Anticoagulation Forum September 2011 Newsletter

Below is another clinic story in our Successful Anticoagulation Clinics series. In this series, clinics describe their model of care to help our members understand reimbursement issues, staffing models, and various ways to set up an anticoagulation clinic.

We would love to highlight the wonderful things you are doing at your clinic! If you would like to submit a short write-up describing your clinic's successes, please email it to egoldstein@acforum.org

Athens Regional Medical Center - AMS Coumadin Clinic

Solutions to Growth Limitations

The Anticoagulation Management Service (AMS) Coumadin Clinic at Athens Regional Medical Center (ARMC) was established in November 2000. In December 2008, the clinic's enrollment reached over 1000 patients inhibiting further growth of the clinic. The wait time for new patient appointments was approaching 4 weeks. In order to allow for continued growth without an overall increase in budget expenses for the hospital, a "stable" patient clinic was created within the AMS clinic. The purpose of this clinic was to allow ongoing management for patients whose warfarin dose did not require adjustment and continue enrolling complicated, difficult to manage patients requiring anticoagulation. In March 2009, our stable patient clinic was developed and named the "Blue Clinic".

The AMS Coumadin Clinic is a division of the ARMC Pharmacy Department and was created as a Performance Initiative to decrease adverse drug events and hospitalizations due to anticoagulants. The AMS Coumadin Clinic provides quality anticoagulation management by providing face-to-face monitoring, thorough education and the benefits of a timely PT/INR test result in a hospital-based outpatient clinic setting. Each patient visit includes a fingerstick PT/INR (via the I-STAT device), evaluation of the result, and adjustment in the dose, if necessary. Warfarin doses are adjusted based on established protocols. Each patient visit is communicated with the patients' physician through a progress note faxed at the completion of the visit. Patients are reeducated annually. The clinic is staffed by 3 Pharm.D.'s (2.5 FTE) and one secretary.

Stable patients were identified as those with a therapeutic INR on the same warfarin dose for at least 6 months. The proposal to discharge stable patients from the clinic was immediately discarded as medical literature supports ongoing anticoagulation clinic management (Pharmacotherapy 2008; 28(1):20-16). In addition, our referring physicians were strongly opposed to discharging any patient.

Patients are seen every 5 weeks as long as their INR is within therapeutic range or within 0.2 of target range on one visit. To staff the clinic, we identified 2 RNS from the adjacent Cardiac Rehabilitation department. This department's volume had decreased and was facing budget adjustments. The Blue Clinic nurses perform the INR test and conduct the patient interview. If the INR is within therapeutic range and no other identified medications or events have occurred that would affect anticoagulation, the RN instructs the patient on follow up and timing of next clinic visit. If the visit or INR result does not meet this criteria, the Pharm.D. is notified and dose adjustments and subsequent visits are then handled per clinic protocols by the Pharm.D. The Blue Clinic operates as a walk-in clinic 2 mornings and 2 afternoons each week. The Blue Clinic is located in the same space as the clinic, which allows the Pharm.D's to be available immediately. Patients have commented favorably on the flexible drop-in schedule and are pleased that the clinic has continued to manage their anticoagulation therapy.

Since the inception of the Blue Clinic, wait time for new patients is obsolete. Patients are scheduled within the physician's requested time frame.