It's been 15 years since the Institute of Medicine published the "To Err is Human" report and two years later put out a follow-up report "Crossing the Quality Chasm: A New Health System for the 21st Century"; yet, two of the most fundamental health-related problems, medication non-adherence and medication mis-management remain commonplace.
A little over one year ago the IMS Institute for Healthcare Informatics published a report on "Avoidable Costs in U.S. Healthcare". In this report, the IMS Institute quantified the indirect and direct avoidable cost estimates for six medication-related problem areas in healthcare in 2012. It may not be surprising that non-adherence was problematic. However, non-adherence wasn't just one of six, but rather was the overwhelming contributor, to the tune of $105 billion out of $213 billion.
In a time when we have some of the most advanced technologies and informatics capabilities, why is non-adherence still so problematic? Why hasn't the profession of pharmacy stepped up to own this problem and to produce solutions that really make a difference? There has been a great deal of change within pharmacy to address non-adherence. The vast majority of pharmacies are doing more to automate refills and track refill frequencies. Many pharmacists are addressing adherence when conducting a comprehensive medication therapy management assessment. Yet these changes were in place, while the $105 billion avoidable costs, due to non-adherence, were generated.
This brings me back to Ms. Esposito's article. In healthcare, we may give the best of therapies and we may provide the best of instruction and directions; yet, many times for many different reasons, what happens when the patient gets home is very different from the best of our intentions. For years, my clinical teaching site was part of an aging agency, Resources for Seniors, Inc, in Wake County, North Carolina. Students would often accompany me on home visits to review medications and to assess medication management for patients referred by local nurses, social workers, case managers and physicians. After conducting a home visit, it was not uncommon to have a student say "wow, I never would have expected to see 'that'". It is my opinion, that without the ability for pharmacists to interact and see into the patient's home environment, we will never be able to truly address the negative health impact of non-adherence.
So I ask our profession two things: 1) isn't it time, that we accept the responsibility for medication adherence and actively implement interventions, which really improve adherence and treatment outcomes; and 2) should pharmacists step away from the counter and consider making house calls in person or virtually?
The IMS Institute presented the alarming $213 billion medication-related, avoidable costs data as an "opportunity". Does a possible solution rest within pharmacy? Does an innovative solution rest within future pharmacists harkening back to the days of old and offering up a solution in the form of house calls?
I totally agree. Pharmacists should take responsibility for educating and ensuring patient education. House calls would provide a better service to patients as they would be more likely to remember the education that they have already received. It would reinforce encounters that they had in the doctor's office or hospital and hopefully help to reduce negative outcomes directly correlated with non-adherence. I see this opening the door for pharmacists to be able to put together patient specific medication packs during these visits. One downside to this would be that it may be a higher liability for pharmacists and boards of pharmacy may not agree to give that duty to the pharmacist.
ReplyDeleteUnfortunately, some disease states cause a higher propensity for patients to have poor adherence because the disease, in and of itself, breeds non-adherence. Psychiatric disorders may fall under this category due to the pathophysiology of the specific diseases. Alternate programs may need to be considered for aiding these patients with proper adherence.
I recently had the experience of working in a retail pharmacy that also had a home delivery service available. The pharmacy would “bubble” package monthly medication regimens for patients on the same date each month, in which they were then delivered to their door, where the patient had to sign that they received their prescription and OTC medications. However, the deliverymen were elderly part-time workers and did not have a pharmacy background. I would sometimes think to myself how beneficial it would be to have a pharmacist delivering a patient their medications. This would allow for medication follow-up in which the pharmacist could re-counsel a patient if needed, assess therapy (safety, adherence, efficacy and indication), and would also allow the patient to ask any questions he or she might have. Having all the patients medications packaged in the same monthly organizer also makes it easier for the pharmacist to recognize any drug interactions and contact the patients physician regarding any disputes. This concept is logical for long-term therapy management, but may be time consuming to implement with short-term therapy treatments such as antibiotics and hospital discharge regimens. The need for pharmacists is sure to increase if house calls become common in our profession. Pharmacists making house calls would be beneficial in moving toward patient-centered care.
ReplyDeleteThis is an interesting concept that I had never thought to consider. The idea of pharmacists making house calls is something that I would be very interested in taking part in. The estimated amount of avoidable costs coming from non-adherence is outrageous and definitely needs to be addressed. As Dr. Shelton suggested, seeing the patients in their own environment can really help the pharmacist come up with the best plan of action for treatment. From working in a community pharmacy and also doing medication reconciliation at the hospital, I have seen a lot of health problems and emergency situations arise from the lack of patient adherence. These problems could have easily been prevented if the patients had better adherence. Making house calls as a pharmacist would not only encourage the idea of patient-centered care, but it would also give patients greater access to healthcare professionals, engaging them further in their own health, in the comfort of their own home.
ReplyDeleteI agree with Dr. Shelton on the importance of house calls. I have noticed that most elderly patients have multiple prescribers, and that the care between these providers is poorly coordinated. Medications started by one physician are rarely questioned by another. If the patient is relatively home bound, and therefore not coming into the pharmacy, then the usual check and balance provided by the pharmacist for their care may be lost. Pharmacists making house calls reduces the risk for medication problems and may reduce admittance to the emergency room. I do know there are some hospitals starting to provide home-based care that utilizes a pharmacist for specific patient populations, such as HIV. Therefore it will be interesting to see the results of pharmacist-provided house calls for the elderly.
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