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Journal articles on the topic 'Ambulatory Care Clinic'
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Mason, Julie D., and Colleen A. Colley. "Effectiveness of an Ambulatory Care Clinical Pharmacist: A Controlled Trial." Annals of Pharmacotherapy 27, no. 5 (May 1993): 555–59. http://dx.doi.org/10.1177/106002809302700503.
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OBJECTIVE: To compare two general medicine clinics to determine the effectiveness of an ambulatory care clinical pharmacist in assisting recognition of drug therapy problems for physicians and decreasing drug therapy costs. DESIGN: Controlled trial SETTING: Two general medicine ambulatory care clinics associated with a large, tertiary-care teaching hospital. PATIENTS: Those with scheduled and completed appointments in the clinics during the two-week study period. METHODS: Medication profiles of patients attending clinic A (pharmacist intervention) and clinic B (no pharmacist intervention) were reviewed by the pharmacist prior to clinic appointments. Potential drug therapy problems were identified at each clinic, but interventions were performed only at clinic A. Postappointment audits determined the number of recommendations implemented at clinic A versus the number of drug therapy problems (potential interventions) recognized and addressed by clinic B physicians independently of pharmacist intervention. Potential and actual savings were extrapolated to one year from the two-week study period. RESULTS: Implementation of interventions at clinic A was greater than at clinic B (p<0.001). Drug therapy cost savings at clinic A were annualized to yield $185 per intervention. Potential cost savings of $176 724, or four times the pharmacist salary costs, is projected. CONCLUSIONS: An ambulatory care pharmacist is effective in identifying drug therapy problems, resulting in significant cost savings to the institution.
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Pincavage, Amber T., Rabia R. Razi, Vineet M. Arora, Julie Oyler, and James N. Woodruff. "Resident Education in Free Clinics: An Internal Medicine Continuity Clinic Experience." Journal of Graduate Medical Education 5, no. 2 (June 1, 2013): 327–31. http://dx.doi.org/10.4300/jgme-d-12-00127.1.
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Abstract Background Most internal medicine (IM) residency programs provide ambulatory training in academic medical centers. Community-based ambulatory training has been suggested to improve ambulatory and primary care education. Free clinics offer another potential training setting, but there have been few reports about the experience of IM residents in free clinics. Objective We assessed the feasibility and acceptability of inclusion of an ambulatory rotation in a free clinic and IM residency curriculum and the advantages of the free clinic setting over the traditional ambulatory clinic model. Methods In 2010, the University of Chicago Internal Medicine Residency Program partnered with a free clinic in order to establish a community-based continuity clinic experience. To assess the feasibility of this innovation, 16 residents were surveyed 9 months after implementation of the clinic to determine satisfaction, perceived preparation to address common medical conditions, and attitudes toward the underserved care population. A subset of these responses was compared to responses from residents in the traditional clinic model. Results Residents in the free clinic rotation were more satisfied and perceived they were more prepared to work in low-resource settings and reported similar levels of preparation regarding common outpatient conditions than residents in a traditional continuity clinic format. They reported increased future likelihood of working in an underserved clinic. Conclusions Our exploratory study suggests free clinics may be an effective platform for community-based continuity clinic training.
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Wieland, Mark L., Thomas M. Jaeger, John B. Bundrick, Karen F. Mauck, Jason A. Post, Matthew R. Thomas, and Kris G. Thomas. "Resident Physician Perspectives on Outpatient Continuity of Care." Journal of Graduate Medical Education 5, no. 4 (December 1, 2013): 668–73. http://dx.doi.org/10.4300/jgme-05-04-40.
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Abstract Background The outpatient continuity clinic is an essential component of internal medicine residency programs, yet continuity of patient care in these clinics is suboptimal. Reasons for this discontinuity have been inadequately explored. Objective We sought to assess perceived factors contributing to discontinuity in trainee ambulatory clinics. Methods The study encompassed 112 internal medicine residents at a large academic medical center in the Midwest. We conducted 2 hours of facilitated discussion with 18 small groups of residents. Residents were asked to reflect on factors that pose barriers to continuity in their ambulatory practice and potential mechanisms to reduce these barriers. Resident comments were transcribed and inductive analysis was performed to develop themes. We used these themes to derive recommendations for improving continuity of care in a resident ambulatory clinic. Results Key themes included an imbalance of clinic scheduling that favors access for patients with acute symptoms over continuity, clinic triage scripts that deemphasize continuity, inadequate communication among residents and faculty regarding shared patients, residents' inefficient use of nonphysician care resources, and a lack of shared values between patients and providers regarding continuity of care. Conclusions The results offer important information that may be applied in iterative program changes to enhance continuity of care in resident clinics.
