Dr. Lipi Soni, a transitional care pharmacist at Trinitas Regional Medical Center in Elizabeth, New Jersey, counsels patients on their medications after they are discharged from the hospital and, in some cases, makes a follow-up visit to the patient’s home or meets with them in her office. Her work is part of a program funded by the Grotta Fund for Senior Care of the Jewish Community Foundation of Greater MetroWest NJ—in collaboration with Holy Redeemer Home Care North and Jewish Family Service of Central New Jersey—in which patients identified as high risk for readmission receive a home visit from a nurse practitioner and/or a pharmacist after hospital discharge.

A recent example of her work occurred when Dr. Soni saw a congestive heart failure (CHF) exacerbation patient. Dr. Soni talked to the patient about the new program and promised to visit her at home after discharge. However, when Dr. Soni tried setting up an appointment, the patient refused because she had a visiting nurse that also saw her regularly. After several attempts, Dr. Soni convinced the patient to allow her to visit at home. The patient was a little skeptical at first, but when she saw Dr. Soni and realized she was the same person that had visited her in the hospital, she became more welcoming.

During the home visit, Dr. Soni asked the patient to bring out all of her medications so that she could review what each was used for, how to take it and any side effects that may occur.

“I always start by asking what the patient knows about his or her disease and medicine,” Dr. Soni said. She mentioned the importance of understanding that each patient is different and may require diverse methods of education on these important topics.

“My job is to make sure they understand what is going on and how they can manage themselves better,” Dr. Soni said. “We package this information to suit the patient’s needs and understandings.”

Dr. Soni also checked each medication bottle to determine how many pills were left and whether or not the patient was compliant. While doing so, Dr. Soni came across a bottle of glipizide (a diabetes medication), which was filled to the top. Upon further inspection, Dr. Soni realized the patient had mixed two medications together. She had combined the glipizide in the same bottle with digoxin (a potent heart medication). Instantly, Dr. Soni separated the two medications to fix the problem.

“I immediately told her not to refill new bottles of medications into older bottles because this is a huge error,” Dr. Soni said.

Had Dr. Soni not caught this error in time, the patient could have experienced a serious adverse drug event, which could have led to patient harm and quite possibly a return to the hospital.

This program exhibits important and effective medication safety and Dr. Soni believes that home visits should be conducted for most patients, especially those at high risk for readmissions.

“Patients often think that health care is only available at doctor offices or hospitals; they don’t think that health care can continue in their homes. It helps when a health professional comes to their home and demystifies the self-care process,” Dr. Soni said. “Home visits can also help ensure that the patient is able to manage their health at home and continue his or her recommended diet that was started in the hospital, as well as take medications safely and compliantly.”

“Over the past four years, we developed a team of health care professionals and community partnerships that addresses the medical, social and economic issues that contribute to hospital readmissions. This past year, complex medication issues were addressed by adding a pharmacist to the team,” said Monica Castano, RN, BSN, Interim Administrator/Director of Nursing at Holy Redeemer Home Care North.

“Numerous national studies show that the home is the best setting for providing health care for older adults – not only is it less expensive, but it is a key to optimal health outcomes,” said Renie Carniol, Director of the Grotta Fund for Senior Care, an Advisory Council Fund of the Jewish Community Foundation of Greater MetroWest NJ.


Quality Insights Quality Innovation Network originally published this patient story