As Larry Greer neared the end of a week-long stay at the MedStar Washington Hospital Center, he grew anxious.
Greer, 57, had suffered a severe leg burn in a hot bath at home in May. Greer has diabetic neuropathy, which reduces feeling in his legs, and he didn't realize how hot the water was. He received a skin graft at the hospital, where daily doses of oxycodone helped ease the pain.
Greer, of Washington, lives alone, uses a wheelchair and would be going home with a bulky bandage on his leg. He wondered how he would get to the pharmacy several blocks from his apartment building for the narcotic he'd need on his first day home.
But Greer didn't need to worry about that. After counseling him about the painkillers, a pharmacist at the hospital left a few days' supply at the nurses' desk. "That was so helpful, because it took away the need for the trip to the pharmacy, and the stress," Greer said.
The University of California at San Francisco Medical Center, the Ronald Reagan UCLA Medical Center and the Montefiore Medical Center in New York are among many hospitals nationwide that have begun "meds to beds" or "meds in hand" programs, in which prescription drugs are given directly to patients just before they are sent home.
About 35 percent of U.S. hospitals offer discharge prescriptions, according to a 2016 survey by the American Society of Health-System Pharmacists.
Many hospitals begin the meds-to-beds program with a single department, such as cardiology or transplant medicine, see how well it works and then add more.
Because hospital pharmacies can bill only for medications used on the premises, drugs that will be used at home must come from outpatient pharmacies. While some hospitals have long had pharmacies for patients whose doctors have outpatient offices on the facility's grounds, others have recently added on-site pharmacies that all inpatients can use at discharge. Many hospitals, including UCSF, partner with Walgreens for both discharge counseling and dispensing.
The recent growth in meds-to-beds programs stems from a 2012 Medicare rule that penalizes hospitals if patients are readmitted within 30 days of discharge, said John Rother, president of the nonprofit National Coalition on Health Care.
"And once Medicare acted, other insurers began levying penalties for early readmission as well," said Joshua Seidman, a senior vice president at the health-care consulting firm Avalere. To avoid fines, Seidman said, many hospitals launched "transitions of care" programs that connect patients with post-hospital services such as follow-up doctor visits and medications to be used at home.
Data published this year by the Kaiser Family Foundation suggests such efforts work: Hospital readmissions have fallen since 2012, although how much can be attributed to the new prescription programs isn't broken out by Kaiser. Tricia Neuman, senior vice president and director of Kaiser's program on Medicare policy, said: "For older patients with complex medical conditions or dementia, taking their drugs, as prescribed, can be a serious challenge unless they have the support they need once they get home. Programs that target patients as they transition from one setting to another can help avoid preventable U-turns to the emergency room or hospital — which could lead to better patient care and lower costs."
Several studies confirm that patients don't always fill prescriptions, even after a hospitalization. A 2010 study of more than 75,000 recently discharged patients found that almost 30 percent failed to pick up a first-time prescription. That failure can be deadly. A 2014 study found that, over a two-year period, 30 percent of more than 15,000 Canadian hospital patients who had stents inserted to open blocked coronary arteries failed to pick up prescriptions for the blood thinner clopidogrel (Plavix) within three days of being discharged.
"Following a stent insertion, patients have to take clopidogrel daily, often for life," said Nilesh Desai, administrator of pharmacy and clinical operations at Hackensack University Medical Center in New Jersey. Clopidogrel helps keep blood clots from forming in the stent, preventing further heart problems that can lead to death.
In 2011, Louis Teichholz, Hackensack's chief of cardiology, in collaboration with the hospital's pharmacy services department, launched a meds-to-beds program that targeted recent stent patients. A survey two years later found that the opt-in rate for the program was 94 percent.