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Hixson-Wallace, Julie A., Beth Barham, Randell K. Miyahara, and Charles M. Epstein. "Pharmacist Involvement in a Seizure Clinic." Journal of Pharmacy Practice 6, no. 6 (December 1993): 278–82. http://dx.doi.org/10.1177/089719009300600604.
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The role of the clinical pharmacist in ambulatory care settings has expanded in the last several years. Various types of clinical pharmacy services in ambulatory clinics have been reported in the literature. This article seeks to describe the involvement of clinical pharmacists as primary-care givers in an outpatient neurology-seizure clinic of the Veterans Affairs Medical Center in Atlanta, GA. The Neurology-Seizure clinical pharmacy services are provided by faculty, residents, and students from Mercer University Southern School of Pharmacy. The faculty members have been granted clinical privileges to practice in the ambulatory clinics in order to function with authority to perform such duties as giving medication renewals, and writing in the medical chart. In the clinic itself, the pharmacist is responsible for providing a medication profile, an initial interview with the patient, a minor neurological examination, presentation of the patient to the attending neurologist, writing of a SOAP (subjective, objective, assessment and plan) note, an end-of-appointment consultation, completion of a clinic flow sheet, maintenance of the clinic record, follow-up phone calls relating the results of anti-epileptic drug levels, and monthly quality assurance summaries. Clinical pharmacist-supervised primary care outpatient clinics can be rewarding endeavors. Through close patient contact and interaction with attending physicians, pharmacists can greatly assist with pharmaceutical care and provide expert drug management of seizure patients.
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Mohiuddin, AK. "The New Era of Pharmacists in Ambulatory Patient Care." INNOVATIONS in pharmacy 10, no. 1 (January 15, 2019): 4. http://dx.doi.org/10.24926/iip.v10i1.1622.
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Ambulatory care pharmacy practice is defined as the provision of integrated, accessible healthcare services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community. This is accomplished through direct patient care and medication management for ambulatory patients, long-term relationships, coordination of care, patient advocacy, wellness and health promotion, triage and referral, and patient education and self-management. The ambulatory care pharmacists may work in both an institutional and community-based clinic involved in direct care of a diverse patient population.
A variety of specialty clinics are available for allergy and immunology, pulmonology, endocrinology, cardiology, nephrology, neurology, behavioral health, and infectious disease. Such services for this population may exist as a primary care clinic or an independent specialty clinic, typically in a PCMH, which is instrumental in coordinating care between various providers. Once a practice site is identified, it is important to establish a strong, trusting, and mutually beneficial relationship with the various decision-makers (e.g., administrators, providers) involved with the clinic. If pharmacy services are currently in existence, the pharmacy director may be able to identify and initially contact the appropriate person. If another pharmacist is providing clinical services, this person would be a resource to help determine areas for expansion of patient care and to whom to direct the proposed business plan.
Additional individuals to consider as an initial point of contact include the clinic manager, clinic medical director, or administrative assistant to either of these persons. If the clinic setting is affiliated with a medical school, it may be necessary to contact the Department of Family Medicine head.
Article Type: Commentary
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Tafreshi, Javad, Michelle A. Chui, and Amy B. Riley. "Implementation of an amiodarone ambulatory care clinic." American Journal of Health-System Pharmacy 66, no. 22 (November 15, 2009): 1997–2001. http://dx.doi.org/10.2146/ajhp080555.
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Olson, Kimberly. "Integrating Pharmaceutical Care into an HIV Clinic." Journal of Pharmacy Practice 10, no. 1 (February 1997): 52–67. http://dx.doi.org/10.1177/089719009701000106.
