Developing a patient-centered care model for pharmacy services is key to delivering comprehensive pharmaceutical care to every patient in our facility. Previously, Cleveland Clinic Florida’s (CCF) pharmacy operated under a clinical specialist service-based model where each clinical specialist reviewed and monitored patients on their service. However, under the specialist model, a limited number of patients were seen by a pharmacist; those not on a specialty service, such as nutrition, infectious disease, and anticoagulation, were generally not followed by a pharmacist.

Process standardization of clinical workflows was also impossible as our clinical specialists used a variety of paper and electronic monitoring tools, creating a lack of consistency among practitioners. CCF decided to transition to a patient-centered model for pharmaceutical services in August 2011 with the goal of ensuring that a clinical pharmacist is available to monitor every patient admitted to the inpatient setting, while still maintaining specialty monitoring services. All clinical service documentation was transferred to a standardized paperless process to improve efficiency and remove duplications in workflow. 

Electronic Monitoring
To help facilitate this transition, we created a clinical dashboard for electronic monitoring and documentation of all daily clinical services. The dashboard is customized to meet our facility’s needs, and allows each pharmacist to view their patients for the day, prioritize their workload, capture all discharges, and share patient communications. All the data is stored in one place so if a patient is transferred to a different unit, there is no need for a hand-off of paper forms or duplicating documentation. 

It is important to measure the impact of any practice change; as such, productivity metrics were identified to evaluate the impact of this practice model on an ongoing basis. We track the number and specific types of clinical interventions, with each type of intervention assigned a weight based on the estimated time required to complete it (see FIGURE 1). For example, if 30 patient counseling/education interventions are conducted in one month (each of these are weighted at 20 points), education would be scored at 600 points for that month. Over time, this metric demonstrates whether we are improving our interventions as the high value interventions indicate more direct patient care activities. 



The interventions are marked at the time of documentation, and are then tracked in our monthly reports. The volume of discharge prescriptions captured and all Hospital Consumer Assessment of Health Plans Survey (HCAHPS) scores are also noted in this report. Because HCAHPS scores provide a standardized measurement of patient perspectives on hospital care, we are vigilant in monitoring our scores and make every effort to improve our patients’ experiences.

Workflow Transition
Prior to implementing this program, only specialty patients were targeted to receive counseling. For example, patients receiving anticoagulants would receive one-on-one counseling with the pharmacist to review the medication’s indication, side effects, and any other specific teaching points. Upon completion of the specialty patient counseling, the pharmacist left a note in the patient’s record detailing what had been covered. This patient also received a written packet containing information about their medication.

Under the new unit-based practice model, each pharmacist is responsible for all clinical services and monitoring for all patients in their designated patient care area. Core clinical services include nutrition support, anticoagulation monitoring, antibiotic stewardship, pharmacokinetic monitoring, discharge counseling, and specialized patient education. This coverage expansion was managed with existing staff members; no additional staff was necessary for this undertaking. On average, each pharmacist is assigned two units and visits with approximately 20 to 30 patients per day. Pharmacists use students as extenders to help manage the workload. Patients in all units are covered under this approach, including the ICU. For those patients that are intubated or not fully awake, a note is made within the clinical dashboard tool, indicating that they will require education when it is appropriate to do so. This note carries over when the patient transfers from the ICU allowing the receiving pharmacist on the new unit to address the patient’s education needs. With the rollout of this program every patient receives counseling, with a particularly strong focus on discharge counseling. 

To enable this switch, several changes were made to daily workflow for clinical services, including implementation of a shared clinical dashboard, the removal of paper monitoring forms, standardization of daily electronic progress notes, intervention documentation, and the introduction of an electronic handoff process. Each pharmacist was trained to consistently follow a single method of clinical documentation. 

The shared clinical dashboard allows prioritization of patients based on acuity scoring. Pharmacists in the different areas can document follow-up tasks and daily reminders within the same location allowing the entire clinical staff to view the same information and avoid duplication of efforts. Patients are marked in the system as having been reviewed, allowing clinical staff to share their workload. This fosters a team effort in patient care and also helps mitigate the learning curve for the different clinical workflows, as the entire clinical staff is responsible for all services in their designated areas. 

