In total, ten interviews and one focus group were completed across both institutions. At Site A, six interviews were conducted with intervention pharmacists and pharmacists in administrative roles. Also at site A, one focus group comprised of five intervention pharmacists was conducted. At Site B, four interviews were conducted with intervention pharmacists and pharmacists in administrative roles. Pharmacists performing the intervention participated in qualitative interviews and focus groups, with a smaller number of pharmacists at Site B providing the intervention.
From qualitative analysis, deductive coding identified representative pharmacist quotations for all of the CFIR domains. Further, two study authors agreed on three overarching themes after the inductive coding process: 1) PHARM-DC and Institutional Contexts, 2) Importance of PHARM-DC adaptability, and 3) Recommendations for PHARM-DC improvement. The themes, as well as associated CFIR domains and constructs can be found in Table 2. In the following section, themes (with CFIR constructs italicized in parentheses), and representative quotes from pharmacists at Site A (SAP) and Site B (SBP) have been included.
CFIR Domains and Constructs associated with Qualitative Themes and Subthemes
1: PHARM-DC and Institutional Contexts
Characteristics of Individuals
Relative Advantage, Complexity
External Policies and Incentives
Patient Needs and Resources
Structural Characteristics, Culture, Compatibility, Available Resources, Networks and Communication
Other Personal Attributes
2: Importance of PHARM-DC adaptability
Adaptability, Trialability, Complexity, Relative Advantage
Patient Needs and Resources
External Policies and Incentives
Compatibility, Networks and Communication
3:Recommendations for PHARM-DC improvement and sustainability
Characteristics of Individuals
Patient Needs and Resources
External Policies and Incentives
Networks and Communication
Readiness for Implementation
Access to Knowledge and Information
Theme 1: Pharm-dc And Institutional Contexts
At Site A, the size of the existing TOC program and staffing were consistently noted as facilitators for PHARM-DC implementation (Structural Characteristics). Pharmacists at Site A had specific TOC training and had worked in a TOC setting for a number of years (Other Personal Attributes). For Site A, intervention pharmacists felt the intervention was a modest increase in TOC services compared to preexisting service offerings (Relative Advantage). Site A has a robust TOC program outside of the PHARM-DC intervention, which facilitated the intervention (Available Resources, Culture, Compatibility) Recently, the TOC program received additional FTEs to support pharmacy technician lines within the overarching TOC program. Some intervention pharmacists at Site A reported that the intervention was supported by additional staffing and personal resources such as pharmacy students, residents, and technicians, with technicians assisting with medication reconciliation and technical intervention components focusing on medication access and cost. Pharmacy technicians involved in the PHARM-DC intervention were designated TOC technicians, who assisted pharmacists with technical TOC tasks such as completing prior authorizations for medications and contacting pharmacies to adjudicate potential insurance difficulties. At Site A, pharmacists suggested that newly adopted California state policy (SB 1254) may have contributed to their ability to focus pharmacist staffing on TOC initiatives such as PHARM-DC (External Policies and Incentives).
The PHARM-DC patients, I feel like they get a little bit more service than we would typically provide for the other patients. [SAP4]
So, we've been able to expand, in part because of the state laws, SB1254. But comparing how even after that, we've been able to expand additionally when other hospitals are maybe only hiring techs and not pharmacists, or they might get one pharmacist, and we have our huge, wonderful team and get to do all these fun things. [SAP1]
Whatever the issue is, the technician will triage it. If it's as simple as, they can't get medication from the pharmacy, the technician can resolve that issue on their own. If there are more questions about side effects and the patient is wondering if they should change their dose, then our technician will forward this call to one of our pharmacy residents. And pharmacy resident will address this question. They will call back the patient and if something needs to be done, they will touch base with physician and they try to get new prescription or modify regimen. So, the clinical portion goes to resident, but if some [task is] more like a technical [one], the technicians can do, they resolve it themselves. [SAP2]
Site B had fewer members of the TOC team, with intervention pharmacists having formal training and expertise in areas outside of TOC (Structural Characteristics, Other Personal Characteristics). Pharmacists at Site B reported that organizational transitions and limitations in staffing made providing all components of the intervention to a large number of patients especially challenging, noting that the level of complexity of the PHARM-DC intervention made it difficult to adopt (Complexity). Site B previously had pharmacy technicians involved in a medication reconciliation program, but were not currently involved in the pharmacist intervention, leaving Site B TOC pharmacists to perform all clinical and technical intervention tasks (Compatibility). While Site B did not use pharmacy technicians in TOC interventions, pharmacy students were available to conduct BPMHs in both control and intervention patients.
