2026 Eastern States Conference

Title: Adverse reactions by body mass index in intensive care unit patients receiving dexmedetomidineAuthors: Dellani Fix, PharmD; Brian Hodges, PharmD, BCCCP, BCNSP; Brian Burton, MS
Learning Objective: At the conclusion of this presentation, the participant will be able to describe the relationship between body mass index and hemodynamic adverse reactions in intensive care unit patients receiving dexmedetomidine. Background/Objective: To compare rates of hypotension and bradycardia in obese versus non-obese intensive care unit patients receiving dexmedetomidine infusions.Methods: This retrospective, single-center cohort study evaluated adult intensive care unit patients who received dexmedetomidine for at least 24 hours between January 1, 2022,and January 1, 2023, and were hemodynamically stable at initiation. Exclusion criteria included age less than 18 years, transfer on dexmedetomidine, cirrhosis, alcohol use disorder, mechanical circulatory support, pacemaker, or procedural sedation only. Patients were stratified by body mass index greater than 30 kilograms per meter squared. Primary outcomes were incidence of hypotension (systolic blood pressure less than 90 millimeters of mercury) and bradycardia (heart rate less than 55 beats per minute). Secondary outcomes included intensive care unit length of stay and vasopressor initiation within one hour. Outcomes were compared between groups. 
Results: Of 639 patients screened, 147 met inclusion criteria, including 82 obese and 65 non-obese patients. Maximum dexmedetomidine dose was similar between groups. Bradycardia occurred in 21.9% of non-obese patients and 18.5% of obese patients (p=0.60). Hypotension occurred in 62.2% of non-obese patients and 49.2% of obese patients (p=0.12). No significant differences were observed in secondary outcomes.
Conclusions: Obesity was not associated with increased hemodynamic adverse reactions or differences in clinical outcomes in patients receiving dexmedetomidine infusions. These findings support the use of total body weight-based dosing in patients with obesity.

Title: Characterizing Urine Drug Screening Utilization in Patients with Medication Use Agreements within a Learning Health System
Authors: Julia Iskra, PharmD, Donielle Beiler, BS, Antoinette Dicriscio, PhD, Vanessa Troiani, PhD
Learning Objective:
At the conclusion of this presentation, audience members will be able to describe medication use agreement (MUA) adherence and urine drug screen (UDS) ordering habits for patients seen by an MTDM pain management clinic.
Background/Objective: Patients prescribed controlled substances sign a medication use agreement (MUA), allowing for routine urine drug screening (UDS) monitoring. Examining UDS and clinical actions in MUA patients may highlight ways pharmacists can improve patient care.
Methods: We conducted an observational quality improvement analysis to document current clinical processes and outcomes related to UDS compliance and standard practices within the context of MUAs. We began by documenting initial clinical observations from interactions with patients with MUAs in the context of standard clinical care. We are in the process of auditing a subset of patients with MUAs, referred to a medication drug therapy management (MTDM) pain management pharmacist in January and February of 2026. Patients were only included if they completed an intake visit. Extracted data on each patient will include demographics, details of the MUA, UDS order history, panel components, and confirmatory testing. Using the data extracted from patient records, we will assess MUA policy adherence and UDS ordering heterogeneity as the primary outcomes.
Results: Initial observational analysis demonstrated practice variability in UDS ordering, with inconsistent panel composition, underutilization of confirmatory testing, and the absence of standardized protocols, suggesting opportunities for process improvement. For the audit phase, 23 patient charts were identified as relevant for review based on referral and MUA data. A standardized chart review extraction tool was developed to operationalize UDS-related process and outcome measures within pain pharmacist referral workflows, allowing for systematic assessment of current practice variation and identification of quality improvement opportunities. Chart review is currently ongoing; results will be shared at the conference.
Conclusions: This quality improvement study evaluates UDS ordering compliance and result monitoring for patients with an active MUA referred to an MDTM pharmacist. Our chart review aims to standardize UDS documentation, identify deviations from MUAs, and improve pharmacist-led monitoring to support safer prescribing and controlled substance management.
Self-assessment question: What role can pharmacists play in ensuring MUA adherence and consistent UDS monitoring?