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The purpose of this article is to describe the integration of clinical pharmacy services into an already exist ing HIV clinic. Ambulatory care pharmacy services were the only discipline not represented in the hospi tal based HIV clinic. With the move toward ambulatory care, the introduction of the new class of HIV drugs called the protease inhibitors, and the strong physician support of inpatient pharmacy services, the tim ing for pharmacy integration into the clinic was optimal. This article describes our goals for the clinic, the need for justification of pharmacy services through documentation, and the preparation steps made which established permanent pharmacy services in the HIV clinic. Daily procedures, interventions, statis tics of the pharmacy service, and barriers to success are also described. Patient information materials and examples of the documentation forms used by the clinic pharmacists are provided. This article is meant to aid other pharmacists who wish to integrate pharmacy services into an ambulatory HIV clinic setting.
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Siedner, Mark J., John D. Kraemer, Mark J. Meyer, Guy Harling, Thobeka Mngomezulu, Patrick Gabela, Siphephelo Dlamini, et al. "Access to primary healthcare during lockdown measures for COVID-19 in rural South Africa: an interrupted time series analysis." BMJ Open 10, no. 10 (October 2020): e043763. http://dx.doi.org/10.1136/bmjopen-2020-043763.
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ObjectivesWe evaluated whether implementation of lockdown orders in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN).DesignObservational cohortSettingData were analysed from 11 primary healthcare clinics in northern KZN.ParticipantsA total of 46 523 individuals made 89 476 clinic visits during the observation period.Exposure of interestWe conducted an interrupted time series analysis to estimate changes in clinic visitation with a focus on transitions from the prelockdown to the level 5, 4 and 3 lockdown periods.Outcome measuresDaily clinic visitation at ambulatory clinics. In stratified analyses, we assessed visitation for the following subcategories: child health, perinatal care and family planning, HIV services, non-communicable diseases and by age and sex strata.ResultsWe found no change in total clinic visits/clinic/day at the time of implementation of the level 5 lockdown (change from 90.3 to 84.6 mean visits/clinic/day, 95% CI −16.5 to 3.1), or at the transitions to less stringent level 4 and 3 lockdown levels. We did detect a >50% reduction in child healthcare visits at the start of the level 5 lockdown from 11.9 to 4.7 visits/day (−7.1 visits/clinic/day, 95% CI −8.9 to 5.3), both for children aged <1 year and 1–5 years, with a gradual return to prelockdown within 3 months after the first lockdown measure. In contrast, we found no drop in clinic visitation in adults at the start of the level 5 lockdown, or related to HIV care (from 37.5 to 45.6, 8.0 visits/clinic/day, 95% CI 2.1 to 13.8).ConclusionsIn rural KZN, we identified a significant, although temporary, reduction in child healthcare visitation but general resilience of adult ambulatory care provision during the first 4 months of the lockdown. Future work should explore the impacts of the circulating epidemic on primary care provision and long-term impacts of reduced child visitation on outcomes in the region.
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Harrison, Joshua W., Astha Ramaiya, and Peter Cronkright. "Restoring Emphasis on Ambulatory Internal Medicine Training—The 3∶1 Model." Journal of Graduate Medical Education 6, no. 4 (December 1, 2014): 742–45. http://dx.doi.org/10.4300/jgme-d-13-00461.1.
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Abstract Background Resident dissatisfaction in ambulatory care training has prompted the need for new scheduling models that support a positive learning climate. Intervention We instituted a 3∶1 scheduling model for postgraduate year (PGY)–2 and PGY-3 residents. We hypothesized this model would provide a more structured ambulatory educational atmosphere, better continuity of care, and more exposure to subspecialty outpatient medicine. This model would also eliminate conflict with inpatient duties and contribute to enhance residents′ satisfaction with ambulatory medicine and their ambulatory education experience. The model used weeklong ambulatory blocks every fourth week, consisting of morning continuity clinic and afternoon subspecialty clinics. The PGY-1 residents maintained a traditional schedule. Results Residents were surveyed regarding their ambulatory experience, with an overall response rate of 73 of 80 (91%). The PGY-2 and PGY-3 responses were analyzed descriptively and compared with PGY-1 responses. Residents reported that the 3∶1 model positively affected their satisfaction with residency training in general, their satisfaction with outpatient/primary care training, and their outpatient/clinic educational experience. Residents in the 3∶1 model perceived improvements in continuity of care and in the quality of care they provided for patients. The experience in ambulatory subspecialty training was positive. Conclusions A 3∶1 scheduling model appears to mitigate some of the conflict between inpatient and outpatient duties. Residents agreed the new model promoted an improved ambulatory experience.
