Existing Knowledge and Barriers to Widespread Implementation of Medication Education Programs

A number of smaller studies of patient discharge processes and related medication education programs have been published reporting positive results on patient safety outcomes. 

Harrison et al 2001 have shown that reorganization of discharge planning and transition care to include a patient workbook and an education map stored in a patient-held documentation tool leads to significant improvements at six weeks in the quality of life of heart failure patients. The work of Pollum 2004 has illustrated that a multidisciplinary system for early preparation of diabetic patients for hospital discharge, including medication education and counseling by a multidisciplinary care team, provides effective diabetes care management and is helpful in modifying risks to patients with diabetes in the hospital setting.  Survey results from Beggs et al 1998 illustrate that coronary artery bypass graft patients’ perceived knowledge about adverse effects of medications was inversely associated with length of stay, and that their highest learning priorities include possible complications, incision care, whom to call with questions, and medication schedule.  An evaluation of the impact of discharge information conducted by Henderson et al 2001 showed that surgical patients who had received information regarding wound care and pain management from a nurse were less likely to access a health facility than those who did not receive information.  However, at one to two weeks post-discharge, there was no evidence that patients who believed that they were appropriately educated within 24 hours of discharge still felt well informed.  An assessment of patient expectations of and satisfaction with the hospital discharge planning process following total hip-joint replacement surgery conducted by Fielden et al 2003 demonstrated that patients receiving information at appropriate times had improved satisfaction with their discharge planning processes.  However, written information was viewed as restrictive for dialogue with health professionals, limiting patient knowledge and understanding of recovery. 

With respect to medication education in particular, prior research has shown that successful programs lead to improved medication adherence behaviors, reduced patient stress, and improved function of daily living (Cortis 1996).  Al Rashed 2002 found that the combination of medication information with pharmaceutical counseling and medication reminder cards leads to a significant increase in patient adherence and decrease in hospital readmission; inpatient counseling was found to be cost effective in light of the decrease in readmissions.  A study by Evans et al 1996 showed a significant increase in knowledge of medications among psychiatric patients when educational sheets are combined with clinical discussion, concluding that this practice may be easily replicated in different treatment settings with larger numbers of patients.  Finally, Calabrese et al 2003 found that a multidisciplinary medication education program including continuous verbal and written medication education by nursing throughout the hospital stay, improved medication administration. In addition, pharmacist and respiratory consultation was shown to result in a significant increase in specific medication knowledge as well as improvements in satisfaction and adherence among general medicine patients. (The Calabrese study is described more fully in Section C).

Despite the positive patient safety outcomes achieved in these studies, a number of barriers to widespread implementation and expansion of these and similar programs have been identified, including limited funding, lack of generalizable data across all patient units, and inconsistent implementation. Additional barriers identified in the literature include early hospital discharge (Martens 1998); lack of good communication (Al Rashed 2002); medication education programs that are inappropriately targeted to patients’ health literacy levels (Cortis 1996, Baker 1999); and inadequate training of clinicians or lack of time allocated to clinicians for providing appropriate patient education, assessing patient knowledge, needs, and understanding, and reinforcing education (Brukhead 2003).  Inadequate health literacy has significant impact on medication adherence, and it is essential to target medication education programming to the appropriate patient level  (Baker 1999). 

The Utility of the Proposed Approach for Advancing Knowledge in the Field: The Healthy People 2010 initiative seeks to increase quality and years of healthy life through areas that include educational and health communication.  (Healthy People 2010).  As prior research has shown, the development of effective discharge medication education programs requires a multidisciplinary, multifaceted approach that provides consistent, ongoing education, patient assessment, and reinforcement (Robinson 1996, Haynes 2004, Calabrese 2003, Mallion 2001).  Multi-focused medication education interventions are clearly more successful than single component interventions (Dunbar-Jacob 2001).  Despite numerous reports of the benefits of patient counseling in community and ambulatory settings, and accumulating data on the benefits of inpatient counseling as well, there has not yet been a report of an ideal, consistent, sustainable, outcomes-driven model for the discharge medication education process. Our work addresses this gap by using the established benefits of the Calabrese medication education model as the foundation for an administratively supported, hospital-wide patient medication education system designed to enhance specific patient safety outcomes, including polypharmacy, 30-day hospital readmission, patient satisfaction, and medication adherence behaviors.