Category: Professional Posters
Purpose: Patients with multiple comorbidities and high hospital/ED utilization rates result in increased healthcare costs. Literature shows that team-based ambulatory care for these patients can decrease hospital readmissions and emergency room visits (HR/EV) and reduce healthcare expenditures, and that clinical pharmacy plays an important role on these teams. The newly formed Complex Care Practice (CCP) at Greater Baltimore Medical Center is a patient-centered approach that actively utilizes an ambulatory-residency trained clinical pharmacy specialist. The team influences patient behaviors and outcomes by addressing clinical issues, including medical and pharmacologic, and social determinants of health (SDH) in the ambulatory setting, thus reducing HR/EV.
Methods: The practice consists of 2 internists, an ambulatory-residency trained clinical pharmacy specialist, nurse, social worker, practice manager and medical assistant. CCP was designed throughout 2018 and welcomed its first patient in March 2019. Patients are identified through the hospital’s EHR, Maryland’s HIE system, and physician referrals. Patients with more than 5 HR/EV within the past year are considered for inclusion. If both the patient and their PCP agree, care is temporarily transferred to CCP. The team—with active involvement from the ambulatory clinical pharmacy specialist—meets with the patient, either in the office or the patient’s home, and assesses clinical indicators and SDH that are root causes of high utilization. A comprehensive care plan is developed with the patient, and involves multidisciplinary coordination, self-management, and often includes home visits. The clinical pharmacist is present during clinic hours to review patient cases with the interprofessional team and to address medications and barriers to access/adherence. The clinical pharmacist proactively identifies medication issues that could lead to a HR/EV, performs regular face-to-face and telephonic communications with patients, recommends interventions and evidence-based cost-effective regimens, educates patients, and contributes to the development of new team-based care plans. Weekly group rounds ensure outreach and follow-up care are adequate and consistent. Once the patient graduates from the practice, a warm handoff occurs with their PCP or a patient-centered medical home near their home/workplace.
Results: Hospital leadership identified a cohort of patients who were responsible for a disproportionately high number of HR/EVs and related costs. Sixteen patients were enrolled during the first two months of the CCP model. Initial data show that HR/EVs for this cohort decreased from a monthly average of 7.3 in the 12 months pre-enrollment to a monthly average of 2.5 post-enrollment. In one case, a hemodialysis patient had a low hemoglobin and was instructed to go to the ED by his dialysis nurse. Because the patient was engaged in the CCP, he first called the CCP hotline and the team arranged for an immediate blood transfusion in the hospital’s ambulatory infusion center. This eliminated the need for an ED visit, led to a satisfied patient who was home a few hours later, and saved thousands of dollars in health care costs. In two recent cases involving opioids, the ambulatory clinical pharmacist prevented ED visits by making medication recommendations, securing pre-authorizations, educating the patients, and obtaining medication use contracts. Enrollment in the program is continuing, and while initial data are limited, the team anticipates an ongoing decrease in HR/EV that is statistically significant.
Conclusion: The transfer of high-risk patients from traditional primary care to the CCP holds great promise. Review of CCP data shows an initial reduction in HR/EV and suggests this improvement is sustainable, due to the multidisciplinary team’s approach in reducing costs by assessing clinical indicators and SDH. Every team member has a workflow focused on the program’s success, and the ambulatory clinical pharmacist specialist is an essential member who enables an immediate response to medication-related issues, including adherence and access. The complementary knowledge and skills of the team lead to improved patient care, medication use and reduced healthcare costs.