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Rina Ramirez, MD, FACP
Teresita Lawson, BSPharm, RPh, CDE
Suyen Segura, MPH, CHES
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Name three approaches that address specific health needs of seniors
Discuss how different disciplines may be integrated into the expanded primary care team
Describe three ways in which the primary care team can improve the safety of seniors with regards to medications
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Established in 1990 in church basement in Dover by Dr. Zufall and volunteer physicians
FQHC since 2004; providing entire range of primary medical, dental and enabling services
Have 5 sites, 3 Dental Facilities a mobile medical van, and a Wellness Center
Serving uninsured, underinsured, homeless, residents of public housing, farm workers, veterans
Open 7 days a week, extended hours
NCQA PCMH Level 3 for 2 of its sites- seeking multisite recognition for PCMH 2014
Bilingual staff and on call services
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Pediatrics Adult Medicine Women’s Health Ryan White Part A, C & F Dental Podiatry Behavioral Health Neurology Clinical Pharmacy Services Outreach and Health Fairs 340B Pharmacy Reach Out and Read Patient Navigation Case Management Health Literacy Program ACA Enrollment School-based dental
program
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Served 25,838 patients with approximately 86,751 visits 6.5% of patients are seniors, majority live in public
housing or with family members
Polypharmacy- Seniors are more likely to be on 5 or more medications, increasing risk of adverse drug events and increased utilization
Multiple risk factors- health literacy, cognition, disabilities, lack of self efficacy, risk of falling
Senior/Medicare Population growing
Increased risk for depression-isolation, multiple chronic conditions, loneliness
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Medical provider refers to ◦ Clinical pharmacist
◦ Behavioral health
◦ Patient navigator
Accountable Care Org. ◦ ER/Hospitalization-real time
Assessments and Screenings ◦ Annual Well Visits
◦ Identification of Risks
◦ Preventive Services
•Evidence Based •Multidisciplinary •Better Outcomes •Integrated into QA/PI Process
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Caring for a Senior Patient
Primary CareClinical
Pharmacy Services
Behavioral Health
Services
Senior Navigator
Accountable Care
Organization
Caring for the Senior Patient
Primary CareClinical
Pharmacy Services
Behavioral Health
Services
Senior Navigator
Accountable Care
Organization
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Identification of High Risk Patients
Hospitalizations- updates during
admission
ER visits- frequent users
Secure Communications- Hospitalists, Specialists and PCP
Additional Resources- Atlantic Care Coordination Center
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Coordination of Care- Interdisciplinary Team ◦ Engagement of team members
◦ Enhanced communications
Population Management ◦ Identification of high risk population
◦ Tracking- patient follow-up
◦ Community Resources
Medication Therapy Management ◦ Identification of Medication Related Problems
◦ Meaningful Use
Continuous Quality Improvement ◦ Patient Satisfaction
◦ Development of Patient Education Tools
◦ Reduction of Utilization/Costs
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Improves patient satisfaction and outcomes ◦ Nurtures Trust ◦ Whole Team Engaged ◦ Patient Engaged
Population management ◦ Clinical Pharmacy Services ◦ Senior Navigators/Case Managers ◦ Behavioral Health- LCSWs ◦ Primary Care Team
Reduction Utilization/Cost ◦ Address patient risks ◦ Identification of Barriers (MTM, AWV) ◦ Identification of Needs ◦ Reduce re-admission rates
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•Chief Medical Officer
•Clinical Staff Meetings
•QA/PI/PCMH
•CPS -pADE/ADE
Reporting
•ENABLING SERVICES
•BH
•Senior Navigator
•Case Managers
•Provider Referral
Clinical Pharmacy
Services
Senior Navigation
Behavioral Health
Case Managers
MTM
Interventions/DSMT
Co-management
