On the Friday before Labor Day 2024, Pharmacist Monika Tawfik made a bedside visit to John*, a patient who was hospitalized at Hennepin Healthcare. John was due to be discharged later that day.
During the visit, Tawfik read a note about John that her colleague had written earlier that week: “Due to staffing issues, his home healthcare agency is not likely to be able to come out over the holiday weekend to help him with his medications.”
As Tawfik dug deeper into her colleague’s note and John’s pharmacy records, she realized the importance of not discharging John until after the weekend or until a better plan was in place.
“His providers had made several medication changes, including four new meds and a different diuretic dosing,” she recalls. “And his pill boxes hadn’t arrived.” Additionally, John was not a native English speaker, and it was clear to Tawfik that this made it harder for him to understand his complicated medication instructions.
Tawfik explained the situation to John’s clinical team and encouraged them not to discharge the patient right away to avoid readmission. Working together, Tawfik and the floor’s clinical coordinator reached out to John’s home healthcare agency to share what was happening. Finally, the agency was able to secure a nurse to come to John’s home over the holiday weekend, and his son was able to take him home.
The story showcases the success of Hennepin Healthcare’s Pharmacist Transitions of Care program. Through the initiative, Transitions of Care pharmacists promote equitable health outcomes by identifying hospitalized patients – like John – with unique medication needs. Then, they offer these patients and their caregivers support to succeed at home.
That support is wide-ranging. Transitions of Care pharmacists can help patients set up their MyChart account or plan for how they will adhere to their medication regimens at home. If a patient doesn’t have access to a personal phone or computer to receive messages from their health care providers, it can also mean directing them to public computers they can use once they’re discharged. They may also help patients transition refills to a community pharmacy or discontinue prescriptions to prevent accidental refills of medications that are no longer intended by the treatment team."
"We can do everything right for a patient when they're in the hospital, but if they can't replicate it at home after they leave the hospital and get home, then what's the point?" says Pharmacist Kelsi Giller, a colleague of Monika Tawfik in the Pharmacist Transition of Care program. "Patients may be in the hospital for two days or 10 days, but the rest of the time they're out in the world. Through patient and caregiver interactions we can design and implement a realistic, individulized, patient centered medication plan."
How it started
Hennepin Healthcare launched the Pharmacist Transitions of Care program in September 2021. The initiative is funded by Hennepin Health, a health insurance plan that serves people who are eligible for Medical Assistance and MinnesotaCare. People with Hennepin Health insurance are racially diverse and experience serious mental health issues, substance use disorder, and homelessness at a higher rate than the general population. One impetus that leaders had for launching the Pharmacist Transitions of Care program was an internal review of adult Hennepin Health patients hospitalized at Hennepin Healthcare. The review found that up to 40 percent of hospital readmissions were medication related.
Program outcomes were analyzed following the first full calendar year of program implementation. Patients have primarily been men in their late 40s. During the evaluated timeframe, 82 percent received medication counseling and 63 percent received bedside medication delivery. Within 72 hours of discharge, pharmacists reached 60 percent of the patients for follow-up -- an impressive feat considering that many did not have their own phone or computer.
While the program initially served people who had Hennepin Health as their health insurance plan, it’s since grown through hospital funding to serve additional community members.
A typical day
For Tawfik, Giller, and their colleagues, a typical day involves pulling a list of patients who have been newly admitted to the hospital. Then they perform chart reviews to see if they can identify medication related issues which may have led to hospitalization and proactively address barriers the patients might encounter once they’re discharged.
But a full assessment of the barriers can only be accomplished in person. That’s why the pharmacists follow up their chart reviews with a visit to the patent’s room to talk with them and their caregivers.
“You can have the most evidence-based, pristine health care plan, but our role is to make sure the patient can execute the intended plan after discharge,” says Tawfik. “And the big thing is knowing the patient." She recalls working with a person who couldn’t do the math on their insulin dosing. “No one would have known that without a bedside conversation,” she says.
“We are able to spend a lot of time with patients,” adds Giller. “In health care everything is fast-paced and nurses and providers can be stretched thin. But this program allows us to slow down and take the time that’s needed for comprehensive medication counseling and teaching, particularly with challenging or high-risk medications such as new insulin starts. It is rewarding to witness patients’ increased confidence throughout our interactions.”
The Transitions of Care pharmacists continue to follow their patients throughout their hospital stay and visit the patient again right before they’re discharged. They also try to call the patient within the first few days after they leave the hospital to make sure they’re succeeding at home.
The outcomes
Through the program, Tawfik, Giller, and their colleagues have discovered numerous safety risks. For example, one patient’s family member brought in 37 bottles of medication that the patient had at home. “What you see on paper and in the chart does not reflect what patients are or are not doing at home,” says Giller. The situation highlighted for her that, “The United States healthcare system is built so that if you receive care at multiple health systems and pharmacies, there are inherent breakdowns in communication and one entity might not know the other system’s plans,” she said.
By identifying safety risks, the Transitions of Care pharmacists have been able to reduce them. “We’re that last safety check for day of discharge,” says Tawfik.
The pharmacists share their discoveries, stories, and experiences with their teammates. "You become more rounded in your clinical skills,” says Giller. “I love thinking through the alternatives to find the best fit for each patient.”
Prior to the program’s inception, hospital readmissions in the Hennepin Health population who received care at Hennepin Healthcare peaked at over 24%. Since then, readmissions have declined to 12.5%. The median time to rehospitalization has also increased to 15 days, worth noting because readmissions that occur within 7 days of discharge are more likely to be preventable and related to insufficient care transitions.
According to claims data, Hennepin Health readmissions are the lowest they’ve been at Hennepin Healthcare in 7 years.
Hospital patient experience scores have also increased during this timeframe, driven by patients reporting that they understood the purpose of taking their medications.
In 2024, Hennepin Healthcare and Hennepin Health were recognized by the Minnesota Hospital Association with a Clinical and Quality Innovation award for the initiative.
“We’re a very novel program for the Twin Cities,” says Tawfik. “We follow patients for the entirety of their inpatient experience and discharge. In looking at literature, we also didn’t find a lot of transitions of care pharmacy programs that served Medicaid patients specifically. We’re unique to target this population and the socioeconomic factors that affect their ability to follow through.”
For Tawfik and Giller the work is personal. “I watched my husband’s grandma go out of the hospital,” says Tawfik. “She was extremely well-supported, and it was still hard. The average patient we see has nobody ‒ or a skeleton support system ‒ and may not have the same health literacy as me. I want to help people take back control and empower them to understand and meet their care goals.”
*The patient’s name has been changed to protect their identity.