Clinical outcomes of daptomycin and ceftaroline combination therapy in methicillin-resistant Staphylococcus aureus bacteremia
Bailey Coleman, PharmD; Meredith Todd, PharmD, BCPS, BCIDP; Brian Burton, MS
Learning Objective
Describe the risks of 30-day recurrence, in-hospital mortality, and readmission with combination daptomycin and ceftaroline versus early de-escalation in methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.
Self Assessment Question
True or False: Early use of combination daptomycin and ceftaroline therapy may influence clinical outcomes in MRSA bacteremia.
Background
This study aims to evaluate clinical outcomes of combination daptomycin and ceftaroline therapy for MRSA bacteremia. Vancomycin or daptomycin are first-line agents, though the optimal timing and duration of combination therapy remain unclear.
Methods 
This retrospective observational study screened patients between September 14, 2016, and May 31, 2025. The primary outcome was a composite of clinical failure, including 30-day recurrence, in-hospital mortality, and 30-day readmission. Secondary outcomes included bacteremia duration and antibiotic exposure, including time to escalation, combination therapy duration, and monotherapy duration after de-escalation. Patients receiving more than 7 days of combination therapy were assigned to cohort 1, and those de-escalated within 7 days comprised cohort 2.
Results 
Among the 54 patients included in this study, there were n=46 patients in cohort 1 and n=8 patients in cohort 2. The primary outcome of 30-day recurrence occurred in 6.5% vs. 25% (p=0.15), in-hospital mortality in 4.3% vs. 0% (p=1.00), and 30-day readmission in 15.2% vs. 50% (p=0.05) in cohorts 1 and 2, respectively.
Conclusion
Based on data collected, there were no significant differences in 30-day recurrence, in-hospital mortality, or bacteremia duration between prolonged combination therapy and early de-escalation. However, 30-day readmission was higher among patients de-escalated within 7 days, suggesting daptomycin plus ceftaroline may be an acceptable alternative for MRSA bacteremia, though larger studies are needed to evaluate earlier use.

Title: Comparing 30-day readmission rates with varying diuresis strategies in heart failure exacerbation
Authors: Kaitlyn Burchett, PharmD; Jaclyn Collier, PharmD; Brian Burton, MS; Michael Czupryn, PharmD, BCPS
Learning Objective: Explain the potential implications of diuresing until achieving a rise in serum creatinine during an acute heart failure exacerbation.
Self-assessment Question: How can the achievement of a serum creatinine rise while diuresing during a heart failure exacerbation impact the guideline-directed medical therapy prescribed at discharge?
Background/Objective: Guidance on how to diurese patients with heart failure (HF) exacerbations exists but does not address determining euvolemia. The aim of this study was to assess the effect of diuresing until a serum creatinine rise and its impact on HF readmissions.
Methods: Medical records of patients aged 18 years or older admitted to non-intensive care units at Charleston Area Medical Center Memorial Hospital with an acute left-sided heart failure exacerbation from January 1st, 2024, to January 1st, 2025, were retrospectively reviewed. Records were selected by relevant ICD.10 codes and included the entire spectrum of ejection fractions. Thirty-day readmission rates and lengths of stay were compared between patients who did and did not achieve an increase in serum creatinine (SCr) of at least 0.3 mg/dL from the lowest documented SCr during the qualifying admission.
Results: Out of the 1453 patients reviewed, 479 met inclusion criteria. Of those included, 141 achieved a bump in SCr. This increase in SCr resulted in a higher readmission rate than not achieving an increase (19.1% vs. 16.0%; P=NS) and was associated with a lower likelihood of being discharged on all components of guideline-directed medical therapy (GDMT) for heart failure. Length of stay was significantly shorter for patients without a SCr bump (6.8 days vs. 6.2 days; P=0.0152).
Conclusions: In patients with acute left-sided HF exacerbations, diuresing with intravenous loop diuretics until achievement of an increase in SCr does not appear to positively impact HF readmission rates and may negatively influence the GDMT patients are prescribed at discharge. Thus, this diuretic strategy cannot be recommended at this time.

Title
Efficacy of sodium zirconium cyclosilicate versus lactulose in the treatment of acute hyperkalemia

Authors
Debika Kundu, PharmD; Alexa M. Campbell, PharmD; Kerri M. Smith, PharmD, BCPS; Jennifer A. Szwak, PharmD, BCPS, FCCP; Michael Snitzer, PharmD; Jose Manuel Monroy-Trujillo, MD; Dannielle R. Brown, PharmD, BCPS

Learning Objective
Compare the efficacy and safety of sodium zirconium cyclosilicate (SZC) and lactulose for treatment of acute hyperkalemia.

