There’s no place like home—Integrating a pharmacist into the hospital-in-home model

Abstract

Background:

Hospital-in-home (HIH) is an innovative model that provides hospital-level care in a patient’s home. Pharmacists can enhance the HIH model through medication reconciliation and medication optimization.

Objectives:

To integrate a clinical pharmacist into the HIH model and to conduct a formative evaluation of pharmacist contributions, including medication discrepancy resolution, cost savings, and cost avoidance.

Practice description:

This is a prospective quality improvement study conducted at the Veterans Affairs Boston Healthcare System.

Practice innovation:

We integrated a pharmacist into the HIH model. The pharmacist conducted a medication reconciliation at hospital discharge and after discharge through home video telehealth and provided longitudinal medication management.

Evaluation methods:

We adapted the PRECEDE-PROCEED model to guide program implementation. We conducted a formative evaluation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, evaluating the reach, efficacy, adoption, and implementation of the pharmacist in the HIH team. We calculated cost savings associated with pharmacist-managed home intravenous (IV) therapy, cost avoidance from deprescribing, and cost avoidance from earlier hospital discharge.

Results:

The HIH program enrolled 102 patients from May 2019 to March 2020. The pharmacist completed 99 (97%) discharge and 95 (93%) postdischarge medication reconciliations, most of which 71 (75%) were conducted using home video telehealth. The pharmacist identified and resolved a total of 453 medication discrepancies: 181 (40%) at discharge and 272 (60%) during postdischarge medication reconciliation. A total of 84 (19%) discrepancies were considered high risk. The pharmacist managed 104 days of home IV therapy, resulting in a cost savings of approximately $17,000. The cost avoided by identifying and deprescribing 145 inappropriate medications was approximately $51,000. The cost avoided by earlier hospital discharge was $1.2 million.

Conclusion:

Integrating a pharmacist into the HIH model enables the detection and resolution of medication discrepancies. Cost savings from medication deprescribing, cost avoided from pharmacist-managed home IV therapy, and cost avoided from early hospital discharge totaled $1.268 million.

Background

Hospitalizations are costly; and, in some cases, cost can be reduced through the provision of hospital-level care at home.^1,2 Within the Veterans Affairs (VA) Health Care System, a traditional inpatient stay for chronic obstructive pulmonary disease was estimated to cost $4786 per day in 2018.³ With the average length of stay of 3 days, this yields a total inpatient cost of $14,358; a hospitalization involving an intensive care unit stay is associated with even higher costs.³ By contrast, acute care provided in the home, compared with the traditional cost of an inpatient stay, may be less costly; at Cincinnati VA Medical Center (VAMC), an average cost difference per person of $3168 was projected when using the hospital-in-home (HIH) care model.⁴ HIH programs also offer early hospital discharge or substitutive care for an inpatient admission in eligible patients.¹ The model provides acute patient care services such as intravenous (IV) medication administration, laboratory monitoring, and wound care in the home.^2,5,6 A growing number of other health systems are adopting HIH models,^1,2,4–9 and many have shown that HIH reduced mortality, readmission rates, and cost compared with an inpatient stay, with no major differences in the quality and safety of patient care.^2,5

Hospitalizations are also frequently associated with medication discrepancies at transitions of care, especially for older adults taking multiple daily medications.^10,11 Targeting medication reconciliations before and after discharge can help reduce medication discrepancies and associated harm.¹² Pharmacists consistently reduce medication discrepancies and potential harm through medication reconciliation and medication optimization at transitions of care.^11,13,14 Only the Cincinnati VAMC HIH publication included a dedicated pharmacist on the HIH team. Although other HIH programs may include a pharmacist, to our knowledge, these programs have not published.⁴ Furthermore, the role of Cincinnati VAMC’s pharmacist and the pharmacist’s contributions to the program were not explicitly defined.⁴

This article describes how we integrated a pharmacist into the HIH model to provide ongoing medication optimization, including deprescribing, and pharmacist-managed home IV medication preparation and administration, which resulted in cost saving and cost avoidance for the hospital. To our knowledge, no publications have explicitly described how to integrate a pharmacist into the HIH model or the role of the pharmacist on the HIH team.

Objectives

The primary objective of this study was to describe how we integrated a pharmacist into the HIH model, using an evidence-based implementation approach. We provide an implementation blueprint for others interested in doing the same. Secondly, we conducted a formative evaluation of integrating a pharmacist into the HIH model, including the cost savings and cost avoidance associated with the HIH pharmacist’s activities.