340B/Med Access
Risk Reductions
Identification of
Barriers
Outcomes Tracking &
Reporting
Senior Navigation-
ACO
AIMM
APhA Impact Database
Team Collaboration
Medication Problems
Addressed
Linkage to Resources
BH Counseling
Patient Follow-up
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2008 to present -7th year High risk patients Integrated into expanded primary care team Approximately 900 seniors Consistent Favorable Outcomes
AWARDS/RECOGNITIONS
1 of 25 communities selected nation wide-APhA Foundation Project Impact Diabetes
2014-Patient Centered Innovation Award by the New Jersey Academy of Family Physicians (NJAFP)
2013-Becton-Dickenson/Direct Relief/National Association of CHC Award for Innovation in Diabetes Care in the underserved
2014-Outstanding Executive Leader Award- Eva Turbiner, CEO and Dr. Rina Ramirez
2014-Quality Leadership Award-Terry Lawson
CLINICAL PHARMACY SERVICES (CPS) - AIMM Collaborate- Alliance for Integrated Medication Management -PSPC
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The
Patient
Patient
Counseling Preventive
Care
Drug
Information
Medication
Reconciliation
Provider
Education
Retrospective
Drug
Utilization
Review
Medication
Therapy
Management
Disease State
Management
Prospective
Chart Review
& Provider
Consultation
Medication
Access-340B
Patient Centered Comprehensive Conducted Regularly Team Collaboration Prevention Care Transitions
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Teach Back Personal Medication Record Medication Action Plan Health Literacy/Literacy Self Management Tool Used in AWV
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Differentiates between Patient Driven and Medication Driven Medication Related Problems Or Misuse- Especially Important to our Seniors
•Identifies Medication Errors •Classifies level of Harm •Designates Level of Severity
Captures Specific Pharmacist Driven Interventions- Comprehensive Data Collection
Reviewed Monthly with CMO Quality Assurance and P&T Patient Safety Coordination of Care
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N=109- 100% out of control
63% of Diabetics <9% 39% <8% 76% LDL at Goal 66% <140/90
Patient Satisfaction with clinical pharmacy services
in 2015- 95%
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Enrolled and followed 84 patients for one year ◦ Average of 4 visits per patient ◦ More >50% received action plans
Results ◦ HbA1c levels significantly reduced by 0.9% (p=.0002). ◦ Improvements were seen in cholesterol and blood
pressure (p=0.164, p=0.444) ◦ 65.2% had eye exams, 84.2% had foot exams, and 70%
received their flu vaccine ◦ 28.6% of patients that smoked cigarettes quit
smoking
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Measure Results Interventions
Depression Screening 25% screened 56% PHQ-9 > 10 100% referred or counseled
BMI and Healthy Weight Advice
35% Overweight 33% Obese
76% counseled, will focus on nutrition visits
Hypertension in control (BP <140/90)
58% Referrals to CPS and review of BP guidelines for seniors
Diabetes in control (HbA1c <9)
81% Referrals to CPS and review of DM guidelines for seniors
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Integrated into Primary Care Team
Collaboration with CPS, PCP,
Navigators and Case Managers
Available at the majority of our sites
Big emphasis for Integration from PCMH 2014 initiatives
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ACA established in 2011 for Medicare Recipients
Goal -design and maintain a Personalized Prevention Plan Services (PPPS).
Eligible beneficiaries are those who have had Medicare Part B for at least 12 months AND have not received either within the past 12 months: ◦ Initial Preventive Physical Examination- “Welcome to
Medicare” Visit OR
◦ An Annual Wellness Visit
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Medical Assistant ◦ Vitals ◦ Medication Reconciliation ◦ Vaccine schedule ◦ Referrals Needed ◦ Fall risk assessment
Medical provider assessment - provides referrals to: ◦ Fall prevention classes – partnership with Atlantic Care
Coordination Center ◦ Ophthalmologist, podiatrist, cardiologist appointments etc.
