Southcoast’s Transition of Care and Pharmacy Discharge Liaison Programs
Southcoast programs aid patients leaving the hospital by ensuring they have their medications in-hand and the knowledge to take them correctly.
Each day, Southcoast’s three Transition of Care pharmacists and two Pharmacy Discharge Liaisons work tirelessly for patients. You can find them combing through patient records, consulting with other clinical staff, researching medication information, educating patients, and more.
The goal: successfully transitioning patients from hospital to home so they stay well and do not need to be readmitted in a few days or a few weeks because of medication-related issues. This requires they ensure each patient leaves the hospital with the medications they need and the understanding to know how to take those medications appropriately. They also provide information and assistance, if needed, for patients to be able to afford those medications.
The Transition of Care Pharmacy (TOC) program at Southcoast was one of the first of its kind in the Northeast. Over the last half-decade, the program has come to be respected and relied upon as a crucial part of the healthcare delivery team.
While the functions of the TOC and Pharmacy Discharge Liaison (PDL) programs have changed over time to meet current patient and hospital needs, the mission remains the same: to promote positive post-discharge clinical outcomes through access, education, and promotion of adherence.
The Transition of Care (TOC) effort involves responding to clinical requests for review of patient medications, educating patients regarding their medications and conditions, and developing a plan for medication adherence to ensure success at home.
On the ground spearheading the TOC effort are pharmacists Traci Fontaine at Charlton Memorial, Meg Moniz at St. Luke’s, Caitlin Botelho at Tobey, and Beth Sylvia, who covers all our hospitals. They work within Southcoast’s inpatient pharmacy program.
“Our job is to identify problems before they happen and put in place a plan before discharge,” Fontaine says.
“We focus on medication-intensive disease states, mainly involving chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF),” Moniz adds. “We also receive consultation requests for patients with diabetes, asthma, and other conditions as well, including patients on anticoagulant medications.”
The work is satisfying and stimulating, but ongoing. In one six-month period back in 2017 and 2018, the TOC pharmacists saw almost 2,000 patients and logged over 4,500 interventions across the system. This was before the program added Tobey, where Botelho fills the role part-time.
“On a typical day, we begin by reviewing the consultation requests that come in and reviewing the list of patients and their diagnoses. The morning is taken up by a lot of research,” Fontaine says. “We also participate in rounds at 11am, and then the afternoons are busy with medication reviews and teaching patients. Our afternoon schedule is dictated by who is being discharged.”
Adds Moniz: “Our interventions vary in intensity. Some patients require just a medication review, while others need a great deal more help.”
Both Fontaine and Moniz emphasize the multidisciplinary nature of their work.
“We work with colleagues across the hospital – patient financial services, nursing, social work, case management, and, of course, the hospitalists,” Moniz says. “It takes a multidisciplinary effort to get our patients what they need.”
With COVID-19, Moniz and Fontaine say they’ve seen a lot more people with difficulty accessing needed medications because they have lost insurance coverage, mainly due to loss of employment.
“It’s a new target group we’re seeing,” Moniz says.
Access and Affordability
When it comes to medication access and affordability, Southcoast’s Pharmacy Discharge Liaison (PDL) program is like dollars in the bank for patients. PDLs Audrey O’Brien at Charlton Memorial and Brittany Soucy at St. Luke’s help patients who are uninsured or underinsured obtain medications at costs affordable to them.
The two liaisons, who are members of the Southcoast Retail Pharmacy staff, also check coverage to see if the medications are covered by the patient’s insurer or if a prior authorization is required. They fill out the needed paperwork and follow up with pharmaceutical firms, as needed for those requiring ongoing assistance.
To do their work, they draw on several programs. In concert with the TOC pharmacists, they’ll even arrange for medication changes with the clinical team if affordability is an issue and an appropriate similar medication is available.
“We assist Medicare patients in the donut hole with high deductibles through Patient Medication Assistance programs or the 340b program,” says Soucy, referring to two different programs, one in which pharmaceutical firms provide free medication to patients in need who qualify and another federal program that allows hospitals to purchase medications for outpatient use at a reduced cost.
They also help patients take advantage of pharmaceutical company voucher cards and coupons, free trials of medications, and the Transitional Medical Assistance program, which enables Southcoast to provide two to four weeks of free medication to uninsured patients.
“We had a patient in the donut hole who needed insulin pens. The prescription was going to be $150. We discounted the drug to help get them through the end of the plan year. They were very happy,” O’Brien says.
Soucy agrees: “There was a very similar situation we encountered with a patient unable to afford their insulin at St. Luke’s recently, as well.”
“The cost for one patient with a commercial plan with high drug co-pays was going to be $175 a month,” O’Brien adds. “We got them a 12-month copay card that reduced the cost to $10 a month. The patient was so appreciative that they said they almost wanted to cry.”
“We’ve had patients on expensive meds such as Dificid, which costs over $1,000 for a ten-day course of treatment,” Moniz says. “Our PDLs have been able to get these kinds of medications for outpatient use at no cost so patients can leave the hospital sooner, rather than having to stay for medication that can be taken at home.”
Situations like this happen daily across the Southcoast Hospital System, and the PDLs and TOCs play an integral role in transitioning these patients successfully.
There are so many stories and examples of the PDL/TOC program ensuring medication access for our Southcoast patients. It takes effort and a lot of behind the scenes work. The PDLs are on the floors a lot, talking with patients, ringing out medications and delivering them bedside, and collaborating with the TOC pharmacists, nurses, and others.
O’Brien and Soucy are the face of Southcoast’s Retail Pharmacies to inpatients.
“Patients don’t always know we have a Retail Pharmacy right in the hospital at St. Luke’s and Charlton Memorial,” O’Brien says. “They don’t realize that they can go home with prescriptions from us and then continue with their own pharmacy later on. It’s very convenient. We want patients to know about us, and that we’re here to help them. It’s rare that a patient doesn’t want our assistance, once they know what we can do for them.”