Practice description

This study took place at VA Boston Healthcare System (VABHS). The research and development committee approved this study as a nonresearch quality improvement initiative, exempt from committee oversight. The HIH program was implemented in April 2019, and the first patient was enrolled on May 21, 2019 (Figure 1).

Figure 1.

VABHS HIH pharmacist timeline. Abbreviations used: VABHS, Veterans Affairs Boston Healthcare System; HIH, hospital-in-home; IV, intravenous; EHR, electronic health record. Note: Bolts indicate the first enrolled patient (May 21, 2019) and the end of Reach, Effectiveness, Adoption, Implementation, and Maintenance evaluation (March 27, 2020).

The HIH program was created to achieve 3 goals: (1) avoid costs by creating a mechanism for eligible patients to be discharged earlier from the hospital and deprescribing potentially inappropriate medication discrepancies at discharge; (2) increase cost savings through pharmacist-managed IV therapy; and (3) increase hospital revenue from Veterans Equitable Resource Allocation Model (VERA) vesting. VERA is a VA financial model developed to allocate federal funds for patient care practices; patient classification systems determine reimbursement to health care centers, with increased funding allocated to systems with more complex patients.¹⁵

Per VABHS leadership, the HIH team would need to enroll and discharge 75 patients from the program over the first year. This would account for $483,615 in VERA reimbursement. Leadership considered the first year a success if the program either: (1) met the 75 patient VERA goal or (2) exceeded the cost of the program through cost avoidance, cost savings, and incremental VERA revenue.

The HIH team included 9 members: 1 advanced medical support assistant, 1 pharmacist, 1 physician assistant, 1 physician, 1 nurse manager, 3 registered nurses, and 1 social worker. The team provided hospital-level at-home care to veterans with complex medical conditions who were experiencing acute medical complications.⁴ Common complex conditions included congestive heart failure and chronic obstructive pulmonary disease; patients were able to be treated at home but required more intensive care such as IV medication administration and acute titration of medications that would have otherwise been administered in the hospital.

The role of the HIH pharmacist would be to conduct medication reconciliation and reduce medication discrepancies across the transition points from the hospital to the home. The pharmacist would also provide ongoing medication optimization, including deprescribing, and would coordinate IV medication preparation and administration. Before HIH implementation, medication reconciliation by a pharmacist was not routinely performed during inpatient stays or after discharge at VABHS. Instead, nurses within the VABHS Coordinated Transitions of Care (C-TraC) Program conducted telephone postdischarge mediation reconciliation.¹⁶ The C-TraC team identified high rates of postdischarge medication discrepancies: among those with discrepancies, the average was 3 per patient (450 total) over 14 months, 190 (42%) of which had the potential to cause harm.¹⁶

To identify and resolve medication discrepancies and reduce potential harm before patient discharge, VABHS hospital leadership created a new position for 1 full-time HIH clinical pharmacist with assistance from geriatrics and extended care (GEC) start-up funding. To keep the position beyond 2 years, the HIH team would need to demonstrate its financial sustainability, as there may be competing priorities for GEC pharmacist full-time equivalents (FTEs) in the future.

Per VABHS leadership, the pharmacist had 2 goals for the first year of the program. First, they needed to demonstrate that the time spent on medication reconciliation and additional pharmacist HIH activities justified a full-time job, based on time spent, cost savings, and cost avoidance. Second, the pharmacist needed to quantify the number of inpatient bed days saved by pharmacist-managed home IV therapy and HIH care coordination. These 2 goals would specifically determine if the pharmacist’s first year in the program was a success.

Practice innovation

In preparation for implementation, our team gathered best practices from previously effective HIH models.^2,4,7 The Cincinnati VAMC’s HIH team mentored our program throughout this process.⁴ Their team included a full-time pharmacist, but a published description of their service did not describe how they integrated a pharmacist or the pharmacist’s individual contributions into their program’s success.⁴ The VABHS HIH nurse manager, pharmacist, and physician attended an in-person training hosted by the Cincinnati VAMC HIH team. During this training, the VABHS HIH team reviewed Cincinnati VAMC’s policies and procedures and then developed measurable objectives for the VABHS HIH program.

