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