Methodology for Expansion of the SMART Charitable Care Formulary to Enhance Medication Access at Discharge

Medication adherence leads to improved health outcomes, significant decreases in health care costs, and reduced preventable rehospitalizations, but can be challenging for uninsured or underinsured patients facing financial barriers to medication access. Pharmacist interventions during hospital admission can ensure patients receive clinically optimized and financially sustainable medications at discharge. The purpose of this project is to expand one of the academic medical center's charitable care programs, the SMART (Streamlined Medication Access for high Risk patienTs) Formulary, which provides medication access to uninsured or underinsured patients in the ambulatory setting.

This manuscript will describe the process and methods for a pilot expanding the Formulary to inpatients discharging from an internal medicine floor.

After obtaining approval from the institutional Department of Care Coordination, the SMART team identified an appropriate internal medicine service and an appropriate time frame to pilot this intervention. The process for identifying patients, appropriate interventions, and communication methods were developed by a pharmacy resident with the oversight of the SMART Team and Care Coordination leadership. Case management and social workers on the medicine floor were oriented to the process and alerted how to contact the team via secure chat in the electronic medical record. During the study period, the SMART team would be alerted prior to discharge if a patient needed assistance with medication access. The SMART Team would then provide recommendations for sustainable medication coverage options prior to discharge. Outcomes were selected to characterize the effort and type of interventions, as well as the financial impact of the service on the medical center. Collected data included patient demographics, medication details, health care utilization (emergency department visits and hospitalizations), time spent pursuing medication access, and which medication access activities were completed prior to discharge. The SMART Team will compare the financial and health care utilization outcomes for the intervention group with a comparator group/benchmark which consisted of a historical cohort of patients discharged from the medicine service during the same period the previous year. This manuscript describes the framework for a service to provide prospective and retrospective pharmacist support for medication acquisition at discharge. Expansion of clinical pharmacist services to ensure charitable medication access for patients at hospital discharge requires input from several stakeholders and communication with provider teams, nurses, case managers, and social workers. This pilot is anticipated to improve sustainable access to evidenced-based medications, enhance the efficiency of charitable care funds, and reduce avoidable health care utilization.

Uninsured and underinsured patients frequently encounter barriers to obtaining discharge medications, which contributes to medication nonadherence, preventable emergency department utilization, and suboptimal health outcomes, which are challenges that directly complicate effective care coordination by case managers. The pharmacist-led expansion of the SMART (Streamlined Medication Access for high-Risk patienTs) Formulary supports case management practice by integrating medication access planning into the discharge workflow. Through evidence-based formulary optimization and proactive enrolment in patient assistance programs, the initiative enables case managers to more effectively address social and financial barriers to treatment, engage patients in discharge planning, and support continuity of care beyond hospitalization. By improving access to essential medications at discharge, this model enhances longitudinal adherence, reduces avoidable utilization, and promotes more efficient use of charitable care funds. For case managers, the SMART Formulary functions as a scalable, interdisciplinary tool to advance pharmacoequity, strengthen discharge planning, and improve patient-centered outcomes across care transitions.