Behavioral Health and/or CPS for high intensity MTM/DSMT ◦ Action plan review with patient
Patient navigator follows up with patient to help he/she follow the doctor’s recommendations
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Medical Referral Verifies eligibility and schedules appointment for assessment Assessments Conducted ◦ Health Risk Assessment (HRA) ◦ Depression Screening (PHQ) ◦ Mini Cog test ◦ The CAGE questionnaire ◦ Hearing Loss assessment ◦ Activities of Daily Living screening ◦ List of Providers
Reviews the following information ◦ Annual Wellness Visit FAQs ◦ Home Safety brochure ◦ Advance Directives
Schedules appointment with medical provider
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72yoF-DM,HTN,HLP,MI Scheduled for Abdominal Aneurysm Surgery
Conducted prior to surgery- ◦ AWV-Risks- fall, podiatry, ophthalmology, hearing loss ◦ Medication Therapy Management
Navigator-Identified for patient ◦ Specialists- close to home and within insurance network ◦ Transportation- facilitate patient independence ◦ Home Health Care Services/Contact/Engagement
Clinical Pharmacy Services- after surgery/rehab ◦ Long list of medication changes – patient confused ◦ Still on old regimen- assessed safety -stable ◦ Collaborated with PCP for immediate post surgery visit ◦ Today patient stable and at goal for all conditions-still on old
regimen
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Medication Therapy Management-post hospital ◦ Collaboration with PCP after hospitalization- Care transition
and Continuity of Care ◦ Medication Action Plan ◦ Patient Counseling
Patient Navigation ◦ Identified resources for patient for any needs that patient
needed after surgery ◦ Collaborated with expanded team to conduct AWV and
identify needed preventive services and patient risks, navigated to specialists
◦ Collaborated with CPS for MTM
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Navigator for Seniors
◦ Bilingual
◦ Predominantly Hispanic
PCP Refers Patient
◦ Accessing specialty care
◦ Closing the Loop- testing/treatment needs
◦ Social issues of concern
Face to Face Meeting
◦ Patient and/or caregiver
◦ Assessment of needs
Plan of action-based on need
◦ Available resources
◦ Navigation for appointments
◦ Transportation
◦ Trouble shooting problems that arise in accessing care
Program Goals
◦ Improve patient adherence to medical treatment plan
◦ Improve quality of life, health and wellbeing
Funding from UWNNJ
◦ Patient Navigator assisted nearly 100 senior patients in 2014
◦ 95% of these patients adhered to treatment plan
◦ Social issues addressed
◦ 59% with multiple challenges completed a more in-depth assessment and long-term plan to help address other areas of concern or personal goals
Program Tools
◦ Provider ID tool
◦ Health Assessment
◦ Long-term Plan
◦ Satisfaction survey
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Wellness Center
◦ Healthy Cooking
◦ Chair yoga
◦ Qi Gong
◦ Zufall Intergenerational Program
◦ Tech Savvy Class
Address emotional/social needs- isolation, loneliness, depression, neglect
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82yo M-Medicare-Parkinson’s, HTN, RA, Depression, prostate, incontinence
Lives alone-isolated
Participated in our senior program Live Your Better Life (LYBL) several years ago
Navigator-Assessed Needs ◦ Housing- transition from mobile home to senior housing-
located realtors ◦ Obtained Housing application- helped complete ◦ Letter to Housing Authority- helped complete ◦ Helped patient participate in speech treatment program for
Parkinson’s ◦ Helped schedule pain mgt appt
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Trust patient-team relationship
Patient centered- Comprehensive
Face to Face encounters
Frequent Touches- follow-up as needed
Targeted interventions ◦ Disease-specific
◦ Culturally competent
◦ Health literacy conscious
◦ Barriers identified
◦ Evidence Based
Team Collaboration
Tools
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Medication adherence
Patient safety
Access to medications
Patient self-management
Effectiveness of health care delivery model
Close the loop
Screening and prevention services
Improved outcomes
ED visits and hospitalizations
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Contact Information:
◦ Teresita Lawson – [email protected]
◦ Rina Ramirez – [email protected]
◦ Suyen Segura – [email protected]
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1. http://www.acpm.org/?MedAdherTT_ClinRef 2. CDC’s Noon Conference/ Medication Adherence/March
27, 2013 3. IMS Health Study Identifies $200+ Billion Annual
Opportunity from-Using Medicines More Responsibly- June 2013
4. ADA 2013 Fast Facts professional.diabetes.org/facts 5. http://scriptyourfuture.org/wp-
content/themes/cons/m/release.pdf 6. Choudhry 2011, N Engl J Med; Yeaw 2009, J Manag Care
Pharm; Script Your Future press release, November 2, 2011; accessed here: http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf.
7. AADE 7 Self Care Behaviors- American Association of Diabetes Educators
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