Advancing Pharmacy Practice through an Innovative Ambulatory Care Transitions Program at an Academic Medical Center.

Hospital readmissions are common and often preventable, leading to unnecessary burden on patients, families, and the health care system. The purpose of this descriptive communication is to share the impact of an interdisciplinary, outpatient clinic-based care transition intervention on clinical, organizational, and financial outcomes. Compared to usual care, the care transition intervention decreased the median time to Internal Medicine Clinic (IMC) or any clinic follow-up visit by 5 and 4 days, respectively. By including a pharmacist in the hospital follow-up visit, the program significantly reduced all-cause 30-day hospital readmission rates (9% versus 26% in usual care) and the composite endpoint of 30-day health care utilization, which is defined as readmission and emergency department (ED) rates (19% versus 44% usual care). Over the course of one year, this program can prevent 102 30-day hospital readmissions with an estimated cost reduction of $1,113,000 per year. The pharmacist at the IMC collaborated with the Family Medicine Clinic (FMC) pharmacist to standardize practices. In the FMC, the hospital readmission rate was 6.5% for patients seen by a clinic-based pharmacist within 30 days of discharge compared to 20% for those not seen by a pharmacist. This transitions intervention demonstrated a consistent and recognizable contribution from pharmacists providing direct patient care and practicing in the ambulatory care primary care settings that has been replicated across clinics at our academic medical center.

Implementing Lean in Academic Primary Care.

BACKGROUND: Lean is emerging as a quality improvement (QI) strategy in health care, but there has been minimal adoption in primary care teaching practices. This study describes a strategy for implementing Lean in an academic family medicine center and provides a formative assessment of this approach. METHODS: A case study of the University of North Carolina Family Medicine Center that used the Consolidated Framework for Implementation Research to guide a formative evaluation. The implementation strategy included partnering with Lean content experts and creating a leadership team; planning and completing QI events and Lean training modules; and evaluating and reporting activities related to QI and training. RESULTS: During the initial period of Lean implementation, there was (1) minimal to no change in the quality of care as determined by the Preventive Care Index (46-48); (2) a decrease patient appointment cycle time from 89 minutes to 65 minutes; (3) an increase in overall practice productivity from $8144 to $9160; (4) a decrease in patient satisfaction from 94% to 91%; and (5) an increase in monthly visit volume from 4112 to 5076. CONCLUSION: Lean had an uneven effect on QI in an academic primary care practice during the first year of implementation.

Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home.

PURPOSE: Results of a study evaluating quality-of-care, financial, and patient satisfaction outcomes of pharmacist-conducted telehealth visits for diabetes management and warfarin monitoring are reported. METHODS: A retrospective pre-post study was conducted to determine the impact of an electronic visit (e-visit) program targeting 2 groups of outpatients: adults with uncontrolled diabetes and warfarin-treated adults performing patient self-testing (PST) for monitoring of International Normalized Ratio (INR) values. RESULTS: A total of 36 patients participated in the e-visit program during the 2-year study period. Among warfarin-treated patients, the percentage of INR values in the desired range increased relative to preenrollment values (from 62.5% to 72.7%, p = 0.07), and the frequency of extreme INR values (values of <1.5 or >5.0) decreased (from 4.8% to 0.01%, p = 0.01); the margin per patient was $300 during the first year and $191 annually thereafter. In the diabetes group, a decrease from baseline in glycosylated hemoglobin values of 3.4 percentage points was observed at 5.7 months after enrollment (p < 0.001), with significant improvements in frequencies of statin use, aspirin use, and blood pressure control; the margin was $100 per patient. The overall median patient satisfaction survey score was 39 of 40. CONCLUSION: An online e-visit model for warfarin monitoring was an efficient, safe, and cost-effective method for implementing PST. Pharmacist-led management of diabetes through e-visits, often in combination with in-person visits, generated revenue while significantly improving clinical outcomes.

Post-Hospital Discharge Care: A Retrospective Cohort Study Exploring the Value of Pharmacist-Enhanced Care and Describing Medication-Related Problems.

