Through a "Meds to Beds" program, Texas Children’s Hospital (TCH) used its outpatient pharmacy to provide discharge prescriptions and medication counseling at the bedside for 1,008 ambulatory surgery patients over three months. Because of this service, patients' families face significantly fewer challenges in filling prescriptions during their transition home, and they receive focused medication counseling and education. The financial impact of the pilot program was minimal due to the relatively low cost of the medications prescribed after ambulatory surgery. However, we estimate that the hospital could add more than $100 million to its bottom line by aggressively extending the outpatient pharmacy service hospital wide and including specialty medications. Anecdotal evidence suggests that the program reduces readmissions and improves quality of care; we are seeking to quantify those benefits.
Provision of a “Meds to Beds” service for pediatric patients and families is helpful in closing gaps in the care continuum for patients upon discharge.
Bedside prescription delivery and pharmacist education can be supported through increased acceptance of commercial prescription insurances and greater 340B participation.
Patients at Texas Children’s Hospital (TCH), a 600+ bed freestanding pediatric institution that is the largest of its kind in the country, face challenges getting their prescriptions filled after discharge. Community pharmacies generally lack pediatric pharmacy expertise, which may result in dosing and dispensing errors. (The Institute for Safe Medication Practices cites pediatric dosing error rates of between 15 and 35%.) Also, community pharmacies may not routinely stock medications that pediatric patients need, particularly with compounded suspensions, creating delays in starting prescribed regimens. Despite these challenges, nearly 91% of families surveyed by TCH were filling their child’s discharge prescriptions at community pharmacies on their way home from the hospital after ambulatory surgery.
At the same time, the outpatient pharmacy at TCH was an underused resource. It provided prescription services for patients with Medicaid, but did not have relationships with commercial pharmacy benefit plans and, therefore, could not serve a large portion of the patient mix. Even families of Medicaid patients were not always aware that they could fill prescriptions at the hospital’s pharmacy. Prescription services were contained within the pharmacy, requiring families to leave the child’s bedside to come to the pharmacy and wait to have prescriptions filled. Initially, the hospital’s electronic health record (EHR) system was not set up to allow electronic prescribing to the outpatient pharmacy, even though it could transmit prescriptions directly to community pharmacies. This meant that families had to carry paper prescriptions if they used the hospital’s outpatient pharmacy.
The hospital realized that the gaps in pharmacy service hindered the goal of providing comprehensive care and equipping families with everything needed to ensure a smooth and safe transition out of the hospital.
Our immediate goal was to ensure that patients had all their medications, along with counseling and instruction on their use, before they left the hospital. This goal required fundamental changes in the operation of our outpatient pharmacy. We began with ambulatory surgery patients because these patients are fairly incapacitated at discharge, and forcing a stop at a pharmacy on the way home can be onerous for both the patients and their families. Delivering the prescriptions to the patient’s bedside (“Meds to Beds”), with medication counseling by a pharmacist, would eliminate the immediate need to deal with a community pharmacy and improve both continuity of care and the patient experience.
We made a thorough assessment of the resources and limitations of our outpatient pharmacy. We issued a questionnaire to a sample of families to assess demand for the proposed service and identify potential concerns. Sixty percent of respondents said they would use the hospital’s outpatient pharmacy if they had the option, and 63% either said they had no concerns or did not respond to that question.
We convened a core project team that met weekly and included physician, nursing, and pharmacy leadership. The team routinely engaged family services, patient experience, and patient advocacy staff as well. The team’s tasks included:
- Establishing contracts with commercial insurance plans. We entered into an agreement with the Community Independent Pharmacy Network (CIPN), which negotiates agreements with insurers on behalf of independent pharmacies. Establishing the CIPN relationship and getting payer agreements in place took about 12 months, after which our pharmacy was able to serve patients covered by all commercial insurers.
- Coordinating bedside pharmacy services. Families were offered the new option to have prescriptions filled and delivered to the bedside while they were with their recovering child.
- Advocating for and executing electronic prescribing of medications from the unit to our own outpatient pharmacy. Our EHR is set up to send electronic prescriptions to a patient’s preferred pharmacy. We put in place a manual process at registration, where families could temporarily select our pharmacy as their preferred pharmacy, enabling electronic prescribing. The system automatically reverted to the patient’s original preferred pharmacy after the ambulatory surgery episode of care was complete.
- Informing key players of new procedures. Process changes were communicated among the multi-disciplinary team and within the organization.
- Determining how to collect co-pays. We adopted a point-of-sale system for collecting co-pays at the bedside via credit card based on our IT department’s criteria for end-to-end encryption of transactions and compliance with all requirements for protecting personal credit information.
The team included the Surgical Director of Patient Experience, nursing leadership, the Director of Pharmacy Services, and several representatives of the pharmacy staff.
After expanding outpatient pharmacy services to patients with commercial insurance and instituting the Meds to Beds program, our outpatient pharmacy filled 64% of ambulatory surgery patients’ prescriptions prior to their discharge, compared with less than 1% before the program. The pharmacy dispensed 2,119 prescriptions for a total of 1,008 patients in the three months after go-live, compared with 25 prescriptions for 15 patients in the three months prior to go-live.
After three months of implementation, the same-day surgery prescription volume made up 24% of the outpatient pharmacy’s average workload per month. Most of the prescriptions were analgesics, anti-emetics, post-operative antibiotics, and steroids.
When patients and families were surveyed about their participation in the program, 100% said they were “Very Satisfied” with the prescription delivery, and 99% indicated “Very Satisfied” with prescription education provided by the pharmacist. All the participants said they would be very likely to use the service for future visits. (In contrast, satisfaction with previous services rendered by an outside pharmacy was 48%.)
When families were surveyed before the start of the program, they voiced concerns around timeliness, cost, and the pharmacy having the medication in stock. In a follow-up survey after receiving the new service, families most appreciated the convenience and timeliness, as well as the education from the pharmacist.
We plan to expand use of our outpatient pharmacy to other areas of the hospital, particularly services that use more expensive specialty medications, and extend Meds to Beds to our inpatients at discharge. By increasing the number of prescriptions filled at our outpatient pharmacy, we will also be able to leverage additional savings through our participation in the 340B Drug Pricing Program, which requires drug manufacturers to provide outpatient drugs to eligible health care organizations at reduced prices. We are also working to develop functionality within our EHR that will change the patients’ preferred pharmacy automatically upon registering for ambulatory surgery, removing the need for a manual change.
Thanks to Jamie Kim, PharmD, Jennifer McCarthy, RPh, Rosa Lopez, Nancy Wong, CPhT, Julianna Fernandez, PharmD, BCPS, CGP, Joseph Bloom, Beth Jones, Rebecca Hanson, Lorianne Classen, Cameron Bisset, Juan Rivera, and Tabitha Rice.
This case study originally appeared in NEJM Catalyst on October 11, 2016.