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Lampkin, Stacie J., Brooke Gildon, Sandra Benavides, Kelly Walls, and Leslie Briars. "Considerations for Providing Ambulatory Pharmacy Services for Pediatric Patients." Journal of Pediatric Pharmacology and Therapeutics 23, no. 1 (January 1, 2018): 4–17. http://dx.doi.org/10.5863/1551-6776-23.1.4.
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Pediatric clinical pharmacists are an integral part of the health care team. By practicing in an ambulatory care clinic, they can reduce the risk of medication errors, improve health outcomes, and enhance patient care. Unfortunately, because of limited data, misconceptions surrounding the role of pharmacists, and reimbursement challenges, there may be difficulty in establishing or expanding pediatric clinical pharmacy services to an ambulatory care setting. The purpose of this paper is to provide an overview of considerations for establishing or expanding pharmacy services in a pediatric ambulatory care clinic. The primer will discuss general and pediatric-specific pharmacy practice information, as well as potential barriers, and recommendations for identifying a practice site, creating a business plan, and integrating these services into a clinic setting.
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Darr, Amber Y., and Sarah Gottfried. "Identifying vaccination rates of adult patients in ambulatory care clinics." SAGE Open Medicine 8 (January 2020): 205031212093546. http://dx.doi.org/10.1177/2050312120935461.
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Background: While pharmacists have provided vaccinations to patients in the community pharmacy setting, pharmacist involvement within the medical office setting is not well documented in the literature. The American Society of Health-System Pharmacists reports that ambulatory care pharmacists are screening for and administering vaccinations at a declining rate, despite standards of practice. Vaccination rates for adults 19–64 years of age remain low, based on Healthy People 2020 goals, putting them at risk for vaccine-preventable diseases. Objectives: The aim of the study was to assess vaccination rates of ambulatory care pharmacy clinic patients aged 19–64 years and to compare the rates between three clinics and to Healthy People 2020 goals. Methods: This was a baseline retrospective analysis of vaccination rates for patients aged 19–64 years who attended at least one pharmacy clinic visit at one of the three medical office practices. Age, sex, medical conditions, cigarette or alcohol use, immunosuppressive medications, and vaccines recommended and received were recorded. Vaccination status was assessed according to the Advisory Committee for Immunization Practices recommendations. Data were collected from January 2016 to March 2017. The percentage of eligible patients who received each vaccine was determined overall and for each clinic. Results: There were 240 patients who met the inclusion criteria, with a mean age of 52.8 years. The percentage of patients with vaccination documented in the medical record was 25% for pneumococcal conjugate, 35.7% for pneumococcal polysaccharide, 26.9% for zoster vaccine live, 6.4% for hepatitis B, and 50.6% for tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis. Vaccination rates for pneumococcal conjugate, pneumococcal polysaccharide, and zoster vaccine live were below established Healthy People 2020 goals. Conclusion: Vaccination rates remain low in adults 19–64 years of age. Ambulatory care pharmacists should consider assessing vaccination status during clinic visits as a component of comprehensive vaccination programs.
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Nguyen, Patrick Viet-Quoc, and Andrea Vázquez Martínez. "Impact of Pharmacist Interventions in an Ambulatory Geriatric Care Clinic: The IMPACC Study." Senior Care Pharmacist 35, no. 5 (May 1, 2020): 230–36. http://dx.doi.org/10.4140/tcp.n.2020.230.
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OBJECTIVE: To compare the impact of a pharmacist's presence for the detection of drug-related problems (DRP) in an interdisciplinary geriatric-ambulatory clinic with a control group without a pharmacist.<br/> DESIGN: Retrospective quasi-experimental study.<br/> SETTING: A geriatric ambulatory-care clinic of a 772-bed tertiary-care teaching hospital in Montreal, Canada.<br/> PARTICIPANTS: A total of 227 ambulatory patients 65 years of age and older presenting to their appointment at the geriatric ambulatory clinic between May 1, 2018, and April 30, 2019.<br/> MAIN OUTCOME MEASURE(S): DRP detected by the interdisciplinary team during the patient evaluation process. Data were collected from clinical notes written by the health care professionals in the electronic medical chart.<br/> RESULTS: The mean age was 80.8 years, and 60.8% of the population were female. Patients were prescribed a mean of 11.3 medications at home. Overall, 636 DRP were detected in the study population. In the adjusted analysis, the difference between the two groups was 2.7 (95% confidence interval 2.0-3.3) DRP detected favoring the group with a pharmacist.<br/> CONCLUSION: The inclusion of a pharmacist in an interdisciplinary team in an ambulatory geriatric-care clinic was associated to a positive impact on care by substantially increasing the number of DRP detected in older patients.