BACKGROUND Medication-related problems occur at high rates during care transitions. Evidence suggests that pharmacists are well-suited to identify and resolve medication-related problems during hospital admission and at discharge. Additional evidence is needed to understand the impact of face-to-face pharmacist visits in primary care after discharge. The purpose of the study was to describe medication-related problems found during face-to-face pharmacist visits in a medical home after hospital discharge.METHODS A retrospective cohort study was conducted within an academic primary care center staffed by family medicine trained physicians that evaluated patients who attended a hospital follow-up visit with pharmacist-enhanced care (N = 86) versus usual care (N = 86). The primary objective was to describe medication-related problems identified by pharmacists using a modified individualized Medication Assessment and Planning tool for patients receiving pharmacist-enhanced care. Secondary analyses were also conducted to compare 30-day and 60-day hospital readmission and emergency department visit rates in those exposed to pharmacist-enhanced care versus those who were not.RESULTS At baseline, the mean hospitalizations in the prior year were 1.1 ± 1.7 (pharmacist-enhanced care) and 0.76 ± 1.2 (usual care), indicating a low initial readmission risk. Of patients receiving pharmacist-enhanced care, 97.7% were found to have at least 1 medication-related problem, with an average of 4.36 medication-related problems per patient. The 30-day readmission rate was lower, but not significantly different between groups (8.1% for pharmacist-enhanced care versus 12.8% for usual care; adjusted odds ratio (OR), 0.47; 95% confidence interval (CI), 0.16-1.36).LIMITATIONS Limitations include the retrospective cohort study design and small sample size. Medication-related problems were identified and collected prospectively during pharmacist visits.CONCLUSION Medication-related problems are ubiquitous after hospital discharge. Larger prospective studies will be needed to understand the potential value of pharmacist-enhanced care during hospital follow-up visits on readmission rates in low-risk patient populations receiving care within a primary care medical home.

Accountable Care in Transitions (ACTion): A Team-Based Approach to Reducing Hospital Utilization in a Patient-Centered Medical Home.

BACKGROUND: There is limited data describing the role of the patient-centered medical home (PCMH) in successful transitions programs and more information is needed to determine the transition points where pharmacist involvement is most impactful. METHODS: A family medicine center developed a multidisciplinary outpatient-based transitions program focused on reducing emergency department (ED) and hospital use in medically complex patients. Key team members were a medical provider, clinical pharmacist practitioner (CPP), and care manager. The objective was to evaluate the impact of the program by comparing utilization before and after the intervention and to identify patient and process characteristic predictors of 30-day rehospitalizations. RESULTS: Of the 268 patients included, the mean time to follow-up appointment attended was 11.6 (11.8) days after discharge. The majority of patients (72%) saw their primary care provider at follow-up. Patients experiencing the multidisciplinary intervention had lower 30-day rehospitalizations at 7, 14, and 30 days postdischarge with significance achieved at 14 and 30 days. Compared to before the intervention, reductions in both ED visits and hospitalizations as well as increases in clinic visits were seen at 1, 3, and 6 months. CPP involvement was associated with lower rehospitalizations (7.7% vs 18.8%; P = .04). CONCLUSION: A multidisciplinary outpatient-based transitions program embedded in the PCMH increased access to primary care and reduced hospital and ED utilization. Face-to-face CPP involvement significantly lowered rehospitalizations. This program describes a standardized approach to complex care needs with defined roles, a model that may be generalizable and reproduced in other medical homes.

What's the Right Referral Rate? Specialty Referral Patterns and Curricula Across I3 Collaborative Primary Care Residencies.

BACKGROUND AND OBJECTIVES: Specialty physician visits account for a significant portion of ambulatory visits nationally, contribute significantly to cost of care, and are increasing over the past decade. Marked variability in referral rates exists among primary care practices without obvious causality. We present data describing the referral process and specialty referral curriculum within the I3 collaborative. METHODS: Residency directors were surveyed about residency characteristics related to referrals. Specialty physician referral rates were obtained from each program and then correlated to program characteristics referral rates in four domains: presence and type of referral curriculum, process of referral review, faculty preceptor characteristics, and use of referral data for administrative processes. RESULTS: The survey response rate was 87%; 10 programs submitted complete referral data. Three programs (23%) reported a formal curriculum addressing the process of making a referral, and four programs (31%) reported a curriculum on appropriateness of subspecialty referrals. Specialty referral rates varied from 7%-31% of active residency patients, with no relationship to age, payor status, or race. DISCUSSION: Marked variability in referral rates and patterns exist within primary care residency training programs. Specialty referral practices are a key driver of total cost of care yet few curricula exist that address appropriateness, quantity, or process of specialty referrals. Practice patterns often develop during residency training, therefore an opportunity exists to improve training and practice around referrals.

Bringing Patients Into the Patient-Centered Medical Home: Lessons Learned in a Large Primary Care Practice.

There is consensus that patients need to be engaged with their care, but how to do this in a primary care setting remains unclear. This case study demonstrates Patient Advisory Council engagement with the operations of a patient-centered medical home.

