Rina Ramirez, MD, FACP Teresita Lawson, BSPharm, RPh, CDE Suyen Segura, MPH, CHES 1
Name three approaches that address specific health needs of seniors Discuss how different disciplines may be integrated into the expanded primary care team Describe three ways in which the primary care team can improve the safety of seniors with regards to medications 2
Established in 1990 in church basement in Dover by Dr. Zufall and volunteer physicians FQHC since 2004; providing entire range of primary medical, dental and enabling services Have 5 sites, 3 Dental Facilities a mobile medical van, and a Wellness Center Serving uninsured, underinsured, homeless, residents of public housing, farm workers, veterans Open 7 days a week, extended hours NCQA PCMH Level 3 for 2 of its sites- seeking multisite recognition for PCMH 2014 Bilingual staff and on call services 3
Pediatrics Adult Medicine Women s Health Ryan White Part A, C & F Dental Podiatry Behavioral Health Neurology Clinical Pharmacy Services Outreach and Health Fairs 340B Pharmacy Reach Out and Read Patient Navigation Case Management Health Literacy Program ACA Enrollment School-based dental program 4
Served 25,838 patients with approximately 86,751 visits 6.5% of patients are seniors, majority live in public housing or with family members Polypharmacy- Seniors are more likely to be on 5 or more medications, increasing risk of adverse drug events and increased utilization Multiple risk factors- health literacy, cognition, disabilities, lack of self efficacy, risk of falling Senior/Medicare Population growing Increased risk for depression-isolation, multiple chronic conditions, loneliness 5
Medical provider refers to Clinical pharmacist Behavioral health Patient navigator Evidence Based Multidisciplinary Better Outcomes Integrated into QA/PI Process Accountable Care Org. ER/Hospitalization-real time Assessments and Screenings Annual Well Visits Identification of Risks Preventive Services 6
Caring for the Senior Patient Caring for a Senior Patient Clinical Primary Care Pharmacy Clinical Services Primary Care Pharmacy Services Behavioral Health Behavioral Services Health Services Accountable Senior Care Navigator Accountable Senior Organization Care Navigator Organization 7
Identification of High Risk Patients Hospitalizations- updates during admission ER visits- frequent users Secure Communications- Hospitalists, Specialists and PCP Additional Resources- Atlantic Care Coordination Center 8
Coordination of Care- Interdisciplinary Team Engagement of team members Enhanced communications Population Management Identification of high risk population Tracking- patient follow-up Community Resources Medication Therapy Management Identification of Medication Related Problems Meaningful Use Continuous Quality Improvement Patient Satisfaction Development of Patient Education Tools Reduction of Utilization/Costs 9
Improves patient satisfaction and outcomes Nurtures Trust Whole Team Engaged Patient Engaged Population management Clinical Pharmacy Services Senior Navigators/Case Managers Behavioral Health- LCSWs Primary Care Team Reduction Utilization/Cost Address patient risks Identification of Barriers (MTM, AWV) Identification of Needs Reduce re-admission rates 10
Provider Referral ENABLING SERVICES BH Senior Navigator Clinical Pharmacy Services MTM Interventions/DSMT Case Managers Senior Navigation Behavioral Health Case Managers Co-management 340B/Med Access Risk Reductions Identification of Barriers CPS -pade/ade Reporting Team Collaboration Medication Problems Addressed Linkage to Resources BH Counseling Patient Follow-up Outcomes Tracking & Reporting Senior Navigation- ACO AIMM APhA Impact Database Chief Medical Officer Clinical Staff Meetings QA/PI/PCMH 11
CLINICAL PHARMACY SERVICES (CPS) - AIMM Collaborate- Alliance for Integrated Medication Management -PSPC 2008 to present -7th year High risk patients Integrated into expanded primary care team Approximately 900 seniors Consistent Favorable Outcomes AWARDS/RECOGNITIONS 1 of 25 communities selected nation wide-apha Foundation Project Impact Diabetes 2014-Patient Centered Innovation Award by the New Jersey Academy of Family Physicians (NJAFP) 2013-Becton-Dickenson/Direct Relief/National Association of CHC Award for Innovation in Diabetes Care in the underserved 2014-Outstanding Executive Leader Award- Eva Turbiner, CEO and Dr. Rina Ramirez 2014-Quality Leadership Award-Terry Lawson 12
Patient Centered Provider Education Patient Counseling Preventive Care Comprehensive Conducted Regularly Team Collaboration Prospective Chart Review & Provider Consultation Disease State Management The Patient Drug Information Medication Reconciliation Prevention Care Transitions Medication Therapy Management Retrospective Drug Utilization Review Medication Access-340B 13
Teach Back Personal Medication Record Medication Action Plan Health Literacy/Literacy Self Management Tool Used in AWV 14
Reviewed Monthly with CMO Quality Assurance and P&T Patient Safety Coordination of Care Identifies Medication Errors Classifies level of Harm Designates Level of Severity Captures Specific Pharmacist Differentiates between Driven Interventions- Patient Driven and Comprehensive Data Collection Medication Driven Medication Related Problems Or Misuse- Especially Important to our Seniors 15
N=109-100% out of control 63% of Diabetics <9% 39% <8% 76% LDL at Goal 66% <140/90 Patient Satisfaction with clinical pharmacy services in 2015-95% 16
Enrolled and followed 84 patients for one year Average of 4 visits per patient More >50% received action plans Results HbA1c levels significantly reduced by 0.9% (p=.0002). Improvements were seen in cholesterol and blood pressure (p=0.164, p=0.444) 65.2% had eye exams, 84.2% had foot exams, and 70% received their flu vaccine 28.6% of patients that smoked cigarettes quit smoking 17
