Transitioning from Inpatient to the Home Setting
During the transition of care, a patient likely needs to be able to readily understand how the new post-discharge medication regimen is different from one’s preadmission medications. When medications, doses, or frequencies change from pre- to post-hospitalization, a patient must quickly adjust and correctly adhere to the latest treatment plan in order to strengthen outcomes.
According to the Annals of Internal Medicine, nonadherence causes nearly 125,000 deaths and 10% of hospitalizations, costing the US healthcare system between $100–$289 billion annually. A critical component of adherence is Medication Therapy Management (MTM). During MTM, a pharmacist helps a patient be more engaged in one’s own care via a better understanding of the role and usage of one’ medications.
MTM is defined as the ongoing management of a patient’s overall medication regimen in order to optimize therapeutic effectiveness, prevent adverse events, and achieve optimal medication therapy goals. MTM services enhance patient understanding and adherence to medication therapies while reducing potential misuse and the risk of adverse drug events.
MTM is moving from the pharmacy to the home setting in order to better educate and engage patients. A study published in the Journal of the American Pharmacists Association demonstrated that including a pharmacist on a home health care team will significantly reduce ER visits and rehospitalizations. Pharmacist inclusion should not be ‘one-and-done.’ Instead, consistent pharmacist inclusion is critical especially with patients facing multiple chronic conditions. Throughout the episode of care, the pharmacist can identify medication-related problems, promote medication adherence and safety, and highlight potential cost savings.
Accelerating MTM with Virtual Care
For a more convenient and cost-effective transition of care, the pharmacist can be integrated into virtual visits when the patient is being supported by a home health care team. With the Synzi platform, a visiting nurse can virtually include the pharmacist at the beginning of the episode of care as well as whenever a patient has a medication-related question. Instead of providing MTM via telephone or expending time and expense to drive to a patient’s home, the pharmacist can reinforce the optimal use of the correct medications via video or secure messaging. During the HIPAA-compliant interactions with the patient and the home health care team, the pharmacist can:
- Set the individualized care plan that includes medication-related goals
- Discuss how a patient can overcome his/her barriers to adherence
- Conduct one-on-one coaching sessions with the patient
- Remind patients about the need to refill prescriptions on a timely basis
Synzi’s platform revolutionizes the way a pharmacist can provide MTM services and creates a more effective partnership with the patient and the home health care team.