Background/Objective
Quantify and compare the efficacy of sodium zirconium cyclosilicate (SZC) and lactulose for potassium (K) reduction in acute hyperkalemia (K ≥ 5.5 mmol/L) and evaluate safety by assessing the incidence of hypokalemia

Methods
This single-center, retrospective study included adults treated for acute hyperkalemia who were admitted to internal medicine services or treated in the emergency department between March 2020 and June 2024. Patients were included if they had serum potassium ≥ 5.5 mmol/L and received SZC or lactulose for treatment of hyperkalemia. Patients were excluded if they received intravenous insulin or hemodialysis within 24 hours of the index elevated potassium. Concomitant medications affecting potassium given within 24 hours of index elevated potassium were documented. Potassium was assessed at 6, 12, and 24 hours following the index potassium value. The primary endpoint was change in potassium at 12 hours. Secondary endpoints included change in potassium at 6 and 24 hours, the proportion achieving potassium < 5.5 mmol/L at 6, 12, and 24 hours, incidence of hypokalemia (K < 3.5 mmol/L), and quantification of study medication utilization.

Results 
A total of 341 hyperkalemia episodes involving 317 unique patients were included. Median age was 61.5 years, 42.5% were female and 20.8% had chronic kidney disease. SZC and lactulose were used in 65.7% and 34.3% of the incidences with median total doses over 24 hours of 10 g and 30 g, respectively. At 12 hours, K reduction was similar (-0.6 vs -0.55 mmol/L, p=0.208) with similar rates achieving K < 5.5 mmol/L (60.3% vs 61.9%, p=0.857). Similar reduction (-0.6 vs -0.35 mmol/L, p=0.0505) and goal attainment (54.64% vs 58.00%, p=0.697) were also observed at 6 hours. However, at 24 hours, SZC showed greater reduction (-0.7 vs -0.4 mmol/L, p=0.0002) and higher goal attainment (74.4% vs 63.8%, p=0.041). Hypokalemia occurred once in the SZC group.

Conclusion(s)
At 24 hours, SZC demonstrated significantly greater potassium reduction and patients were more likely to achieve a target potassium level < 5.5 mmol/L compared to lactulose. However, SZC demonstrated similar efficacy compared to lactulose for the treatment of hyperkalemia at 6 and 12 hours, with no significant differences in potassium reduction or proportion of patients achieving K < 5.5 mmol/L. Both treatments were generally safe, with only one case of hypokalemia identified.

Self-Assessment Question:
At 24 hours, which treatment was more effective in achieving potassium < 5.5 mmol/L in patients with acute hyperkalemia?
Lactulose
SZC [correct answer]
Both were equally effective
Neither achieved target potassium

Authors: Samia Rahman Adity, PharmD, Sharon Janak, PharmD, BCPS, Claudia Rondon, PharmD, BCCCP, Keyur Patel, PharmD, DPLA, Melissa Rufo, PharmD, BCPS, Kasia Gejdel, PharmD, BCOP, BCPS 
 
Learning Objective: Describe safe and effective prescribing and monitoring practices for injectable haloperidol use in the emergency department.   
 
Self-assessment question: Haloperidol is associated with QT prolongation and extrapyramidal symptoms.  True/False 
 
Background: Describe current injectable haloperidol prescribing and safety monitoring practices for older adults treated for acute agitation in the emergency department at Long Island Jewish Forest Hills and identify opportunities for improvement.  
 
Methods: A retrospective chart review was conducted; patients were included if they were 65 years or older and received injectable haloperidol in the emergency department (ED).  Patients were excluded if they were treated for alcohol withdrawal, or if they received oral haloperidol or another antipsychotic prior to receiving the first dose of injectable haloperidol. Collected parameters included patient history of schizophrenia or dementia; dose and route of haloperidol; time from ED triage to haloperidol administration; time from haloperidol administration to receipt of additional haloperidol, another antipsychotic, a benzodiazepine, diphenhydramine, or benztropine, if given; baseline and post-treatment QTc, if EKGs were performed; baseline  oxygen delivery; and time to post-treatment escalation of oxygen delivery, if required.   
 
Results: A total of 215 patients were included. Dementia was common, present in 63.7% of patients treated with injectable haloperidol. Patients received initial doses between 1 and 5 mg, with 60% of patients receiving 5 mg. Overall, 42.3% of patients required repeat medication, with benzodiazepines being used most frequently (52.7%). Approximately 4.7% of patients required new supplemental oxygen, while 1.9% of patients already receiving oxygen required an increase from their baseline oxygen need. Anticholinergic rescue was needed for 4.2% of patients. Of the 7% of patients who had both baseline and post-treatment EKGs performed, 53.3% of patients experienced QT prolongation.  
 
Conclusion: Initial doses of haloperidol 5 mg were not associated with reduced need for repeat sedation, suggesting limited benefit from dose escalation alone. Coadministration with lorazepam complicated the interpretation of treatment effectiveness.  Anticholinergic use was infrequent, suggesting low rates of extrapyramidal symptoms after initial haloperidol administration.  Baseline EKGs were inconsistently ordered, indicating the possible need for a standardized protocol for QTc monitoring.

