Impact of an In-Home Pharmacist Working in Conjunction with Nurses

 Team 
 Technology 

Agency
Visiting Nurse Association of Kansas City, Kansas City, Kansas.

Agency Description:
Established in 1891, Visiting Nurse Association (VNAKC) is a nonprofit home health agency. VNAKC offers a wide range of in-home services for people in and around Kansas City. As a United Way agency, VNAKC welcomes all qualifying patients regardless of ability to pay.

Through dedication to the health and wellness of their community, VNAKC delivers positive clinical outcomes that exceed national averages. VNAKC uses the latest technology available to meet the changing needs of their community.

What they do for their patients may be complex, but VNAKC's mission is simple: to bring exceptional health care into the homes of everyone they serve.

Population Impacted:
The population impacted by this program is Medicare patients with congestive heart failure (CHF), COPD (chronic obstructive pulmonary disease), diabetes, and those patients taking eight or more medications.

Target Population and Communities:  

  • The 2014/15 VNA Visiting In-Home Pharmacist program reached 228 patients (66 percent female, 34 percent male) in the metropolitan Kansas City area. 
  • Disease conditions – Patients qualified for this program by presenting with a primary diagnosis of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes or poly-med (eight or more medications). 
  • Patients were seen in their home by two senior pharmacy interns and/or a Pharmacist Preceptor from June 1, 2014 through May 31, 2015.
  • Average age of the patients:  72 years old
  • County break-down for 228 patients
    • Cass County, MO: 9 percent
    • Lafayette County, MO: 4 percent
    • Jackson County, MO: 62 percent
    • Johnson County, KS: 13 percent
    • Wyandotte County, KS: 9 percent
    • Other Missouri Counties: 3 percent

Strategic Partners:
VNA worked closely with the University of Missouri-Kansas City School of Pharmacy during the implementation of the visiting pharmacist in-home program. The School of Pharmacy Dean and senior staff have been invaluable by providing their expertise and guidance during the first year.  

After an extensive search for a part-time pharmacist, an agreement has been established with TRIA Health, a medication management organization, to provide necessary oversight of students. This position attained adjunct faculty status with the University of Missouri- Kansas City School of Pharmacy to enable the pharmacist to provide the required oversight of the senior pharmacy students that provide the in-home visit.  

The collaboration with VNA, TRIA, and UMKC School of Pharmacy on the pharmacy program is beneficial for all parties. As a designated rotation and preceptor site, TRIA understands the needs of the school and the students who have chosen the VNA Pharmacy program as part of their community rotation. Two TRIA Pharmacists are designated as coordinators for the VNA pharmacy program and students, meaning there is a knowledgeable staff person at all times in case one is absent for vacation or illness. TRIA staff pharmacy licenses in Missouri and Kansas meet state requirements for student oversight.

The program is an excellent example of both integration and coordination of care. Integration is a plan component by virtue of the communications and medication planning between the patient, their physician(s), and the hospital, home health, and pharmacy staffs.
This program was funded by a grant from the Health Care Foundation of Greater Kansas City.

Project Description:
In 2014, an in-home pharmacist grant was submitted with the objective of improving health outcomes by increasing medication education, lowering medication discrepancies, and lowing rehospitalization for Medicare patients with CHF, COPD, diabetes, and those patients taking eight or more medications.

A partnership was developed with UMKC School of Pharmacy to include the in-home pharmacist programs as an option in the community rotation for senior level students. TRIA Health was contracted by VNAKC to provide preceptor and pharmacist supervision to the students.

The in-home pharmacist program provides an innovative education opportunity for the pharmacy interns as well as a significant savings to the health care system overall ($342,000 with 228 patients seen by a pharmacist in the first year.)

The program is easily replicated and information on partnerships, outcomes, case studies and patient/student satisfaction will be provided.

