Systematic Anticoagulation Management in the Rural Health Setting Lisa Vaughn RN, CACP Clinical Manager Anticoagulation Services Wenatchee Valley Medical Center

Wenatchee Valley Medical Center Serving more than 160,000 unique 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

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 4 labs

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

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