Aging Q3: Continuity of care Kimberly S. Davis, MD Physician Clinical Director, University Internal Medicine

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. It has several components….a longitudinal relationship w a single provider and cooperation b/n providers and caregivers

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 County level comparisons of physician supply vs cancer stage at diagnosis. The more primary care physicians available to see patients the earlier the stage at diagnosis of the malignancy. And if you add in specialists into the mix it does not change the stage of diagnosis.

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. If a person has a primary care physician…they will get more effective care, have better outcomes, and have lower costs….STATE of FLORIDA

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)

Evidence for Primary care: Ecologic studies, observational and probably confounded… Observations make clinical sense Based on regional workforce and cost data Demonstration program data suggest primary care can add more value to patient care if reconfigured and better supported – Medical Homes 1/3/2018 12

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 20 x 220 + 4400 x 30 working years approx 130000

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 Patients expect for you to know what has happened to them in the interim and the results of their tests

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 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 NO 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?

Funding provided by D.W. Reynolds Foundation 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… 1. What are the names of the medications (including OTC, vitamins and herbal supplements) you are currently taking? 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? Medication Reconciliation Steps MD action… 1. Compare list to the list in the patient’s chart. 2. Compare dose, frequency, with/without food.. 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 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. 21

Medication Reconciliation Medication Reconciliation Process Medication Reconciliation MED REC PROCESS

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

There must be an indication for every medication. 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. Pts at risk when at transitions of care-hospitalizations, ER, other physicians

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. Need quote for hospitalization from jama adverse drug events

Segments of primary care: Inter-visit 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 _____ NO _____ 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 Comment on web sit with fax numbers for community physician practices

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? YES NO (NO, I am a unit resident or my patient already has one)

Aging Q3 Patient knows who the name of their doctor and nurse Patients knows how to access primary care Patient knows what meds they are taking PCP knows too

Practice Partner TIPs 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.

So Why should is this important to the Hospitalists? Quality of Care Avoids bad outcomes Medicare wont pay for readmissions within 30 days

ACOVE Quality Indicators Identification of Source of Care Follow-Up on Medication in the Outpatient Setting Continuity of Medication Between Physicians Communication Concerning Consultations Follow-Up of Diagnostic Tests in the Outpatient Setting Follow-Up of Missed Periodic Outpatient Preventive Care