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Bristol, Alycia A., Sobaata Chaudhry, Dana Assis, Rebecca Wright, Derek Moriyama, Katherine Harwood, Abraham A. Brody, David M. Charytan, Joshua Chodosh, and Jennifer S. Scherer. "An Exploratory Qualitative Study of Patient and Caregiver Perspectives of Ambulatory Kidney Palliative Care." American Journal of Hospice and Palliative Medicine® 38, no. 10 (January 13, 2021): 1242–49. http://dx.doi.org/10.1177/1049909120986121.
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Objectives: The ideal clinical model to deliver palliative care to patients with advanced kidney disease is currently unknown. Internationally, ambulatory kidney palliative care clinics have emerged with positive outcomes, yet there is limited data from the United States (US). In this exploratory study we report perceptions of a US-based ambulatory kidney palliative care clinic from the perspective of patient and caregiver attendees. The objective of this study was to inform further improvement of our clinical program. Methods: Semi-structured interviews were conducted to elicit the patient and caregiver experience. Eleven interviews (8 patients with chronic kidney disease stage IV or V and 3 caregivers) were analyzed using qualitative description design. Results: We identified 2 themes: “Communication addressing the emotional and physical aspects of disease” and “Filling gaps in care”; Subthemes include perceived value in symptom management, assistance with coping with disease, engagement in advance care planning, program satisfaction and patient activation. Significance of Results: Qualitative analysis showed that attendees of an ambulatory kidney palliative care clinic found the clinic enhanced the management of their kidney disease and provided services that filled current gaps in their care. Shared experiences highlight the significant challenges of life with kidney disease and the possible benefits of palliative care for this population. Further study to determine the optimal model of care for kidney palliative care is needed. Inclusion of the patient and caregiver perspective will be essential in this development.
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Do, Tina, Steph Luon, Kimberly Boothe, Martha Stutsky, and Marie Renauer. "Advancing ambulatory pharmacy practice through a crisis: Objectives and strategies used in an ambulatory care action team’s response to the COVID-19 pandemic." American Journal of Health-System Pharmacy 78, no. 8 (February 27, 2021): 720–25. http://dx.doi.org/10.1093/ajhp/zxab063.
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Abstract Purpose The objectives and strategies used by an ambulatory care action team operating within a large health system’s pharmacy incident command structure during the initial response to the coronavirus disease 2019 (COVID-19) pandemic are discussed. Summary In a time of crisis, a pharmacy ambulatory action team was formed to provide ambulatory clinical pharmacy expertise and meet an immediate and ongoing need to limit nonemergent care during the COVID-19 pandemic. By building a strong communication infrastructure and partnership with ambulatory care providers, clinic medical and operational leaderships, clinical laboratory staff, and infusion centers, the team was able to swiftly execute solutions and respond to new issues and requests. Ambulatory care pharmacy practice continued to advance through provision of services to vulnerable patient populations with chronic conditions that were anticipated to experience gaps in care management during the COVID-19 pandemic. These efforts resulted in expansion of pharmacists’ involvement in collaborative drug therapy management, support of patients’ transition from in-clinic injection to home self-administration, provision of medication assistance support, and management of 1,300 patients via protocol-based warfarin management. Additionally, ambulatory pharmacy services in 15 primary care, anticoagulation, and specialty clinic sites were transitioned to telehealth. The ambulatory action team also implemented several strategies to manage medication therapy associated with COVID-19–related shortages and implemented electronic decision support to guide prescribing of hydroxychloroquine and azithromycin. Conclusion Building a strong communication infrastructure and a pharmacy ambulatory action team were essential to respond to a crisis and continue ambulatory clinical pharmacy services expansion.