Authors: Samia Rahman Adity, PharmD, Sharon Janak, PharmD, BCPS, Claudia Rondon, PharmD, BCCCP, Keyur Patel, PharmD, DPLA, Melissa Rufo, PharmD, BCPS, Kasia Gejdel, PharmD, BCOP, BCPS 
 
Learning Objective: Describe safe and effective prescribing and monitoring practices for injectable haloperidol use in the emergency department.   
 
Self-assessment question: Haloperidol is associated with QT prolongation and extrapyramidal symptoms.  True/False 
 
Background: Describe current injectable haloperidol prescribing and safety monitoring practices for older adults treated for acute agitation in the emergency department at Long Island Jewish Forest Hills and identify opportunities for improvement.  
 
Methods: A retrospective chart review was conducted; patients were included if they were 65 years or older and received injectable haloperidol in the emergency department (ED).  Patients were excluded if they were treated for alcohol withdrawal, or if they received oral haloperidol or another antipsychotic prior to receiving the first dose of injectable haloperidol. Collected parameters included patient history of schizophrenia or dementia; dose and route of haloperidol; time from ED triage to haloperidol administration; time from haloperidol administration to receipt of additional haloperidol, another antipsychotic, a benzodiazepine, diphenhydramine, or benztropine, if given; baseline and post-treatment QTc, if EKGs were performed; baseline  oxygen delivery; and time to post-treatment escalation of oxygen delivery, if required.   
 
Results: A total of 215 patients were included. Dementia was common, present in 63.7% of patients treated with injectable haloperidol. Patients received initial doses between 1 and 5 mg, with 60% of patients receiving 5 mg. Overall, 42.3% of patients required repeat medication, with benzodiazepines being used most frequently (52.7%). Approximately 4.7% of patients required new supplemental oxygen, while 1.9% of patients already receiving oxygen required an increase from their baseline oxygen need. Anticholinergic rescue was needed for 4.2% of patients. Of the 7% of patients who had both baseline and post-treatment EKGs performed, 53.3% of patients experienced QT prolongation.  
 
Conclusion: Initial doses of haloperidol 5 mg were not associated with reduced need for repeat sedation, suggesting limited benefit from dose escalation alone. Coadministration with lorazepam complicated the interpretation of treatment effectiveness.  Anticholinergic use was infrequent, suggesting low rates of extrapyramidal symptoms after initial haloperidol administration.  Baseline EKGs were inconsistently ordered, indicating the possible need for a standardized protocol for QTc monitoring.  

Title: Implementation of a Pharmacist-Led Shared Medical Appointment for Weight Management at a Veterans Affairs Medical Center  
Authors: Shelby Efird, PharmD, Anita Henderson, PharmD, BCACP, Merid Belayneh, PharmD, Sarah Pierce, PharmD, BCACP; VA Maryland Health Care System 
Learning Objective: Describe the development and implementation of a pharmacist-led shared medical appointment for weight management pharmacotherapy. 
Background/Objective: This project describes the creation and implementation of a pharmacist-led shared medical appointment (SMA) for weight management pharmacotherapy with the goal of improving access to weight management services.  
Methods:
This quality improvement project was conducted within the VA Maryland Health Care System. The SMA was run by Primary Care Clinical Pharmacist Practitioners (CPPs) who provided disease-state education, brief lifestyle intervention, and medication management. Patients were screened via chart review to determine eligibility. Eligible patients included Veterans not already prescribed a glucagon-like-peptide-1 receptor agonist (GLP-1 RA), active participation in lifestyle interventions within the past 12 months, and who met VA criteria for GLP-1 RA therapy. Ineligible patients included those age 65 years or older with a BMI under 35 kg/m2, those with known contraindications to GLP-1 RA therapy, or those with non-optimized type 2 diabetes requiring medication adjustments. This referral-based clinic conducted all visits via VA Video Connect and included up to eight Veterans per 60-minute visit with two CPPs facilitating. Descriptive statistics were used to analyze results. 
Results:
Eight SMA cohorts were piloted from October 2025 to February 2026. Eighty-seven Veterans were referred with 61 meeting eligibility and were scheduled. Of patients eligible for the SMA, 59 completed the first visit and were prescribed tirzepatide. Participants had a mean age of 54 years (range 29-77), were predominantly male (76.2%), and had a mean BMI of 39.44 kg/m2 (range 31.27-53.87).  Veterans attended an initial visit followed by three bimonthly groups during medication titration with discharge to primary care providers for long-term follow-up.  As part of ongoing process improvements, various SMA structures were trialed. The final SMA structure consisted of one CPP facilitating four to five Veterans in a 60 minute visit.   
Conclusion:
This project demonstrates that a pharmacist-led SMA model can expand access to weight management services and allow CPPs to manage a higher patient volume than traditional individual visits leading to increased access to care. Future steps include scaling the program to all Patient Aligned Care Team CPPs across the VA Maryland Health Care System.  
Self-Assessment Question: 
Pharmacists within the VA are well equipped to lead shared medical appointments for weight management. (T/F) 