So, [REDACTED] and I are the only two full-time pharmacists. Typically, this is a rare day where we're both staffing. But typically, most of the time, it's just one. Then, we have one per diem pharmacists. We are training another per diem. But that's also difficult because we run into issues of… continuity of care. At a certain point, you're here for one day, I don't really know these patients, it's difficult. [SBP2]
The other thing, too, is, that no one here really has a background in transitions of care or chronic disease state management. [SBP1]
It's generally one pharmacist at a time that wears many hats. We recently increased our staffing such that [REDACTED] and I can both be together on Sundays, out of the week. [SBP1]
What makes this program, I think, difficult to adopt, is just the levels of complexity of it. [SBP1]
So, for example, the last week, I've been in the vault. So then, today I'm here, staffing intervention. I think sometimes it's hard to switch gears. [SBP2]
When we had a medication reconciliation service, we used to employ certain pharmacy technicians on top of pharmacy interns, and they consistently provided good work. We had no objections to them. [SBP1]
Despite the size and training of the TOC team at Site A, intervention pharmacists still struggled to complete some intervention components. Pharmacists consistently reported difficulty contacting patients for the post-discharge follow-up call, which pharmacists attributed to inconsistencies in notifying the patient of the upcoming post-discharge call during hospitalization and identifying whom to contact. Additionally, Site A pharmacists suggested that many intervention components were more challenging due to the variety of patient needs and available resources. Site A pharmacists reported patient experiences that included language barriers and the need for translators to assist in delivering intervention components, including motivational interviewing (Patient Needs and Resources). Site A also has an automated post-discharge follow-up phone call system (CIPHER) which was not a component of the intervention, but all patients who are discharged from the hospital receive Site A pharmacists suggested these phone calls may be associated with their difficulty in reaching patients with post-discharge follow-up calls.
I probably mentioned this already, but we do have a large portion of non-English-speaking population here in the hospital, too. So, there are times where we have to use, either in-person or over the phone interpreter in order to communicate to these patients. [SAP5]
Multiple reasons, one, obviously for language barriers, when we have to use an interpreter. It's hard to tell, but sometimes even if you're trying motivational interviewing, I don't know if the interpreter is interpreting it the exact same as the way I'm asking it, so I would say when patients are not English speaking. [SAP7]
The other pharmacists I talked to, they shared the experience that they have trouble reaching patients, so they call them, but they're not able to reach anyone. [SAP2]
We do a post-discharge follow-up call on them and they're like, "Three people have called me already," probably the surgeon's office, then the CIPHER call and then us calling them to see if they're doing okay. So yeah, there's definitely some overlap there. Everyone gets a CIPHER call. [SAP3]
Site B had fewer struggles contacting patients after discharge, as a checklist developed by a TOC pharmacist emphasized the importance of notifying the patient in the hospital that they would be receiving a post-discharge call.
“We have a checklist of things that we discuss with the patient. One of the things that we discuss is, we let them know that we'd like to call them when they leave the hospital, we get their consent. If someone helps them with their medications, we might call them instead, whoever is the point person. We confirm with them the phone number and what time of day works best for them and let them know that a phone call's coming. So, we find that cold calls, we don't get as much response rate back. [SBP1]
Both sites emphasized the importance of networks and communication, specifically pharmacist relationships with prescribers to improve recommendation uptake (e.g., to modify medication regimens to reduce polypharmacy or otherwise improve the regimen’s appropriateness). Pharmacists reported that prescribers with familiarity with the TOC service and team, as well as a direct line of communication, improved the intervention pharmacist’s ability to complete intervention components (Networks and Communication). Pharmacists at Site A frequently reported that some prescriber groups were familiar with pharmacist TOC activities, but challenges remained with prescribers outside of the institution (e.g., private hospitalists or other physicians). Site A Pharmacists also reported that patients with a strong relationship with their PCP were more resistant to PHARM-DC intervention activities (i.e., to make changes to their preadmission medication regimen).
