Post on 12-Jan-2016
Interdisciplinary Teamwork in a
Transitional Primary Care Clinic
Tamara Malm, PharmD, MPH, BCPSSeptember 18, 2015
DisclosureO I have nothing to disclose concerning
possible financial or personal relationships with any entities that may be referenced in this presentation.
Objectives - Pharmacists
O Define post-discharge Transitions of Care (TOC) and associated risks to the patient.
O Explain the outpatient interdisciplinary team, their roles in patient care and the importance of clinical pharmacist involvement.
O Describe the barriers and areas for growth of pharmacists that work in the ambulatory setting.
Objectives - Technicians
O Define post-discharge Transitions of Care (TOC) and associated risks to the patient.
O Explain the outpatient interdisciplinary team (including pharmacists) and their roles in patient care.
O Describe the barriers and areas for growth of pharmacy technicians that work in the ambulatory setting.
APCC at YNHHO Adult Primary Care Clinic (APCC) is the
preferred method of consistent care for many patients
O 1.2 million outpatient visits/year at Yale-New Haven Hospital (YNHH)
O Shortage of primary care providers
APCC at YNHH
O Resident Run Clinic - July 2014O Diabetes, Hep C, Addiction, Urgent,
Pre-OpO Supervising Attendings
O Social Worker, Financial Coordinator, Medical Assistants, Licensed Practicing Nurses
Gaps in CareO ~20% of patients experience an adverse
event within 3 weeks of discharge O 75% of which could have been
avoided
O Majority of adverse events are related to medications O 33% of discrepancies have moderate
harm potential O 6% of discrepancies have severe harm
potential
Agency for Healthcare Research and Quality
Post-Discharge TOCO Transition from hospital admission to
O Home O Loved one’s homeO Long Term Care Facility/Assisted Living
Facility O Group Home O Homeless?
First 30 days after discharge
Biggest risk for adverse events
Pop QuizO Majority of adverse events that occur
after hospital admission are related to:
a) Post-op complications b) Medications c) Too much discharge counseling d) Lack of patient understanding
What can be done?
O Start a Hospital Follow Up Clinic (HFUC)
O Hire a Pharmacist!
Objective
To increase MTM and decrease thirty day readmissions during
transitions of care from the hospital through increased pharmacy services as part
of the interdisciplinary team at the APCC.
HFUCO Patients referred after meeting ≥1
defined criteriaCriteria for Referral
2+ Active medical conditions
Uses VNA services
5+ Medications
>2 Admissions in last 3 months
Pending lab tests
High risk medications
No primary MD
Provider discretion
HFUCO Appointment made within 30 days of
discharge O Ideally 7-14 days after discharge
O Contacted by the pharmacist by telephone 24-72 hours ahead of appointmentO Encounter documented in chart
O 10 patients scheduled two at a time, one per resident for 45 minute appointments two days a week
Pharmacy ServicesO 5-25 minutes of 1:1 time at the
beginning of their appointment
INITIAL ENCOUNTERPatient/family interviewMedication reconciliation
TEAM ENCOUNTERCalls to pharmacyClinical interventionsAid financial assistanceCounseling
POST ENCOUNTERCall in prescriptions Full SOAP note
Pop QuizO Name the members of the outpatient
interdisciplinary team.
Social Worker
Physician
Nurse
Pharmacist
Financial Assistance Coordinator
Results
• 576 patients scheduled Oct14-April15• 241 (41.8%) arrived
Attendance
• 15 days between discharge and scheduled appointment (range 0-101 days)
Time
• 80% of patients called ahead of time• Patients more likely to attend appt if
successfully contacted in a pre-visit call (p=0.0001)
Pre-appt call
Results
Pharmacy Services
Medication Reconciliation, n(%)
187 (77.6)
Clinical Interventions, n(%)
121 (64.7)
Time (min) 20.4/patient (range 5-120)
Results
Drug
rec
Dose/
rout
e/fre
q
Optim
izat
ion
No in
dica
tion
Mon
etar
yADE
Inte
ract
ion
75
5145
35
15
82
Type of Pharmacist Interventionn=231
Unique PracticeO Inpatient model in at outpatient setting
O Epitome of interdisciplinary practice and care
O Did not focus on:O One specific disease state O One particular drug O One particular demographic
O Instead, focused on:O Any patient at risk for a bumpy transition
Barriers - PharmacistsLow attendance rate/no phone number
Limited outpatient EHR functionality
No reimbursement
Readmissions to outside hospitals are unknown
Barriers - Technicians
Insufficient technician resources for hand-deliveries
Difficulty contacting prescriber
Limited outpatient EHR functionality
Pop QuizO Which of the following was a barrier
experienced by the pharmacist conducting this service? a) Too many patients b) Too many pharmacy technicians c) Limited EHR functionality d) Long commute for home visits
Future GrowthO Expanding services to 5 days/week
O Multiple different clinics
O Partnering with inpatient pharmacists and technicians to predict discharges and provide pharmacy services at discharge
O Potential for home visits/consults O Pharmacist + Technician Team
O Incorporating new technology to help patients in clinic and at home
Questions?
Ideas?!
Interdisciplinary Teamwork in a
Transitional Primary Care Clinic
Tamara Malm, PharmD, MPH, BCPSSeptember 18, 2015