Transcript Slide 1

Aging Q3: Continuity of care
Kimberly S. Davis, MD
Physician Clinical Director,
University Internal Medicine
UIM
Agenda
• Having a primary care physician: How
much of a difference does it make towards
patient care? Is it valuable?
• Anatomy of Primary Care
• Outpatient medication reconciliation
• Using Practice Partner as a tool to
communicate
– short cuts for the user
Continuity and Coordination of
Care
Continuity is ‘‘care over time by a single
individual or team of healthcare
professionals’’ including
‘‘effective and timely communication of
healthcare information.’’
Institute of Medicine 1996
Continuity and Coordination of
Care
Continuity and coordination of care have
several components,
including a longitudinal relationship with
a single identifiable provider and
cooperation between providers
and between venues of care.
Meijer et al. Int J Qual Health Care 1997;9:23–33.
The next few slides will show some
of the evidence that Primary Care is
effective---and improves quality of
care and outcomes as well as
reduces cost!
Evidence: Primary care
improves process of care
Persons who receive primary care are:
• More likely to receive the recommended
preventive services
• More likely to adhere to treatment
• More likely to be satisfied with their
care
Bindman and Grumbach, J Gen Intern Med 1996;11:269. Safran et
al. J Fam Pract 1998;47:213
Evidence: Primary care improves
outcomes
• Breast cancer: early detection is
greater when the supply of primary
care physicians is higher
• Cervical cancer: Incidence of advanced
stage presentation is lower in areas
well-supplied with family physicians
• No advantage having a greater supply
of specialist physicians
Ferrante et al. J Am Board Fam Pract 2000;13:408.
Campbell et al. Fam Med 2003;35:60
Evidence: Primary care improves
outcomes and reduces costs
Adults with a primary care physician rather
than a specialist as their personal physician
• 33% lower annual adjusted cost of care
• 19% lower adjusted mortality, controlling
for age, gender, income, insurance,
smoking, perceived health (SF-36) and 11
major health conditions
Franks and Fiscella. J Fam Pract 1998;47:103
Evidence: Primary care improves
outcomes and reduces costs
For 24 common quality indicators for Medicare
patients:
• High quality significantly associated with lower
•
•
per capita Medicare expenditures
States with a greater ratio of generalist
physicians to population had higher quality and
lower costs
States with a greater ratio of specialist
physicians to population had lower quality and
higher costs
Baicker and Chandra. Health Affairs Web Exclusive. April 7, 2004.
Evidence: Primary care improves
outcomes and reduces costs
• The higher the primary care to population
ratio the lower the hospitalization rate for 6
ambulatory sensitive conditions (asthma,
copd, chf, diabetes)
• Health care costs are higher in regions with
higher ratios of specialists to generalists
Parchman and Culler. J Fam Pract 1994;39:123 Welch et al.
NEJM 1993;328:621
Evidence: Primary care reduces
disparities in care
• Reduced stroke risk
• Better CAD care and reduced CAD
mortality
• Narrows effect of income and gender
differences on care outcomes
Starfield, Shi, Macinko. The Milbank Quarterly, Vol. 83, No. 3,
2005 (pp. 457–502)
Continuity of Care ACOVE:
Quality Indicators
• Identification of source of care
• Follow up on medication in outpatient
setting
• Continuity of medication between
physicians
• Continuity in the ED and at Hospital
Admission
• Follow up after hospital discharge
General Internists
• Average General Internist has a panel of
1500-2000 patients
• At 20 visits a day, we do 130,000
outpatient visits in a career
• We should review what we do
Components of Meaningful Primary
care Visit
• Pre-visit
• Visit
• Post-visit Follow-up
• Inter-visit care
Components of primary care:
Pre-visit
• How to prep for clinic visit
– Review notes—your last note, any notes by
other MDs in the interim, ER or discharge
summaries
– Review interim labs
– Review interim studies—ex mammo, stress
test, colonoscopy, etc
– Review any consults
– Set up any needed health maintenance
Components of primary care:
Visit
• Inform pt. of their PCP and nurse –
provide resources (card and photo
composite)
• Review all meds (purpose, frequency,
dose, other) with patient and give them a
copy of the updated med list
• Give patient a medication bag; encourage
taking it with them to all provider visits
Segments of primary care:
Post-visit Follow-up
• Assign PCP in EMR
• Document diagnostic test and studies ordered
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and pending (IP) and FU on them
Notify UIM PCP when seeing another providers
patient by using the .cc code (OP)
How to look up provider codes in EMR through
knowledge base.
Notify patients of test results
So…what does this mean to
you?
What will you be doing
in this part of Aging Q3?
Aging Q3
CONTINUITY OF CARE –
Outpatient Blue sheet
PCT or Nurse:
YES
1. Have you visited the ER, been admitted to the hospital, or
seen any other providers since your last visit to this clinic?