The physicians that we see the most, they're used to us, and I think they know our names now, or at least they recognize our names, and they're used to us reaching out to make these interventions. In particular, a few of our highest volume physicians actually have, over the past year, gotten some PAs or NPs to help with them, so they're even more accessible and even more willing to respond to our interventions. Those were good things to speed up our efficiency and actually make the changes. [SAP1]
Definitely, there's variation of how [providers] respond to our recommendations. I found doctors respond better if you already have a working relationship with them, if they know you, and they worked with you in the past, they are more open to accept your recommendations because trust is present already. [SAP2]
I would just say, which is going to be a barrier potentially anywhere is how certain providers are more open to interventions from pharmacy versus others. I think we have a pretty good team of hospitalists. If there's a hospitalist involved, then they're usually pretty good at making these changes that we recommend, but if there's a private physician, some of them are a little bit more apprehensive. [SAP4]
There are times where patients have relationships with our outpatient providers where…we only know them throughout their hospitalization, they're a little bit more resistant I would say to interventions or changes that they've worked closely with their primary care doctors or outpatient providers with. [SAP7]
Theme 2: Importance Of Pharm-dc Adaptability
Intervention pharmacists at both institutions emphasized the importance of intervention adaptability. At Site A, a note template was adapted and used to document intervention delivery in addition to a Microsoft SharePoint site, which was created and adapted to streamline the intervention and track and communicate patient progression throughout their hospital stay (e.g., between different pharmacists caring for the same patient). Alternatively, pharmacists at Site B described a checklist used to guide intervention delivery and the use of “iVents” within the electronic health record to collect data and patient information needed to improve the yield of a variety of intervention components and communicate the tasks completed and still required by other intervention pharmacists (Adaptability, Trialability).
We had one template and then a couple months ago, we started to make recommendations to improving it to make it easier and to make documentation faster. And so, I think what we have now is a shortened version and it gives all the information we need to give. So, I think now the note is better. [SAP3]
One aspect of the pre-discharge interview that I forgot to mention, so when we touch down with the patient in a perfect world, if we're able to see them in the hospital, at least, once while they're in the hospital, and during the initial touchdown with the patient, we have a checklist of things that we discuss with the patient. One of the things that we discuss is, we let them know that we'd like to call them when they leave the hospital, we get their consent [SBP1]
Pharmacists at both sites emphasized they are often had difficulty reaching the patient prior to discharge due to the timing of discharge and not wanting to delay the discharge process (Compatability). There were inconsistencies in pharmacist perceptions of when the best time was to provide education, suggesting that flexibility was required for when pharmacists were providing patient education (Adaptability). Several pharmacists felt that the day of discharge was not the best time to provide medication education based on the specific needs and resources available for each patient (Patient Needs and Resources). Further, there were additional variations between sites. Site A used an icon within the electronic health record to notify pharmacists when a patient was close to being discharged, prompting the pharmacist to complete the discharge medication reconciliation process and provide patient medication education prior to leaving the hospital. Site B pharmacists typically saw patients earlier in the hospitalization, focusing on medication regimen review and past problems with medication adherence, rarely seeing patients closer to discharge and deferring discharge medication reconciliation and patient education to the post-discharge call. Site B pharmacists suggested these differences could be due to the perceived value that seeing patients earlier in the hospitalization may have on TOC initiatives and the patient-pharmacist relationship. Additionally, Site B pharmacists reported that ordering clinicians often did not write discharge orders until immediately prior to patient discharge, leaving them with less time for medication reconciliation and discharge counseling prior to discharge (Compatibility, Networks and Communication).