The clinical progress notes for the core clinical services were redesigned to follow a standard format, allowing for the removal of paper logs, binders, and clinical data that previously followed the patient throughout their hospitalization. The process for completing daily notes was also simplified to avoid repetition and duplication of documentation. For example, some services required the pharmacist to enter a daily inpatient progress note, which often meant entering the same clinical information each day, while also maintaining a paper log. The re-designed clinical documentation process eliminated this redundancy (see online-only FIGURE 2 at www.pppmag.com/dailyprogressnote). The goal was to minimize the time required to complete daily clinical documentation, thus allowing sufficient time for the patient education and discharge counseling. 

Daily handoff for all clinical services is managed electronically. Previously, follow up tasks for the next shift or next day were communicated using paper forms and logs. The clinical staff would need to leave the paper form for the pharmacist in the main pharmacy for follow up. With the conversion to electronic monitoring, patients were added to a real-time patient list with an electronic note to communicate follow up tasks. This note is seen by all other clinical staff; if the patient is transferred to a new unit, clinical follow up tasks are not lost (see online-only FIGURE 3 at www.pppmag.com/edailyhandoff).

Practice Benefits
Removing the paper clinical monitoring forms from the workflow process made it possible to free an FTE pharmacist to spend more time conducting patient education and completing discharge counseling. The implementation of electronic notes and clinical dashboards removed the inefficient process of transcribing and writing out forms that were then discarded upon patient discharge. The automated system now produces a living record of all patient interactions. 

To measure the impact of these changes, we recorded the total number of interventions per month from January 2011 to July 2011 pre-implementation as well as from January 2012 to July 2012 post-implementation. During this period, the average number of monthly interventions increased from 3,126 prior to implementation to 4,322 subsequently; a per patient increase from 0.84 to 1.14 interventions, respectively (see FIGURE 4). 

Total inpatient discharge prescription volume generated from January 2012 to July 2012 was also tracked as an additional measure of program effectiveness. We discovered that post-implementation approximately 40% of all discharge prescriptions were filled in-house prior to the patient leaving the hospital. Previously, the pharmacy captured very few discharge prescriptions, as no discharge delivery process was available. Now the clinical dashboard alerts the pharmacist after a patient’s discharge orders are written; this serves as a trigger for pharmacy staff to prioritize that patient, offer to fill their appropriate prescriptions, and provide education. Patients receive education on the discharge medications even if they choose not to fill their prescriptions at our facility.

Conclusion
Adopting a patient-centered practice model supported by a standardized, electronic monitoring and documentation tool resulted in an increase of monthly interventions at our facility. In addition, the augmented profits from the volume of prescriptions generated from the discharge program supported the addition of an FTE pharmacy technician to the decentralized pharmacy group in order to provide discharge prescription services and education to all patients. Our practice has successfully transitioned to this patient-centered model, which allows us to work as a team in providing comprehensive pharmaceutical care to every patient who enters our facility. 

Other benefits of this process change include improved nurse and physician satisfaction, with both groups actively engaging pharmacy staff for more patient-related medication education. Our HCAHPS scores under the communication of medication domain have increased for four consecutive quarters — a direct testament to patient recognition of our efforts. Overall, this undertaking has allowed our facility to remove redundancies in our processes to create a more efficient workflow that allows the pharmacy staff to provide better clinical services for all patients. The facility has seen improvements in patient safety, satisfaction, and medication compliance. We expect that this positive impact during a patient’s transition in care will also have long-term effects on reducing readmission rates and facilitating the patient’s continuum of care.

Darshika Patel, PharmD, BCPS, is a clinical informatics pharmacist at Cleveland Clinic Florida. She received her PharmD from Samford
University.

Osmel Delgado, PharmD, BCPS, MBA, is the administrative director of clinical operations at CCF. He received his PharmD from Nova Southeastern University College of Pharmacy.

William Kernan, PharmD, BCPS, is the assistant director for the pharmacy department and PGY1 residency program director at CCF. He received his PharmD from Purdue University College of Pharmacy.

Martha Espinoza-Friedman, PharmD, BCPS, is the internal medicine and anticoagulation clinical pharmacist at CCF. She received her PharmD from Nova Southeastern University College of Pharmacy.