After the training, the VABHS pharmacist developed a checklist of implementation goals (Appendix 1). To track progress toward leadership goals, the pharmacist created organizational tools for personal patient care and coordination (Appendix 1 and 2 for the full toolbox of pharmacist materials). Finally, the pharmacist developed a daily workflow comprising of 4 key parts: prerounding, HIH team rounds, medication reconciliation, and supportive clinical tasks (Figure 2).

Figure 2.

The HIH pharmacist workflow. Abbreviations used: HIH, hospital-in-home; EHR, electronic health record; IV, intravenous.

The VABHS pharmacist adapted the workflow from Cincinnati VAMC, making several key changes at the outset with respect to pharmacist location, IV procedures, and data collection. The VABHS HIH pharmacist was on site daily at the inpatient pharmacy facility. The Cincinnati VAMC HIH pharmacist was not. Cincinnati VAMC had a dedicated IV technician, whereas the VABHS did not. Instead, the VABHS HIH team worked within existing inpatient IV protocols and procedures. Existing VABHS inpatient pharmacy technicians prepared all HIH IV medications. Existing VABHS inpatient pharmacists checked the final prepared IV medications. The HIH pharmacist coordinated this process and coordinated IV medication delivery to the patient’s home. The VABHS HIH pharmacist created the data collection tool (Appendix 2) discussed in Figure 2. Cincinnati VAMC used different data collection procedures.

As the program continued, the pharmacist adjusted the workflow on the basis of patient and program needs and time spent on various activities. Workflow changes were determined through continuous audit and feedback. HIH team members provided feedback periodically on HIH processes during daily huddle. For example, the HIH team agreed that twice daily rounds were only necessary on Mondays to discuss events that occurred over the weekend and were not as beneficial on the other days of the week. Thus, the HIH team changed their workflow to only include twice daily rounds on Mondays. The pharmacist tracked these adjustments in Table 1.

Table 1.

Lessons learned and pharmacist adaptations during HIH program implementation

Lessons learned	Pharmacist adaptations
It was critical to define a clear process to alert pharmacists when new HIH patients would be discharged from the hospital.	HIH provider(s) now notify the pharmacist immediately by telephone when a patient is accepted on the HIH service. This allows the pharmacist time to prioritize time to conduct the first medication reconciliation before the patient leaves the hospital.
Having team rounds twice daily was necessary during early implementation but eventually became burdensome.	After 10 mo, the HIH team stopped twice daily team rounds. Twice daily rounds now only occur on Mondays (to recap on weekend patient changes), followed by once daily rounds Tuesday through Friday.
The pharmacist previously used 1 note template for all medication reconciliations. This made it difficult to differentiate discharge medication reconciliations from postdischarge medication reconciliations by home video telehealth.	The pharmacist created 2 distinct note titles and note templates. Separate visit locations and telephone versus video telehealth codes were created to specify the modality of the medication reconciliation and reimbursement.
Certain elements were required to document a video visit in the electronic medical record.	The pharmacist added the required statement to home video telehealth notes: “Patient consented to participation in an individual medical appointment via video conferencing modality. Consent process included discussion of the privacy and confidentiality as well as the risks and responsibilities unique to Shared Medical Appointments.”
Commonly used medications were cumbersome to order. Medications dispensed for HIH in-home use needed a specific barcode to interface with outpatient pharmacy dispensing systems.	With assistance from IT, the pharmacist generated quick order sets. IT interfaced medications for HIH in-home use with the outpatient pharmacy system so that outpatient pharmacy personnel could use barcode scanning procedures for medication dispensing to the home.
HIH patients received oral and IV medications in the home. Current local pharmacy policies and procedures did not include IV medication dispensing and administration in the home.	The pharmacist created policies and procedures for IV medication preparation, dispensing, and transport in line with local facility and admixture stability standards. The pharmacist trained pharmacy staff on the process of preparing and dispensing an IV medication for in-home use.
The pharmacist was required to present pharmacy-related data in HIH team rounds and to justify time spent on interventions and clinical tasks to justify workload credit.	The pharmacist developed a personal data collection sheet in Excel to record pertinent patient information and track pharmacist-specific interventions (Appendix 2).
New HIH policies and procedures were unknown to existing inpatient and outpatient pharmacy staff at VABHS.	The pharmacist provided continuous pharmacy education to pharmacy personnel to ensure that they understood the process of filling, checking, and dispensing HIH medications (including IV therapy).