I think for part of the study, we agreed that we're going to do med review, med reconciliation at discharge and patient education, and then when we do phone call, we reinforce those education points that we provided. Sometimes it's not always feasible, appropriate, or time permitted to do education at discharge, for different reasons. So, then I'll focus more and spend more time on education to provide their family members after discharge, or even before discharge, but over the phone. Maybe not every patient requires education at the time of discharge. We might need to do that post discharge, and just at discharge make sure that actual, the discharge med list is correct. [SAP2]
It's a heated debate about patient education. So, is patient education at the time of discharge a good idea or not? Are patients receptive to the information or does it get glossed over in the 50 other pieces of paper the nurses give them? [SAP8]
We don't know if a discharge is happening until an hour before and then the whole team is reacting. [BP3]
Going over their discharge summary, because we know that patients do not recall a lot of the information that's explained to them at the point of discharge.[BP1]
The intervention at Site B was further adapted to accommodate a large number of patients who were discharged to skilled nursing facilities (Adaptability). This involved contacting the skilled nursing facility and engaging facility staff with discharge processes and recommendations (i.e., identifying any discrepancies between the hospital discharge medication list and the medications administered at the facility). This adaptation was facilitated by existing networks, relationships, and communication between Site B and the skilled nursing facilities (Networks and Communication).
So, some of our patients get discharged to skilled nursing facilities or rehab... In those cases, since someone's ordering their medications and administering their medications, our process is a little bit different on the post-discharge side. We will call the facilities, ask to be redirected to the patient's floor nurse, explain who we are and why we're calling. Essentially, we first want to compare our discharge summary or our validated discharge medication list against the actual medication administration record at the facility just to make sure the discharge medication reconciliation was appropriate. [SBP1]
While study pharmacists at both sites noted that the intervention contained a large number of intervention components, Site B pharmacists specifically emphasized the complexity of the PHARM-DC intervention compared to other programs (Complexity). Limited by staffing constraints, Site B pharmacists inquired if the intervention might benefit from additional adaptation to focus on further stratification of risk and associated intervention delivery in high-risk patients given the difficulty of offering all intervention components to a large patient population.
What makes this program, I think, difficult to adopt, is just the levels of complexity of it. I know [REDACTED], down the street, has a similar service to what we have. It's called the red something. But they target a very small subset of very high-risk patients, and it's very, less patients, but patients that require a lot of steps to help them get them on their way out. The only thing that I wonder is, if we're not able to see that many patients, because we're doing so many things per patient, is that still going to have the return on investment that perhaps a med rec service would have? [SBP1]
Theme 3: Recommendations For Pharm-dc Improvement And Sustainability
Pharmacists at both sites had a wide variety of recommendations for intervention improvement, as well as statements on what would need to occur or be observed to assure intervention sustainability. Site A pharmacists provided a number of recommendations to improve care transitions related to medication discrepancies and errors, including developing protocols, collaborative practice agreements, and medication substitution policies that would allow for medications prescribed inpatient to be adjusted more efficiently (External Policies and Incentives, Structural Characteristics).
One thing that they are trying to push through is reverse therapeutic auto[substitution] which will be very helpful for us. If something was therapeutically substituted inpatient and they erroneously continued that on discharge, we would be able to switch it back automatically.” [SAP5]
I guess another thing is contacting the doctor takes a while, so if we can increase the way we ... maybe if pharmacists have more privileges, some type of collaboration agreement where things could…not everything we need to contact the doctor potentially. That might save some time and we will be able to reach more patients. [SAP3]
Both sites stressed that pharmacist familiarity, communication, and support from prescriber/hospitalist groups and continuity with patients would improve intervention sustainability and effectiveness (Networks and Communication). Site A pharmacists reported interactions with private attending physicians, which made making recommendations and delivering the intervention more difficult. Site B pharmacists did not mention interactions with private attending physicians, as most inpatient physicians are hospitalists; few primary care physicians admit their own patients. Pharmacists further recommended that increasing the continuity of pharmacist care would potentially improve the PHARM-DC intervention (Structural Characteristics).