Measure Results Interventions Depression Screening 25% screened 56% PHQ-9 > 10 100% referred or counseled BMI and Healthy Weight Advice Hypertension in control (BP <140/90) Diabetes in control (HbA1c <9) 35% Overweight 33% Obese 76% counseled, will focus on nutrition visits 58% Referrals to CPS and review of BP guidelines for seniors 81% Referrals to CPS and review of DM guidelines for seniors 18
Integrated into Primary Care Team Collaboration with CPS, PCP, Navigators and Case Managers Available at the majority of our sites Big emphasis for Integration from PCMH 2014 initiatives 19
ACA established in 2011 for Medicare Recipients Goal -design and maintain a Personalized Prevention Plan Services (PPPS). Eligible beneficiaries are those who have had Medicare Part B for at least 12 months AND have not received either within the past 12 months: Initial Preventive Physical Examination- Welcome to Medicare Visit OR An Annual Wellness Visit 20
Medical Assistant Vitals Medication Reconciliation Vaccine schedule Referrals Needed Fall risk assessment Medical provider assessment - provides referrals to: Fall prevention classes partnership with Atlantic Care Coordination Center Ophthalmologist, podiatrist, cardiologist appointments etc. Behavioral Health and/or CPS for high intensity MTM/DSMT Action plan review with patient Patient navigator follows up with patient to help he/she follow the doctor s recommendations 21
Medical Referral Verifies eligibility and schedules appointment for assessment Assessments Conducted Health Risk Assessment (HRA) Depression Screening (PHQ) Mini Cog test The CAGE questionnaire Hearing Loss assessment Activities of Daily Living screening List of Providers Reviews the following information Annual Wellness Visit FAQs Home Safety brochure Advance Directives Schedules appointment with medical provider 22
72yoF-DM,HTN,HLP,MI Scheduled for Abdominal Aneurysm Surgery Conducted prior to surgery- AWV-Risks- fall, podiatry, ophthalmology, hearing loss Medication Therapy Management Navigator-Identified for patient Specialists- close to home and within insurance network Transportation- facilitate patient independence Home Health Care Services/Contact/Engagement Clinical Pharmacy Services- after surgery/rehab Long list of medication changes patient confused Still on old regimen- assessed safety -stable Collaborated with PCP for immediate post surgery visit Today patient stable and at goal for all conditions-still on old regimen 23
Medication Therapy Management-post hospital Collaboration with PCP after hospitalization- Care transition and Continuity of Care Medication Action Plan Patient Counseling Patient Navigation Identified resources for patient for any needs that patient needed after surgery Collaborated with expanded team to conduct AWV and identify needed preventive services and patient risks, navigated to specialists Collaborated with CPS for MTM 24
Navigator for Seniors Bilingual Predominantly Hispanic PCP Refers Patient Accessing specialty care Closing the Loop- testing/treatment needs Social issues of concern Face to Face Meeting Patient and/or caregiver Assessment of needs Plan of action-based on need Available resources Navigation for appointments Transportation Trouble shooting problems that arise in accessing care 25
Program Goals Improve patient adherence to medical treatment plan Improve quality of life, health and wellbeing Funding from UWNNJ Patient Navigator assisted nearly 100 senior patients in 2014 95% of these patients adhered to treatment plan Social issues addressed 59% with multiple challenges completed a more in-depth assessment and long-term plan to help address other areas of concern or personal goals Program Tools Provider ID tool Health Assessment Long-term Plan Satisfaction survey 26
Wellness Center Healthy Cooking Chair yoga Qi Gong Zufall Intergenerational Program Tech Savvy Class Address emotional/social needs- isolation, loneliness, depression, neglect 27
82yo M-Medicare-Parkinson s, HTN, RA, Depression, prostate, incontinence Lives alone-isolated Participated in our senior program Live Your Better Life (LYBL) several years ago Navigator-Assessed Needs Housing- transition from mobile home to senior housinglocated realtors Obtained Housing application- helped complete Letter to Housing Authority- helped complete Helped patient participate in speech treatment program for Parkinson s Helped schedule pain mgt appt 28
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Trust patient-team relationship Patient centered- Comprehensive Face to Face encounters Frequent Touches- follow-up as needed Targeted interventions Disease-specific Culturally competent Health literacy conscious Barriers identified Evidence Based Team Collaboration Tools 30
Medication adherence Patient safety Access to medications Patient self-management Effectiveness of health care delivery model Close the loop Screening and prevention services Improved outcomes ED visits and hospitalizations 31
Contact Information: Teresita Lawson tlawson@zufallhealth.org Rina Ramirez rramirez@zufallhealth.org Suyen Segura ssegura@zufallhealth.org 32
1. http://www.acpm.org/?medadhertt_clinref 2. CDC s Noon Conference/ Medication Adherence/March 27, 2013 3. IMS Health Study Identifies $200+ Billion Annual Opportunity from-using Medicines More Responsibly- June 2013 4. ADA 2013 Fast Facts professional.diabetes.org/facts 5. http://scriptyourfuture.org/wpcontent/themes/cons/m/release.pdf 6. Choudhry 2011, N Engl J Med; Yeaw 2009, J Manag Care Pharm; Script Your Future press release, November 2, 2011; accessed here: http://scriptyourfuture.org/wpcontent/themes/cons/m/release.pdf. 7. AADE 7 Self Care Behaviors- American Association of Diabetes Educators 33