Mills Peninsula’s discharge pharmacist meets with high-risk patients before discharge to review their home medication plan.
Many of our patients are elderly and about 45% of them are on 10 or more medications at home, making it difficult to keep track of what to take and when. This is especially true upon discharge when many of their medications may change. We learned from our follow up calls and home visits that patients were having trouble managing their medications at home, sometimes leading to unnecessary readmissions.
Mills Peninsula is a non-profit hospital in Burlingame, CA that has partnered with the Palo Alto Medical Foundation and Peninsula Family Services to develop the Peninsula Circle of Care program. The hospital has 241 beds and serves a primarily elderly population (average age of 81) living alone with 90% on Medicare. Peninsula Circle of Care, their transitions program, began in 2012 and is influenced by the Care Transitions Program and a community based model.
What We Tried
As part of a pilot program we approved a 1.0 FTE pharmacist to coach our high-risk patients before discharge to home. He/she focuses on elderly patients that either have to manage a lot of medications (10+) or are taking high-risk medications. Before discharge, the pharmacist meets with these patients and their caregivers to review the medications, how and when to take them, and any side effects to watch out for.
This program has been very successful. Our patients feel a lot more confident about their medication regimens, which we believe has had a positive impact on our readmission rates. In the Press Ganey HCHAPS patient satisfaction survey, we have seen an increasing trend with the two questions on communication about medicines: question 16, “Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?” and question 17, “Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?” Our hospital has seen the value of the program, and has continued the pilot to date.