Title: Improvement of blood pressure metrics through pharmacist telemedicine visits 
Authors: Mojibola Awe, PharmD, Jessica Merrey, PharmD, MBA, BCPS, BCACP, BCGP, FASCP, Maxwell Ditlevson, PharmD, BCCP, Stacey Schott, MD, MPH, Abigail Tran, PharmD, BCACP, Patricia Ross, PharmD, MEdHP, BCACP, Michelle Azar, PharmD, MBA, BCPS, Ari Goldstein, MD 
Objective: Audience members will be able to evaluate the effect of a clinical pharmacist-led telemedicine program on blood pressure reduction among patients with uncontrolled hypertension with or without diabetes in Johns Hopkins ambulatory cardiology clinics. 
Self-Assessment Question: True or False: Factors including involvement of a multidisciplinary care team, telemedicine, and ambulatory blood pressure monitoring have been identified as strategies to improve blood pressure outcomes. 
Background: Hypertension increases the risk of cardiovascular diseases. This study aimed to incorporate pharmacist-led interventions via telemedicine and ambulatory blood pressure monitoring to improve blood pressure control and quality metrics for patients. 
Methods: This was a prospective, pharmacist-led quality improvement program done between November 2025 and March 2026. A  quality dashboard was used to identify patients in cardiology clinics with uncontrolled hypertension per last blood pressure (BP). Chart review identified patients for direct intervention, and those included were outreached up to three times via phone and direct patient messaging. Once enrolled, an initial telemedicine visit was scheduled to assess baseline BP and heart rate (HR), current medications, diet, and exercise. Pharmacologic and non-pharmacologic interventions were made and tracked. Participants were asked to monitor their BP at home for bi-weekly for pharmacist review. These data, lifestyle factors, and any interventions made during the initial visit were reassessed during follow-up visits. Data will be reported as descriptive statistics, and a paired t-test will be used for analysis. 
Results: Of 149 patients screened, 81 were outreached. Most exclusions were due to controlled BP, out-of-state location, or prior pharmacist involvement. Of those outreached, 31 agreed to an initial pharmacist visit; 19 visits occurred, 7 were no-shows, and 5 agreed only to BP monitoring via patient portal. The majority were female with a median age of 66 years. At baseline, patients were on a mean of 2 antihypertensives, and 17 (55%) performed ambulatory BP monitoring. There were 11 pharmacologic interventions recommended, including 5 new BP medications. Thirty-one nonpharmacologic interventions were recommended, primarily to start or continue ambulatory BP monitoring. Systolic and diastolic BP decreased by 15 mmHg (95% CI 7.03–22.84; p=0.0006) and 8 mmHg (95% CI 2.86–12.30; p=0.0026), respectively.
Conclusion: This study aimed to incorporate pharmacist telemedicine visits and ambulatory BP monitoring to improve BP outcomes and achieve quality metrics for cardiology clinics. Results showed 54.8% of patients who engaged met BP metrics, with clinically significant reductions in systolic (-15 mmHg) and diastolic (-8 mmHg) BP from baseline. Success was driven by increased ambulatory BP monitoring and documentation, though bi-weekly monitoring was not sustained. Telephone outreach proved most effective for patient engagement. Strengths included comprehensive visits aligned with guidelines. Limitations included small sample size and high attrition. Multimodal outreach strategies are essential for sustained engagement.

• Title: Improving concordance of continuous glucose monitor protocols through clinical pharmacy practitioner outreach
• Authors: Rebecca Sicat, PharmD; Rita Bodine, PharmD, DPLA; Karen Park, PharmD, BCACP; Rosa Bates, PharmD, BCACP
• Objective: Identify patients utilizing continuous glucose monitors who require evaluation according to facility protocols.
  
