Why Should I Care? Many of the chronic conditions your patients have need almost. You can t do that so we have

Transcription

1 Enhanced Care

2 Why Should I Care? Many of the chronic conditions your patients have need almost constant supervision and care coordination You can t do that so we have

3 Enhanced Care Clinics All led by PharmD, CPP Supervised by MD, approved by BOM Licensed to prescribe and change therapies Working with midlevel practitioners PharmDs, NPs, PAs And care assistants Assist with barriers, medication acquisition, etc.

4 How will this change my visits with these patients? Someone else is doing most of the chronic management Yellow sheets guide you through what disease management steps you need to address in a visit Clinic notes are on WebCIS for EC visits BUT You remain the patient s PCP! (sometimes patients get confused)

5 What kinds of programs are Diabetes currently offered? Pain Anticoagulation

6 What kind of programs are coming? Stroke/Heart Disease Retinal Camera

7 What are these people doing with my patients? Monitoring Glucometer readings INR Titrating medications According to accepted clinical guidelines Changing medications When side-effects are bad Adding medications to help patients meet targets Adherence / Compliance coaching Health maintenance coaching Nutrition Making sure that patients are NOT lost to follow-up

8 Is this going to add to my workload? We work to reduce your repetitive work Most paper work, refills are handled by EC staff

9 How do I enroll a patient? We want to be very flexible: Come talk to us Ask the front desk walkie-talkie us Fill out a webform on the clinic support website Use the Encounter Form

10 What should I tell my enrolling patient? Most patients can be seen within 1 week, but It might take up to 6 weeks to get enrolled in the pain program You will still be their PCP They will likely be coming to clinic more often, but they won t see you every time

11 What do I need to take care of? Other screening: colon cancer, mammograms, contraception, etc. Diagnosis of acute and new chronic problems

12 Does this really work? Yes We safely reduce A1C and blood pressure We use evidence-based medicines We track patients and call them when appointments/ changes are needed We make sure that annual cholesterol screening is done for diabetic patients

13 Diabetes

14 Contact Team Diabetes When New diabetes diagnosis First-time glucometer New insulin start or debate over next glycemic intervention Patient is struggling with diabetes self-care PCP can t accommodate adequate follow-up Use Diabetes Practitioners for interval visits to extend the time to your return visit Complex patients with multiple comorbidities

15 Diabetes Program Utilizes a patient registry, evidenced based algorithms, and a risk-stratified approach Patients are categorized by risk Calculation includes A1c, BP, ASA and statin utilization, and smoking and depression status High Risk patients will be seen by a CA will see at each PCP visit, with DM provider separately, and RD Green diabetes stamp on provider schedule denotes that CA will see the patient, usually before the PCP

16 Care Assistants: Diabetes Shaun McDonald IT/Database Specialist (3-1350) Annie Whitney, Coordinator (ext 292) Maria Walker Administrative Assistant (ext 290) Angela Thompson Care Assistant (ext 275) Natalie Phillips Care Assistant (ext 244) Jenny Chou Care Assistant (ext 244)

17 Role Patient education, activation, encourage self-care Address adherence, barriers, depression screening, glucose monitoring, smoking Phone calls to assess and educate patients Quality improvement projects

18 Diabetes Practitioners Robb Malone, PharmD, CDE Carrie Palmer, ANP, CDE Amy Bouthillette, RD, CDE

19 Role Co-manage glucose, lipids, hypertension, and depression with PCP Follow-up other issues identified by PCP Patient education Patient activation / self-care Do not serve as primary care providers

20 Visit Formats CA follow up before PCP visit Yellow Sheet status guide for PCP visits Separate appts with diabetes practitioners Nutrition counseling by dietician Telephone reminders, follow up ADA approved self-management class

21 Diabetes Self Management Class One-time, 4-hour workshop Offered twice a month on Tuesdays Morning (8AM-11:00AM) and afternoon (12:30-4:30PM) options Content based on ADA guidelines for diabetes self management Patients set personalized goals that are evaluated at follow up visits ADA recognized for Quality Self-Management Education Goal: provide patients with tools to manage diabetes and improve health outcomes

22 Anticoagulation

23 Anticoagulation Practitioners Bart Scott, PA-C Betsy Bryant Shilliday, PharmD Brittain Fish, PA-C Carrie Palmer, NP Angela Cole, Admin Asst (ext 285) Wendy Cox, PharmD

24 Role Initiate and titrate warfarin therapy using CHEST guidelines Manage warfarin therapy minimum of once monthly visits more frequent visits during initiation and medication or health changes Manage warfarin during procedures including bridge therapy with heparin/lmwh

25 Visit Format POC INR testing 3 rd floor GIM POC lab, Desk 1 15 min visit with mid-level provider Discuss changes that may affect warfarin Provide written dosage instructions

26 Chronic Pain

27 Chronic Pain Team Tim Ives, PharmD, MPH Donna Harrell, LPN Cole Andrew, Care Assistant

28 Role Co-manage pain, depression with PCP Assess for mood disorders Evidence-based practice Signed pain contract on file Utox at each visit Do not serve as PCP

29 Contact Pain Team When Patient will require chronic opioids Patient needs assistance with adjuvant medications

30 Visit Format Enrollment Visit Scheduled within 4 wks of referral Prescriptions not provided Sees CA to discuss history, sign medication contract Obtain utox Appt w Dr. Ives Co-manage pain and depression with PCP Nurse Visit Stable patients seen for medication refills

31 How do I enroll a patient? We want to be very flexible: Come talk to us Ask the front desk walkie-talkie us Fill out a webform on the clinic support website Use the Encounter Form

32 Talk to Us Anticoagulation Betsy Bryant-Shilliday or Bart Scott If not available, call Angela Cole Diabetes All returning patients with diabetes are automatically enrolled See team member for new diagnosis or new clinic patient Pain Tim Ives

33 Webform: Clinic Support Website

34 Encounter Form