Mark Gwynne

Embedding Care Management in the Medical Home: A Case Study

Introduction: Care managers are playing increasingly significant roles in the redesign of primary care and in the evolution of patient-centered medical homes (PCMHs), yet their adoption within day-to-day practice remains uneven and approaches for implementation have been minimally reported. We introduce a strategy for incorporating care management into the operations of a PCMH and assess the preliminary effectiveness of this approach. Methods: A case study of the University of North Carolina at Chapel Hill Family Medicine Center used an organizational model of innovation implementation to guide the parameters of implementation and evaluation. Two sources were used to determine the effectiveness of the implementation strategy: data elements from the care management informatics system in the health record and electronic survey data from the Family Medicine Center providers and care staff. Results: A majority of physicians (75%) and support staff (82%) reported interactions with the care manager, primarily via face-to-face, telephone, or electronic means, primarily for facilitating referrals for behavioral health services and assistance with financial and social and community-based resources. Trend line suggests an absolute decrease of 8 emergency department visits per month for recipients of care management services and an absolute decrease of 7.5 inpatient admissions per month during the initial 2-year implementation period. Discussion: An organizational model of innovation implementation is a potentially effective approach to guide the process of incorporating care management services into the structure and workflows of PCMHs.

Patient Care Outcomes of a Tobacco Use Registry in an Academic Family Practice

Purpose: While the potential benefit of a chronic disease registry for tobacco use is great, outcome reports have not been generated. We examined the effect of implementing a tobacco use registry, including a decision support tool, on treatment outcomes within an academic family medicine clinic. Methods: A chart review of 200 patients who smoked and attended the clinic before and after registry implementation assessed the number of patients with clinic notes documenting (1) counseling for tobacco use, (2) recommendations for cessation medication, (3) a set quit date, (4) referrals to the on-site Nicotine Dependence Program (NDP) and/or QuitlineNC, and (5) pneumococcal vaccine. Data from the NDP, QuitlineNC, and clinic billing records before and after implementation compared the number of clinic-generated QuitlineNC fax referrals, new scheduled appointments for the NDP, and visits coded for tobacco counseling reimbursement. Results: Significant increases in documentation occurred across most chart review variables. Significant increases in the number of clinic-generated fax referrals to QuitlineNC (from 27 to 96), initial scheduled appointments for the NDP (from 84 to 148), and coding for tobacco counseling (from 101 to 287) also occurred when compared with total patient visits during the same time periods. Patient attendance at the NDP (52%) and acceptance of QuitlineNC services (31%) remained constant. Conclusions: The tobacco use registrys decision support tool increased evidenced-based tobacco use treatment (referrals, medications, and counseling) for patients at an academic family medicine clinic. This novel tool offers standardized care for all patients who use tobacco, ensuring improved access to effective tobacco use counseling and medication treatments.

Accountable Care in Transitions (ACTion): A Team-Based Approach to Reducing Hospital Utilization in a Patient-Centered Medical Home:

Background: There is limited data describing the role of the patient-centered medical home (PCMH) in successful transitions programs and more information is needed to determine the transition points where pharmacist involvement is most impactful. Methods: A family medicine center developed a multidisciplinary outpatient-based transitions program focused on reducing emergency department (ED) and hospital use in medically complex patients. Key team members were a medical provider, clinical pharmacist practitioner (CPP), and care manager. The objective was to evaluate the impact of the program by comparing utilization before and after the intervention and to identify patient and process characteristic predictors of 30-day rehospitalizations. Results: Of the 268 patients included, the mean time to follow-up appointment attended was 11.6 (11.8) days after discharge. The majority of patients (72%) saw their primary care provider at follow-up. Patients experiencing the multidisciplinary intervention had lower 30-day rehospitalizations at 7, 14, and 30 days postdischarge with significance achieved at 14 and 30 days. Compared to before the intervention, reductions in both ED visits and hospitalizations as well as increases in clinic visits were seen at 1, 3, and 6 months. CPP involvement was associated with lower rehospitalizations (7.7% vs 18.8%; P = .04). Conclusion: A multidisciplinary outpatient-based transitions program embedded in the PCMH increased access to primary care and reduced hospital and ED utilization. Face-to-face CPP involvement significantly lowered rehospitalizations. This program describes a standardized approach to complex care needs with defined roles, a model that may be generalizable and reproduced in other medical homes.

