1. Description of Program/ Measures of Success:
Creating an Intensive Care Management Team and Identifying High Risk Patients in an Academic General Internal Medicine Practice Scott V Joy, MD, Lynn Haley, Leanne Clark, Michael Masse, Katey Morris, PharmD, Alyssa Nash, MD, Meghan Hayes, MD, Steve Mack, MD
Description of Program/
Measures of Success:
Statement of Problem/Question:
Data/Findings to Date:
Number of high risk patients identified: 12
Total number of ER visits/Hospital Admissions for this group: 114
(average 9.5 visits/patient; range 0 to 37 visits/patient)
How can an academic General Internal Medicine Practice create an intensive care management (ICM) team, identify patients at high risk for overutilization, understand current utilization of hospital/ER services for this group of patients, and identify medication adherence issues?
Patients were identified as being high utilizers of ER/Hospital services by clinic referrals or patient reported data from a health risk assessment
A patient-specific alert (Intensive Care Management) was created in our EHR allowing for queries and to notify other practitioners that patient is part of the ICM team.
A multidisciplinary team was created and meets weekly for up to 90 minutes to review each patient. Within the EHR, team conversations are documented in a specific notes section.
A list of ICM patients filling their prescriptions at the facility of our collaborating pharmacy was created, and the pharmacy system was queried to identify any adherence gaps for these patients.
Objectives of Program/Interventions:
Months with highest numbers of ER/Hospitalizations: August (19), October (14), September (13)
Number of patients followed by collaborating pharmacy 5 (42% of group)
Number of patients in this group identified as having potential adherence issues: 1 (20%)
Identify patients who have been high utilizers of ER/hospital services
Determine the frequency of ER visits/hospitalizations over a 12 month period
Create a registry of these patients in an electronic health record (EHR)
Create an electronic method for team members to communicate with each other about these patients
Build a relationship with local pharmacy to identify patients in this group who may have medication adherence issues
A multidisciplinary team can be formed and communication workflows can be developed within the EHR
For patients that fill their medications with a collaborating pharmacy, a mechanism can be developed to proactively track adherence with medication refills.
Lessons Learned: