Implementation and Evaluation of a Prior Authorization Workflow for New-Start Inpatient Medications in Preparation for Discharge

Abstract

Purpose: Medications that require prior authorization can complicate the discharge planning process. This study implemented and evaluated a process for identifying and completing prior authorizations during the inpatient setting prior to patient discharge. Methods: A patient identification tool was developed within the electronic health record to alert the patient care resource manager of inpatient orders for targeted medications that frequently require prior authorization with the potential to delay discharge. A workflow process using the identification tool and flowsheet documentation was developed to prompt the initiation of a prior authorization, if necessary. Following hospital-wide implementation, descriptive data for a 2-month period was collected. Results: The tool detected 1353 medications for 1096 patient encounters over the 2-month period. The most frequent medications identified included apixaban (28.1%), enoxaparin (14.4%), sacubitril/valsartan (6.4%), and darbepoetin (6.4%). For the medications identified, there were 93 medications documented in the flowsheet data for 91 unique patient encounters. Of the 93 medications documented, 30% did not require prior authorization, 29% had prior authorization started, 10% were for patients discharged to a facility, 3% were for home medications, 3% were medications discontinued at discharge, 1% had prior authorization denied, and 24% had missing data. The most frequent medications documented in the flowsheet included apixaban (12%), enoxaparin (10%), and rifaximin (20%). Of the 28 prior authorizations processed, 2 led to a referral to the Medication Assistance Program. Conclusion: The implementation of an identification tool and documentation process can help improve PA workflow and discharge care coordination.

Impact of a Standardized, Pharmacist-Initiated “Test-Claim” Workflow for Anticipating Barriers to Accessing Discharge Antimicrobials

“…However, these barriers might be best suited to be addressed inpatient rather at the point of discharge or outpatient pharmacies. 19 This may also be true in dealing with PAs, one of the most common prescription-related barriers. 14 Prior-authorization, a cost containment tool to ensure appropriateness, can take 30 minutes phone-conversations per prescription to clarify 20 and is associated with delay in acquisition of medications.…”

“…22,23 Individuals of non-Caucasian race were more likely to have public insurance and poor outcomes as well. [24][25][26] Alternative approaches to DMCI have largely focused on dealing with pre-identified medications with high likelihood of requiring PA. 19 However, if an insurance's formulary list and PA criteria are frequently updated and not easily accessible, this approach can have limited impact. It can also be tedious and time consuming, especially if PA requirement is evident at point of discharge.…”