Transcript Tracy Lin - Arizona Pharmacy Association

CustomCare Programs
TLC
After the Hospital and TLC
Tracy Lin, PharmD, CACP
At Home After the
Hospital
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 Cigna
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CustomCare Model
PCP
Pharmacist
CustomCare
TLC
Helps improve quality of life for those
with multiple health conditions
Transition of
Care Nurse
CustomCare
At Home
Program
Clinician
Takes care of
patients who
need care in
their home
environment
-
Care
Coordinator
CustomCare
After the
Hospital
Helps patients
get on the path
to recovery after
hospitalization
Health
Education
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 Cigna
Home
Base
Social
Worker
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TLC
CustomCare After the Hospital
At Home
Helps patients
get on the path
to recovery after
hospitalization.
After the
Hospital
Team Includes:
Care
Coordinator
Dedicated
provider
(not the PCP)
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 Cigna
Transition of Care
Nurse
Social Worker
Pharmacist
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CustomCare After the Hospital: How It Works
Goal: To reduce readmissions and complications for our patients
• Transition of Care Nurses (TOCNs) or other CMG team members schedule follow-up
appointments for Medicare Advantage patients within 72 hours of discharge from the
hospital
• Provider recaps the patient’s hospital stay and focuses on chronic conditions that may
have the potential to decompensate acutely
• Gaps in care should be identified and addressed where relevant
• Referrals to specialty care are evaluated. Nurse is present during the appointment and
can help verify whether or not referrals need to be placed or are already present in the
medical record
• Follow-up labs that could potentially affect patient management within 30 days postdischarge should be ordered by provider
• Medication review and reconciliation by the pharmacist
• Follow-up appointments are scheduled on behalf of the patient
Pharmacist Workflow
Pharmacist preps patient chart. Pharmacist + Provider discuss
potential improvements to medication therapy prior to patient arrival.
Provider + Nurse see and
evaluate the patient.
Pharmacist + Patient
review and reconcile
medications.
Pharmacist + Provider review any medication
changes that occurred during appointment.
Team discusses any discrepancies or issues that
need further action.
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 Cigna
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Pharmacist Interventions
• Medications reviewed, medication
list reconciled, patient counseled
• Medication list/card provided
• Medication list updated (after
provider)
• High Risk Medication (HRM)
identified
• Medication cost savings identified
• Comprehension medication
review (CMR) documented (for
MTM)
• Adverse effects identified
• OTC counseling/recommendation
made
• INR checked (if applicable)
• Duplication of therapy identified
• Drug-drug interaction
• Drug-disease interaction
• ACE/ARB recommended
• Lab issues identified
• ASA addition recommended
• The teach back technique was
used for inhaler and/or devices
• Other (Referrals, etc.)
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 Cigna
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TLC
CustomCare TLC
At Home
Helps improve
quality of life for
those with
multiple health
conditions.
After the
Hospital
Team Includes:
Care
Coordinator
Nurse
Social Worker
Dedicated
provider
(not the PCP)
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 Cigna
Pharmacist
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CustomCare TLC
Goal: To teach patients to live with their chronic disease state(s)
successfully and ideally maximize their quality of life
• Identify high risk patients with
disease specific conditions to
enroll in the program
• Teach Back Technique – using
methods to engage and verify
patient’s assimilation of information
• Developing a mutually agreed
upon plan with the patient to
manage any changes in their
condition(s)
• R-E-M-E-D-Y Modules
Cigna Medical Group
is a NCQA recognized
Patient-Centered Medical Home
1Plan performance summary star ratings are assessed each year and may change from one year to the next.
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Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating
subsidiaries, including Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and Cigna HealthCare of Arizona, Inc.,
and not by Cigna Corporation. Cigna Medical Group (CMG) is an operating division of Cigna HealthCare of Arizona, Inc. All models are used for
illustrative purposes only.
© 2013 Cigna