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Henderson, Dora, Shelly Johnson-Choong, and Sarah Wiles. "Pharmacy technician’s role in an ambulatory care infusion clinic." American Journal of Health-System Pharmacy 57, no. 18 (September 15, 2000): 1664–65. http://dx.doi.org/10.1093/ajhp/57.18.1664.
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Ku, Elaine, Charles E. McCulloch, Bradley A. Warady, Susan L. Furth, Barbara A. Grimes, and Mark M. Mitsnefes. "Twenty-Four–Hour Ambulatory Blood Pressure versus Clinic Blood Pressure Measurements and Risk of Adverse Outcomes in Children with CKD." Clinical Journal of the American Society of Nephrology 13, no. 3 (February 13, 2018): 422–28. http://dx.doi.org/10.2215/cjn.09630917.
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Backgroundand objectives Our objective was to determine whether clinic BPs (taken at either a single visit or two sequential visits) are inferior to ambulatory BPs in their ability to discriminate risk of adverse outcomes in children with CKD.Design, setting, participants, & measurementsWe included 513 participants of the CKD in Children Study who had clinic BPs and 24-hour ambulatory BP monitoring performed during similar timeframes. Predictors of interest were systolic BPs taken at a single visit or two repeated visits within a 1-year period compared with mean wake and sleep systolic ambulatory BPs. Outcomes were left ventricular hypertrophy and ESKD. We determined the ability for each BP parameter to provide risk discrimination using c statistics.ResultsDuring mean follow-up of 3.5 years, 123 participants developed ESKD. In cross-sectional unadjusted analysis, every 0.1 increase in systolic BP index was associated with a 2.0 times higher odds of left ventricular hypertrophy (95% confidence interval, 1.5 to 2.8) by clinic BPs versus 1.8 times higher odds (95% confidence interval, 1.3 to 2.4) by ambulatory wake BP. The c statistic was highest for clinic BP (c=0.65; 95% confidence interval, 0.58 to 0.73) but similar to ambulatory wake BP (c=0.64; 95% confidence interval, 0.57 to 0.71) for the discrimination of left ventricular hypertrophy. In longitudinal unadjusted analysis, every 0.1 increase in systolic BP index was associated with a higher risk of ESKD using repeated clinic (hazard ratio, 1.5; 95% confidence interval, 1.3 to 1.8) versus ambulatory wake BP (hazard ratio, 1.6; 95% confidence interval, 1.3 to 2.0). Unadjusted c statistics were the same for wake (c=0.61; 95% confidence interval, 0.56 to 0.67) and clinic systolic BPs (c=0.61; 95% confidence interval, 0.55 to 0.66) for discriminating risk of ESKD.ConclusionsClinic BPs taken in a protocol-driven setting are not consistently inferior to ambulatory BP in the discrimination of BP-related adverse outcomes in children with CKD.
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Cavanaugh, Jamie, Nicole Pinelli, Stephen Eckel, Mark Gwynne, Rowell Daniels, and Emily M. Hawes. "Advancing Pharmacy Practice through an Innovative Ambulatory Care Transitions Program at an Academic Medical Center." Pharmacy 8, no. 1 (March 12, 2020): 40. http://dx.doi.org/10.3390/pharmacy8010040.
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Hospital readmissions are common and often preventable, leading to unnecessary burden on patients, families, and the health care system. The purpose of this descriptive communication is to share the impact of an interdisciplinary, outpatient clinic-based care transition intervention on clinical, organizational, and financial outcomes. Compared to usual care, the care transition intervention decreased the median time to Internal Medicine Clinic (IMC) or any clinic follow-up visit by 5 and 4 days, respectively. By including a pharmacist in the hospital follow-up visit, the program significantly reduced all-cause 30-day hospital readmission rates (9% versus 26% in usual care) and the composite endpoint of 30-day health care utilization, which is defined as readmission and emergency department (ED) rates (19% versus 44% usual care). Over the course of one year, this program can prevent 102 30-day hospital readmissions with an estimated cost reduction of $1,113,000 per year. The pharmacist at the IMC collaborated with the Family Medicine Clinic (FMC) pharmacist to standardize practices. In the FMC, the hospital readmission rate was 6.5% for patients seen by a clinic-based pharmacist within 30 days of discharge compared to 20% for those not seen by a pharmacist. This transitions intervention demonstrated a consistent and recognizable contribution from pharmacists providing direct patient care and practicing in the ambulatory care primary care settings that has been replicated across clinics at our academic medical center.
