Systematic Anticoagulation Management in the Rural Health Setting

Lisa Vaughn RN, CACPClinical Manager Anticoagulation ServicesWenatchee Valley Medical Center

Serving more than 160,000unique patients annually….

….over 750,000 patient visits per year in an area that covers 12,000 square miles

300 Physicians, Physician Assistants, and Nurse Practitioners….85 Primary Care Physicians, PA’s, & ARNP’s

1500 Employees in eleven communities and four counties

Wenatchee Valley Medical Center

Wenatchee Valley Medical Center

Waterville

Oroville

Tonasket

Omak Brewster

Royal City

Moses Lake

Cashmere

East Wenatchee

Wenatchee

Our Mission

To provide our patients with the highest quality health care and service in a friendly and caring atmosphere

Committed to assisting in the development of one of the nation’s best rural health care delivery systems

Common Scope of Service

Face-to-face visits with APC Patient Self Testing Televideo appointments Home visits POC INR Testing EMR Patient access for lab results, RX renewal,

scheduling, health care questions Patient Education – NOA My Chart access to medical records,

scheduling and health advice

DAWN AC - Organization 7 ACC locations with 8 full time

and 4 part time advance practice providers

2100 patients 5 separate DAWN Organizations Providers with DAWN clinics at

multiple organizations DAWN groups – Home Visits, Self

Testing and APS

Collaboration to Provide Safe Care Patient Tracking Quality Measures

• TTR• Elevated INRs• Time to Therapeutic• Clinical outcomes (Bleeding, TE, Fatalities)

Staff Proficiency and Competency ACC specific practice plan for APCs Standardized Lab Monitoring – POC INRs,

POC-Lab Correlation Studies

Standardized System Wide: Policies and Procedures

Patient education resources

Peri-op/procedure program

Documentation tools (Coded Comments)

Systematic Therapy Management

Evidence Based Protocols:• Warfarin Induction• Risk Assessment • Managing Non Therapeutic INRs• Follow-up Intervals• Peri-procedure/operative Management• Elevated INRs• Anticoagulation Related Labs• Management of Patients with APS

Systematic Scheduling

Transition of care inpatient-outpatient New Patient Enrollment Routine Follow Management of No Shows Management and Documentation of

Non Compliance Peri-procedure/operative visits

Teamwork

Job descriptions/APC Practice Plan Staff and provider training and CME Performance Improvement Projects CACP Certification Bi weekly meetings Standardized workflows Weekend and holiday service

Throughout all locations Advanced Practice Provider Practice Plans

Anticoag Clinic physician oversight

Administrative support

Staff and provider coverage for time off

Pharmacy support

Shared Resources

Shared Medical Record

DAWN AC – continuum of care between ACC locations

EMR with interfaces with DAWN AC

Interactive Medical Record

Cadence

EpiCare

DAWN AC

DAWN – Lab Interface

Lab-all WVMC lab locations export INR to DAWN

Diminishes manual data entry errors No delay in time from reporting to

appearance in DAWN List View Worklist

Undosed INRs visible at all ACC locations

DAWN – EMR ADT Interface

Demographic information

Appointment scheduling

Tracking and documenting non compliance in DAWN

Cadence Appointment → Dawn Dose Schedule

DAWN – Communication with Multiple Health Care Providers

Exporting DAWN Quick Note to EMR and link in EMR to DAWN

Immediate access to DAWN records:• Other WVMC healthcare providers• Outside healthcare providers: DAWN→EMR→Epicare

Link

Peri-procedure/surgical anticoag management plan – Two hospitals

Shared in DAWN Treatment Plan Annual physician order updates - Reviews Patient tracking – List Views Quality Measures – Benchmarking and

Reports Patient Education – Letters Groups- Home visits, APS, PST

Documentation – Coded Comments

Load Leveling

DAWN List Views

Annual Order Updates

Tracking No ShowAnd

Non-compliance

Tracking Hospital Admits

ACC Required Related Lab

Tests

New Patient Pre-work

Risk ClassNew Starts

Acute to Chronic

List Views Filter by provider

Cross Coverage Telemedicine Visit

Weekend Coverage

Peri-operative/procedure management

Unexpected INR results

Looking Forward

Increase in patient population+

Multiple locations for care+

Addition of new anticoagulants

Continued need for expertise and standardization and systematic process for administrative and clinical

management

Reference

Delivery of Optimized Anticoagulant Therapy: Consensus Statement from the Anticoagulation Forum

David Garcia, Daniel M Witt, Elaine Hylek, Ann K Wittkowsky, Edith A Nutescu, Alan Jacobson, Stephan Moll, Geno J Merli, Mark Crowther, Laura Earl, Richard C

Becker, Lynn Oertel, Amir Jaffer, and Jack Ansell

The Annals of Pharmacotherapy 2008 July/August, Volume 42

List View - Worklist

List View-Risk Class

List View-All Patients

List View – New Patients

List View – Annual Requirements