South Peninsula Hospital

Practice setting

South Peninsula Hospital is a 22-bed, community-owned, critical access hospital that sees an average of 1-2 admissions per day. We also have an outpatient clinic, Homer Medical Center, operating under the umbrella of South Peninsula Hospital providing mainly primary care, OB/GYN, and behavioral health services. The family medicine providers from the clinic serve as the hospitalists for our acute care patients while we receive traveling hospitalists on some weekends.

Our current focus is to improve the quality and safety of transitions of care. Since April of 2018, our pharmacy technicians have been obtaining medication histories on all admitted patients within 24 hours of transfer to the acute care floor which are verified by a pharmacist. Our pharmacists then provide discharge counseling to patients with high risk disease states (diabetes, heart failure, chronic kidney disease, COPD) and those who are being initiated on a high risk medication(s). Our future plans include the integration of a pharmacist within the primary care clinic, which will likely target Chronic Care Management (CCM) services for Medicare patients.

Why was the pharmacy service developed?

Prior to planning our medication reconciliation and discharge counseling service, we joined the A3 Collaborative as we knew it would be a great way to learn how to strategically plan, build, and test a new transitions of care service that could be extrapolated into the ambulatory care setting. We wanted to begin with transitions of care as we recognized an issue with the accuracy of medication histories, leading to issues with safety and quality during the admission and discharge processes. Our baseline analysis revealed that only 19.5% of medication histories collected during admit were 100% accurate, meaning no discrepancies were discovered through follow up medication reconciliation conducted by a pharmacist. Furthermore, our average HCAHPS score for question 25, “When I left the hospital, I clearly understood the purpose for taking each of my medications” for the year of 2017 was 56%.

What training, certification, credentialing, and practice agreement is utilized by the practice site?

We spent a little over a month training the pharmacy technicians on how to accurately collect medication histories within their scope of practice. We emphasized the need to obtain objective information before interviewing the patient, which includes medication fill history from the pharmacy or medication administration records from the patient’s care facility. For the discharge counseling portion, we are currently working on assembling disease state and medication education pamphlets to ensure consistency in information being given to the patient at discharge. Furthermore, we want to ensure that our education materials align with the teach-back method and health literacy of our patient population. 

What outcomes are being measured to evaluate the model's success?

Our goals for the transitions of care service is to have 100% accurate medication histories for all admitted patients and to achieve an average HCAHPS score of 80% beginning June, 2018. We are also collecting supplementary data to assess the time we are spending and the impact we are having by looking at the discrepancy rate, the pharmacist intervention rate, and medication order change or modification rate. Cost data has not been deemed necessary at this time, but will be necessary as we look at expanding into primary care.

How have you made this service sustainable?

Due to a recent change in workflow, our technicians have become very autonomous with the daily process of collecting medication histories. Our administration decided that it would be more cost-effective for our attached LTC facility to obtain their medications through a local retail pharmacy rather than the hospital’s inpatient pharmacy. The timing of this transition aligned with this project, allowing the technicians to replace the LTC processes with the medication history processes. As far as discharge counseling is concerned, we face the challenge of not having enough time to counsel every high risk patient. So, right now we are working on finding ways to efficiently identify and educate these patients earlier during their stay.

How did you gain support of administrators, providers, and other key stakeholders?

Our transitions of care services are not associated with an increase in cost, so we have been able to gain great support in implementing this project. It also hasn’t significantly affected the workflow of the other departments, such as nursing, so that has also helped to ensure a smooth transition.

We are starting to explore the financial resources that will be necessary to place a pharmacist within the primary care clinic. The plan is to begin with 1 or 2 days of pharmacy presence within the clinic per week using resources already in place and expand from there as needed. We are exploring various alternative payment models, including the ACO Investment Model initiative. We plan to remain very in tune with the financial model of the clinic while planning this project as the CMS quality strategy continues to expand and evolve.

What are some lessons learned while implementing your practice model that you would like to share?

On a smaller scale, we have learned the immense value of testing smaller processes utilizing PDSA (Plan-Do-Study-Act) cycles. Several times we found ourselves in the middle of a PDSA cycle without even realizing it. Or, when we have felt stuck, our A3 Collaborative coach has brought us back to the PDSA cycle to troubleshoot and to move forward to reach our goals. Through the A3 Collaborative, we have shared our stories and our data through monthly team calls with other hospitals across the country and coaching calls with our assigned A3 coach. This has given us a lot of perspective and motivation to further our practice, keeping in mind that we are located within a rural healthcare setting where we have relatively limited access to resources and networking opportunities.

On a larger scale, we believe that our transitions of care project will be a great test case for our potential within the CCM model. As we are identifying the specific disease state management needs of the community and the population we serve, we see the need for pharmacists within primary care, especially in rural and underserved areas where there is a shortage of practitioners, lack of resources, and barriers to access care.