Abbreviations used: HIH, hospital-in-home; IT, information technology; IV, intravenous; VABHS, Veterans Affairs Boston Healthcare System.

When the implementation phase was complete, the HIH team enrolled their first patient. HIH enrollment was initiated by inpatient medical teams submitting an electronic consult to enroll a patient in the HIH program. The HIH team reviewed the consult and enrolled patients in the program on the basis of preset inclusion and exclusion criteria. These criteria were adapted from Cincinnati VAMC’s HIH program.

Each time a new patient was enrolled in the program, the pharmacist recorded the patient’s baseline characteristics and the number of medication discrepancies at the time of hospital discharge. The pharmacist updated an electronic patient file for each veteran every morning, including medication changes, laboratory monitoring, vital signs, and active medical problems. The HIH team discussed each patient during inter-professional team rounds. After rounds, the pharmacist’s priority each day was to complete medication reconciliations with the HIH patients and their caregivers. When all medication reconciliations were completed for the day, the pharmacist spent time on HIH clinical tasks, such as deprescribing, coordinating IV medications, and answering drug information questions (Figure 2).

Each patient’s medications were reconciled before and after hospital discharge. At discharge, the pharmacist conducted a chart review to identify discrepancies between the discharge medication list and active outpatient orders. After the patient was discharged, the pharmacist completed a medication reconciliation by home video telehealth or telephone. This was in line with procedures at Cincinnati VAMC, as both programs covered a similar geographic area.⁴ Using home video telehealth and the telephone allowed the pharmacist to remain physically present at the hospital to conduct daily tasks that would be difficult to complete if the pharmacist was traveling or at the patient’s home (e.g., pharmacist-managed IV therapy, interacting with inpatient teams at discharge, conducting multiple medication reconciliations over a large geographic area in a single day). The pharmacist’s time was accounted for based on Current Procedural Terminology codes. The pharmacist billed for either a home video telehealth visit or a telephone visit and was reimbursed as such.

During the postdischarge medication reconciliation, the pharmacist asked the patients and their caregivers, when applicable, to physically gather all of their prescription and nonprescription medications in their home. When using home video telehealth, the pharmacist compared the medication bottles, examined the patient’s pillbox, and identified and resolved inconsistencies in real time. After each medication reconciliation, the pharmacist categorized the medication discrepancies and recorded any resultant interventions in the medical record and in the pharmacist data collection tool in real time (Appendix 2). The pharmacist used validated methods from the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS)¹³ for this process. The pharmacist also tracked the total days of IV therapy per patient in real time in the pharmacist data collection tool.

Evaluation methods

We used the PRECEDE-PROCEED model to guide our implementation approach.¹⁷ Planning models such as PRECEDE-PROCEED allow researchers to understand contextual factors affecting implementation, and are critical for planning and evaluating interventions.^17–22 To evaluate our success in achieving VABHS leadership’s goals, we conducted a formative evaluation. The formative evaluation occurred from May 2019 to March 2020 using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) evaluation framework.^23,24 Our evaluation excluded maintenance, as the HIH program had only been implemented for 1 year.^23,24 The core of our evaluation was the effectiveness and implementation components, described in later text, which aligned with VABHS leadership’s major goals for the HIH program and for the HIH pharmacist.

The effectiveness component of the RE-AIM evaluation focused on medication discrepancies. The pharmacist categorized medication discrepancies on the basis of the MARQUIS toolkit classifications.¹³ A medication discrepancy was considered severe if related to a medication found on the Institute for Safe Medication Practices high-risk list.^25,26 The pharmacist used a deprescribing protocol to guide reduction of inappropriate medications.²⁷

The implementation component of the RE-AIM evaluation focused on medication cost savings, cost avoidance and incremental revenue from the program. We calculated the cost savings from pharmacist-managed home IV therapy by subtracting the total cost of IV drug preparation and administrations from a contracted infusion company from the cost of the same drug prepared and infused by the HIH team. We calculated the cost avoidance from deprescribing by multiplying the individual cost of each drug by the frequency of administration times per day, multiplied by the days of therapy in 1 year. This estimated the 1-year cost if HIH patients had otherwise continued the medications deprescribed by the HIH team. As-needed medications, short-term courses of therapy (e.g., antibiotics) or dose reductions that did not result in a change of prescription quantity (e.g., dose decreasing insulin that did not affect total dispensing quantity) were not included. We calculated incremental revenue on the basis of actual VERA reimbursement to our hospital for HIH patients.¹⁵

Results

Between May 21, 2019 and March 27, 2020, 102 individuals were enrolled in the HIH program. Veterans were an average age of 77 years and were primarily male (99%) and white (89%). HIH patients had a near-maximal care assessment needs (CAN) score of 98, which indicated that patients had a high risk of admission or death within 1 year.²⁸ On average, patients received prescriptions from 13 unique prescribers the year before HIH enrollment and took an average of 17 daily medications (Table 2).

