Rachel Yard, Center for Health Care StrategiesMay 7, 2019
Complicated drug regimens, also known as medication complexity, can cause adverse health outcomes, leading to avoidable hospitalizations and sometimes even death – an estimated 119,000 annually. In the U.S., approximately 30 percent of adults take five or more medications daily, each with their own dosage and instructions for use. That alone can be confusing for many people to follow accurately, but for individuals with complex health and social needs, who often take as many as 15-20 medications daily, their focus may be consumed by other issues, such as a lack of transportation and housing, and food insecurity. Monitoring for medication complexity is important for quality patient care, but may not be enough for low-income individuals who may also face challenges related to social needs.
Towncrest Pharmacy, a community pharmacy in Iowa, developed an innovative process for screening patients for medication complexity and unmet social needs. The Center for Health Care Strategies (CHCS) recently spoke with Randy McDonough, PharmD, co-owner and director of clinical services at Towncrest, to hear about their social determinants of health (SDOH) screening process, what they are learning from it, and how they address patients’ identified unmet social needs. Towncrest is a participant in the Community Management of Medication Complexity Innovation Lab, led by CHCS with support from the Gordon and Betty Moore Foundation.
Q: Towncrest was already using a medication risk score to identify patients at risk for medication complexity, why did you add an SDOH screening tool to this process?
We focus on screening our high-risk group as we know that many of these individuals not only have medication complexity, but likely have social issues that put them at greater risk of poor health outcomes.
A: We knew the importance of measuring social determinant needs and connecting patients with community resources, but it was not something we had tackled until we began working with CHCS. We decided it made sense to add SDOH screening as part of our medication review system. We focus on screening our high-risk group as we know that many of these individuals not only have medication complexity, but likely have social issues that put them at greater risk of poor health outcomes. Although, eventually, we would like to see the screening expand to our greater patient population.
Q: How does the SDOH screening process work? How do patients respond to the screening?
A: The SDOH screening is a verbal survey, including eight questions, that either a pharmacist or technician completes with a patient. Our team asks the questions, documents responses, and identifies any issues. With most patients, the screen only adds about five minutes to a comprehensive medication review, which we consider fairly negligible. If an issue is identified, we will spend more time with that patient, which is a good thing. We want to be spending more time with high-risk patients.
Patients have been very forthcoming during the screening, although we have been working with many of them for a long time. We aim for positive therapeutic relationships with all of our patients — we promise to use our skills and knowledge as pharmacists to make sure we are optimizing their medications, and in return, patients agree to provide us with the information we need to do that. The SDOH screening is part of that medication optimization process. It is in line with what we have already been doing with our patients, only it is focused on these other areas of their life — transportation needs, food insecurity, income-related issues, among others. We have not experienced any pushback since rolling it out in the fall of 2018, so implementation has been fairly easy.
Q: How does a community pharmacy implement the SDOH screening tool?
A: Our pharmacists use motivational interviewing techniques and health coaching when working with patients, so they were already comfortable asking patients about their medical and social histories — including SDOH-focused questions was a relatively easy process. For a pharmacy unfamiliar with motivational interviewing or this type of patient outreach, it may be more difficult to integrate into the practice, especially if difficult topics arise, like abuse or substance use. Most pharmacy schools do not address this type of training, so the onus is on the pharmacy to incorporate continued education and training for its team to address these patient needs.
Q: What did you learn about your patients from the screening process? Did it cause you to approach your work in a new way?
[Screening] is making us more aware of the issues our patients are facing, as well as spurring us to identify available resources in our county that we were not previously aware of.
A: It is making us more aware of the issues our patients are facing, as well as spurring us to identify available resources in our county that we were not previously aware of. Earlier this year we met with Johnson County Social Services to explain our SDOH screening and explore available community resources. We mapped Johnson County resources to our eight-question screen to ensure we always have someone to call when an issue is identified.
So far, we have identified two major issues in our population: (1) transportation; and (2) inability to afford medications. Towncrest offers free delivery; however, patients’ transportation needs may extend beyond transportation to the pharmacy, so we have identified a county mobility coordinator that we can refer patients to for assistance. If we find that a patient is unable to afford his/her medications, we conduct a comprehensive medication review to see if we can find lower-cost alternatives and collaborate with prescribers to ensure patients are optimizing their medications in a cost-effective manner. We also have a number of cost-assistance programs we can refer patients to, such as the general assistance program at the county social services center, which provides short-term monetary assistance to residents in extreme financial crisis, and the Iowa Prescription Assistance Program, which can provide significant savings for patients.
Q: Can you share a patient story that illustrates how the SDOH screening has benefited patients?
A: There was a high-risk, complex patient with mental health issues. The patient was living in a community home following an institutional stay. From speaking with her care coordinator, as well as the individual who manages her finances, I learned that the patient could not afford all of her medications — specifically three that were not covered by her Medicaid insurance. She also had a pharmacy bill of several hundred dollars. Concerned about these medication-related finances, she stopped taking all three uncovered medications. I began looking for comparative drugs that were covered by Medicaid and had little or no out-of-pocket requirements. I connected with her prescribing physician to let him know what was going on, and provided my suggestions for new medications that would be covered by her insurance. We were able to reduce her monthly spend from 100 dollars to five dollars, and deprescribed two medications that were actually not needed. She is now being more closely monitored by her physician as well as our pharmacy. In the past, we had not really looked at cost issues, but now that we know it is an issue for many of our patients, we are looking for it.
Q: What advice would you give to a community pharmacy interested in screening patients for unmet social needs?
The pharmacy and staff must transform their practice from the old model of simply dispensing medication to a patient care site.
A: The pharmacy and staff must transform their practice from the old model of simply dispensing medication to a patient care site. In order to do that, you have to free up the pharmacist so that s/he is able to focus more on patient care. One way to do this is to use pharmacy technicians optimally — let them be the drivers of dispensing. If you are in a state that allows technician product verification, use it. Look for other ways to increase efficiency, such as through automation and robots.
It takes a true vision to undergo these types of changes as well as a commitment to transform. In some cases, people quit way too early when working on these types of overhauls. Each day presents an opportunity to get closer to the bigger goal of transformation. They may not be sweeping changes, but take the victories, no matter how small, and sustain the vision.
WebinarAddressing Medication Complexity Through Innovative Community-Based Strategies and Partnerships May 2019
InfographicAddressing Medication Complexity Through Community-Based Strategies January 2019
Fact SheetUnderstanding and Addressing Medication Complexity January 2019
ReportOpportunities to Enhance Community-Based Medication Management Strategies for People with Complex Health and Social Needs June 2018