Two small studies indicate the programs can reduce readmission rates. Researchers at Ohio State University's Wexner Medical Center found that the hospital's baseline readmission rates for stent patients from July 2015 to June 2016 was 17.8 percent — higher than the national average of 16.5 percent. But the hospital found that the readmission rate fell to 10 percent between June and November 2016 for 75 stent patients who participated in the discharge medication program. And a 2016 study of 124 children hospitalized for asthma found that the 77 children whose families opted to get medications at discharge reduced their odds of returning to an emergency room within 30 days by 78 percent compared with those who didn't use the program.
Marilyn Stebbins, vice chair of clinical innovation at the UCSF School of Pharmacy, said meds-to-beds programs, such as the one she helped launch, often reduce barriers, such as transportation, insurance authorizations, concern about tiring the patient or leaving them at home alone while caregivers pick up medications, and cost.
"It was so carefree, all I had to do was come home," said Bette Taylor, who had a kidney transplant at UCLA last year. "I didn't have to go to the pharmacy as I had to do after many previous hospitalizations."
But this is no mere drop-off service. Counseling about the medication is a critical component of the meds-to-beds programs. Taylor said a pharmacist went over all 23 new drugs prescribed for her, provided a list, taught her how to pronounce the drugs' names to help her ask questions, and gave her a business card so she could follow up with any questions. Many programs have a pharmacist contact the patient within a day or two, and a week or two later.
Patients have co-pays, just as they do at their neighborhood pharmacy, and pharmacists accept credit cards or cash at bedside. But they also check insurance coverage. If the prescribed drug isn't covered or the patient is unable to cover the co-pay, the pharmacy staff works to find a less expensive drug or helps the patient apply for discounts.
"Problems that can take days or longer to resolve when a patient tries to fill a prescription at a neighborhood pharmacy can usually be resolved before a patient goes home," Stebbins said. At Montefiore, for example, the prescription discharge team includes a social worker who can help access hospital funds for the co-pay if a patient can't afford the cost as well as help patients navigate benefits to pay for future doses.
For some drugs — such as blood pressure medication, which can require a dose adjustment after it is first prescribed — hospital physicians may prescribe only a short-term course and advise patients to follow up with their doctor when they return home. For longer-term drugs such as clopidogrel, some programs will dispense the discharge prescriptions and send refill prescriptions to any pharmacy the patient chooses.
Some patients who opt out of meds-to-beds programs do so because they want all their prescriptions dispensed from their local pharmacy, said Jonathan Hatoun, lead author of the report in Pediatrics. In that study, a third of parents preferred to have their children's prescriptions sent to their neighborhood pharmacy.
Patients learn about the programs from pharmacists and nurses and from discharge brochures, as Taylor did at UCLA. At Montefiore, information about the program plays on the in-house television network that patients watch.
Many hospitals start the discharge medication process as early as admission, asking patients then whether they want to opt in. Pharmacists work with doctors to learn which drugs will be prescribed and when the patient is likely to be discharged.
Hospitals with their own outpatient pharmacies may earn substantial profits from the service, said Regina Lohr, a senior consultant with the Advisory Board Co. At Hackensack, for example, at least 40 percent of patients who chose to get their medications at discharge continued to use the hospital's pharmacy for other prescriptions. While that may be a good option for some patients, Hatoun said he hoped that the pharmacists who dispense the discharge drugs make it clear that patients do not need to continue using the hospital pharmacy and that they don't feel pressured to leave their neighborhood drugstore.
The programs are not without bugs. For example, many hospitals provide the service only when the on-site pharmacy is open and thus may not be able to dispense medications if a patient is discharged at an odd hour. And the Institute for Safe Medication Practices recently issued an advisory noting that some patients had been given their daily medication in the hospital on their discharge day and taken the drug again when they got their package of medications for home.
"One reason MedStar Washington Hospital Center has nurses store the drugs rather than leave them with the patients," said Jenny Brandt, a pharmacist at the center, "is for a final reminder about which drugs to take when."
Correction: An earlier version incorrectly reported that UCLA partners with Walgreens on it discharge pharmacy. UCLA operates its own discharge pharmacy.