Implementation of a Protocol to Manage Patients at Risk for Hospitalization Due to an Ambulatory Care Sensitive Condition
Background: Ambulatory care sensitive conditions (ACSCs), such as type 2 diabetes mellitus, chronic obstructive pulmonary disease, hypertension, congestive heart failure, urinary tract infections, asthma, dehydration, bacterial pneumonia, angina without an in-hospital procedure, and perforated appendix put patients at risk for hospitalization. Currently at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, no standardized process or protocol exists that can identify and optimize primary care for patients with ACSCs who have been hospitalized but are predicted to be at low risk for rehospitalization.
Methods: This project aimed to evaluate the implementation of offering further referrals and care for these patients. A pharmacy resident conducted a baseline chart review using a standardized template in the US Department of Veterans Affairs (VA) Computerized Patient Record System to identify additional referrals or interventions a patient may benefit from based on any identified ACSC. Potential referral options included a clinical pharmacy specialist or nurse care manager disease management, whole health/wellness, educational classes, home monitoring equipment, specialty clinics, nutrition, cardiac or pulmonary rehabilitation, social work, and mental health.
Results: Comparing the 3 months prior to and the 3 months after offering referrals, there was a cumulative quantitative decrease in the number of emergency department visits (5 to 1) and hospitalizations (11 to 5).
Conclusions: Identifying patients at risk for hospitalization from an ACSC via a review and referral process by using the VA patient aligned care team structure was feasible and led to increased patient access to primary care and additional services.
As there were 69 eligible patients identified over a 3-month period for a single VA facility, including all community-based outpatient clinics serving an estimated 130,000 veterans, the additional time and workload for an individual PACT to reach out to these patients is minimal. Completing the review and outreach process for an average of 21 minutes per patient for at most 5 patients per primary care provider team is feasible to complete during the recommended 4 hours of weekly CPS population health management responsibilities.
Limitations
Several limitations were identified with the implementation of the project. A variety of PACT members completed initial outreach to veterans regarding additional referrals, which may have resulted in a lack of consistency in the approach and discussion of offering referrals to patients. Although there may be a difference in how the team members made referral offers to patients and therefore varying acceptance rates by patients, the process was thought to be more generalizable to the PACT approach for providing care in the VA. In addition, the time to contact patients to offer referrals was not always documented in the electronic health record, making the documented time an estimate. Given that patients identified were managed by a variety of PACT members, there were differences noted among PACTs in terms of acceptability of offering referrals to patients.
While there was a decrease noted in ED visits and hospitalizations when comparing 3 months before and afterward, additional data are needed to provide further insight into this relationship. As the patients identified were at low risk for hospitalization from an ACSC and had 1 or 2 hospitalizations within the year prior, additional time is warranted to compare 12-month ED visits and hospitalization rates postintervention. Finally, these findings may be limited in generalizability to other health care systems as the project was conducted among a specific, veteran patient population with PACT CPSs practicing independently within an established broad scope of practice.
Future Directions
Future directions include incorporating the review and referral process into the PACT CPS population health management responsibilities as a way to use all PACT members to enhance primary care delivered to veterans. To further elucidate the relationship between the referral process and hospitalization rates, a longer data collection period is needed.
Conclusions
Identifying patients at risk for hospitalization from an ACSC via a review and referral process by using the VA PACT structure and team members was feasible and led to increased patient access to primary care and additional services. The PACT CPS would benefit from using a similar approach for population health management for low risk for hospitalization patients or other identified chronic conditions.
Acknowledgments
Presented at the Wisconsin Pharmacy Residency Conference at the Pharmacy Society of Wisconsin Educational Conference April 10, 2019, in Madison, Wisconsin.
