BETHESDA, MD 26 April 2013—The Medicare program's focus on patient satisfaction is providing opportunities for pharmacists to use their medication expertise to help make the hospital stay as pleasant as possible for patients.
One way pharmacists are doing this is by focusing on the medication-related questions in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
"We see this as an opportunity for us to help provide patient education and for patients to know that they have pharmacists available to help answer any questions they have about their medications," said Meghan Davlin Swarthout, division director of ambulatory and care transitions at The Johns Hopkins Hospital department of pharmacy in Baltimore, Maryland.
The HCAHPS-improvement efforts are part of an institutional focus on coordinating patient care to reduce hospital readmissions, Swarthout said. Pharmacy's role in the process includes helping patients new to anticoagulants, insulin, or metered-dose inhalers understand the purpose of the medication and know the adverse events that may occur with its use.
Conversations with these and other targeted patients are scripted to include wording that matches the questions in the HCAHPS survey, a change that has correlated with improved HCAHPS scores at Johns Hopkins, Swarthout said.
"We now say, 'Hi Mr. Jones, I'm your pharmacist,' or 'I'm a pharmacy student working with your pharmacist, and I want to make sure you understand what your medications are for and the important side effects,'" she said.
Along with the educational interventions, patients are given a greeting card with the message, "Your pharmacist hopes you feel better soon." Inside that card is a business card that provides the number for the hospital's dedicated medication-assistance phone line.
"It's a number our patients can call, while they're in the hospital or after they get discharged, with any questions they have about their medications," Swarthout explained. She said the number reaches a voicemail box that's checked hourly by pharmacy residents and students. The medication-assistance line typically gets fewer than a half dozen calls per week but nevertheless lets patients know that pharmacists are involved in their care, she said.
Swarthout said Johns Hopkins uses trial and error with a rapid-cycle process to monitor quality improvement efforts. For example, she said, a month after an intervention begins, staff meet to decide what is working well and should be expanded and what efforts aren't getting positive results.
Since the campaign began, the proportion of HCAHPS respondents who said hospital staff always explain both what new medications are used for and what adverse events are associated with their use has risen from about 45% to 62%, and preliminary data suggest the latest figure may be around 70%, Swarthout said.
"I'm proud of all the work we have accomplished, but we still have a lot to learn," she said.
The HCAHPS survey has been used since 2006 to measure how patients view their hospital care, according to the Centers for Medicare and Medicaid Services (CMS). Hospitals that participate in the inpatient prospective payment system must report HCAHPS scores to CMS or face reduced Medicare reimbursement.
The survey, which contained 27 questions as of this past January, also factors into hospitals' Medicare reimbursement through the Value-Based Purchasing program, thanks to a provision of the Patient Protection and Affordable Care Act of 2010.
Three questions in the survey directly address medication-related patient education. Two are related to the inpatient stay, and the third and newest question concerns the discharge process.
For pharmacy, HCAHPS is about ensuring that patients "understand what their medications are being prescribed for and how to use them effectively in order to produce the best possible health outcomes and prevent hospital readmissions," said Kasey K. Thompson, ASHP vice president of policy, planning, and communications.
"There are a lot of different ways to do things effectively. I think what's really key is determining that the intervention that they're using is actually resulting in a better patient outcome and ultimately, for the organization, enhanced reimbursement," he said.
Jeffrey Reichard, senior pharmacy administration resident at the University of North Carolina (UNC) Hospitals in Chapel Hill, recently completed a master's degree project evaluating portions of the health system's reengineered transitional care program.
Reichard, working under assistant director of pharmacy Scott Savage, said pharmacy's tasks for this pilot project include delivering medications before discharge, transmitting prescriptions to outpatient pharmacies, and educating patients and their families about the discharge medications. This work is coordinated by a pharmacy technician who serves as a transition specialist.
For his project, Reichard said he wanted to find out "how patients are feeling about these comprehensive transitional care services that we're providing."
Unfortunately, he said, too few patients returned their HCAHPS survey forms for him to make any statistically valid conclusions about the services. He said the low survey-return rate was frustrating from his standpoint as a researcher as well as for the hospital as a whole, since Medicare reimbursement is tied to the survey responses.
But data recently obtained through Press Ganey, a private consulting firm, were robust enough to document statistically significant improvements in patients' satisfaction with their care in the hospital's solid-organ transplant and oncology services.
Reichard said the next step is to look more closely at patient care in those two services.
"We're going to have to go back to the teams that showed significance and say, 'What did we do initially that maybe we're not doing across the board, and how do we do that to ensure that we're getting the best product out there for our patients?'" he explained.
HCAHPS questions on pain control provide another area where pharmacists can help improve their patient-satisfaction scores, said Virginia Ghafoor, clinical pharmacy specialist in pain management at the University of Minnesota Medical Center in Minneapolis.
"We have an acute pain steering committee [that] is charged with looking at ways to improve pain management," Ghafoor said. "And they had asked pharmacy specifically to look at some of the medication issues and try to see if there are ways to improve the medication administration up on the floors."
During a two-month pilot program on the hospital's oncology and medical–surgical units, Ghafoor reviewed medication administration records for each patient whose pain score was at least 5 out of 10. During multidisciplinary rounds, she recommended ways to maximize these patients' pain therapy with opiates and other analgesics.
Important to the process was a review of each patient's medication history, including data on controlled substance use obtained from the state's prescription drug monitoring program.
"If the patient is missing a medication that they were on [at home], we want to make physicians aware of that so they can order that, because that, a lot of times, contributes to the pain," Ghafoor said.
In the hospital's oncology unit, Ghafoor's efforts resulted in 84% of patients saying the staff always did everything they could to control pain, a 14-percentage-point increase on that HCAHPS measure. On the medical–surgical unit, the score rose from 78% before the pilot program to 91% afterward.
"That's about as good as it gets," Ghafoor said.
She said an upcoming pilot study will examine deficiencies in the medication reconciliation process at admission that lead to specific pain medications not being recorded and then use order sets or other practices to better automate the capturing of that data in the medication history.