A project aimed at increasing referrals and decreasing costs
- Incorporating nursing referrals to pharmacists as part of routine patient care can help reduce polypharmacy, pharmacy and healthcare costs, and adverse drug–drug reactions.
- Evidence indicates that nurse referrals to pharmacy can help reduce side effects as a result of deprescribing, improve patient medication adherence, decrease costs, reduce hospitalizations, and improve quality of life.
As the main point of patient contact, nurses can help quickly identify potential health-related issues. Taking a whole person/population health management approach provides patients with individualized care management plans tailored to their specific needs, desires, and capabilities. Nurse-driven interventions, including the initiation of and connection to supportive services, can improve patient outcomes.
For example, incorporating nursing referrals to pharmacists as part of routine patient care can help reduce polypharmacy, pharmacy and healthcare costs, and adverse drug–drug reactions. The Pharmacy Referrals to Decrease Costs in Adult Case Management (PRDCA-CM) quality improvement (QI) project conducted at a health insurance managed care organization aimed to determine the effectiveness of a nurse-driven pharmacy referral program to decrease pharmacy costs within a group of patients with complex conditions who receive care via telephonic adult case management. The project included use of the organization’s telemedicine AnyWhere Care (AWC) web application, which patients can download to their smartphones. The application then feeds data to the patient’s electronic health record (EHR).
The nurse’s role in medication safety
Preventing polypharmacy in older adults
Background and gap analysis
An organization gap analysis by the PRDCA-CM project team (telephonic nurse care managers [CMs], telephonic CM director, and myself as the project manager) revealed no standardized process for nurse CMs to refer patients with polypharmacy (five or more prescriptions) to a pharmacist for a free medication review. To reduce medication-related injury, the World Health Organization and the National Institute on Aging recommend a comprehensive medication review for any patient beginning a new treatment or when changing healthcare settings.
Existing organizational data showed a 55% increase in pharmacy costs for adult patients in the complex managed care department over the 16 weeks before PRDCA-CM implementation.
Potential reasons for the increased costs include a high number of prescriptions filled monthly per patient, changes to prescription benefit tier coverage, and an increased number of providers prescribing medications per patient. A root-cause analysis also indicated a direct link between rising pharmacy costs and the lack of standardized nursing processes to address polypharmacy. The project aimed to fulfill the lack of nursing interventions focused on reducing polypharmacy-related problems while aligning organization practice with the National Committee for Quality Assurance standard of improving case management through telemedicine services.
Evidence summary
An exhaustive literature search validated the benefit of the proposed intervention. Main themes identified from current literature included reduced side effects as a result of deprescribing, improved patient medication adherence, cost savings, reduced hospitalizations, and improved quality of life, all relating to early identification of polypharmacy and timely completion of comprehensive medication reviews with pharmacists. Evidence also indicates that medication reviews reduce patient pharmacy costs by improving adherence, decreasing symptoms, and reducing patient prescription burdens. Ultimately, comprehensive risk reduction enhances patient quality of life. (See Impact of polypharmacy.)
Impact of polypharmacy
One in five adults in the United States and Canada, between the ages of 40 and 79, take at least five prescription medications routinely. Polypharmacy is linked to increased falls, cognitive impairment, harmful drug reactions, drug–drug interactions, financial burdens on patients and families, and increased medication adherence issues. An estimated 20% of adverse drug reactions result from underlying drug interactions, and this risk rises as the number of drugs taken increases.
Medication reviews performed for older adult patients help reduce health problems that impact daily life, improve medication adherence, decrease hospital admissions, and lower drug–drug adverse reactions. Clinician use of the 2023 updated Beers Criteria (guidelinecentral.com/guideline/340784), a list of medications to avoid or use with caution in older adults, further aids identification of potentially inappropriate drugs that lead to reduced quality of life.
Polypharmacy persists as a prevalent health concern, especially in adults 65 and older with multiple chronic health conditions. Proper identification of potential medication errors and adverse interactions occurs when the nurse reviews medications with the patient, collaborates with the interprofessional team, and seeks to improve patient adherence and decrease costs. An interprofessional approach to pharmacist-led medication reviews through nurse case management, discharge planning, and routine follow-up sessions can improve polypharmacy-related outcomes.
Project description
The project team used the plan, do, study, act (PDSA) framework to devise and implement the project, evaluate the results, and make recommendations to address the lack of a process for nurse CMs to make pharmacy referrals. At the conclusion of the project, the team gathered final data and analyzed it against proposed outcomes to determine project feasibility and guide post-project sustainment. Ongoing assessment of PRDCA-CM processes led to micro-level changes that improved the project site’s likelihood of implementing sustainment actions.