• Self Assessment Question: What is the primary goal of identifying veterans using continuous glucose monitors (CGMs) in this project?
  A. To transition all patients to glucometers
  B. To ensure periodic CGM data evaluations are completed for veterans not receiving endocrinology or pharmacy follow‑up
  C. To discontinue CGM use for nonadherent patients
  D. To replace endocrinology follow-up
  
• Background: This study aims to improve adherence to VA facility protocols for continuous glucose monitor (CGM) data review through targeted Patient-Aligned-Care-Team (PACT) pharmacy clinic outreach and enrollment.
• Methods: This prospective project identified veterans at the Veterans Affairs Hudson Valley Health Care System (VAHVHCS) using continuous glucose monitors (CGMs) to determine whether periodic data reviews were completed per facility protocols. Patients with active outpatient prescriptions for CGM sensors were identified on January 1, 2026. Clinic data were collected from February 19 to May 4, 2026. Veterans not followed by an endocrinologist or clinical pharmacy practitioner at VAHVHCS were assessed for outreach. Exclusion criteria included utilization of insulin pumps or active participation in the Patient-Aligned-Care-Team (PACT) pharmacy clinic or endocrinology clinic. Eligible patients were offered enrollment in the PACT pharmacy clinic for CGM data evaluation. Data collection included demographics, device type, indication, adherence to device use and clinic visits, treatment recommendations, and available glycemic outcomes such as hemoglobin A1c and ambulatory glucose profile metrics.
• Results: A total of 527 veterans with active prescriptions for continuous glucose monitor (CGM) sensors were identified. Seventy-five veterans were eligible for outreach, and contact was attempted for 57. Twenty-one veterans were scheduled with the clinical pharmacy practitioner (CPP), however, two did not show. Majority of veterans were Caucasian males with type 2 diabetes mellitus using a Dexcom device. Veterans showed high adherence to CPP visits (85%) and diabetes medications (81%). CGM data was unavailable for 5 veterans. About 38% of veterans were below their 30-day Time-In-Range (TIR) goal at initial CPP visit, indicating opportunities for improvement. Follow-up visits were limited, with only slight improvements seen in hemoglobin A1c.
• Conclusion: Overall, clinical pharmacy practitioner outreach facilitated identification of veterans not adherent to CGM facility protocols. Enrollment into the PACT pharmacy clinic provided an opportunity for further glycemic optimization as some veterans were not at target TIR. Future steps include extending follow-up intervals to every 3-6 months for well-controlled patients in the clinic while continuing outreach and enrollment.

Background  
Medication access teams play a critical role in reducing time to therapy, ensuring reimbursement, and supporting patients through complex benefit and prior authorization (PA) processes. At our academic health system, these services have historically been decentralized across infusion and specialty pharmacy, resulting in fragmented workflows, inconsistent performance metrics, and challenges demonstrating operational value. Under new pharmacy leadership, a systemwide transition is planned to unify these services under a single structure, migrate from manual shared-drive processes to a centralized digital platform, and implement technology solutions to support sustainable growth. 
Purpose  
This project seeks to streamline medication access services across an academic health system by centralizing fragmented workflows, standardizing prior authorization processes, and leveraging digital infrastructure. Currently, medication access functions are decentralized across infusion and specialty pharmacy teams, leading to inefficiencies, inconsistent performance metrics, and difficulty demonstrating value. The planned initiative will establish a unified medication access service under pharmacy leadership, supported by centralized Epic workqueues, a standardized Request for Proposal (RFP) process for technology vendors, and cloud-based operational tools. Anticipated outcomes include improved efficiency, sustainability, and scalability of patient access services. 
Methods  
A phased, systemwide redesign of medication access operations is planned. The project will begin with mapping of current workflows, staffing models, and technology infrastructure to identify inefficiencies and redundancies. Next, centralized Epic referral workqueues will be implemented to standardize case intake and routing across sites of care. A structured RFP process will be conducted to evaluate prior authorization management software platforms, including drafting requirements, vendor scoring, and preparation for contracting. Concurrently, a cloud-based infrastructure will be designed to include centralized case tracking logs, a standardized SOP library, and an operational KPI dashboard. Stakeholder engagement will be prioritized, with iterative feedback planned from pharmacy leadership, frontline access staff, and IT partners. A future-state roadmap will then be developed to ensure scalability, sustainability, and alignment with organizational priorities. 
Results 
Since the project is in progress, results are not yet available. Planned evaluation metrics include: 

• Case routing efficiency and reduction in manual processing following Epic workqueue implementation. 

• Standardization of intake and triage across infusion and specialty pharmacy. 

• Vendor selection outcomes from the RFP process, including anticipated automation of prior authorization workflows. 

• Impact of cloud-based infrastructure on real-time workload monitoring, case tracking, and KPI reporting. 

