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Case Studies
Supporting Community Pharmacist
Pharmacists use Medication Therapy Management (MTM) program services to do in-depth medication reviews, follow-up phone calls to assess and promote patient medication adherence and other clinical services. MTM services ensure patients are receiving optimal therapeutic outcomes.
Use Case: Pharmacists regularly perform medication reviews on patients, but a major challenge for community pharmacists obtaining necessary clinical information is manual, slow and time consuming.
Project Details
•Collaborative effort between SDHL, SDSU and Lewis Drug to enable pharmacists access to clinical data via Point of Care Exchange, to support their MTM program and other direct patient care services.
•SDHL assisted community pharmacists with aligning current clinical programs initiatives and workflows.
Impact
•Spend more time for patient care services
•Recommend less expensive, more effective med therapy
•Reduce unnecessary phone calls and faxes
•Enable accurate and specific patient counseling
•Easily confirm diagnosis codes for drug/dose adherence, Medicare Part B billing
•Enhance CMRs resulting in more productivity
•Confidently identify Drug Therapy Problems
Accurate Clinical Documentation: Poor Historians
Trying to capture accurate medical histories from poor historian patients takes tremendous time and effort. Often, it requires clinical teams to go through the manual process of multiple phone calls and faxing to receive accurate medical information for patients who are not able to provide accurate information themselves.
Use Case: Provide access to Point of Care as well as medication history.
Project Details
•Triage/Intake: Provides immediate and expanded access to community clinical.
•Provider: Assists with medical decision making
•Patient: Assists with capturing accurate medication histories.
Impact
•Reduce unnecessary duplicate, high cost testing.
•Improved patient satisfaction and safety.
•Workflow efficiencies.
•Improved provider/staff satisfaction.
ED Utilization for Chronic Pain Management
Recent current events and the opioid epidemic impacting the nation have highlighted the need for appropriate chronic pain management. With options to receive care at multiple end points in the community, a patient’s drug regime can change frequently.
Use Case: The ability to access a patient’s entire medication regime from multiple endpoints can be very complex and challenging, requiring a great deal of time and manual intervention.
Project Details
•Triage/Intake: Provides immediate and expanded access to community clinical data to assist with accurately capturing medication fill and encounter history.
•Provider: Assists with medical decision making
•Pharmacy Team: Supports with accurate data access medications reconciliation for patients.
Impact
•Improves staff satisfaction by eliminating the phone and fax process to obtain a patient medication history information.
•Provided support with evaluation and ongoing medication management post discharge and early identification of misuse of substance abuse issues
Case Management Awareness
Division of Long Term Services and Supports (LTSS) provides home and community-based services for South Dakotans who meet program eligibility to help them remain living in the community who without these services, would require nursing facility care.
Use Case: Provide Event Notifications and Point of Care access to LTSS Specialists in order to actively participate in discharge planning and improve care coordination for program eligible consumers.
Project Details
•SDHL provides real-time clinical event notifications
•Access to Point of Care clinical documentation
•Outcomes for successful diversions to LTC
Impact
•LTSS real-time notifications allow specialist to actively participate in the discharge process to determine consumer needs and avoid potential admissions to nursing facilities
•Improved care coordination for consumers and improves their ability to return home
•Patient satisfaction.
Managing Medicaid Health Home Patients
Health Homes is a method of delivering enhanced health care services that promises better patient experience and better results than traditional care. The Health Home has many characteristics of the Patient-Centered Medical Home but is customized to meet the specific needs of Medicaid recipients with chronic medical conditions or behavioral health conditions.
Use Case: Enable Health Home Notifications and access to Point of Care clinical documentations.
Project Details
6 federally mandated Core Services
•Comprehensive Care Management
•Care Coordination
•Health Promotion
•Comprehensive Transitional Care
•Patient and Family Support
•Referral to Community and Support Services
Impact
•Care Transition Follow-Up within 72 hours of discharge
•Follow-Up within 7 ow 30 days after hospitalization for mental illness
•Follow-Up post Emergency Department visit
FQHC Practice: Improving Transitions of Care
One of the largest risks for readmission after hospital discharge is lack of timely follow-up with their PCP. A challenge is to know when a patient has been discharged in order to provide ongoing support during this critical time.
Use Case: Use Event Notifications so providers and care teams can create the best outreach and treatment plan.
Project Details
•Leverage existing ADT feed to SDHL
•Subscribe to event based notifications
•Upload specialized patient list
•Use Point of Care to access post-discharge instructions, and to schedule follow-up appointment to support continuity of care.
Impact
•Enhances ability to spend less time on administrative work and more time on supporting and coaching the patient as event occurs.
•Patient: improves safety and reduces exposer for adverse drug or medical events
•Allows for opportunities to increase reimbursement rates for chronic care management
Timely Care Delivery: Incapacitated/Unresponsive Patient
Clinical care teams are unable to acquire medical history information by traditional methods for incapacitated patients who may be unable to speak for themselves. Medical history information is not always readily available and can require a manual process of phone calls and faxing.
Use Case: Provide access to Point of Care for immediate and expanded access to community clinical data to assist with accurately capturing medical history information.
Project Details
•ED Admissions: Access to demographic, insurance, and PCP information.
•Pharmacist: Access Medication History to support medication reconciliation efforts.
•ED Provider: Access to recent visit histories, testing, and results data.
Impact
•Timely intervention and medical decision making.
•Reduced phone calls and faxing.
•Expedited ED chart creation in EMR.
•Improved patient safety
•Improved Workflow Efficiencies
Expediting Admission Assessments/Orders
Patients requiring inpatient admission can have difficulty remembering current medications, procedures and/or treatments. It may not always be possible to obtain this information directly from patient, requiring clinical teams to make multiple phone calls and faxing.
Use Case: Provide access to Point of Care for immediate and expanded access to community clinical data to assist with accurately capturing medical history information.
Project Details
•Admissions: Access to demographic, insurance, and care teams.
•Pharmacist: Access Medication History to support medication reconciliation efforts.
•Hospitalists: Access to recent visit histories, testing, and results data.
•Inpatient RN: Access to community clinical data
Impact
•Accurate medical history information
•Avoid unnecessary duplicate testing upon admission
•Reduce phone calls and faxing •Patient safety and satisfaction
Identifying Misuse and Abuse: Opioid Management
More people died from drug overdoses in 2014 than in any year on record. The majority of drug overdose deaths (more than 6 out of 10) involve an opioid. 78 Americans die every day from an opioid overdose.
Use Case: The ability to access a patient’s up-to-date medication history is not only critical to the treatment rendered, it can also be helpful in supporting identifying potential misuse and abuse of medications impacting this national epidemic.
Project Details
•Provide immediate and expanded electronic access to community medical history data to assists with identifying compliance issues and early detection for identifying potential drug seeking behaviors.
Impact
•Accurate medical history information
•Improves staff satisfaction by reducing phone and fax process