Pharmacist-Physician Split-Shared Visits in a Federally Qualified Health Center: Lessons Learned from a Novel Reimbursement Model using Telehealth.

Introduction: The Federally Qualified Health Center (FQHC) setting poses unique challenges to reimbursement of services provided by ambulatory care pharmacists; however, recent changes to telemedicine reimbursement have created new opportunities to help overcome these challenges. This article describes the experience and outcomes of the implementation of a novel, pharmacist-physician split-shared telehealth model at AltaMed Medical Group, a large, multi-site FQHC in Los Angeles and Orange counties. Program Development and Implementation: A pilot program for pharmacist-physician split shared tele-visits was launched at one clinic site with one clinical pharmacist and has since been expanded to a total of 6 sites and 5 clinical pharmacists. Prior to this program, clinical pharmacists saw patients for diabetes mellitus (DM) video-conference disease management appointments. With the launch of the pilot program, additional steps were added to pre-existing workflows to create a model in which visits with the clinical pharmacists were followed by an "enhanced visit" with an eligible, billable clinic provider. Outcomes: Average A1c change for all patients in the split-shared model was -1.5%, and average A1c change for program graduates from enrollment through graduation was -3.8%. Evidence from similar services have also been associated with significant increases in revenue from a split-shared model, indicating this design can be a viable option for financial justification of ambulatory care pharmacy services. Conclusion: In the setting of current limitations, we advocate for increased utilization of shared visits and split-shared visits as a viable method to generate revenue and aid in the justification of clinical pharmacy services.

Medication regimen complexity and readmissions after hospitalization for heart failure, acute myocardial infarction, pneumonia, and chronic obstructive pulmonary disease.

OBJECTIVES: Readmission rate is increasingly being viewed as a key indicator of health system performance. Medication regimen complexity index scores may be predictive of readmissions; however, few studies have examined this potential association. The primary objective of this study was to determine whether medication regimen complexity index is associated with all-cause 30-day readmission after admission for heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. METHODS: This study was an institutional review board-approved, multi-center, case-control study. Patients admitted with a primary diagnosis of heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease were randomly selected for inclusion. Patients were excluded if they discharged against medical advice or expired during their index visit. Block randomization was utilized for equal representation of index diagnosis and site. Discharge medication regimen complexity index scores were compared between subjects with readmission versus those without. Medication regimen complexity index score was then used as a predictor in logistic regression modeling for readmission. RESULTS: Seven hundred and fifty-six patients were randomly selected for inclusion, and 101 (13.4%) readmitted within 30 days. The readmission group had higher medication regimen complexity index scores than the no-readmission group (p < 0.01). However, after controlling for demographics, disease state, length of stay, site, and medication count, medication regimen complexity index was no longer a significant predictor of readmission (odds ratio 0.99, 95% confidence interval 0.97-1.01) or revisit (odds ratio 0.99, 95% confidence interval 0.98-1.02). CONCLUSION: There is little evidence to support the use of medication regimen complexity index in readmission prediction when other measures are available. Medication regimen complexity index may lack sufficient sensitivity to capture an effect of medication regimen complexity on all-cause readmission.

Comparison of 3-Factor Prothrombin Complex Concentrate and Low-Dose Recombinant Factor VIIa for Warfarin Reversal.

INTRODUCTION: Prothrombin complex concentrate (PCC) and recombinant Factor VIIa (rFVIIa) have been used for emergent reversal of warfarin anticoagulation. Few clinical studies have compared these agents in warfarin reversal. We compared warfarin reversal in patients who received either 3 factor PCC (PCC3) or low-dose rFVIIa (LDrFVIIa) for reversal of warfarin anticoagulation. METHODS: Data were collected from medical charts of patients who received at least one dose of PCC3 (20 units/kg) or LDrFVIIa (1000 or 1200 mcg) for emergent warfarin reversal from August 2007 to October 2011. The primary end-points were achievement of an INR 1.5 or less for efficacy and thromboembolic events for safety. RESULTS: Seventy-four PCC3 and 32 LDrFVIIa patients were analyzed. Baseline demographics, reason for warfarin reversal, and initial INR were equivalent. There was no difference in the use of vitamin K or fresh frozen plasma. More LDrFVIIa patients achieved an INR of 1.5 or less (71.9% vs. 33.8%, p =0.001). The follow-up INR was lower after LDrFVIIa (1.25 vs. 1.75, p < 0.05) and the percent change in INR was larger after LDrFVIIa (54.1% vs. 38.8%, p = 0.002). There was no difference in the number of thromboembolic events (2 LDrFVIIa vs. 5 PCC3, p = 1.00), mortality, length of hospital stay, or cost. CONCLUSIONS: Based on achieving a goal INR of 1.5 or less, LDrFVIIa was more likely than PCC3 to reverse warfarin anticoagulation. Thromboembolic events were equivalent in patients receiving PCC3 and LDrFVIIa.