Table 2.

HIH patient characteristics (N = 102)

Characteristic	HIH enrollees (N = 102)
Age, y, mean (range)	77 (51–101)
Male, n (%)	101 (99)
Self-identified ethnicitya, n (%)
White, non-Latino	91 (89)
Black, non-Latino	7 (7)
Other	4 (4)
Admission diagnosis, n (%)
Congestive heart failure	57 (56)
Chronic obstructive pulmonary disease	15 (14)
Infectious disease	15 (14)
End-of-life care	6 (6)
Diabetes complications	4 (5)
Other	5 (5)
VA CAN score 1-yb, mean (range)	98 (90–99)
No. of medications, mean (SD)	17 (7)
No. of unique prescribers in the past year, mean (SD)	13 (6)
Days enrolled in HIH program, mean (SD)	29 (15)
Patients with readmissions within 30 d of HIH enrollment, n (%)	17 (17)
Patients with emergency department visits within 30 d of HIH enrollment, n (%)	10 (10)

Abbreviations used: HIH, hospital-in-home; VA, Veterans Affairs; CAN, care assessment needs.

^aSelf-reported by patient when enrolled in the VA Health Care System.

^bCAN score identifies patients who are veterans who are statistically at the highest risk of hospitalization or mortality in 1 year. This score is the probability of admission or death within 1 year, converted to percentile, in relation to all other enrolled veterans.²⁸

Reach

The HIH team received 126 consults for HIH enrollment: 102 (85%) individuals qualified and were enrolled in the program. Veterans were geographically dispersed across a span of 2850 square kilometers. The pharmacist conducted 99 (97%) discharge and 95 (93%) postdischarge medication reconciliations. Most of the postdischarge medication reconciliations were completed using home video telehealth (n = 71, 75%; Table 3).

Table 3.

RE-AIM outcomes for our process, impact, and outcome evaluation

Domain	Outcome	Count
Reach	Total consults placed to HIH program	126
	Individuals enrolled in HIH program	102 (85)
	Geographic area of HIH patient residences	2850 sq km
	Completed discharge medication reconciliations	99 (97)
	Completed postdischarge medication reconciliations	95 (93)
	Completed by home video telehealth with patient	71
	Completed by telephone with patient	11
	Completed by telephone with home health care provider	13
Efficacy	Discrepancies identified and resolved by HIH pharmacista	453
	Discrepancies identified in 99 discharge medication reconciliationsa	181
	Omitted medication	88
	Incorrect dose	30
	Incorrect frequency	6
	Substitution	1
	Additional medication	56
	Discrepancies identified in 95 post discharge medication reconciliationsa	272
	Omitted medication	36
	Incorrect dose	23
	Incorrect frequency	35
	Additional medication	178
	Total discrepancies involving high-risk medicationsb	84 (19)
Adoption	Patients referred to pharmacist for medication reconciliation	102
	Patients who declined medication reconciliation	7 (7)
	Patients with targeted disease-state management visits	50 (49)
Implementation	Average length of in-home reconciliations, min	28
	Inappropriate medications deprescribed	145
	Days of pharmacist-managed home IV administration	104
	HIH pharmacist time spent on various activities	Figure 2
Cost savings	Cost savings from pharmacist-managed home IV therapyc	$17,000
Cost avoidance	Cost avoided from deprescribingd	$51,000
	Cost avoided from inpatient bed days of caree	$1,200,000
Incremental revenue generated	VERA model reimbursementf	$655,567

Abbreviations used: HIH, hospital-in-home; IV, intravenous; RE-AIM, Reach, Effectiveness, Adoption, Implementation, and Maintenance; VERA, Veterans Equitable Resource Allocation.

Note: Values are given as n (%) unless otherwise specified.

