Which pharmacy or pharmacies should we use to distribute medications to our Hospital at Home patients?
The dispensing pharmacy for oral and intravenous medications is an important consideration when developing a Hospital at Home (HaH) program. This decision could influence patient safety, efficiency, and the quality of care provided. Staff processes and workflows will be affected by the decision.
There are two key decisions to make:
- Inpatient pharmacy dispensing versus outpatient pharmacy dispensing, and
- Insourced versus outsourced medication dispensing.
Medication dispensing is in large part driven by the board of pharmacy in your state. Licensing of pharmacies and which dispensing functions are allowed in each type of pharmacy differ from state to state. Understand the local regulatory environment before making a decision. Even under the CMS Hospital at Home waiver in which patients are considered inpatients, some boards of pharmacy still will not allow an inpatient pharmacy to dispense medications to a patient’s home. And key to using an inpatient pharmacy will be compliance with needed outpatient labeling.
If inpatient-based dispensing is chosen, inpatient orders can be utilized, and all oral and intravenous medications can be dispensed from a single pharmacy. Check with your inpatient pharmacy to verify they can accommodate the dispensing and labeling required if allowed.
Inpatient dispensing is designed to accommodate high acuity patients with the assumptions that medication titration and changes are frequent and that all medications will be dispensed daily. Inpatient pharmacy has access to inpatient orders via the hospital EMR, and is not reliant on e-prescriptions to prompt dispensing. Inpatient dispensing is often partnered with inpatient pharmacist clinical involvement during verification of orders, which offers an additional layer of safety.
If outpatient-based dispensing is chosen, prescription orders are needed to drive dispensing through e-prescribing, as well as information on patient lines and access, so that the correct supplies can be dispensed with the medications. A single outpatient pharmacy will not be dispensing both oral and infusion medications, so the HaH program will need to contract with both an outpatient and home infusion pharmacy. The outpatient pharmacy will then supply orals and bulk medications in a variety of packaging depending on the capabilities of the chosen pharmacy: bottles, pill planners, blister packaging, or strip packaging. The home infusion pharmacy will supply any intravenous medications with needed supplies. The supplies can include IV poles and pumps as well as dressing changes, saline, and heparin flushes. Both home infusion and outpatient pharmacies are used to dispensing multiple days of therapy, eliminating the need for daily pick-ups or deliveries if the patient therapy plan is stable.
Regardless of choice of pharmacy, it is essential that services are available 7 days a week. 24 hour a day services are less essential, as very few programs change therapy in the middle of the night in the patient home. Clarifying weekend and night access for any of your pharmacy options is critical, and this should be incorporated into any contract with an outside vendor. The contract should also specify how quickly all medications should be delivered to the patient’s home.
Examples of state by state complexities:
Even within a healthcare system, if pharmacies are in different states, they likely have different dispensing laws through their respective boards of pharmacy. In Wisconsin, each pharmacy is licensed as a pharmacy – not a specific type such as outpatient or inpatient. Therefore, all types of dispensing can occur from a single pharmacy if labeling and recordkeeping requirements are met. In Florida, an inpatient pharmacy cannot dispense medications to a patient’s home without a variant in place. Even with a variant, narcotics cannot be dispensed to homes, and the variant only covers emergent/urgent scenarios, such as evening/overnight dispensing. In Massachusetts, hospital pharmacies are regulated by the Department of Public Health, not by the Board of Pharmacy, leading to a different regulatory environment to negotiate. The Department of Public Health establishes the definition of “inpatient” and “outpatient,” leading to negotiations around what type of patient a Hospital at Home patient is, which in turn affects labeling and dispensing.
Patient medications need to be labeled in a way that complies with outpatient and home infusion labeling practices in the state.
Medications for multiple days will probably be stored in the patient home. Oral medications can be dispensed in appropriately safe bottles, pill planners, blister packaging, or strip packaging, depending on patient needs and the pharmacy capabilities.
Any medicine requiring cold storage will be most likely held in the patient refrigerator; very few programs bring in additional refrigerators to store medications in the patient home. Medications in the refrigerator can be placed in special plastic bags or boxes clearly labeled as medications. Nurses in the home should review medication safety with the patient and family to assure they understand medications should not be accessed by anyone other than Hospital at Home staff.
How many doses are dispensed can be affected by: the stability of the patient’s clinical condition and the likelihood that the medications will need to be titrated or changed, which type of pharmacy is dispensing the medication (inpatient pharmacies are much less likely to dispense multiple days of therapy), and staff and delivery capabilities. Programs range from dispensing five days of medication on admission from a home infusion pharmacy to dispensing medications daily from an inpatient pharmacy.
A key consideration for choosing a pharmacy partner(s) is how medications will get to the patients. Will the HaH nurses go to a specific location at the beginning of the day to pick up medications to take to the home? Will you ask the patient’s caregivers to pick up outpatient medications? Or will your program use a delivery system or a courier service? Tracking of medication deliveries is important. Consider how your program will document that the medications were received in the home. Use of couriers for medications may require specific workflows and coolers to ensure that medications are not subjected to inappropriate temperatures. This will be dependent on the medication, of course. And if vaccinations are part of Hospital at Home care, the program will need to work with the pharmacy to develop storage, transportation, administration, and waste policies for vaccines to ensure they are well cared for.
PRN medications are most likely oral medications and can be dispensed with a label similar to other outpatient PRN medications. In addition, some program providers carry a small emergency or “first-dose” supply of medications with them (click here an example of two different medication lists from two HaH programs). These medications can be dispensed during a visit for a rapid first dose of any new therapy.
