Medicare will soon release new rules requiring hospitals to focus more attention on patients after they are discharged. Readmissions have cost Medicare $26 billion a decade and the program plans to cut payments to hospitals that have high readmission rates. Nonadherence to medication regimens may be one factor in high readmission rates. After leaving the hospital, patients are not always likely or able to adhere to the medication regimens they were prescribed, sometimes with disastrous results. Without supervision from a health care provider, some patients either never take the prescribed medication, or take the wrong dosage. One study found that more than seven in ten (72 percent) of adverse events after a patient left the hospital were related to medication.
A new study, conducted by an interdisciplinary research team based at The Johns Hopkins Hospital including two nurses and a pharmacist, and funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI), indicates that the solution may lie with having a registered nurse oversee medication management during that transitional period. The study is in the current issue of the Journal of Nursing Quality Care.
“It can be days, weeks or even months before a patient sees his or her primary care provider after leaving the hospital,” said Linda L. Costa, Ph.D., R.N., N.E.A.-B.C., nurse researcher at The Johns Hopkins Hospital and assistant professor at Johns Hopkins University School of Nursing. “Very often, during that time, no one is checking to be sure that the patient is taking the right doses of the medication at the right times, or even that the patient is taking medication at all. And even if they meet sooner with their primary care providers, there’s not always a guarantee that the provider will have access to the hospital records for that patient in a timely fashion. Having a nurse coordinate care during this period can literally make the difference between remaining at home or going to the emergency room in some cases.”
The researchers conducted a pilot study using a hospital-based nurse-pharmacist team to provide care during the transition from hospital to home and from hospital health care provider to primary care provider. The study focused on inner city residents with limited education and financial means.
The nurses in the study consulted with a clinical pharmacist on patients’ medication regimens and were responsible for ensuring that the home list of medications was complete and correct in patients’ electronic health records. Nurses were expected to call patients 48 hours after discharge from the hospital and visit patients in their homes within 14 days of discharge to conduct a structured interview about medication. The nurses observed whether patients had obtained the prescribed medication, how they were organizing various drugs in order to reduce confusion, how often and how they were taking the medication and whether they obtained refills.
Nurses also spoke with patients’ families in and out of the hospital, when possible, and coached whoever served as the primary caregiver about the medication prescribed.
The research team found that nurses were able to detect medication discrepancies and help correct them, and encourage patients to fill and take their prescribed medications in the correct dosages. The study also revealed that nurses could facilitate transferring information to primary care providers. Furthermore, in-person meetings with patients and their families after discharge were more helpful than phone calls when it came to providing education and coaching about medication and helping patients develop plans and systems to help them adhere to their prescribed medication regimens.
In addition to Costa, the research team included her co-principal investigator, Robert Feroli, Pharm.D., F.AS.H.P., medication safety officer for the Johns Hopkins Hospital; Stephanie Poe, D.N.P., R.N., director ,nursing clinical quality and Chief Nursing Information Officer at The Johns Hopkins Hospital; and Mei Ching Lee, M.S., B.S.N, research fellow at the Johns Hopkins University School of Nursing.
INQRI supports interdisciplinary teams of nurse scholars and scholars from other disciplines to address the gaps in knowledge about the relationship between nursing and health care quality. It is helping to advance the recommendations of the Institute of Medicine’s landmark report, The Future of Nursing: Leading Change, Advancing Health, which include fostering interprofessional collaboration and preparing and enabling nurses to lead change. By requiring research teams to include a nurse scholar and at least one scholar from another health care discipline, INQRI not only fosters interprofessional collaboration, the Initiative also ensures that diverse perspectives are brought to bear in research.
# # # #
The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to health and health care, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, measureable and timely change. For nearly 40 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. For more information, visit www.rwjf.org.