The Role of the Pharmacist in Healthcare Transitions

Introduction

Over the course of receiving treatment, a patient who has been diagnosed with a chronic illness will likely require care from more than one healthcare professional or care team. This may include admission or discharge from hospital, or transfer from hospital to another care setting. One healthcare transition may lead to another, such as when referral to a specialist leads to an inpatient admission, or when issues after discharge lead to a hospital readmission. Whatever the reason for a transfer of care, healthcare transitions can create safety risks for patients due to poor communication, coordination and/or integration of treatment, and subsequent changes in medication therapy along the way.

A pharmacist’s role is to ensure optimal outcomes for a patient from his or her medication therapy. This article will explore how pharmacists can positively contribute to patient care during healthcare transitions by applying their unique knowledge, skills and judgment. During a healthcare transition, this contribution can be crucial in reducing the potential for serious adverse events leading to patient harm. A pharmacist has access to a number of tools to guide his or her practice and approach to decision-making for the benefit of the patient, including the Code of Ethics and Standards of Practice.

Pharmacist Practice

Pharmacists provide care in numerous settings and can assist patients through inter-professional collaboration and the provision of advanced pharmaceutical care, wherever the patient is located. In long-term care facilities, pharmacists work with nurses and physicians to ensure patients are receiving optimal medication therapy — including, as an example, ensuring that residents’ drug regimes are not contributing to a higher risk of falls. In Family Health Teams and Community Health Centres, pharmacists collaborate with other healthcare practitioners to improve chronic disease management and health promotion. Pharmacists are also well integrated in hospital facilities, including acute general, teaching and psychiatric hospitals, and rehabilitation and chronic care facilities. In these settings, pharmacists contribute at all stages of a patient’s stay, including generating Best Possible Medication Histories (BPMH) on admission, verifying drug orders during treatment, managing medication therapy, and undertaking comprehensive medication reconciliations, including patient education at discharge. Pharmacists also provide clinical care by reviewing laboratory results and suggesting changes to medication therapy as required.

Patient Risk During Care Transitions

During healthcare transitions, patients are particularly vulnerable to disjointed care which may lead to medication discrepancies, potential adverse drug events, delays in treatment, inappropriate treatment, duplication of treatment, avoidable healthcare costs, and ultimately, potential harm. These issues are directly related to poor communication between providers, patients and families, and the absence of overall accountability for patient care when patients cross boundaries within the treatment continuum. In addition to these issues, there are few mechanisms in place to coordinate care across settings and between providers.

Health Quality Ontario’s findings confirm that fragmented patient care leads to hospitalizations and readmissions that could likely be avoided. Approximately nine per cent of acute care patients are readmitted to an acute care hospital within 30 days of discharge, with one in every six patients returning multiple times within seven days of discharge. The highest rates for readmission are associated with congestive heart failure and chronic obstructive pulmonary disease. With respect to seniors, it is estimated that adverse drug reactions (ADRs) account for up to two-thirds of drug-related hospital admissions and emergency department visits. Senior patients in rural areas are more likely to be readmitted than any other group, generally due to a lack of home cares services, and patients who received medical as opposed to surgical or obstetric care accounted for nearly two-thirds of unplanned readmissions. Further, among the factors known to increase the risk of ADRs are the number of drugs a patient is taking, whether or not he or she has started new medication therapy, and the number of pharmacies visited.

The Role of the Pharmacist in Optimizing Patient Care

The current trend to early discharge of patients from hospital means that more acutely ill and complex patients are receiving therapies in the community. A recent survey found that 65% of Canadians reported difficulty in receiving after-hours healthcare without visiting an emergency department, and emergency department wait times remain well above target for high complexity patients. There are several routine pharmacist actions that can ensure a patient’s medication therapy is appropriate, including conducting medication reviews, identifying medications that pose risks to the patient and taking action, educating patients about medication therapy, identifying and reconciling changes in therapy during transitions, and documenting decisions and actions in the patient record. As the acknowledged experts on medication therapy, pharmacists can address or prevent many of these medication-related challenges and assist patients in managing their health conditions. Conducting regular reviews of a patient’s medications can reduce the risk of ADRs.

Including a pharmacist in team-based care has been found to improve the overall quality of medication use and has been recommended by Health Quality Ontario. In some circumstances, where patients are seeing multiple health providers, or do not have a dedicated primary healthcare provider, the pharmacist may be the only health professional that has a complete record of medications prescribed and dispensed to a patient. With this record, the pharmacist is well-placed to spot potentially serious drug interactions and inappropriate therapy and address these issues immediately. The pharmacist will also monitor medication use and refill intervals to help identify patients who are not compliant.

Conclusion

The role of pharmacists is rapidly changing across Canada as pharmacists are taking on new roles and expanding clinical services. As new roles and services emerge, research continues to quantify the positive patient outcomes associated with the pharmacist’s involvement, such as reducing drug interactions and lengths of stay in hospital, improving disease control, reducing drug costs, and reducing the use of health services. There is evidence that in times of healthcare transitions, the pharmacist’s contribution can reduce both risks to a patient, and costs to the system. Continuing to integrate pharmacists working in all settings with other healthcare professionals could further improve patient outcomes during healthcare transitions.