Category: Diabetes Management and Prevention, Heart Disease Management and Prevention, Provider Education, Provider Education Network
Hardtner Medical Center in Olla recently brought their pharmacist into the Center’s Chronic Care Management team to better serve their at-risk chronic care patients.
Chronic Care Management (CCM) is a set of coordinated services provided outside of regular office visits to Medicare patients with at least two chronic conditions. Hardtner established a CCM program for eligible high-risk patients in 2016 led by Chronic Care Nurses Daphanie Veillion and Brenda Evans.
Through the program, Daphanie and Brenda are referred to eligible patients who have a primary care physician at Hardtner. They reach out to each patient, go over their medications, all of the healthcare providers they see and establish logs such as blood pressure or blood sugar readings to obtain a comprehensive look at the care the patient is receiving.
While they have to do a little paperwork and have regular calls with the CCM team members, Brenda and Daphanie say that their patients love the program. “We call them our VIP patients,” noted Daphanie, “if we find out on a call that they need to see a doctor, we are able to get them in either that day or the next.”
Knowing that the high-risk patients in CCM commonly manage their chronic conditions with prescribed medications and are often seen by a pharmacist, Hardtner approached Well-Ahead Louisiana last fall about ways to better use their staff pharmacist, Bona Rockett, to improve patient outcomes.
With the assistance of Marie Darr, health systems consultant at Well-Ahead, and training opportunities from the Avant Institute, Bona and her team reviewed best practices for the provision of CCM services. She met with Daphanie and Brenda to discuss the best way to identify patients who would most benefit from a conversation with the pharmacist, determine the regularity of pharmacy calls, and how to ensure the documentation was compliant with CCM requirements.
On being part of CCM, Bona said. “Daphanie and Brenda had done so much work crating a foundation and establishing relationships with the patients that I found the patients to be very receptive. I was very excited to get on board with their team.”
A key aspect embraced by the project team was evaluation and demonstrating the positive impact the pharmacist would have within the CCM program. Noting the high rates of diabetes and blood pressure in the region around Olla and LaSalle Parish, Hardtner’s team chose to focus on A1c levels, blood pressure screenings and immunization rates as key outcomes for the first year of the program. These numbers will be tracked by Bona and reviewed regularly.
“It’s very beneficial from a pharmacy standpoint, because you have another set of eyes looking at their chronic care conditions and the medications that they’re taking. We provide extra counseling that they may not get from the doctor’s office of the pharmacy where they’re filling their prescriptions,” said Bona. “All around, it’s just very beneficial for the patients.”
Despite the challenges presented by the ongoing pandemic and an unprecedented vaccination rollout, Hardtner Medical Center successful integrated Bona within their CCM care team within two months in early 2021. As of September 2021, she had reached out to all of the 24 patients currently in the program.
Brenda pointed out another benefit of the calls made to patients through CCM is that their team provided education about COVID-19 and the importance of vaccination, as well as where to get the vaccine, leading some to choose to get vaccinated who might not have otherwise.
“Some were scared to come in because of COVID-19, and Daphanie acted as a liaison with the doctor’s office” to make them feel comfortable, noted Brenda.
Hardtner Medical Center began more than 50 years ago with efforts from residents of Olla, Tullos and Urania who saw the need for a hospital in LaSalle Parish that would provide quality healthcare services to local communities. This 35-bed medical facility combines state-of-the-art technology with personal attention to make each patient’s stay as beneficial as possible. Register now to learn about patient management and more at the 2021 Virtual Rural Health Workshop! Well-Ahead Louisiana and the Louisiana Rural Health Association are joining forces to host the Workshop on December 6, 7 and 8, and there will be something for all rural healthcare professionals. Hear from federal and state-level leaders on current hot topics, find out about available funding and technical opportunities and get education that aims to improve your efficiency and effectiveness and lead your patients into a healthier future.