Patient care outcomes of a tobacco use registry in an academic family practice.

PURPOSE: While the potential benefit of a chronic disease registry for tobacco use is great, outcome reports have not been generated. We examined the effect of implementing a tobacco use registry, including a decision support tool, on treatment outcomes within an academic family medicine clinic. METHODS: A chart review of 200 patients who smoked and attended the clinic before and after registry implementation assessed the number of patients with clinic notes documenting (1) counseling for tobacco use, (2) recommendations for cessation medication, (3) a set quit date, (4) referrals to the on-site Nicotine Dependence Program (NDP) and/or QuitlineNC, and (5) pneumococcal vaccine. Data from the NDP, QuitlineNC, and clinic billing records before and after implementation compared the number of clinic-generated QuitlineNC fax referrals, new scheduled appointments for the NDP, and visits coded for tobacco counseling reimbursement. RESULTS: Significant increases in documentation occurred across most chart review variables. Significant increases in the number of clinic-generated fax referrals to QuitlineNC (from 27 to 96), initial scheduled appointments for the NDP (from 84 to 148), and coding for tobacco counseling (from 101 to 287) also occurred when compared with total patient visits during the same time periods. Patient attendance at the NDP (52%) and acceptance of QuitlineNC services (31%) remained constant. CONCLUSIONS: The tobacco use registry's decision support tool increased evidenced-based tobacco use treatment (referrals, medications, and counseling) for patients at an academic family medicine clinic. This novel tool offers standardized care for all patients who use tobacco, ensuring improved access to effective tobacco use counseling and medication treatments.

The implementation of a tobacco use registry in an academic family practice.

PURPOSE: Patients who use tobacco often are not provided evidence-based interventions because of barriers such as lack of time or expertise. Using a chronic disease model, we sought to improve delivery of care with an innovative decision support tool and a tobacco use registry. METHODS: We designed and implemented a decision support tool in an academic family medicine clinic. To assess barriers, we measured duration of visit and provider confidence (scale of 0-10) in prescribing cessation medications before and after the introduction of the tool. We examined fidelity through daily counts of returned forms. RESULTS: No significant differences in mean office visit cycle times occurred for tobacco users (64.7 vs 63.1 minutes; P = .90) or between tobacco users and nontobacco users (63.1 vs 62.5 minutes; P = 1.00) before or after implementation of the decision support tool. Mean provider confidence in prescribing cessation medications increased significantly for nicotine inhalers (4.8 vs 6.4; P = .01), nicotine nasal spray (3.9 vs 5.5; P = .03) and combination nicotine replacement therapy (5.5 vs 6.2; P = .05). Two years after implementation, 88% of forms were filled out and returned daily, and >2200 tobacco users have been entered into the registry. CONCLUSIONS: The tobacco use decision support tool resulted in an increase in provider confidence in prescribing cessation medications without lengthening the duration of patients' visits, and the tool continues to be used routinely in the practice 2 years after introduction, indicating sustainability. The use of a tobacco use registry and decision support tool aids in standardizing care and overcoming barriers to cessation counseling.

Embedding care management in the medical home: a case study.

INTRODUCTION: Care managers are playing increasingly significant roles in the redesign of primary care and in the evolution of patient-centered medical homes (PCMHs), yet their adoption within day-to-day practice remains uneven and approaches for implementation have been minimally reported. We introduce a strategy for incorporating care management into the operations of a PCMH and assess the preliminary effectiveness of this approach. METHODS: A case study of the University of North Carolina at Chapel Hill Family Medicine Center used an organizational model of innovation implementation to guide the parameters of implementation and evaluation. Two sources were used to determine the effectiveness of the implementation strategy: data elements from the care management informatics system in the health record and electronic survey data from the Family Medicine Center providers and care staff. RESULTS: A majority of physicians (75%) and support staff (82%) reported interactions with the care manager, primarily via face-to-face, telephone, or electronic means, primarily for facilitating referrals for behavioral health services and assistance with financial and social and community-based resources. Trend line suggests an absolute decrease of 8 emergency department visits per month for recipients of care management services and an absolute decrease of 7.5 inpatient admissions per month during the initial 2-year implementation period. DISCUSSION: An organizational model of innovation implementation is a potentially effective approach to guide the process of incorporating care management services into the structure and workflows of PCMHs.

PURLs: would this long-acting bronchodilator be better for your patient?

Tiotropium outperformed salmeterol in reducing the frequency of exacerbations in patients with moderate-to-severe COPD.

