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

2. 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

3. 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

4. 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

5. 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!

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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)

12. 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

13. 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

14. General Internists
Average General Internist has a panel of patients
At 20 visits a day, we do 130,000 outpatient visits in a career
We should review what we do
20 x x 30 working years approx

15. Components of Meaningful Primary care Visit
Pre-visit
Visit
Post-visit Follow-up
Inter-visit care

16. 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

17. 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

18. 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

19. So…what does this mean to you?
What will you be doing in this part of Aging Q3?

20. 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?

21. 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:S
Varkey, P. et al (2007) “Improving Medication Reconciliation in the Outpatient Setting.” Jt. Comm J on Quality & Patient Safety 33:5. 21

22. Medication Reconciliation
Medication Reconciliation Process
Medication Reconciliation
MED REC PROCESS

24. 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

25. Adverse Drug Events
2 year national study 1/ /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

26. 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

27. 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

28. 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.

29. 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
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.

30. 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 #
UIM Faculty Practice Fax #
Other local MD’s Fax #s can be found on the Aging Q3 website:
Comment on web sit with fax numbers for community physician practices

31. 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 pager # _________________.
Thanks for allowing us to participate in your patient’s care.
Physicians at MUSC

32. 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)

33. 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

34. 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.

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

36. 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