Bringing Patients Into the Patient-Centered Medical Home Lessons Learned in a Large Primary Care Practice

There is consensus that patients need to be engaged with their care, but how to do this in a primary care setting remains unclear. This case study demonstrates Patient Advisory Council engagement with the operations of a patient-centered medical home.

Post-Hospital Discharge Care: A Retrospective Cohort Study Exploring the Value of Pharmacist-Enhanced Care and Describing Medication-Related Problems

BACKGROUND Medication-related problems occur at high rates during care transitions. Evidence suggests that pharmacists are well-suited to identify and resolve medication-related problems during hospital admission and at discharge. Additional evidence is needed to understand the impact of face-to-face pharmacist visits in primary care after discharge. The purpose of the study was to describe medication-related problems found during face-to-face pharmacist visits in a medical home after hospital discharge. METHODS A retrospective cohort study was conducted within an academic primary care center staffed by family medicine trained physicians that evaluated patients who attended a hospital follow-up visit with pharmacist-enhanced care (N = 86) versus usual care (N = 86). The primary objective was to describe medication-related problems identified by pharmacists using a modified individualized Medication Assessment and Planning tool for patients receiving pharmacist-enhanced care. Secondary analyses were also conducted to compare 30-day and 60-day hospital readmission and emergency department visit rates in those exposed to pharmacist-enhanced care versus those who were not. RESULTS At baseline, the mean hospitalizations in the prior year were 1.1 ± 1.7 (pharmacist-enhanced care) and 0.76 ± 1.2 (usual care), indicating a low initial readmission risk. Of patients receiving pharmacist-enhanced care, 97.7% were found to have at least 1 medication-related problem, with an average of 4.36 medication-related problems per patient. The 30-day readmission rate was lower, but not significantly different between groups (8.1% for pharmacist-enhanced care versus 12.8% for usual care; adjusted odds ratio (OR), 0.47; 95% confidence interval (CI), 0.16–1.36). LIMITATIONS Limitations include the retrospective cohort study design and small sample size. Medication-related problems were identified and collected prospectively during pharmacist visits. CONCLUSION Medication-related problems are ubiquitous after hospital discharge. Larger prospective studies will be needed to understand the potential value of pharmacist-enhanced care during hospital follow-up visits on readmission rates in low-risk patient populations receiving care within a primary care medical home.

Patient-Centered Medical Home

The patient-centered medical home (PCMH) is a conceptual framework and operational model for primary care service delivery that began over a decade ago in response to a dysfunctional health-care system in the United States. In 2007, four national organizations representing primary care issued the joint principles of PCMH which include personal physician, physician-directed medical practice, whole-person orientation, coordinated care, quality and safety, enhanced access, and payment. These principles provide the framework for the key functions of robust medical homes. A review of the PCMH evidence base points to inconclusive results with some favorable effects on quality of care, hospital and emergency department use, and patient or caregiver experience and a few unfavorable effects on costs.

Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home

PURPOSE Results of a study evaluating quality-of-care, financial, and patient satisfaction outcomes of pharmacist-conducted telehealth visits for diabetes management and warfarin monitoring are reported. METHODS A retrospective pre-post study was conducted to determine the impact of an electronic visit (e-visit) program targeting 2 groups of outpatients: adults with uncontrolled diabetes and warfarin-treated adults performing patient self-testing (PST) for monitoring of International Normalized Ratio (INR) values. RESULTS A total of 36 patients participated in the e-visit program during the 2-year study period. Among warfarin-treated patients, the percentage of INR values in the desired range increased relative to preenrollment values (from 62.5% to 72.7%, p = 0.07), and the frequency of extreme INR values (values of <1.5 or >5.0) decreased (from 4.8% to 0.01%, p = 0.01); the margin per patient was

The Implementation of a Tobacco Use Registry in an Academic Family Practice

300 during the first year and

Implementing Lean in Academic Primary Care

191 annually thereafter. In the diabetes group, a decrease from baseline in glycosylated hemoglobin values of 3.4 percentage points was observed at 5.7 months after enrollment (p < 0.001), with significant improvements in frequencies of statin use, aspirin use, and blood pressure control; the margin was

What’s the right referral rate? Specialty Referral Patterns and Curricula Across I3 Collaborative Primary Care Residencies

100 per patient. The overall median patient satisfaction survey score was 39 of 40. CONCLUSION An online e-visit model for warfarin monitoring was an efficient, safe, and cost-effective method for implementing PST. Pharmacist-led management of diabetes through e-visits, often in combination with in-person visits, generated revenue while significantly improving clinical outcomes.