Council tax valuation bands and contacts with a GP out-of-hours service.

UK GPs are no longer responsible for the organisation of out-of-hours care for their patients, but resources remains capitation-based. This cross-sectional study tests whether council tax valuation bands can predict the demand for such services. All out-of-hours contacts made by patients in North Wiltshire over 4 months were classified by council tax band; frequencies compared with official population statistics. Council tax band predicts out-of-hours GP workload irrespective of age and sex: the more modest the home, the higher the GP contact rate. It may prove more difficult to sustain out-of-hours services in deprived parts of the UK.

Council tax valuation band predicts breast feeding and socio-economic status in the ALSPAC study population.

BACKGROUND: Breast-feeding rates in the UK are known to vary by maternal socio-economic status but the latter function is imperfectly defined. We test if CTVB (Council Tax Valuation Band - a categorical assessment of UK property values and amenities governing local tax levies) of maternal address predicts, in a large UK regional sample of births, (a) breast-feeding (b) personal and socio-economic attributes of the mothers. METHODS: Retrospective study of a subset (n.1390 selected at random) of the ALSPAC sample (Avon Longitudinal Study of Parents and Children), a large, geographically defined cohort of mothers followed from early pregnancy to 8 weeks post-delivery. Outcome measures are attitudes to breast-feeding prior to delivery, breast-feeding intention and uptake, demographic and socio-economic attributes of the mothers, CTVB of maternal home address at the time of each birth. Logistic regression analysis, categorical tests. STUDY SAMPLE: 1360 women divided across the CTVBs--at least 155 in any band or band aggregation. CTVB predicted only one belief or attitude--that bottle-feeding was more convenient for the mother. However only 31% of 'CTVB A infants' are fully breast fed at 4 weeks of life whereas for 'CTVB E+ infants' the rate is 57%. CTVB is also strongly associated with maternal social class, home conditions, parental educational attainment, family income and smoking habit. CONCLUSION: CTVB predicts breast-feeding rates and links them with social circumstances. CTVB could be used as the basis for accurate resource allocation for community paediatric services: UK breast-feeding rates are low and merit targeted promotion.

The costs of care in general practice: patients compared by the council tax valuation band of their home address.

BACKGROUND: It is difficult to measure and compare workload in UK general practice. A GP/health economist team recently proposed a means of calculating the unit cost of a GP consulting. It is therefore now possible to extrapolate to the costs of other clinical tasks in a practice and then to compare the workloads of caring for different patients and compare between practices. OBJECTIVES: The study aims were: (i) to estimate the relative costs of daily clinical activities within a practice (implying workload); and (ii) to compare the costs of caring for different types of patients categorized by gender, by age, and by socio-economic status as marked by the Council Tax Valuation Band (CTVB) of home address. METHODS: The study design was a cross-sectional cost comparison of all clinical activity aggregated, by patient, over one year in an English semi-rural general practice. The subjects were 3339 practice patients, randomly selected. The main outcome measures were costs per clinical domain and overall costs per patient per year; both then compared by gender, age group and by CTVB. RESULTS: CTVB is as significant a predictor of patient care cost (workload) as is patient gender and age (both already known). CONCLUSIONS: It is now possible to estimate the cost of care of different patients in such a way that NHS planning and especially resource allocation to practices could be improved.

Council tax valuation band of patient residence and clinical contacts in a general practice.

BACKGROUND: There is a dearth of data relating UK general practice workload to personal and social markers of individual patients. AIM: To test whether there is a significant association between general practice patient contact rates and the council tax valuation band of their residential address. DESIGN OF STUDY: Cross-sectional analyses using data recorded, over 1 year, for over 3300 general practice patients. SETTING: One medium-sized group practice in an industrialised English market town. METHOD: Face-to-face contacts between the patients and the doctors and nurses in the practice were compared by patient age, sex, registration period, distance from surgery, Underprivileged Area 8 (UPA8) score, and council tax valuation band. RESULTS: Patient sex, age, recent registration, distance from surgery, and council tax valuation band were each significantly associated with face-to-face contact rate in univariate analyses. UPA8 score was not significantly associated with contact rates. On multivariate testing, sex, age, recent registration, and council tax valuation band remained significantly associated with contact rates. The last is a new finding. CONCLUSION: Council tax valuation bands predict contact rate in general practice; the lower the band, the higher the contact rate. Council tax valuation band could be a useful marker of workload that is linked to socioeconomic status. This is a pilot study and multipractice research is advocated.