Lincoln Medical Center
Lincoln Medical Center is part of New York City Health + Hospitals, the largest public hospital system in the region. H+H is the public safety net health care system for New York City. We are a 362 bed hospital with expansive primary medicine and subspecialty clinics. Lincoln is a busy hospital, with 550,000 outpatient clinic visits and 144,000 emergency department visits in 2016.
Located in the South Bronx, Lincoln provides medical care to an underserved population. Many of our patients are immigrants and speak a language other than English at home. Our patients and staff come from many different cultures with variable health care beliefs. Patients are seen in one of the primary care clinics (adult medicine, pediatrics, or women’s health), and over 80 specialty services are available throughout the hospital.
The adult medicine clinic at Lincoln serves around 22,000 patients annually. The clinic is divided into three teams of attending physicians, resident physicians, nurses, and patient care assistants. We’ve had a pharmacist in the geriatric clinic full time since 2015 and had a CDTM pharmacist in the hepatitis C clinic from 2015-2016 however, pharmacy has never been directly involved in the adult medicine clinic. It was a great opportunity to add a clinical pharmacist to the physician teams.
Why was the pharmacy service developed?
Lincoln developed a transitions of care (TOC) program for both the emergency department (ED) and the inpatient medicine floors under a grant from the city. There was one transitions of care pharmacist for the ED team. During this time, it was noted that the medication concerns for many of the ED patients (e.g. adherence, chronic conditions) could have been better handled in the primary care setting. After the grant ended, findings were discussed with the chief of ambulatory care. It was decided to move the clinical pharmacist from the ED to the primary medicine clinic so that medication problems could be addressed in clinic rather than in the ED.
Out of the 22,000 patients with a primary care provider in the medicine clinic, approximately 10,600 have a diagnosis of diabetes. In clinic, the pharmacist works with patients having a HbA1c >9% and age 65 years or older. We decided to work with one physician team to make the population of focus more manageable and to use the two other physician teams as a control group to help measure success. Taking all of this into consideration, the initial population of focus for the pharmacist was 87 patients, with plenty of room to expand as the service continues to grow.
We had help from the A3 Collaborative in developing and implementing our new clinic service. We knew that expanding to primary care was a great opportunity, and our physicians readily identified diabetes as a disease state for us to target. The collaborative helped us with strategies to hone in on the patient population and engage our stakeholders.What training, certification, credentialing, and practice agreement is utilized by the practice setting pharmacist?
The team preferred a pharmacist with clinical experience, but specific qualifications were not required. New York State has requirements for working as a CDTM pharmacist, but not for working incident-to a physician. At present, the primary care clinic pharmacist has a board certification in geriatric pharmacotherapy and previously completed a certificate training program for Medication Therapy Management Services. She is working to become credentialed by the state board of pharmacy with the goal of progressing to CDTM visit model under a collaborative practice agreement. She works as part of the primary team and visits are billed incident-to the attending physician.
What outcomes are being measured to evaluate the model's success?
Our initial clinic measures revolve around medication therapy problems (MTP). We look at the number of MTP identified and resolved, the number of interventions recommended to correct a MTP, and the percent of interventions accepted for implementation. We are also recording patient HbA1c so we can start tracking trends in diabetes control. In the future, we plan to assess other measures of clinical impact, including emergency and inpatient utilization and HEDIS measures for medication adherence to evaluate big-picture impact.
How have you made this service sustainable?
The pharmacist visits are billable as incident-to under the attending physician. We decided to implement a separate CMM visit instead of a group visit for two main reasons: due to limited clinic space and because separate visit is billable. The revenue from billing is used to demonstrate sustainability of this clinical pharmacy service. We are also collaborating with one of our biggest payors to track HEDIS measures for medication adherence, which have a large potential for reimbursement.
How did you gain support of administrators, providers, and other key stakeholders?
While working with the ED TOC team, the pharmacist reported directly to the chief of ambulatory care. When we began discussing next steps toward the end of the grant, we proposed moving into primary care and the chief helped facilitate the move by assigning the team to work with. He also assisted with ideas for how to demonstrate sustainability. In the medicine clinic, Team 1 was excited to learn that they were going to have a pharmacist on board and the physicians helped identify potential target patient populations.
What are some lessons learned while implementing your practice model that you would like to share?
Be persistent! It took seven months of behind-the-scenes planning, developing, and paperwork before the first patient visit. Between identifying the target population, forming bonds with the providers, identifying the technology requirements, various stakeholders were followed up with regularly to check the progress of the implementation.
Be flexible! Some days the designated clinic space is not available. Some days the pharmacist will reach out to a group of patients and get voicemails for everyone. Some days the workload becomes heavy and we have to balance performing a thorough CMM visit with respecting each patient’s time. During a recent team meeting data from the first two months of clinic visits was shared with the group; the providers decided it was time to expand pharmacy services to a broader patient cohort. We were ready to jump in with ideas because as we had also been thinking about expansion. Having a plan for certain foreseeable circumstances, such as the clinic workload for the day or the vision for the clinic scale, will help navigate some of the variables of implementing a new service.