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Care Connections

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Pharmacist fits on high-intensity transitional
care team

Lancaster General Health is using a supercharged medical home model to care for some of its costliest patients, and clinical pharmacy services are an important part of that care.

“It’s a very tight-knit team. Everyone has an equal say and opinion about what they think is going on with the patient,” said Amber Jerauld, ambulatory pharmacist clinician. “Everyone’s voice is heard and valued.”

The program, Care Connections, identifies patients with complex medical and psychosocial issues that may be a barrier to care. These individuals also have a history of multiple hospital admissions.

When new patients are enrolled in Care Connections, Jerauld meets with them before they see a physician. She reviews their electronic medical record to identify drug interactions, renal function issues that could affect medication dosages, therapeutic duplication, and other medication-related problems.

Patients are asked to bring their medications with them to their initial appointment, and Jerauld performs a detailed medication reconciliation to identify problems and suggest changes to the treatment plan.

The team convenes a “huddle” each morning to review the day’s schedule and go over issues that may affect the patients’ health.

“Many times, patients don’t know how to access certain kinds of transportation or know of certain community resources. They may not have the right insurance plan or need a pillbox to help them keep medications organized. The team works to break down any barriers they may have to care,” Jerauld said.

She said the ability to visit patients in their homes is critical to the success of Care Connections.

Jerauld recalled visiting one patient, now a success story, who had been struggling with her insulin regimen. The team was also unsure if she was taking her other medications correctly.

“Her husband was filling her pillbox, but we didn’t know whether it was being done correctly,” Jerauld said. “During a visit I checked and the medications were organized correctly, however, since she had difficulty seeing, she was not drawing her insulin appropriately; and was  guessing.”

Jerauld said the patient was then provided with an insulin pen and taught how to use it properly.

“What you see and observe in the home is sometimes different than during an office visit,” Jerauld said. “Since you can see how they have everything set up in their home.”

Lancaster General Health President & CEO Thomas Beeman, in testimony before Congress in May, said the health system had previously determined that 480 “superutilizer” patients accounted for $36 million in hospital charges during 2008 and 2009.

During a pilot program in 2011–12, LG Health enrolled a small number of patients  to provide intensive team-based transitional care to stabilize the patients’ health and resolve psychosocial issues before transitioning  them to their primary care provider (PCP).

“There was some positive data from the pilot program showing that we were able to decrease length of stay and number of hospitalizations and improve quality of care for the patients,” said Jerauld, who participated in the pilot project.

Those positive findings led to the launch of Care Connections in August 2013.

According to Beeman, inpatient visits for the pilot and Care Connections patients have decreased by 67 percent since 2011, inpatient days fell by 84 percent, and emergency department visits dropped by 26 percent. Jerauld said a pharmacy residency project also found improved medication adherence among 51 Care Connections patients. She attributed the improvements to the “high-touch” care and one-on-one education provided by the healthcare team.

Jerauld said 93 patients were actively enrolled in Care Connections in Spring 2014, with 36 graduating from the program by the end of June.

“We’re hoping to have them from 90 to 120 days and then eventually transition them back to their PCP’s office,” said Jerauld, who works mornings for Care Connections and afternoons for LG Health Physicians Downtown Family Medicine, which is a National Committee for Quality Assurance–recognized level III patient-centered medical home.

Jerauld said the team’s patient care navigators have worked as paramedics or emergency medical technicians and are critical to the program’s success.

“They go on many home visits and  coordinate transportation to make sure patients get to and from their appointments. They look at the medications in the home and develop that relationship with the patient,” Jerauld said.

She said the team’s social workers counsel patients and ensure access to important community-based services that help patients manage their health and well-being.

Beeman stated that the program’s clinical and social care is supported by an interconnected electronic health records system and related technologies. This includes telemedicine components that allow Care Connections staff to connect with office resources while visiting patients in their homes.

The health system has announced its intent to seek outside funding to sustain Care Connections, and Jerauld said the leadership staff has applied for grants to expand the program.

Traynor, Kate. (2007). 
Pharmacist fits on high-intensity transitional
care team.  American Journal of Health. 71, 1066-1068.

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