I usually find residents are easy to reach, because they'll have pagers, it's part of their learning experience, right? They have to respond to phone calls. I think it's most challenging for some private doctors who don't like to be told what to do, or they might have something in mind that they haven't documented, and sometimes what they did will make sense once they explain their rationale, but because we can't know what they were thinking and we only base our recommendations on lab values/notes that we read, we might not get a full picture and we might recommend something that maybe not always accepted, for a good reason. And I found that private doctors write notes that are not as complete as hospitalists. So, I think it's easier with hospitalist followed by residents and the least easy is with private physicians who see those patients on an outpatient basis. That's my personal experience. [SAP2]
What if we focus on just general medicine and we get to know everyone on these gen med teams very well, and they learn to like us and appreciate the work that we do and they can vouch for us, is that going to be sufficient to get this program off its feet. Having interdisciplinary support definitely did make [the medication reconciliation] program more adoptable because we've had the program for five years now. [SBP1]
I think it would be great if the same pharmacist can follow that patient throughout their whole stay. So, the pharmacist did the history, did the discharge and the post-discharge call because they know the patient the best. I think that would be ideal because right now, there's several different people involved in those different services. So that would be ideal. [SAP4]
When workload became difficult to manage, Site A pharmacists suggested that having open communication and additional team support was essential to intervention sustainability (Networks and Communication).
One of the really great things about our TOC team is that we work really well together. And it is a team. So even though we're covering different units, it's always a communication of hey, it looks like discharge orders just got placed for your patient on a different floor. Do you have time, or do you want me to do it? So even if it's not my patient, then we're making sure it gets done. [SAP1]
I think we communicate really well. [redacted] is always on it, do you need help with this? Or if we can help each other out, we just see if it's busy to work on PHARM-DC discharge because as we said, we have our other high-risk discharge from the floor and the stroke patients, as well. And so, I think we try to help each other out and check in with each other, message each other and say, "Oh, are you working on this patient? Do you need help?" To make sure that we don't miss anybody. [SAP3]
To further promote sustainability, intervention pharmacists at Site A asked for flexibility in the number of interventions, where they could use clinical judgement to provide the intervention components, they felt would produce the highest yield on a patient specific basis.
I think we need to still be given the flexibility to choose how that post discharge follow-up goes. Is it really necessary for every patient, or can we identify specific patients where we think they're higher risk, and so we spend more time with them? Right now, if you compare it to our other post discharge calls, we call them, if they have a bad [health literacy] score, no matter what, even if they end up with no medications on their list when they're discharged because of changes that happen, or maybe they don't need things. [SAP1]
As noted above, Site A pharmacists reported that patients with existing relationships with primary care providers (PCPs) were more resistant to the pharmacy-provided interventions, making the intervention more challenging to implement and execute for these patients (Patient Needs and Resources). Additional pharmacist conversations with PCPs and patient MI may be possible solutions to patients resistant to medication changes initiated by the PHARM-DC TOC pharmacists.
I think the most challenging thing for outpatient is when... I think it's most challenging when patients don't have enough trust in their hospitalist or hospital doctors, and they just want to follow the instructions from their PCP. I think that's hard to overcome because it requires a lot of counseling, and we don't have enough time to establish this trusting relationship. [SAP2]
Pharmacists at both sites had an appreciation for how MI positively impacted the intervention. Despite this appreciation, intervention pharmacists had difficulty consistently engaging patients with motivational interviewing, commenting they were uncertain the techniques they were using were correct, asking for additional training, and emphasizing that time constraints made the motivational interviewing process more difficult to sustain within the intervention (Self-Efficacy). In some instances, pharmacists had patients that denied difficulties taking medications as prescribed which made identifying opportunities for MI more challenging. As such, pharmacists suggested that additional practice, training, and resources on MI may provide benefit for pharmacists providing the PHARM-DC intervention (Available Resources, Access to Knowledge and Information).
…especially right after we finished the [motivational interview] trainings and feeling like it definitely made a difference in the tone of conversation with patients, so I would say that's held true. It's nice to feel more collaborative and not quite so prescriptive in our discharge education. That's another thing that we've been trying to do, that we had talked about in the ideal state. [SAP1]
I don't think all patients need motivational interviewing, but the patients who do need it, I do try to provide it. It does take some time. I did motivational interviewing two weeks ago on a patient and it did take 20-30 minutes to complete it. [SAP3]
There are variables that we can't predict until we see the patient. For example, if they're going to need motivational interviewing, if they're going to need 5 minutes on the phone versus 45 minutes on the phone, those things definitely limit our efficiency. [SBP1]
[The trainer] can effectively do motivational interviewing in like 2 minutes [and that it is] as effective as a pharmacist who's on the phone for 17 minutes. And so, [the trainer] emphasized that it takes a lot of practice, and I think that that's something that needs time to develop. I don't think all patient encounters can be done in 2-5-10 minutes. [SAP7]
In some instances, pharmacists at Site B reported MI behaviors and techniques without specifically referring to these processes as motivational interviewing.