The six remote telephonic nurse CMs involved in the project worked in the complex managed care department and cared for patients over age 18, all of whom had higher rates of polypharmacy than those under the care of other CM groups within the organization. Patients excluded from the project included those prescribed fewer than five medications per month (excluding as-needed medications), pediatric patients, patients declining telephonic case management services, those not assigned to a nurse CM, and pregnant patients. The CMs implemented the pharmacy referral intervention over 8 weeks to allow for adequate data collection and purposeful evaluation and data analysis. As project manager, I provided training to the CMs a week before the project start date as well as weekly during team checkpoint sessions.
The nurse CMs used the organization’s EHR system to identify patients taking five or more routine medications. They then provided telephonic education to those patients about polypharmacy, the benefits of a pharmacist-led medication review, and the AWC web application. The CMs documented all referrals as a problem, goal, and intervention (PGI) in the EHR and offered to assist with scheduling appointments. Patients had the option to decline or to make the appointment on their own. Over the 8-week implementation period, the project team tracked the number of patients eligible to participate, the number of PGIs documented in the EHR, the number of completed pharmacist-led medication reviews in AWC, and the total pharmacy costs (per patient per month) pre- and post-project. The last step involved the review and analysis of all pre- and post-project data to evaluate intervention effectiveness.
Interested patients scheduled a pharmacist session using AWC, choosing from one of nine available pharmacists. After completing the medication review, which was conducted via remote video appointment, the pharmacist entered the encounter into the patient’s EHR. The project team retrieved data for completed medication reviews from the EHR and AWC application metrics tools.
The QI project received approval after the organization’s chief medical officer reviewed the feasibility and study design. The institutional review board described the project as non-human research that didn’t require their oversight. The project presented no ethical risk, consent wasn’t required, and access to protected health information or patient identifiers was unnecessary.
Data collection
Collected quantitative data included weekly pharmacy costs (per patient per month), the total number of eligible case management patients, the total number of nurse CM referrals documented, and the weekly number of completed pharmacist-led medication reviews in AWC. The project team collected 8 weeks of retrospective quantitative data before project initiation and compared them with final project data (pre-post comparison) to determine success related to stated goals and objectives.
Twice-weekly EHR chart audits by the project team tracked nurse CM compliance with pharmacy referrals. In addition, the team retrieved pharmacy costs and completed medication reviews from the organization’s reporting and EHR metrics systems. In the wake of numerous mandates and reimbursement guidelines, the organization’s QI oversight committee determined as acceptable the high quality and completeness of data obtained from the EHR systems. In congruence with the approved charter and project site requirements, the project team tracked data weekly using an Excel spreadsheet and stored it on the organization’s password-protected secure server. Data will remain secured for 7 years.
Project results
The PRDCA-CM project used pre-post analysis to examine the intervention’s effect on specified outcomes. The project team used filtering functions, analytical tools, and descriptive statistics to evaluate and analyze all collected data. However, they did not complete statistical tests to determine outcome significance. (See Project stats and data.)
Pharmacy costs
The project team tracked total pharmacy costs (M = $1,543.75, SD = 875.348), which ranged from $377.31 to $3,065.29 per week. To determine whether the new intervention met the proposed outcome of a 5% reduction in total pharmacy costs (per patient per month), the team completed a calculation using retrospective data ($1,739.90) and postintervention costs ($1,543.75) using a percent-change calculator. The percent reduction in total pharmacy costs between the pre- and post-intervention phases was nearly 12%, doubling the project team’s projected outcome. Whether the intervention directly contributed to the decrease remains unclear, but the team surmises a positive association between the intervention and the outcome. The EHR combined all pharmacy use by all patients in the complex care management department and calculated pharmacy costs on a per patient per month basis, which is the health insurance industry standard for capturing population health data.
CM adherence
The documentation of referrals in the EHR allowed the project manager to track nurse CM adherence with the referral process and determine the need for process changes. The manager also performed twice-weekly CM chart audits and conducted weekly remote team check-ins throughout the project period. In addition, the project team screened new patient referrals received over the implementation period (N = 229) for polypharmacy and tracked total eligible patients identified from all new referrals (n = 67) weekly (M = 8.375, SD = 3.739); 3 to 14 patients were identified per week.
