Franciscan Health – Indiana & Illinois

Prescription Bedside & Education Delivery Service (RxBEDS)

Submitted by Joshua Bitner, PharmD

Site Description

Our 6 outpatient pharmacies are a segment of a 13-hospital health system, with various associated outpatient sites/clinics, as well as a multi-site system wide physician network. We opened our network of outpatient pharmacies in 2016.

Med to Beds Service Description

Our Prescription Bedside & Education Delivery Service (RxBEDS) provides patients with their appropriate discharge medications and education at bedside, prior to leaving the hospital.  The on-site outpatient pharmacy works with physicians, nursing, clinical pharmacists, transitions of care staff, case management, and foundation and/or patient assistance staff, to coordinate the preparation and delivery of medications at discharge to the patient’s bedside.  RxBEDS is available during the outpatient pharmacy’s regular business hours. 

Most all patients admitted into the hospital with an on-site outpatient pharmacy are eligible for RxBEDS.  Upon admission, the nursing staff in coordination with our outpatient pharmacy staff are able to ask the patient if they would like to enroll in the service.  Once the discharge process begins, the outpatient pharmacy processes the prescriptions and works with various departments, clinical pharmacists, and case managers to ensure all medications are appropriate and affordable.

The total number of pharmacy technicians utilized is dependent on the size of hospital.  They are dedicated to the RxBEDS program during the day with the majority of the workload being delivering the medications to the patient’s bedside.  Additional pharmacist hours are needed to support the increase in prescription volume and the quick discharge turnaround time, which is needed when issues arise such as troubleshooting insurance, payment, and therapy questions that arise. 

Our data indicates that this invaluable service reduces the probability of 30-day readmissions, while enhancing the patient experience by alleviating the burden on caregivers to make accommodations to get medication upon discharge.

Policies and Procedures

Nursing and other clinicians are RxBEDS educated through local leadership meetings, training documents, and departmental specific 1:1 meetings.  Interest in the program has grown through grass roots “word of mouth” due to increased patient satisfaction and reduced 30-day readmissions. 

The outpatient pharmacy goes to great lengths to ensure that there are no misunderstandings or any confusion with our part of the discharge process.  The multi-disciplinary medical team utilizes the program by working with the outpatient pharmacy staff prior to discharge to gauge patient copays on high dollar medications in order to ensure their treatment plan is affordable for the patient upon discharge.  Additionally, since affordable is arbitrary depending on the patient’s financial situation, we work with case management and/or foundation to ensure the discharging patients leave with medications to treat their condition and that they are educated to take their medications correctly. 

After the technician delivers the patient’s prescriptions, the pharmacy team documents in the EMR what medications were given to the patient along with any counseling notes.  This communication within our EMR ensures that the nursing staff knows the patient has clearly received their discharge medications and promotes clarity with any follow-up or medication reconciliation after discharge. 

Additional Tools

The outpatient pharmacies work with the inpatient pharmacy teams to verify when the patient is ready for discharge.  Delivery is not initiated until the patient undergoes a medication reconciliation, which is completed by an inpatient pharmacist.  This completion is communicated by a checkmark in our system.  This ensures that the pharmacy team has verified that the patient has been prescribed all medications that they need to continue their treatment. 

Our electronic medical records and system are integrated with the hospital to ensure continuity of care.  Our outpatient pharmacy team can access and read physician notes and the recommendation of the clinical pharmacists to verify the patient’s discharge medications are appropriate.  Likewise, the patient’s care team can see what prescriptions were filled and delivered to the patient to verify what medications the patient is using at home. 

Patient Population Target

Discharging patients are the primary target populations.  In 2022, we serviced ~ 18,000 patients. Tasked with the reduction of 30-day readmissions, the primary goal was to ensure that all medications barriers (getting the actual medication(s), education, access, cost) were alleviated upon discharge by providing convenient service for both the patient, family, and/or caregiver(s).  If the primary objectives were met, we hoped this would influence overall patient satisfaction.

Financial Considerations

Our meds-to-bed service is part of the daily operations of the outpatient pharmacy.  FTEs were allocated and justified during the original and subsequent budget years when and where applicable.  Data indicates that those who enroll in our RxBEDS program have significantly reduced rates of 30-day readmissions.  This is the primary justification for this service offering, which more than pays for itself over the long run.  All departments, where applicable (exceptions NICU, ICU, etc.), are serviced.  We don’t differentiate based on disease states or prioritize based on margin of a patient transaction or insurance type.  Our RxBEDS 30-day readmission reduction rates and growth volume year over year are the primary metrics used to measure performance.  The same risks and expectations apply to non-admitted patients vs. admitted patients.  The goal is an all-around mistake-free and convenient service from admittance to discharge, proper evaluation of the appropriateness of drug regimens (therapy, cost, etc.), while providing an extremely caring, friendly, and person centric relationship.

Patient Assistance

The outpatient pharmacy identifies prior authorizations, high copays, and any other affordability issues during the discharge process.  They work with clinical staff and support staff to either initiate the prior authorizations or work with the physician to change the medication to a more affordable option.  If the patient can’t pay for their medications, case management works with the pharmacy and patient to understand the situation.   Each hospital has dollars set aside to help with patient assistance/charity care based on criteria, which can vary across the system.  If applicable, the Foundation assists in paying for the patient’s medication.  The Foundation is financed through employee giving and outside donations.  Case management ensures the patient will be able to continue their medications the following month by assisting the patient in applying for insurance, state assistance, or working with the local health department.