2. Did you bring your pill bottles with you today?
3. Did you bring your medication list with you today?
4. Are you taking any over-the-counter drugs, vitamins or
supplements?
NO
Continuity of Care
POSTER
Patients 65 years and older have multiple medical problems, are
on multiple medications, and are seen by multiple providers. Having a primary
care physician, communicating among all providers, and reconciling medications
are all essential for quality patient care.
Ask the patient…
Medication Reconciliation Steps
1. What are the names of the
medications (including OTC,
vitamins and herbal
supplements) you are
currently taking?
MD action…
1. Compare list to the list in
the patient’s chart.
2. Compare dose, frequency,
with/without food..
2. How do you take your
medications and how much
have you been taking?
3. Do you understand what
the medication is for?
4. Where do you get your
prescriptions filled?
References: Wenger, N.S. and R.T. Young (2007) “Quality Indicators for Continuity and Coordination of Care in Vulnerable Elders.” JAGS 55:S285-292.
Varkey, P. et al (2007) “Improving Medication Reconciliation in the Outpatient Setting.” Jt. Comm J on Quality & Patient Safety 33:5.
3. If not, teach the patient.
Use plain, non-medical
language; speak slowly; break
down information into short
statements.
4. Call the pharmacy if there
is any discrepancy between
the patient’s reported meds
and your list. Rectify in the
patient’s chart.
5. Be sure there is a clear
indication for each medication.
Funding provided by D.W. Reynolds
Foundation
Medication Reconciliation
So why do Med reconciliation?
• It is a Joint commission requirement for
both inpatient and outpatient
• Patient safety ---ADE higher in 65+ age
group
• Quality Care
Adverse Drug Events
• 2 year national study 1/2004-12/2005,
there were 21,298 ADE reported or 2 per
every 1000 required ER visits.
• Estimate closer to 700,000
• More likely in the 65+ population to have
ADE
Meds initiated by ER, other specialist doctors, hospital DC
reevaluate need for continuation of each medication and
duplication.
There must be an indication for every medication.
Ask about OTC medication and herbal supplements
Encourage patient to bring all medications to every visit.
Aging Q3
CONTINUITY OF CARE –
Outpatient
MD ACTION REMEMBER TO:
Update the Medication list and give a copy to the patient.
Give the patient a business card.
Tell the patient how to reach a UIM physician after hours.
Show the patient your Team Photo page and explain the practice
team concept.
Give the patient a medication bag if appropriate.
Segments of primary care: Intervisit care
• Complete timely DC summary and include the
•
PCP name, H & P, and do med reconciliation
Keep in mind patients medications may change
when admitted based on MUSC’s Automatic
Therapeutic Substitution and they need to
be changed back to patients insurance formulary
at the time of discharge.
How do you know when your
patient is in ER or hospitalized?
• Contracted with company, DDI
• Automated notification system when they are
•
•
•
hospitalized or in ER
You and your case manager will be notified via
email
Expectation- Visit or call patient during
hospitalization when notified of their admission
Case manager will ensure appropriate f/u with
you and that they are getting new meds filled.
Yellow Sheet
Aging Q3 Continuity of Care ACOVE 4
Inpatient
Primary Care Clinic MD ________________________________________
NAME
Was the letter on the reverse side faxed to the primary care office?
YES _____
UIM Resident Fax #792-0448
UIM Faculty Practice Fax #876-0767
Other local MD’s Fax #s can be found on the Aging Q3 website:
http://mcintranet.musc.edu/agingq3
NO _____
Date
_________________________________
Dear Dr. _________________________________
Fax # _______________________
Your patient, ____________________________________, DOB, ____/____/____ was admitted
to the Medical University of South Carolina, General Medicine Service, on ____/____/____ with a
diagnosis of _______________________________________.
We will be contacting you just prior to their discharge to make arrangements for follow up. In
the meantime if you need to contact us, please feel free to page
Dr. ________________________ at 843-792-2123 pager # _________________.
Thanks for allowing us to participate in your patient’s care.
Physicians at MUSC
Continuity of Care: UIM Note Template
Primary Care Provider:
(Pull-down list required)
Has the patient been to the ER, or admitted to the hospital, or seen other out-patient
doctors since the last visit to this clinic?
YES
NO
Did the patient bring all their pill bottles with them today?
YES
NO
Are they taking any OTC medications, vitamins or supplements?
YES
NO
Did you perform medication reconciliation today?
YES
NO
Did you give a copy of the updated medication list to the patient?
YES
NO
Did you give the patient a medication bag?
YES
NO
(Already has one)
Did you give your business card to your patient today?
(NO, I am a unit resident or my patient already has one)
YES
NO
Practice Partner TIPs
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How to assign a PCP provider-pick list only
How to write a new prescription
How to renew a prescription
How to print the ‘reconciled’ med list
How to look up a provider ID in PP using
Knowledge Base?
How to do a .CC to your partners so they are
aware of what has gone on w their patients.