• Staff-reported changes in workload distribution, role clarity, and overall satisfaction. 

It is anticipated that these measures will demonstrate improved consistency in operations, greater transparency of performance data, and enhanced scalability of services. 
Conclusion 
This project is expected to demonstrate the value of centralizing medication access services under unified pharmacy leadership and investing in scalable infrastructure. Anticipated benefits include greater efficiency, standardization, and transparency across the health system. Once implemented, these strategies may reduce workflow redundancies, improve data accessibility, and support informed decision-making. The planned model aims to serve as a replicable framework for health systems seeking to optimize medication access teams and improve patient access to therapy. 

Title:
Pharmacist-Led Streamlined Medication Access for high Risk patienTs (SMART) Charitable Care Formulary at Discharge: A Pilot Study

Authors:
Shay Roth, PharmD, BCPS; Dannielle Brown, PharmD, BCPS; Erin VanMeter, PharmD, BCACP; Robert Green, PharmD; Rosalyn Stewart, MD, MS, MBA, FAAP, FACP; Meghan Swarthout, PharmD, MBA, BCPS, CPEL, FASHP; Lisa Lagana MSN, BSN, RN, CCM, CPHQ, NEA-BC; Caitlin Dowd-Green, PharmD, MBA, BCPS, BCACP

Objective/Background:
To expand the SMART Formulary, a charitable care program that assists patients with affordability barriers to medication access, from the ambulatory to inpatient setting with the goal of improving outcomes and reducing avoidable healthcare usage.

Methods:

• Adult patients admitted to an internal medicine service between August 1, 2025 to September 30, 2025 were eligible for enrollment in the SMART Formulary Pilot Program. Currently , a 30-day medication “voucher” is provided by case managers/social workers at the request of providers for discharging patients to cover medications that are unaffordable. However, no workflow currently exists for consideration of therapeutic alternatives that could be clinically appropriate and financially sustainable. Clinical pharmacists proactively reviewed voucher requests and medications prescribed at discharge for patients with affordability barriers, and recommended sustainable therapeutic alternatives or aided in identifying sustainable means of access, such as patient assistance programs (PAPs). Patient demographics, medication-specific information, and re-presentations within 90 days of discharge were collected and compared to historical data from August 1, 2024 to September 30, 2024.

Results:

• Of 37 patients enrolled, 35.1% were uninsured. The pilot yielded 50 pharmacist interventions, including initiation of 12 PAPs.
• Compared to historical data, The SMART Formulary Program significantly reduced the average number and cost of medications provided via voucher per patient from 4.74 to 2.03 and from $192 to $71, respectively. The program reduced the total amount spent on medications via voucher overall ($6708 to $2637) and total cost covered by voucher for medications with more sustainable means of access ($4088 to $355). The intervention cohort had more re-presentations to the emergency department (ED) as opposed to hospital re-admissions, with lower overall estimated cost of care.

Conclusion:
The program yielded an estimated $126,205 cost reduction over the two-month period driven by optimized medication access and shifting use from high‑cost hospitalizations to lower‑cost ED visits for 90‑day re‑presentations. The SMART Formulary Pilot Program demonstrated meaningful patient impact and cost avoidance, emphasizing the value of clinical pharmacist oversight of charitable care spending to ensure optimized and sustainable medication therapy and improved outcomes.

Self Assessment Question:
Which of the following is a benefit to implementing clinical pharmacist oversight of charitable care program spending for patients at hospital discharge?
Decreased emergency department re-presentations within 90 days
 Decreased mortality at 90 days
Increased prescribing of financially sustainable medications
Increased prescribing of generic medications compared to branded medications

Background: 
Psychiatric disorders are chronic illnesses that often involve recurrent crises, especially when continuity of treatment is disrupted. Antipsychotics play a critical role in preventing relapse, yet poor adherence is affecting nearly 38.7% of patients with psychotic disorder, which significantly increases the likelihood of relapse and rehospitalization. Long-acting injectable antipsychotics (LAIs) help address this challenge by improving adherence and have been associated with lower rates of relapse, hospitalization, and mortality compared with oral formulations.  

Management becomes more complex when mood or substance use disorders co-occur. These comorbidities further reduce adherence, worsen symptoms, and increase inpatient service utilization. Although evidence supports initiating LAIs during inpatient stays, their use in this setting remains limited. Building on these challenges, there is also a notable lack of data on LAIs use among patients with schizophrenia spectrum disorder and co-occurring mood and/or substance use disorders in hospital settings.

Objective: 
To assess the impact of co-occurring mood and/or substance use disorders on readmission rates following LAI treatment among inpatients with schizophrenia spectrum disorders.

