Here’s the scenario: on the 2nd of the month, a patient with diabetes on metformin and high blood pressure on benazepril sees her family physician for a routine follow up.
The patient’s blood pressure is elevated and the decision is made to add carvedilol to help get the blood pressure to goal. The patient’s metformin and benazepril “drop” (are renewed) at the pharmacy on the 18th of every month, a date determined by the patient’s last doctor’s visit. However, the latest doctor’s appointment now “requires” the carvedilol be renewed on the 2nd of every month.
To make matters more confusing, the patient has 2 months left of metformin and benazepril yet has a follow up appointment in 6 months with her family doc. So in 2 months the patient will go to the pharmacy and her prescription medication for benazepril and metformin will have run out. The pharmacist will have to call the doctors office to request a refill. The patient may have to return the next day to pick up the medicine — if she decides to show up at all.
In addition, the patient self-referred herself to a kidney doctor for protein in the urine that was picked up during an insurance physical. She does not tell her primary doctor about the consultation and doesn’t mention that her nephrologist did “something” to help her kidneys because the purpose of her current visit is blood pressure control. The patient does not make the connection that these 2 conditions are related.
Finally, the patient had a sudden bout of back pain. She went to an emergency room the week prior to her appointment. The emergency room doctor started her on “something” for pain. Again, she does not mention the medication to her primary doctor. She doesn’t realize that perhaps that medication is the cause of her elevated blood pressure.
Given the inherent problems presented in this case study, what can the pharmacy do to help the patient synchronize her prescriptions?
Patient centric models of care are popping up all over the country. Examples of patient centric models of care include the patient centered medical home and the patient centered pharmacy. I have a lot of experience with this concept of care. As a kidney doctor, I take care of dialysis patients in conjunction with a team of supporters and advocates for the patients. Our goal is to keep kidney dialysis patients healthy and out of the hospital. The model is sound, and it works!
The patient centered pharmacy is a brilliant concept to help coordinate prescription medication to help patients take their medication correctly. Let me quote the brochure a local Omaha pharmacy is using to promote the project:
“It’s easy and convenient. It saves time and trouble by having all your prescriptions refilled on the same day each month. Everything is handled for you, and you only make one trip to the pharmacy to pick up your prescriptions. Even better, it is free at participating pharmacies. Moreover, the synchronized prescription refill service facilitates adherence to medication and decreases the risk for medication error.” Here is how it works:
You choose an appointment day — the date each month you wish to pick up all of your prescriptions. A week or so prior to this appointment day, you will receive a call from your pharmacy to confirm which prescriptions you want to fill.
Your pharmacist will review your prescription list each month, monitor changes after your doctor visits or hospital stays, and check for possible drug interactions. Best of all, you will have time to talk with your pharmacist and ask any questions you may have about your medications.
You receive free consultations, the convenience of a single monthly trip to the pharmacy, and freedom from worries about forgetting to call for your refills or running out of your medications.
By synchronizing your prescriptions, you simplify your life. The appointment date at the pharmacy drives the system.
How does the pharmacy benefit? With limited resources available, the pharmacist can provide comprehensive care once a month, instead of multiple times, and improve efficiency. Phone calls are drastically reduced — the docs will love this one because they can spend more time with their patients providing world class care!
In what other ways does the health care system benefit? This system helps doctors identify medication non-adherence. I’m told that compliance is boosted to nearly 100% in enrolled patients. Patients who take appropriately prescribed medication stay healthier, stay out of the hospital, and save everybody money. The patient is able to work. The employer has a healthy patient who is working, not costing. Health care costs in general go down because there are fewer hospitalizations. Everybody wins!
Now back to the clinical vignette. At the kidney doctor’s office, the patient was started on lisinopril and asked to hold the benazepril. The patient didn’t understand the directions and was taking both lisinopril and benazepril. The patient is therefore on 2 medications that do the same thing. The medication she was given for pain, ibuprofen (a non-steroidal ant-inflammatory drug), likely worsened the patient’s blood pressure in the setting of taking 2 ace inhibitors. Arguably, the carvedilol is unnecessary because the primary doctor is treating drug-induced hypertension. Can you see how a patient centric pharmacy can help here?
Michael Aaronson is a nephrologist who blogs at his self-titled blog, Michael L. Aaronson M.D.
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