1. Interdisciplinary Teamwork in a Transitional Primary Care Clinic Tamara Malm, PharmD, MPH, BCPS September 18, 2015

2. Disclosure O I have nothing to disclose concerning possible financial or personal relationships with any entities that may be referenced in this presentation.

3. Objectives - Pharmacists O Define post-discharge Transitions of Care (TOC) and associated risks to the patient. O Explain the outpatient interdisciplinary team, their roles in patient care and the importance of clinical pharmacist involvement. O Describe the barriers and areas for growth of pharmacists that work in the ambulatory setting.

4. Objectives - Technicians O Define post-discharge Transitions of Care (TOC) and associated risks to the patient. O Explain the outpatient interdisciplinary team (including pharmacists) and their roles in patient care. O Describe the barriers and areas for growth of pharmacy technicians that work in the ambulatory setting.

5. APCC at YNHH O Adult Primary Care Clinic (APCC) is the preferred method of consistent care for many patients O 1.2 million outpatient visits/year at Yale-New Haven Hospital (YNHH) O Shortage of primary care providers

6. APCC at YNHH O Resident Run Clinic - July 2014 O Diabetes, Hep C, Addiction, Urgent, Pre-Op O Supervising Attendings O Social Worker, Financial Coordinator, Medical Assistants, Licensed Practicing Nurses

7. Gaps in Care O ~20% of patients experience an adverse event within 3 weeks of discharge O 75% of which could have been avoided O Majority of adverse events are related to medications O 33% of discrepancies have moderate harm potential O 6% of discrepancies have severe harm potential Agency for Healthcare Research and Quality

8. Post-Discharge TOC O Transition from hospital admission to O Home O Loved one’s home O Long Term Care Facility/Assisted Living Facility O Group Home O Homeless? First 30 days after discharge Biggest risk for adverse events

9. Pop Quiz O Majority of adverse events that occur after hospital admission are related to: a) Post-op complications b) Medications c) Too much discharge counseling d) Lack of patient understanding

10. What can be done? O Start a Hospital Follow Up Clinic (HFUC) O Hire a Pharmacist!

11. Objective To increase MTM and decrease thirty day readmissions during transitions of care from the hospital through increased pharmacy services as part of the interdisciplinary team at the APCC.

12. HFUC O Patients referred after meeting ≥1 defined criteria Criteria for Referral 2+ Active medical conditions Uses VNA services 5+ Medications >2 Admissions in last 3 months Pending lab tests High risk medications No primary MD Provider discretion

13. HFUC O Appointment made within 30 days of discharge O Ideally 7-14 days after discharge O Contacted by the pharmacist by telephone 24-72 hours ahead of appointment O Encounter documented in chart O 10 patients scheduled two at a time, one per resident for 45 minute appointments two days a week

14. Pharmacy Services O 5-25 minutes of 1:1 time at the beginning of their appointment INITIAL ENCOUNTER Patient/family interview Medication reconciliation TEAM ENCOUNTER Calls to pharmacy Clinical interventions Aid financial assistance Counseling POST ENCOUNTER Call in prescriptions Full SOAP note

15. Pop Quiz O Name the members of the outpatient interdisciplinary team. Social Worker Physician Nurse Pharmacist Financial Assistance Coordinator

16. Results 576 patients scheduled Oct14-April15 241 (41.8%) arrived Attendance 15 days between discharge and scheduled appointment (range 0-101 days) Time 80% of patients called ahead of time Patients more likely to attend appt if successfully contacted in a pre-visit call (p=0.0001) Pre-appt call

17. Results Pharmacy Services Medication Reconciliation, n(%) 187 (77.6) Clinical Interventions, n(%) 121 (64.7) Time (min)20.4/patient (range 5-120)

18. Results

20. Unique Practice O Inpatient model in at outpatient setting O Epitome of interdisciplinary practice and care O Did not focus on: O One specific disease state O One particular drug O One particular demographic O Instead, focused on: O Any patient at risk for a bumpy transition

21. Barriers - Pharmacists Low attendance rate/no phone number Limited outpatient EHR functionalityNo reimbursement Readmissions to outside hospitals are unknown

22. Barriers - Technicians Insufficient technician resources for hand-deliveries Difficulty contacting prescriber Limited outpatient EHR functionality

23. Pop Quiz O Which of the following was a barrier experienced by the pharmacist conducting this service? a) Too many patients b) Too many pharmacy technicians c) Limited EHR functionality d) Long commute for home visits

24. Future Growth O Expanding services to 5 days/week O Multiple different clinics O Partnering with inpatient pharmacists and technicians to predict discharges and provide pharmacy services at discharge O Potential for home visits/consults O Pharmacist + Technician Team O Incorporating new technology to help patients in clinic and at home

25. Questions? Ideas?!

26. Interdisciplinary Teamwork in a Transitional Primary Care Clinic Tamara Malm, PharmD, MPH, BCPS September 18, 2015