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Gums, John G., and J. Daniel Robinson. "Pharmacokinetic Monitoring in the Community Health-Care Setting." Drug Intelligence & Clinical Pharmacy 21, no. 5 (May 1987): 422–26. http://dx.doi.org/10.1177/106002808702100504.
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Ambulatory care pharmacokinetic profiling has been utilized with increasing frequency over the last decade. The demonstration of need is the first step in initiating outpatient pharmacokinetic service. This article identifies methods used in demonstrating a need and discusses the normal daily activities of an ambulatory pharmacokinetic service located in a university-based family medicine clinic. The reader will also learn of trends that ambulatory care pharmacokinetic programs will become involved with in the near future.
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Hohner, Elizabeth, Melinda Ortmann, Umbreen Murtaza, Sheeva Chopra, Patricia A. Ross, Meghan Swarthout, Leigh Efird, Emily Pherson, and Mustapha Saheed. "Implementation of an emergency department–based clinical pharmacist transitions-of-care program." American Journal of Health-System Pharmacy 73, no. 15 (August 1, 2016): 1180–87. http://dx.doi.org/10.2146/ajhp150511.
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Abstract Purpose The implementation of an emergency department (ED)–based clinical pharmacist transitions-of-care (TOC) program is described. Summary The intervention program consisted of collaboration between ED and ambulatory care pharmacists to provide patient-specific comprehensive medication review and education in the ED setting and to help ensure a coordinated transition to the ambulatory care setting by scheduling an ambulatory pharmacy clinic or home-based visit. Patients who sought care at an adult ED for an exacerbation of asthma, chronic obstructive pulmonary disease (COPD), or congestive heart failure (CHF) were assessed for issues with medication adherence or administration technique, patient-specific concerns regarding medication use, access to medications at discharge, the need for modification of chronic therapy, contraindicated medications, and vaccination status, if applicable. The pharmacist then referred the patient to follow up in an ambulatory care pharmacy clinic or with the home-based medication management (HBMM) program. Of the 18 program participants who were referred to follow-up care, 5 successfully followed up with a pharmacist after ED discharge. The mean time from the ED visit to follow-up for these 5 patients was 16.6 ± 8.6 days. In addition, 5 patients followed up with their primary care provider within 30 days of the initial ED visit; 2 of these patients also followed up with a pharmacist. Within 30 days of the initial ED encounter, 4 patients had ED revisits. Conclusion A TOC pharmacist-led program targeting patients who arrived at the ED with the chief complaint of asthma exacerbation, COPD, or CHF provided interventions from an ED or ambulatory care pharmacist as well as follow-up opportunities at outpatient clinics or an HBMM program.
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Engle, Janet P. "Anticoagulation: Practice Focus in an Ambulatory Clinic." Journal of Pharmacy Practice 3, no. 5 (October 1990): 349–57. http://dx.doi.org/10.1177/089719009000300508.
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Pharmacy practice is in an era of change. Opportunities for clinical practice are not only available in the inpatient setting but also in the ambulatory milieu. Anticoagulation is an excellent area for pharmacist involvement in patient care in the outpatient setting. This article describes the rationale and steps necessary for developing and maintaining a pharmacist-managed warfarin anticoagulation clinic. A discussion of the methodology necessary for justification and implementation of such services is presented. Salient points regarding warfarin use will also be covered.
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Panagiotopoulou, IG, JMH Bennett, EM Tweedle, S. Di Saverio, S. Gourgiotis, RH Hardwick, JMD Wheeler, and R. Justin Davies. "Enhancing the emergency general surgical service: an example of the aggregation of marginal gains." Annals of The Royal College of Surgeons of England 101, no. 7 (September 2019): 479–86. http://dx.doi.org/10.1308/rcsann.2019.0061.