Some Hospital at Home programs have very specific systems for prescribing or handling controlled substances. One program sends those prescriptions to an outpatient pharmacy that can deliver medications directly to the patient home. This eliminates the need for Hospital at Home staff to handle those medications.
Reviewing patient medications in the home is a critical part of safe patient care and can offer insight into what the patient is actually taking. Admission to Hospital at Home by the nurse or paramedic should include a home medication review and a reconciliation in the EHR by the nurse and provider. Start by interviewing the patient/family caregiver to establish a complete list of medications that the patient is taking in the home. Determine and document how the patient is actually taking their medications. This may be different than the instructions in the medical record. In the home setting, examples of sources of medication information may include:
- Medication containers in the home, including prescription, non-prescription and natural health products (e.g., blister packs, vials, bottles, sprays, creams, inhalers, injectables, etc.)
- Patient/family caregiver-generated medication lists
- Possibly, pharmacy records from pharmacies outside of your Hospital at Home EMR.
The ability to consult a pharmacist during reconciliation can be valuable; consider building that resource into program planning. A telehealth connection with the patient, nurse and pharmacist could also be the method used for medication reconciliation. Some HaH programs are testing whether a large number of medications on the patient list or certain types of medications (for instance, diabetes, anti-coagulation) should automatically trigger a pharmacist review.
Under the CMS waiver, patients are admitted to the hospital under this program. Given that, it is critical to review all hospital and pharmacy policies that might apply. Those policies will need to be modified to address the differences for in-home acute care. Incorporate the appropriate groups that oversee institutional policies and any institutional surveys in the review to assure compliance. Exempting Hospital at Home from certain policies may be sufficient in some cases.
Policies that are specific to pharmacy might include:
- Medication Storage and Administration (including controlled substances, which may have separate policies)
- Labeling Standards for Medication
- Medication Containers
- Medication Infusion Lines or other Solutions
- Medication Administration (including patient self-administered medications)
- Patient Self-Administered Medications and Use of Own Medications
- Peripheral Intravenous Line, INT Therapy Management
- Patient Wristbands or Identification
Click here for a sample list of policies that might need review.
Click here for a Sample Policy from the perspective of the Pharmacy Department.
This build will depend on the workflows developed for the program, as well as the specific EHR. If medications are dispensed by the hospital pharmacy for use in the home, following the normal workflows when building in the EHR will be relatively straightforward compared to a program where medications are dispensed by an outside pharmacy.
If medications and infusions are being dispensed by on outside pharmacy, it is important to assure that the medications are available in the medication record (MAR) in the EHR for the nurse to document patient administration. If a patient is continuing their own home medications, the ability to document “patient taking own medication” is important.
It is critical for physician/APP medication orders to be electronically sent to the outside pharmacies efficiently. To assist with this, one program designed a method for a single order by a physician to be “translated” into a pair of medication orders – one informing the MAR, the other going to the outside pharmacy electronically.
Infusion pharmacies require a prescription for all supplies to supplement medication administration, such as dressing supplies, flushes, etc. Include these details in any orders, as well as the type of line (peripheral, midline, PICC) the patient has.
One other critical workflow that is currently addressed in EHR builds in hospitals is a pharmacist review of all patient orders prior to dispensing any medications. Using an outside pharmacy will break the normal flow of review in the hospital system, so a method for completing that review needs to be built into the workflow. And how does the pharmacist reviewing medications reach the needed Hospital at Home provider for questions prior to printing labels and dispensing medications? You may need to create a list of numbers for outreach for your pharmacy resource.
There are multiple ways for the pharmacists to engage in Hospital at Home care models, beyond responding to orders in the EHR and dispensing medications. Strong clinical practices across inpatient and outpatient settings exist in pharmacy, and can be applied across the Hospital at Home continuum of care.
Starting with admission to the Hospital at Home program, the pharmacy department can interview the patient to collect the best possible medication history or assist the care team in completing an accurate reconciliation. The pharmacist can then review the medication reconciliation to ensure the medications ordered align with what the patient was taking at home.
During the acute phase of care, pharmacy can engage in daily multidisciplinary rounds. Pharmacy can complete all the clinical monitoring activities performed on traditional inpatients including antimicrobial stewardship. Pharmacy can be available to the care team and patient at any time for education related to medications and administration.
When the patient is ready to discharge or transition to a restorative phase of Hospital at Home, there is the potential to consult a Medication Management Services pharmacist, if that service exists in your health system. These pharmacists can engage in a video visit or phone conversation with the patient and discuss how the patient is going to manage their medications after discharge, with a focus on aligning with best practices for disease management. These conversations usually help address any barriers to cost or adherence and offer up compliance packaging if needed. They then send along recommendations and the medication management plan to the care team. Pharmacists can complete a medication reconciliation on transfer and help coordinate dispensing from the patient’s pharmacy of choice, working with that pharmacy if there are any issues with medication orders or dispensing. They can also help ensure the patient has an accurate home medication list and that the patient has adequate supply and access to the medications they’re expected to continue taking.
Thank you to Maggie Peinovich, PharmD, BCPS, Mayo Clinic Health System, and Michael C. Cotugno, RPh
Director of Pharmacy Patient Care Services, Brigham and Women’s Hospital, for their contributions and expertise in this area.
Copyright 2021 Center to Advance Palliative Care.