Dr. Martin has documented that she has nothing to disclose. This pilot project was funded by the Medical University Hospital Authority.

Transcription

1 // A Patient-Centered Medical Home for Sickle Cell Disease Association of Medicine and Psychiatry Annual CME Conference October th, Medical University of South Carolina TemeiaMartin, M.D., William Moran, M.D., M.S., FACP, Patrick Mauldin, Ph.D. Dr. Martin has documented that she has nothing to disclose. This pilot project was funded by the Medical University Hospital Authority. Objectives ) Establish a better continuity relationship with sickle cell patients ) Provide longitudinal care to better manage overall disease including pain control and complications of the disease ) Provide access to acute management of pain. ) Measure quality indicators ) Decrease the rates of emergency department visits and hospitalizations Revised -

2 // Joint Principles of the Patient- Centered Medical Home (AHRQ, AAFP, AAP, ACP, AOA) Personal physician and ongoing relationship Physician directed medical practice Whole-person orientation Integrated and coordinated care Quality and safety are hallmarks Enhanced access to care Payment appropriately recognizes added value Hypothesis: Acute Care Utilization The hospital (MUSC) provides care to a small subset of sickle cell patients who, on average, have a high utilization of emergency services and hospital admission. An even smaller proportion of this subset appears to be driving this high utilization pattern. UIM population: Chronic diseases Revised -

3 // Emergency Department Visits +years UIM N of PT s Total # in years Mean Median Min Max,,7 SSD N of PT s Total # in years Mean Median Min Max 7,. Hospital Admissions + years UIM N of PT s Total # in years Mean Median Min Max,,. SCD N of PT s Total # in years Mean Median Min Max Re-hospitalizations w/in days + years UIM N of PT s Total # in years Mean Median Min Max,,. SCD N of PT s Total # of years Mean Median Min Max 7 7. Revised -

4 // Hypothesis: Acute Care Utilization Intervention: Greater access to acute and longitudinal medical services will improve utilization patterns and disease management Outcome: This strategy will decrease usage of emergency services and decrease the rate of hospitalizations METHODS METHODS Tier patients according to utilization patterns for clinic enrollment Inter-professional team Monthly clinic visits for longitudinal management Daily acute treatment for intravenous opioid administration and hydration Individualized plans of care Revised -

5 // METHODS PHQ- screening Hydroxyurea Pharmacy Monitoring Clinic Weekly inter-professional team meetings Focus Groups Support Groups Develop a relationship with the emergency department METHODS Initial enrollment Top patients by utilization Sent letters asking if they want to transfer care from current UIM PCP to sickle cell clinic Follow-up phone call One hour clinic visit and orientation METHODS Quality indicators Hydroxyurea Depression screening (PHQ-) Exjade/Desferal Patient Satisfaction Revised -

6 // RESULTS RESULTS The inauguration of the clinic occurred on August st,. Since this time, we have grown from a pilot of patients to > patients / patients enrolled patients died before program started Quality of care measures: baseline data Initial Hydroxyurea % % ExJade % % Folic acid % 7% COMORBID DEPRESSION: Half of SCD patients diagnosed with depression Revised -

7 // Sickle Cell Clinic Start Dates for the First Patients Sum_PTs Top Sickle Cell PTs Tier Top ED Visits for Top 7 Sum_ED Top 7 Sickle cell PTs # of visits # of PTs 7 Hospitalizations for Top 7 Sum_HOSP Top 7 Sickle cell PTs # of visits # of PTs 7 7 Revised - 7

8 // Re-admissions for Top 7 Sum_REHOSP Top 7 Sickle cell PTs # of visits # of PTs 7 ED Visits for Top Sum_ED Top Sickle cell PTs # ofvisits # of PTs 7 7 Hospitalizations for Top Sum_HOSP Top Sickle cell PTs # of visits 7 # of PTs 7 7 Revised -

9 // Re-admissions for Top Sum_REHOSP Top Sickle cell PTs # of visits # of PTs Arrived Clinic Visits for Top 7 Sum_OUT Top 7 Sickle cell PTs # of visits # of PTs 7 7 Arrived Clinic Visits for Top Sum_OUT 7 # of visits # of PTs Top Sickle cell PTs 7 7 Revised -

10 // Overall Arrived Clinic Visits Number of PTs = #Visits Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Criteria:.) MRN = of the current sickle cell clinic patients.) Encounter provider = Dr. Martin, Sherrill Bradsher, UIM Sickle Cell Drop-in, MH, or NP) # of HydroxyureaOrders per Month for Sickle Cell Clinic Patients 7 Count of Orders Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Depression >% of patients identified had a diagnosis of depression (ICD- code) / patients met criteria for depression by PHQ- scores / patients were offered medication management and/or counseling / patients consented to treatment patients were compliant with recommendations Revised -

11 // CONCLUSIONS Impact Decreased emergency department visits Improved longitudinal care Improved access to primary provider(s)/acute service Increased monitoring for addiction and aberrant drug behaviors (Center for Drug and Alcohol Program & The Charleston Center) CONCLUSIONS Impact Increased number in Hydroxyureaprescriptions and monitoring for toxicity / patients are prescribed Hydroxyurea / patients meet criteria for Hydroxyurea therapy No mortalities CONCLUSIONS We have not had a significant impact on the rate of hospitalizations although a downward trend is observed We have not been able to impact 7/ patients in terms of utilization and ultimately disease control Revised -

12 // local hospital s data Funding LIMITATIONS Space Small units of observation (time interval and number of patients) FUTURE DIRECTIONS All UIM patients will be asked if they want to move to SCD PCMH Expansion and further development of support groups Transfusions and Maintenance Exchange Transfusions Formalized monitoring and use of Exjade/Desferal for iron overload FUTURE DIRECTIONS Development of transitional care models to augment pediatric enrollment in the Adult Sickle Cell Clinic Early interventions for end of life/goals of care discussions Revised -

13 // Inaugural Sickle Cell Support Group August nd, Sickle Cell Support Group September 7 th, QUESTIONS? Revised -

14 // APPENDIX A few thoughts from people with Sickle Cell Disease Focus group of patients with SCD and their words The disease Attitudes about SCD Treatment The care system Providers Educating children and young adults with SCD Patient Perceptions of SCD What do you think of when you hear the words sickle cell disease? Pain I m gonna pray for you. That s what I think of Sadness Your worst enemy It s unpredictable Revised -

15 // Unique SCD Problems Weather That was a rude awakening. It was I think the first time that the weather, the climate did it (crisis). I was doing car rider duty and. after that happened (crisis) I was out of work for like days. And I was really dressed well. You know I was warm so I didn t feel cold. And it was explained to me that it doesn t matter that warm or cold. Hydration I drink a lot of water. I drank (alcohol). I partied. I worked hard. Those (things) aggravates it (SCD). Because you re not staying dehydrated because you re drinking (alcohol). Lack of Patient-Provider Agreement Regarding Treatment Plan The doctors tell me to do certain things that I don t like and that don t seem right. I might try. If it (treatment)don t agree with me I won t continue. I guess my body is funny. I pay attention to my body. And if it get worse (with the treatment), then better I leave it alone. This doctor, me and him we was getting into it. about him telling me what to do and I m telling him I m not gone do that. MUSC the hospital of choice They ve (non-musc hospitals) got the MUSC protocol in the ER at their disposal and they don t want to use it in spite of a patient saying this is what I need, this is what I usually have and they don t want to comply with that. That is problematic..i mean even right now just because of horror stories I have heard about (non-musc hospital ), I will say I am allergic to Demerol just so I don t get it. Revised -