associated with readmissions at North Shore and affected more inpatients.

Lee said the hospital in 2010 established an interdisciplinary team to determine why patients with heart failure return and stay as long as they do.

In practice, with the patient in mind. The team—a cardiologist, a nurse practitioner, a social worker, case managers, and a pharmacist—focused on one of the four cardiac care units in 2010–11.

She said the team determined that the returnees do not constitute a large population. Rather, a handful returns many times a year. Those patients became the targets of extra attention.

Patients with heart failure tend to have additional medical conditions, Lee said. Diabetes mellitus, a coronary artery stent or bypass graft because of an earlier myocardial infarction, and atrial fibrillation are common in this population.

"It’s not really heart failure alone that we’re dealing with, it’s multiple comorbidities," she said. "And I think that’s where we have such a hard problem in managing this disease."

The pharmacist’s role in caring for these patients is medication reconciliation and patient education, Lee said.

"Heart failure is a little more difficult to explain to a patient [than diabetes] because it’s so dynamic," she said. "But I really do try to educate the patient on what the heart failure is, what the heart failure means to them, and what are the symptoms when they do have heart failure."

For example, Lee said she explains to patients in simple language the consequences of eating Chinese food or other salty fare and the importance of taking the prescribed diuretic.

"When we educate, we really need to take all these dynamic things and try to make it as one, so that the patient understands the global picture, not just the medications alone," she said.

By deploying a pharmacist to the cardiac care units, Lee said, the department can engage the patients in their health care and empower them to manage their diseases.

On the 42-bed unit where this deployment originated, the effort has paid off.

According to Lee’s poster, the percentage of patients admitted for heart failure who returned within 30 days of discharge declined in the third and fourth quarters of 2011 to levels below those documented during the same periods in 2010. For the two-year period ending December 31, 2011, the average rate of readmissions was 0.9 percentage point less than the currently reported national average.

Deployment of pharmacists to patient care units has paid off in another way, Lee said.

Since the implementation of a computerized prescriber-order-entry system in October 2011, the number of so-called near misses—orders that could have harmed patients if not corrected—has dropped nearly 50%. Lee said many of the near misses before the system went live involved illegible handwriting.

But near misses still occur despite computerization.

One reason, Lee said, is the computerized system offers prescribers at the teaching hospital a free-text field in which to enter a medication name if they do not find the one they want on the system’s programmed medication list.

Pharmacist-conducted medication reconciliation on the patient care units is preventing some near misses, she said. During a project on one of the units, a pharmacist who reconciled patients’ medication lists at admission, during the hospital stay, and at discharge found roughly seven discrepancies per patient. Many of those discrepancies—all of which were resolved through pharmacist intervention—qualified as near misses.

"If we have more of our pharmacists up on the units," Lee said, "we could prevent a lot of the near misses."

North Shore, in a community on the north shore of Long Island, is part of North Shore-LIJ Health System.