Methods:
This retrospective, single-center chart review assessed the use of LAIs in adult patients admitted to a community hospital’s behavioral health unit with a diagnosis of schizophrenia spectrum disorder (SSD). The study aimed to assess the association between co-occurring mood and/or substance use disorders and post-discharge psychiatric outcomes following LAIs treatment.

Electronic medical records were reviewed to collect demographic and clinical variables, including age, sex, race, employment status, psychiatric diagnoses, substance use history, prior psychiatric hospitalizations, involuntary admissions, previous medication adherence, and LAI utilization patterns. Data regarding psychiatric emergency department (ED) visits, 30-day psychiatric readmissions, appropriateness of LAI initiation, and documentation of the next scheduled LAI dose at discharge were also collected.

Patients were stratified into comparison groups based on the presence or absence of co-occurring mood and substance use disorder. Descriptive statistics were used to summarize baseline characteristics and LAI prescribing patterns. Categorical outcomes were compared using odds ratios (ORs) with 95% confidence intervals (CIs), and statistical significance was assessed using p-values, with significance defined as p < 0.05.

The primary outcome was 30-day psychiatric readmission following hospital discharge among patients who received LAI therapy. Secondary outcomes included: (1) subgroup analysis of 30-day psychiatric readmission rates among patients with and without co-occurring mood disorder or SUD; (2) psychiatric ED visits within 30 days post-discharge; (3) appropriateness of LAI initiation during hospitalization; and (4) documentation of the next scheduled LAI dose at discharge.

Patients were included if they were 18 years of age or older, admitted to the inpatient behavioral health unit, carried a diagnosis of SSD, and received treatment with an LAIs during hospitalization. Patients were excluded if they were pregnant or breastfeeding, had a primary diagnosis of substance-induced psychotic disorder without underlying SSD, were admitted primarily for detoxification or medical stabilization without active psychiatric treatment, or had a hospital length of stay less than 24 hours.

Results
A total of 203 patients met study inclusion criteria. The mean age was 39.9 ± 12.5 years, and 52% of patients were female. The cohort was predominantly Black (67%). Socioeconomic instability was common, with 96% of patients unemployed, 20% experiencing homelessness, and 28% lacking a documented high school completion. Clinically, patients had a mean illness duration of 8 years, 55% had a history of ≥7 prior psychiatric hospitalizations, and 57% had involuntary admissions. Among LAIs prescribed, haloperidol decanoate was the most frequently used agent (49%), followed by paliperidone palmitate (22.5%).

The overall 30-day psychiatric readmission rate among patients receiving LAIs was 5.9% (12/203).
Patients with co-occurring SUD demonstrated a numerically higher readmission rate compared with those without SUD (9.3% vs 2.8%; OR 3.51, 95% CI 0.92–13.37; p = 0.052), suggesting a trend toward significance. In contrast, no statistically significant difference in readmission was observed between patients with and without mood disorders (4.4% vs 9.0%; OR 0.47, 95% CI 0.14–1.51; p = 0.197).

Rates of psychiatric ED visits within 30 days post-discharge were comparable between groups; SUD vs No SUD (28.9% vs 31.1%; OR 0.89, 95% CI 0.49–1.63; p = 0.725), and mood disorders vs No mood disorders (29.4% vs 31.3%; OR 0.91, 95% CI 0.48–1.72; p = 0.778).

Among patients initiated on LAIs during hospitalization (n = 149), initiation was considered appropriate in 58.4% of cases, while 41.6% were categorized as inappropriate. Documentation of the next scheduled LAI dose at discharge was associated with lower readmission rates compared with cases lacking documentation (1.3% vs 8.7%; OR 0.14, 95% CI 0.018–1.11; p = 0.063), although this finding should be interpreted cautiously given the small sample size.

Conclusion
Among hospitalized patients with schizophrenia spectrum disorders receiving LAI antipsychotics, the overall 30-day psychiatric readmission rate was low (5.9%). Co-occurring mood disorders were not associated with increased readmission risk, while patients with co-occurring substance use disorders demonstrated a trend toward higher readmission rates, suggesting a subgroup that may benefit from enhanced post-discharge monitoring and support.
This study also identified important practice gaps related to LAI management, including inconsistent appropriateness of LAI initiation and inadequate documentation of follow-up injection plans at discharge. Improved discharge planning, standardized LAI initiation protocols, and stronger outpatient care coordination may further optimize outcomes in this high-risk population. Larger prospective studies are warranted to better evaluate the impact of co-occurring psychiatric comorbidities on outcomes associated with LAI treatment in hospital settings.

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