^aPharmacist categorized medication discrepancies based on the Multicenter Medication Reconciliation Quality Improvement Study toolkit classifications.¹³

^bA medication discrepancy was categorized as severe if the discrepancy related to medications found on the Institute for Safe Medication Practices high-risk medication lists.^25,26

^cIV cost savings was calculated by subtracting the total cost of IV drug preparation and administration from a contracted infusion company compared with the cost of the same drug when prepared and infused by the HIH team. Cost included drug cost, administration fee, fee for nurse infusion, and maintenance fees.

^dCalculated by the individual drug cost multiplied by the frequency of administration per day, multiplied by the days of therapy in 1 year. This estimated 1-year cost if the patient had otherwise continued medication as prescribed. As-needed medications, short-term courses of therapy, and dose reductions that did not result in a change of prescription quantity were excluded from total cost savings.

^eCounted the number of consecutive in-person visits a patient had immediately after. HIH enrollment avoided an average 2.4 bed care days per patient. Average cost of hospital care per day as determined by Veterans Affairs Boston fiscal service ($4900). Calculated an estimated cost avoidance by multiplying the number of bed care days saved per patient (N = 102) by the average cost of hospital care.

^fAfter Veterans Affairs Boston Healthcare System program evaluation, approximately 60% of HIH patients were projected to receive VERA funding. Incremental revenue generated was determined by multiplying 60% of HIH patients enrolled in our study by the VERA cost estimate (approximately $10,762) per veteran for fiscal year 2020.

Efficacy

The pharmacist identified a total of 453 total medication discrepancies: 181 (40%) before discharge and 272 (60%) during postdischarge medication reconciliation. The most common error discovered was patients taking additional medications unknown to other VABHS health care providers. Of all of the discrepancies, 84 (19%) were considered high risk (Table 3).^25,26

Adoption

All 102 patients had the opportunity for a postdischarge medication reconciliation, and only 7 (7%) declined. The pharmacist conducted supplementary visits as needed for device teaching (e.g., inhaler, glucometer, insulin pen) and targeted disease-state management for 50 of the 102 patients (49%).

The HIH team determined that supplementary pharmacist visits (e.g., nonmedication reconciliation visits) were more beneficial when teaching patients new devices. The HIH pharmacist learned that teachings after a full medication reconciliation were less efficient than secondary visits dedicated solely to teaching a new device technique. Thus, the pharmacist scheduled a second visit any time patients required training on a device technique for their new medication.

Implementation

Cost savings from medication deprescribing, and cost avoided from pharmacist-managed home IV therapy and early hospital discharge totaled $1.268 million. The pharmacist managed 104 days of home IV therapy, resulting in cost savings of approximately $17,000. The cost avoided by identifying and deprescribing 145 inappropriate medications was approximately $51,000 over 1 year. The HIH program avoided a mean 2.4 bed days of in-hospital care per person through early discharge: this resulted in $1.200 million in cost avoidance. The HIH program exceeded the goal for patient enrollment (N = 102) within the first year and generated $655,567 in incremental revenue through VERA reimbursement.

The average length of in-home, postdischarge, medication reconciliations was 28 minutes. The pharmacist spent variable amounts of times on daily tasks (Figure 2). Finally, the pharmacist made several adaptations to policies and procedures to meet program objectives. These lessons learned are highlighted in Table 1.

Practice implications

Previous studies have shown the efficacy of delivering acute care in the home.^1,2,4–9 We add to existing literature by describing how to integrate a pharmacist into the HIH model. VABHS leadership deemed the first year of the program a success. The cost savings from medication deprescribing and cost avoided from both pharmacist-managed home IV therapy and early hospital discharge totaled $1.268 million. The incremental revenue from VERA reimbursement was $655,567. The total cost savings, cost avoidance, and incremental revenue of the program over the first year was $1.924 million. By contrast, the total HIH cost for the medical center was $1.524 million over the first year.

The VABHS HIH pharmacist directly contributed $17,000 in cost savings (IV therapy) and $51,000 in cost avoidance (deprescribing) over 1 year. We will leverage this data, in addition to the cost avoided from inpatient bed days of care and projected incremental revenue generated from VERA reimbursement, to sustain 1.0 pharmacist FTE and to request additional resources for the HIH pharmacist, such as a clinical pharmacist technician.