Measuring nurse CM adherence to implemented processes helped the team determine project success. The number of eligible patients with polypharmacy (n = 67) was divided by the number of CM documented referrals in the EHR (n = 59), then multiplied by 100, to reveal a documentation compliance rate of 88%. Daily morning reminders about documentation requirements may have aided CM adherence. However, despite less-than-optimal adherence, the percent change calculation revealed an increase in nursing referrals to pharmacy of 5,900%.
Completed medication reviews
The project team determined the percentage of patients who completed a pharmacist-led medication review in the AWC web application by dividing the total number of completed reviews (n = 2, M = 1, SD = 0) by the total number of documented referrals in the EHR (n = 59), then multiplying by 100. Results revealed only a 3.89% completion rate (the goal was 10%). The project team attributed the low completion rate to not requiring that patients complete the service, patient lack of interest in using the application, or patients not having a smart phone to access the appointment. Weekly follow-up calls with patients to review questions or concerns may have helped increase the completion rate. A patient survey asking about experiences, opinions, awareness, and future interest might prove helpful to improve future iterations of the intervention.
Limitations and challenges
Missing opportunities to correctly identify all patients with polypharmacy and document AWC application referrals resulted in skewed data. In addition, patients weren’t required to complete a pharmacist-led medication review, but they could have done so at any point. Inaccurate medication lists also complicated patient identification. Prescribing providers must manually remove medications from the EHR to reflect accurate prescription totals, which hadn’t been done for most patients involved in the project. This complication may have created a barrier to proper identification and inclusion of patients in the PRDCA-CM initiative.
The targeted group of patients with complex medical conditions may not have had time to complete a pharmacist-led medication review within the project’s timeframe or had completed it after data collection. Some older adults may have experienced difficulty navigating the AWC web application or preferred to conduct a medication review telephonically or in person with their local pharmacist. Four patients scheduled appointments with a pharmacist in the application but didn’t attend and were excluded from the final totals. The project team could not determine whether these patients completed medication reviews with their local pharmacist, which may have contributed to the reduction in overall patient pharmacy costs.
Lessons learned
Nursing referrals to pharmacists have been shown to reduce polypharmacy and its associated financial burden. Despite a subpar nurse CM referral and documentation adherence rate and completed medication review rate, final data demonstrated a reduction in pharmacy costs by nearly 12%. The outcomes indicate a positive association between nursing referrals to pharmacists and decreased pharmacy costs for patients. Future iterations of the project should include surveys to track patient benefits, opinions, and satisfaction with the intervention.
Ongoing stakeholder commitment and nurse CM adherence to workflows are vital to ongoing evaluation of the ability of the new process to achieve stated outcomes. The addition of parameters to the project, such as nurse CMs telephonically transferring patients directly to a pharmacist rather than having the patient schedule independently, might prove beneficial. Other considerations to reduce the incidence of polypharmacy and related costs include deploying personalized text messages to patients about their prescriptions and available pharmacy services, incorporating the use of motivational interviewing by nurses and pharmacists, and creating a system-wide policy to identify and track patients with polypharmacy. The team could combine these steps with components of the PRDCA-CM project and re-launch it within the organization to further evaluate the best process for achieving a 10% medication review completion rate.
The project requires no additional equipment or programming, which minimizes financial costs for the organization. However, pharmacists may experience an increased workload. Research into the project’s impact on pharmacist workloads and time constraints should be considered for future iterations. In addition, sending written information about the pharmacy service to patients may help increase referrals to and use of the program.
Since completion of the initial project, the organization has added an alert message to all eligible patient EHRs, which helps nurses appropriately refer patients to the program. The organization also sends blast emails to all EHR users to remind them of the program and qualifications and explain how to properly identify eligible patients.
Ultimately, the organization adopted the project with the addition of direct CM telephonic transfers to a pharmacist for a medication review across all care management departments. The organization continues to collect and analyze data.
Improve care, promote the profession
Nurses play a key role in patient education, medication management, and prevention of negative health outcomes. Early identification of polypharmacy by the nurse can help improve the nurse–patient relationship, decrease patient pharmacy costs, and reduce polypharmacy. Projects such as the PRDCA-CM can serve as a tool to support nurses in this effort. Knowing the limitations of and enhancements made to this project, consider conducting a similar initiative in your organization. Nurse-led QI projects offer opportunities to improve patient care and promote the nursing profession.
Jamie Briscoe is an adjunct professor at Community College of Allegheny County in Monroeville, Pennsylvania.
American Nurse Journal. 2024; 19(3). Doi: 10.51256/ANJ032416
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Key words: nurse referrals, pharmacy referrals, polypharmacy
