Care coordination helps lower the incidence of anticoagulant-related adverse events among Centura Health Medicare patients.
Medicare patients on anticoagulant therapy are at increased risk for adverse drug events (ADEs). Recognizing an opportunity to improve care coordination for this vulnerable patient population, Telligen, the Centers for Medicare & Medicaid Services Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Colorado, Illinois and Iowa worked with Porter Anticoagulation Center in Denver, Colorado, to identify Medicare patients at high risk for ADEs and to establish care coordination processes between the inpatient and clinic pharmacists.
The Porter Anticoagulation Center is run by a staff of pharmacists who see up to 90 Medicare patients at least once a month. Many Medicare patients were not making appointments for follow-up visits at the outpatient anticoagulation clinic after hospitalizations, putting them at greater risk for ADEs. The clinic staff sought a way to identify patients at high risk for ADEs and tailor their interventions accordingly. In addition, clinic staff saw an opportunity to improve care coordination for non-anticoagulant-related issues due to the frequency of their patients’ visits.
Location- Denver, Colorado.
Organization Type- Outpatient clinic of Porter Adventist Hospital, Centura Health.
Number of Beds- N/A.
Payer Mix Medicare, Medicaid, private insurance.
Population Served- Patients receiving anticoagulant maintenance therapy.
Porter Anticoagulation Center provides warfarin monitoring and dose adjustment with same-day international normalized ratios (INRs) test results.
What We Tried
Telligen’s medication safety task leader and pharmacist worked with the Porter Anticoagulation Center’s director and pharmacist to identify Medicare patients at greatest risk for ADEs. Patients with international normalized ratios (INRs) lower than 1.8 or higher than 4 were identified as at-risk for major ADEs. Patients with INRs between 3.2 and 4 were assessed as at-risk for minor ADEs. Once at-risk patients were identified, pharmacists were able to intervene by teaching and consulting with these patients about their medications and adjusting doses or withholding medications as needed.
Meanwhile, a clinic pharmacist worked with the inpatient pharmacy director to set up a system to notify the outpatient anticoagulation clinic when an enrolled patient is admitted to the hospital. After discharge, an outpatient clinic pharmacist calls the patient to schedule a follow-up appointment.
Clinic pharmacists also began tracking their interventions for non-anticoagulant-related health issues, such as infections, uncontrolled blood pressure, and falls. All patients are screened for fall risk during their initial medication assessments.
At the onset of the pharmacist intervention, 4.7 percent of unique Medicare patients had an ADE; this rate had dropped to 1.4 percent at the end of the nine-month pilot, although the rate decline was not consistent month to month. Of all Medicare patients who had a follow-up visit to the clinic after hospitalization, 39.4 percent required a pharmacist intervention. Based on INR levels, pharmacist interventions contributed to preventing 243 major and 135 minor anticoagulant-related ADEs, respectively. Health care cost savings to date total at least $756,000, using a conservative cost estimate of $2,000 per episode for general ambulatory ADEs. This estimate does not include cost savings associated with prevention of ADEs that otherwise would have led to hospitalization or readmission.
The outpatient clinic pharmacist reports better patient follow-up rates since admission notifications began, which may have helped reduce the incidence of ADEs in at-risk patients still further. In addition, clinic pharmacists continue to refer and counsel patients for falls and other non-anticoagulant-related conditions as part of their care coordination efforts. Clinic pharmacists offer to perform medication assessments for the primary health care provider if dizziness or other potential medication side effects increase fall risk for patients.
This project fosters a sense of teamwork between the clinic and inpatient pharmacy staffs, which translates into improved care coordination and medication safety for patients on anticoagulant therapy. But the clinic’s new ability to identify and document prevention of ADEs is a key element that will continue to demonstrate the clinic’s value to hospital leadership.
For facilities that are setting up notification systems for hospitalized patients, inpatient teams and clinic teams should track notification rates and agree upfront on an acceptable notification rate. If notifications dip below that threshold, the teams can huddle to get back on track.