Especially, if the patient is not willing to stop their benzo[diazepine], there's no moving it off of their medication list because it doesn't change anything. What we will do is, we'll talk to the patient in advance if we're going to make a change like that and say, "Hey, you've been taking Lorazepam to help you sleep, but you still aren't sleeping and you're not feeling that great and it's not doing anything, do you want to try melatonin and see how you feel on that while you're in the hospital? Or, trazadone might give you less side effects, you can give it like a little try and see, if you wanted to try something else." They're usually amenable when you frame it like that, versus, we're taking this off for your own good. So, we try to figure out what the issues are and see if they're open to trying something new. So, it's highest yield if we get them to try it in the hospital before we send them home, but otherwise we would defer it out to outpatient, for a lot of things. [SBP2]
Both Site A and Site B pharmacists agreed that leadership engagement and institutional support are required for intervention sustainability (Leadership Engagement, Readiness for Implementation). Pharmacists at both sites proposed that both rich, detailed stories of how the intervention prevented dangerous medication misadventures and presentation of quantifiable outcomes were important. Pharmacists and pharmacy leadership frequently stressed the importance of sharing important pharmacist interventions within committees and meetings that included institutional leadership and members of the interprofessional care team. Further, pharmacy leadership at both institutions noted the importance of emphasizing the potential severity of medication-related errors and how the intervention prevented the errors from occurring. Tangible outcomes that pharmacists felt were important to justify longitudinal support for the PHARM-DC intervention included reductions in readmissions, improvements in patient satisfaction scores, quantification of preventable medication errors, and return-on-investment calculations to justify additional staffing (Cost). With specific and tangible outcomes highlighted and presented, Site A appeared relatively more successful at leveraging data and anecdotes for additional staffing and pharmacy FTEs.
I drive my people crazy with data… The transitions of care – before even I was in this role – this was something that was felt to be a goal of the medical center. My initial FTEs that I got back then was because we did a study that was a quality mission priority to the organization that demonstrated that even with a pilot study, we made a significant impact on. There was an impact on readmissions.... We worked with the physician and health services researcher, and we published it. It was published in one of the Accountable Care journals several years ago. That study data did go all the way up the C-suite…. I got three pharmacists from that because of that study. The C-suite was interested now because readmissions were a priority. [SAP9]
We have been able to show the percentage of patients who have at least one serious or life-threatening intervention drug-related problem at discharge that we identified and resolved. Then those are the stories and those are what sticks with everybody. [SAP8]
Well, I think our world is still financially driven. If we can show that there is benefit in terms of readmission rates, patient satisfaction scores. I think that we have to think about how we can utilize our resources to maximize returns on the money we spent on pharmacists and technicians. And that will be, I think, more accepted by management. Because our programs are expensive. So, we have to show how can we make more of a difference for less cost. [SAP2]
I'm not in a position to win this thing. That's the problem. So, everything comes down to beauty is in the eyes of the beholder. Make up a million end points and report all the positive ones. Whether it's readmission, patient satisfaction, tangible, intangible. I come back to the same discussion, I sit in on the budget meetings, and it's return on investment. If I'm paying out $150 thousand in salary, what am I getting back? There isn't a single service line here or physician that would turn down a pharmacist. [SBP4]
So, I think, for our hospital, we have a passion for lots of clinical pharmacy pilots that never seem to take off. I think it's just, we're unable to show the hospital the return on investment. Our medication reconciliation program was originally based in the emergency department, and our data was very good. However, we didn't have enough interdisciplinary support just because we were doing a couple patients from oncology, a couple of patients from ortho. So, no one really saw the impact of what we were doing. So, we then said, okay, well, even though we've shown the return on investment, and we've shown error reduction, the hospitals still not taking us up. [SBP1]