Results:
Program Activities and Outcomes
  • Patient Identification – more than 450 patients were identified as viable candidates for the program, 228 visits were made to patients in their home.
  • 2,361 medications were reviewed (an average of 10 medications per patient) by the pharmacist interns or pharmacist preceptor.
  • 464 medication discrepancies were discovered between December 2014 and May 2015. A medication discrepancy is an error of omission on a medication the patient is currently taking that is not reported to the nurse or listed on the medication list.
  • 117 medication changes were recommended to physicians and those changes resulted in more than $69,000 in prescription savings. Medication changes are listed as changing to a generic substitute, less expensive substitutions or discontinuing a medication that is no longer needed.
    
Achievements:
The visiting in-home pharmacist program has achieved a significant health care savings during the first year.
  • $69,360 in prescription savings.
  • $273,604 in health care savings (services/costs avoided).  
Patient satisfaction: 
  • 32 percent of patients completed a patient satisfaction survey (74 out of 228 patients).
  • 81 percent of patients stated they were very satisfied to extremely satisfied with the consultation from the pharmacist.
  • 95 percent of patients felt the information provided by the pharmacist was useful.
  • 82 percent of patients stated they knew more about their medications as a result of the pharmacist’s consultation.
The VNA nursing and therapy staff stated they have an increased knowledge of medications and discrepancies through the increased communication with the pharmacist on their patient’s medication regime.

The program generated interest from The Joint Commission and other VNA organizations throughout the country.  The opportunity for the program to be replicated in other areas throughout the country was a specific point of interest and further conversations have taken place on how to put a program team together with other VNA organizations.

Barriers to Implementation:
Several important discoveries and lessons have been learned during the first year for the project.
  • The VNA Pharmacy In-Home one-month rotation was a new addition to the list of available rotations and without the prior experience of other students, not as many students as estimated signed up for the rotation.  The program has been increased to a two- month rotation and the 2015/16 positions were filled.
  • The number of visits to the patient’s home has been adjusted.  The students prefer to visit a home in tandem to enhance the learning experience. As a result, approximately 50 percent of the visits we estimated have been achieved for the year.
  • Student experience has shown a higher than anticipated amount of time spent researching the patient’s medication, in chart review and reconciliation of medications.
  • Student experience has shown an increased amount of time spent in the home during the visit to gain patient trust, interview, and educate the patient on their medications
  • Patients are receptive of the program and appreciate the education on the medication and its purpose in the disease process.  
  • VNA and TRIA have not fully utilized phone interviews to the fullest extent and will increase usage in the future possibly as a follow-up after an initial visit and also with the patients who reside a considerable distance from the corporate office to decrease the amount of time spent in transit.
  • The internal referral process to the pharmacy program needs to be modified and streamlined to include better succinct patient information to the pharmacist.
  • Pharmacist recruitment: After an extensive search for a part-time pharmacist, an agreement was established with TRIA Health to provide oversight to the students and work in collaboration with the VNA on a consultant basis. 
  • Proper patient referrals: Currently, the process of identification of potential patients is cumbersome and relies heavily on the home health care admission nurse referring a patient to the program. VNA is working toward an automatic referral if the patient qualifies based on the program criteria (diagnosis and number of medications). This will increase the number of potential patients pre-qualified for the program and the need to be contacted to schedule a consultation. 
  • EMR system communication between TRIA and VNA: Both organizations use different Electronic Medical Record systems that are not compatible. VNA has created a separate database to house all demographic information for the pharmacy patients outside of the EMR system. This requires duplication of records but provides accurate data. The TRIA system is used to calculate outcomes and savings information.
  • Higher levels of medication discrepancies after admission to VNA services. Patients failing to mention minor over-the-counter drugs such as Tums, Aspirin, Fish Oil, etc. to their nurse upon admission to VNA service results in a discrepancy in medications, meaning the medication list does not contain all medications the patient is taking.    
  • Patient declining the visit from pharmacist: The rate of non-admission to the program is about 50 percent—patients either do not want a visit from the pharmacist, do not see the need for additional education, the patient has been discharged, or placed back in the hospital before a visit is scheduled by the pharmacist. Talking points for overcoming denials will be provided to the student interns and home health care admission nurses to lower this statistic.