Outcomes & Measures

The primary goal was to ensure that all medication barriers (getting the actual medication(s), education, access, cost) were alleviated upon discharge by providing convenient service for both the patient, family, and/or caregiver(s).  By ensuring the patient discharged with medication(s) to treat the particular ailment, we hoped to decrease 30-day readmissions, which has been validated with data indicating that our approach is effective.  If the primary objectives were met, we hoped this would positively influence overall patient satisfaction. 

Key Stakeholders, Operational Considerations, Key Elements of Success

In order to ensure system wide consistency and implementation success, immense pre-planning occurred prior to rollout.  A strategic plan was developed in coordination with the local outpatient pharmacy leadership.  Effort and time must be spent mapping out your anticipated road to success with well-defined objectives, endpoints, and strategies to keep on schedule from a timing perspective.  Establishing financial and/or clinical metrics to measure success occurs at this point and can evolve over time.  It is extremely important that the outpatient pharmacies integrate seamlessly with their unique hospital cultures and distinct initiatives.

The pharmacists and technicians were all educated on internal procedures (computer system based, all internal and external communication procedures, filling and delivery processes, etc.).  Once the pharmacy is ready to go-live, the pharmacy managers begin to communicate to all stakeholders impacted by the meds-to-bed implementation.  The pharmacy managers schedule 1:1 meetings with departmental leadership and/or nursing staff for a particular unit and the process is explained.  The med-to-bed process needs to be fully understood from all perspectives.  At this point, a roll out date is scheduled for that particular unit.   We typically evaluate implementation for 1 to 2 weeks and if successful, we move on to the next unit.  However, if we need to continue to work out any problems, we will extend the evaluation period before rolling out to any new units.  Period evaluation and follow up of the service with local departmental leadership occurs long after go-live to ensure quality and efficiency remains constant.

Lessons Learned

Our successful reduction in 30-day readmissions and increased patient satisfaction validated our service and overall strategy.  Our outpatient pharmacy leadership group continuously evaluates all aspects of RxBEDS, so that it may evolve into a more impactful program.  Continuous coordination and communication with department/unit leaders helps to ensure RxBEDS remains successful.

With the implementation of RxBEDS, the most common complaint was that we slowed down the discharge process.  The biggest challenge was changing the perception at a unit level of why ensuring the patient actually receives proper medication at discharge is so vitally important in preventing readmissions.  Prior to system wide meds-to-bed implementation, once a patient was discharged, the unit staff generally felt their part of the discharge process was a success (i.e. the patient was discharged in a timely fashion and all medications were ordered and sent to an outside pharmacy), but they had not taken into account all of the many barriers to the patient in actually getting their medication, which ultimately caused these patients to readmit.  Due to the fact that our goals were aligned in not wanting readmissions, we were successfully able to change perceptions.   We explained that the outpatient pharmacy via RxBEDS is 100% ensuring that the patient receives medication(s) for their particular ailment at discharge, while also ensuring all other barriers (cost, prior authorizations, out-of-stock drugs, etc.) are handled.  At this point nursing understood that it was no longer just about sending the medication orders out, but now there was a mechanism to ensure the patient actually received the medication.  They now could see the complexities that exist with the discharge medication phase that could add additional time during the discharge process.

During the planning stage, extensive research and communications with other health systems occurred in order to see how they approached meds-to-bed so that we could tailor our service to leverage our resources and capabilities.  At the onset, we defined our meds-to-bed program as a pure direct to bedside only service, thus other alternative pathways didn’t meet our predetermined criteria when evaluating other options.  Other than incorporating more technology, in hindsight we wouldn’t change much from the original plan.  Continuation of the foundational basics can never cease and further optimization continues.

Corporate and local leadership were and continue to be our biggest champions because we all have 2 goals in mind, which are to provide an excellent patient centric journey from admittance to discharge, while working together to ensure the patient is properly cared for post discharge to prevent readmissions.

Future Goals

Previously, our outpatient pharmacies used a 3rd party pharmacy operating system that was not integrated into our health system’s EMR.  In the end of 2022, our outpatient pharmacies transitioned from our legacy pharmacy operating system to our current pharmacy operating system that fully integrates with our health system’s EMR, which allows us greater capacity to service more patients due to minimizing time loss redundancy inefficiencies.

The primary goal is to maximize discharge capture rates within our hours of operations by minimizing manual processes from the time the patient admits to discharge.  A future enhancement would be based around the admissions process.  We would like to all patients to be automatically enrolled into RxBEDS, with the ability to “Opt-Out” at the patient’s discretion.   This proposal would require coordination amongst various departments and a special build within the EMR would have to be implemented due to the fact that not all hospitals have a retail pharmacy.   Additionally, we hope to better leverage our current systems to precisely identify those patients or departments that provide the most clinical and financial outcomes, so that we can better allocate human and financial resources.  Currently, we use a specially designed do it all mobile workstation at bedside, however it is rather large and bulky.  Now that the technology is more readily available, we would like to transition to a smaller tablet based set up.  We continue to investigate the availability and financial feasibility of automated delivery robot technology integration into our RxBEDS strategy.