The HIH pharmacist identified and resolved hundreds of medication discrepancies. A similar study detailed medication discrepancies that were unique to hospital-to-home care models.²⁹ In this study, most discrepancies identified may have been missed at hospital discharge and were later identified during in-home medication reconciliation. This aligns with our findings, in which the HIH pharmacist identified 272 medication discrepancies (60% of total discrepancies) during postdischarge medication reconciliation through home video telehealth. We designed the HIH pharmacist workflow to have 2 touch points, a hospital discharge medication reconciliation and postdischarge medication reconciliation, which led to further medication discrepancy identification and resolution.

On average, the pharmacist identified 4.6 discrepancies per person among patients with at least 1 medication discrepancy. Many discrepancies involved patients taking medications unknown to other health care providers. We hypothesize that effective motivational interviewing techniques contributed to the pharmacist’s high rates of discrepancy detection. After the training at Cincinnati VAMC, the VABHS HIH pharmacist completed a motivational interviewing training. The pharmacist employed best practices from the MARQUIS toolkit for each medication reconciliation.¹³ For example, the pharmacist asked open-ended probing questions to identify undocumented medications including the use of potentially inappropriate over-the-counter (OTC) medications (e.g., “what medications do you take for sleep” to possibly help identify self-initiated OTC diphenhydramine³⁰).

The pharmacist leveraged home video telehealth to conduct most (75%) postdischarge medication reconciliations. Video technology may have also contributed to the pharmacist identifying additional discrepancies in patients’ home medication supplies.^31,32 The added benefit of video technology for home medication reconciliation may be highlighted with an example from 1 HIH patient in which the pharmacist conducted a postdischarge video medication reconciliation and virtually visualized the patient’s pillbox. The pharmacist identified that the patient was taking an incorrect dose of warfarin by seeing the number and color of warfarin tablets in the patient’s pillbox, which may not have been detected without in-home video capabilities.^31,32 The pharmacist coached the patient to remove the warfarin from the pillbox and to insert the correct warfarin dose. The pharmacist then notified the HIH team and the VABHS anticoagulation clinic to coordinate an in-home laboratory draw to ensure that the patient’s international normalized ratio was at a therapeutic level.

Our study had several limitations. Our patients were primarily white, older males, at a single VA site, which may have limited generalizability. We conducted a formative evaluation from May 2019 to March 2020 of the HIH pharmacist implementation; we did not conduct a comparative analysis of outcomes before and after implementation. VABHS has seen a drop in admissions for ambulatory care sensitive conditions from 32.7 (fiscal year 2019 [FY19] quarter [Q] 1) to 28.8 (FY19 Q3) per 1000 patients based on Strategic Analytics for Improvement and Learning quality measures.³³ The HIH program may have contributed to this positive trend.

We did not assess patient satisfaction as part of this evaluation. In the future, we plan to compare the clinical, quality, and safety outcomes before and after HIH implementation. Patient satisfaction measures will be included in this evaluation. We anticipate IV cost savings to be higher as VABHS IV rooms are currently under construction, which limited our full compounding capabilities. After 2 years of program implementation, VABHS leadership will evaluate the effect of HIH implementation on hospital readmission rates, hospital length of stay, and acute care use.^2,4–8 The HIH team is also expanding their practice to admit patients directly from the emergency department and outpatient clinics for HIH care, avoiding a hospital admission altogether. As the program expands, the team may leverage the HIH pharmacist cost savings data to justify additional pharmacy personnel to meet the growing HIH workload.

Conclusion

Integrating a pharmacist into the HIH model enables the detection and resolution of medication discrepancies, medication deprescribing, and the management of home IV therapy to reduce medication cost. Future studies are needed to evaluate the VABHS HIH impact, beyond the scope of pharmacy, on hospital readmission rates and length of stay.

Supplementary Material

Suppementary data

Supplementary data related to this article can be found at https://doi.org/10.1016/j.japh.2021.01.003.

Key Points.

Background:

Hospital-in-home (HIH) is an innovative model that provides hospital-level acute care in a patient’s home. This model has demonstrated a reduction in mortality, readmission rates, and cost compared with an inpatient stay.

Hospitalizations are often associated with medication discrepancies at transitions of care.

Pharmacists can enhance the HIH model through medication reconciliation and medication regimen optimization.

Findings:

We describe how to integrate a pharmacist onto the HIH team and what the pharmacist contributed to the HIH team.

We conducted a formative evaluation of integrating a pharmacist into the HIH model, including the cost savings and cost avoidance associated with the pharmacist’s activities.