Transitional Care and Discharge Medication Counseling

Hospital Administrators and Prescription Benefit Managers; sit up and listen, we have something to discuss here.

I live in a mid-sized town on the coast of Northern California. Both my wife and I grew up in the local area and we both come from large families. Along with working at the local community hospital, my ever growing, extended family, gives me quite a few opportunities to visit relatives while they are patients in the hospital.

This past weekend I had the opportunity to go with my wife to visit her 94 year old Great Aunt who had been admitted to the hospital a few days prior. Just as we got to her room, at about 2 in the afternoon, the nurse was arriving to begin the discharge process. My wife's Great Aunt has a son, who is the primary care giver at home, who manages all of the medications, blood monitoring for coagulation and diabetes, and other necessary treatments and appointments.

As the nurse was preparing my wife's Great Aunt to get into the wheel chair, I was discussing the morning with her son.  He stated that they began the discussion of discharge yesterday afternoon after the completion of a diagnostic procedure. All morning long they had been waiting for the hospitalist to come along and review her case and write some discharge orders. 

He had talked with the nursing staff first thing that morning to see if there was anything they could do to prepare for discharge and the nurses said no, they needed to wait for the doctor to write orders. 

Until the doctor came, they were instructed to just relax in the room and wait.

At about 1:30 p.m. the doctor walked into the room, talked with them for a few minutes and said they were ready to go home. Now, here we are at 2:15 p.m., and the nurse is efficiently printing off a stack of discharge papers complete with after care instructions, who to call with questions, notes about their stay at the hospital, and yes, a list of all of the medications, including new medications, that she is to be taking when she gets home. Included with the stack of papers, somewhere near the end, is some counseling information about the new medications.

The nurse has the son (the caregiver) sign a statement that he has received all of the required paperwork and then she asks him if he has any questions. He has been taking care of his mom for quite some time now so he just makes sure the prescriptions have been sent to his pharmacy and their transaction is complete. Very quickly and efficiently my wife's Great Aunt is discharged from the hospital, wheeled to the parking lot and situated in the passenger side of her car to be taken home.

Here's the catch, the patient and her son (the caregiver) sat in their room for well over five hours waiting for the hospitalist to write discharge orders. I am not blaming the hospitalist; they are very busy doctors with significant caseloads. I am disappointed with a system that does not take advantage of a captive audience for educational purposes. 

I realize that quite a few hospitals have developed excellent programs where the pharmacist is able to discuss medications with patients before discharge. However, it is my understanding that this is a challenge for most hospitals. Based upon my knowledge from our facility alone, resources to provide this type of service are limited.

The current process requires a physician to write discharge orders prior to any of the discharge medication counseling taking place. Once the discharge orders are written, an efficient discharge machine is kicked into gear that concludes with the patient successfully exiting the hospital.  Some style of multi-disciplinary team coordinator needs to be following and directing the discharge process if a pharmacist is going to have a minimum of 15 minutes face-to-face education time with the patient and their caregiver prior to completion of discharge.

Someone, besides the patient, must have some knowledge that the patient will be discharged soon. I realize that the discharge orders are not yet written; however, it seems such a crime to pass up this fantastic, captive, educational time. 

At the very least, the patients nurse could print up copies of the medication information sheets for all of their current medications. The patient or their caregiver could read the information and the raise questions prior to discharge. 

Again, at a minimum, the nurse could get the hospital pharmacist on the phone and coordinate a phone conversation between the patient and the hospital pharmacist so the patient could ask questions about their medications. Alternatively, the nurse could provide a portable computer to the patient the evening or morning prior to discharge and set them up to LISTEN to 6-8 minute medication information sessions for all of their currently prescribed medications.

Similarly, after listening, the patient could then ask educated questions about their medications to the nurse, the pharmacist, their doctor or any other health care provider.

The patient or caregiver would then be sent home with access to this medication information so they may log onto their own computer and LISTEN to the same medication information they received in the hospital.

It is clear to me that patient medication education is lacking, both in the institutional and community setting. As health care providers and policy makers, we need to do what we can to increase the level of Health Literacy among the patients we work with. This is a difficult task and resources do not always allow for the time and personnel to get it done. If we take a different look at patient medication education by providing the appropriate tools to the patients, perhaps they may be more motivated to participate in their own medication education.

About the Author

Steve Leuck, Pharm.D., is President/Owner of AudibleRx^TM. Dr. Leuck also works full time as a Community Pharmacist in a clinic setting where he practices his counseling on a daily basis.
 

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