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Learn how Crusader Community Health took control of medication requests by implementing an annual prescription refill process and electronically routing medication refill requests and prior authorizations to divert them from provider inboxes.
Crusader Community Health (Crusader) is a nonprofit organization of 75 providers caring for the underserved in Rockford, Illinois. Most of the providers specialize in primary care. More than 230,000 outpatient visits take place each year at the 8 Crusader Community Health clinic locations. Crusader serves more than 55,000 patients every year, including 40% of the area's underinsured population.
The medication refill process was frustrating and creating stress. There were three main contributors to this problem:
First, all requests for refills during the day were being sent directly to the providers' inbox, but the providers didn't have time to address them. The number of refills continued to grow throughout the day while the providers were busy seeing patients in clinic. Stress increased along with the number of requests in the inbox.
Second, by the time providers were able to send the refills it was the end of the day or they were sending them after hours from home. Patients were left waiting hours, or sometimes until the next day, for their medications.
Third, if a patient was completely out of medication the nurses were instructed to interrupt the provider and “catch her between patients”. This distracted the provider from the patient or problem at hand, and each time they were interrupted it took time to refocus. This also disrupted the nursing workflow and contributed to the nursing team's stress.
Once a year Crusader leadership holds a dinner to re-energize the staff and honor their hard work. During this event they often host a speaker to share relevant practice improvement tips. After hearing a talk about more efficiently managing medication refills, the team was struck by the amount of time that could be saved by writing a prescription for a chronic medicine for 1 year rather than every 6 months. At the same time, they were considering how to address the challenges posed by prior authorizations.
The team started a task force of the Pharmacy and Therapeutics (P&T) Committee to address these issues. This multidisciplinary group reevaluated these issues under the direction of Laura Dee, PharmD, and Shayna Chiarelli, RN, BSN. The task force met 6 times over a 2-month period to discuss potential interventions.
The task force took four actions:
First, all current providers started following annual prescription renewal protocols. Annual prescription renewal is the process of writing a prescription for a 90-day supply that is filled 4 times over the course of the year (90 x 4). Input from the teams guided how medications and criteria were selected to establish the protocols.
Second, they launched an orientation program to train new providers and make them aware of the benefits of annual prescription renewals. Dr Dee created and leads the program, which stresses the importance of medication adherence as well as the positive impact and timesaving they can realize by prescribing medications once per year.
Third, all medication refill requests and prior authorizations were electronically rerouted to a new inbox named "medication request bin." This bin was assigned to a single nurse at 1 of the 5 clinics where the provider offered care.
Lastly, standing orders were developed to enable the nurse to quickly and efficiently address medication requests coming into the medication request bin. These standing orders included categories of eligible medicines, contraindications to a full 1-year refill, such as no recent lab or no visit to the provider within the last year, and approved substitutions. For example, asthma inhalers were one category where several substitutions were covered by standing orders. Additionally, the task force agreed on classes of medicine that were not eligible for annual refills and this was included in the standing orders.
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Some providers were reluctant to delegate medication requests and send them to the newly created bin because they felt it meant they were “losing control of their patients.”
Annual prescription renewals
The benefits of refilling medications for 1 year rather than 6 months will be realized soon. Crusader expects an approximately 50% decrease in the number of refill requests. The time saved will hopefully be used to uncover nonadherence to first-line therapies, thus decreasing need for prior authorizations or streamlining the prior authorization process.
Medication refill bin and standing orders
The first week nurses filled approximately 500 prescriptions for 1 year according to standing orders, addressed 130 prior authorizations, and identified 136 duplicate medicine refills (these had already been sent by a nurse or provider). One nurse noted that she was able to handle about 90% of the requests on her own, leading to less delay for the patient as well as fewer repeat requests. The organization did not need to hire additional nurses to complete this task.
Providers immediately noted a 70% decrease in medication requests in their inbox and fewer interruptions throughout the day. Nurses found that time was saved immediately because urgent phone calls from patients and pharmacies decreased, as did the number of duplicate requests. Patient satisfaction improved and provider stress was alleviated.
In 10 months, 27,400 messages, 3,400 prior authorizations, and over 7,000 duplicates were filtered through all medication request bins. The duplicates were subsequently deleted. Over this time, nurses noted that they were efficiently able to handle about 70% of the requests—meaning that only 30% of the previous request volume was now being sent directly to providers.
Providers who expressed reservations about the medication request bins are now comfortable utilizing a team approach to medication refill requests and are asking to expand the program.
The nurse medication request bin has not realized the same benefits as the physician bins. Analysis suggested two possible issues: 1) quarterly formulary updates that result in the need to send a new medication refill to the pharmacy and 2) prior prescription numbers not being linked to newly written prescription numbers. Crusader recognizes that this workflow will continue to evolve, and the organization hopes for a decrease in volume over time with the realization that some necessary changes at the pharmacy and insurance plan level are out of their control.
Dr Dee and Nurse Chiarelli hope the interventions described here will free up provider time, so they are able to establish more meaningful relationships with patients, build trust, improve adherence and ultimately improve patient outcomes. Nurses hope to have time to provide outreach to patients who failed appointments while also improving quality of care.
This workflow change decreased medication related inbox messages for the providers by 70% across the organization. After this experience, providers are excited to expand upon developing standing orders and are embracing a greater team-based approach. This positive, cost-neutral workflow change resulted in better patient care, saved time, and more joy in their practice. Providers are leaving work on time with less frustration and an empty inbox, renewed to return to work the next day with more energy and empathy!
“Just a note to tell you how much a difference it has made with the volume of telephone messages and amount of time spent answering them since the nurses have been allowed to fill medications. As you know, on Fridays, which is my day off, I always go into ECW and tie up any loose ends from the week and also answer telephone messages. I could have as many as 30 TEs to answer by 10 a.m. on a Friday and spend up to 2 hours working on those alone. In the past few weeks, that time has been reduced to half. I've also noticed how I am able to work on writing my morning notes over the noon hour, instead of spending that hour answering telephone messages. Thanks for making a difference and addressing such a need. I'm sure other providers are seeing a change, too.” —Lynn Yontz, APN
“Incorporating RNs into the medication refill process has given patients the ability to receive their medications in a much timelier fashion. It has also allowed providers to spend additional face-to-face time with their patients or allotting them more time to handle more critical situations because they have the reassurance the RNs are assisting with this task. Additionally, it has allowed nurses to practice at the top of their scope.” —Jackie Aleksich, RN, BSN; Medical Unit Manager
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