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Introduction We aimed to enhance the emergency general surgical service in our high-volume centre in order to reduce four-hour target breaches, to expedite senior decision making and to avoid unnecessary admissions. Materials and methods The aggregation of marginal gains theory was applied. A dual consultant on-call system was established by the incremental employment of five emergency general surgeons with a specialist interest in colorectal or oesophagogastric surgery. A surgical ambulatory care unit, which combines consultant-led clinical review with dedicated next-day radiology slots, and a dedicated working week half-day gastrointestinal urgent theatre session were instituted to facilitate ambulatory care pathways. Results The presence of two consultant surgeons being on call during weekday working hours decreased the four-hour target breaches and allowed consultant presence in the surgical ambulatory care clinic and the gastrointestinal urgent theatre list. Of 1371 surgical ambulatory care clinic appointments within 30 months, 1135 (82.7%) avoided a hospital admission, corresponding to savings of £309,752 . The coordinated functioning of the surgical ambulatory care clinic and the gastrointestinal urgent theatre list resulted in statistically significantly reduced hospital stays for patients operated for abscess drainage (gastrointestinal urgent theatre median 11 hours (interquartile range 3, 38) compared with emergency median 31 hours (interquartile range 24, 53), P < 0.001) or diagnostic laparoscopy/appendicectomy (gastrointestinal urgent theatre median 52 hours (interquartile range 41, 71) compared with emergency median 61 hours (interquartile range 43, 99), P = 0.005). Overnight surgery was reduced with only surgery that was absolutely necessary occurring out of hours. Conclusion The expansion of the ‘traditional’ on-call surgical team, the establishment of the surgical ambulatory care clinic and the gastrointestinal urgent theatre list led to marginal gains with a reduction in unnecessary inpatient stays, expedited decision making and improved financial efficiency.
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Katz, Sophie E., Hillary Spencer, Jim Zhang, Ritu Banerjee, and Ritu Banerjee. "1345. Impact of the COVID-19 Pandemic on Pediatric Ambulatory Antibiotic Use in an Academic Health System." Open Forum Infectious Diseases 7, Supplement_1 (October 1, 2020): S683—S684. http://dx.doi.org/10.1093/ofid/ofaa439.1527.
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Abstract Background It is unclear how the COVID-19 pandemic has impacted outpatient pediatric antibiotic prescribing. Methods We compared diagnoses and antibiotic prescription rates for children pre- vs post-COVID-19 in 5 ambulatory settings affiliated with Vanderbilt University Medical Center: emergency department (ED), urgent care clinics (including pediatric-only after-hours clinics [AHC]s and walk-in clinics [WIC] for all ages), primary care clinics (PCC), and retail health clinics (RHC). Time periods were pre-COVID-19 3/1/19 – 5/15/19 (P1); and post-COVID-19 3/1/20 – 5/15/20 (P2). Diagnoses and percent of encounters with an antibiotic prescription were analyzed by encounter (in-person vs telemedicine [TMed]), clinic and provider type. We also interviewed 16 providers about perceived COVID-19 impact on pediatric ambulatory antibiotic prescribing. Student’s T and χ 2 tests were used as appropriate. Results The number of pediatric ambulatory visits was 16671 in P1 and 7010 in P2. There were no TMed visits in P1 vs 188 in P2 (2.7% of total P2 visits); 186 (99% of TMed visits) were in PCC (Table). In all settings, the number of encounters was lower in P2 vs P1 (p< 0.001). The percent of encounters with an antibiotic prescription was lower in P2 (32%) than in P1 (38.2%) (p< 0.001) (Table) overall and in all settings except RHCs. Only 14 (7.4%) TMed visits resulted in an antibiotic prescription. There were no differences in antibiotic prescribing rates by provider type. Diagnoses varied significantly between periods in all clinic types except the ED, with noninfectious diagnoses being higher in P2 vs P1 (Figure 1). Providers felt that COVID-19 led to fewer but sicker patients presenting for care, and variable impact on antibiotic prescribing (Figure 2). Table. Percent of Encounters with an Antibiotic by Clinic Type, Pre- and Post-COVID-19 Figure 1. Diagnosis Rates by Clinic Type, Pre- and Post-COVID-19 Figure 2. Themes from Provider Interviews about perceived Impact of COVID-19 on Clinician Practice Conclusion The proportion of encounters with non-infectious diagnoses increased and antibiotic prescribing rates decreased significantly in all pediatric ambulatory settings post-COVID-19 except RHCs. Almost all TMed encounters occurred in the primary care setting, and few resulted in an antibiotic prescription. Providers felt they saw fewer patients and higher acuity of illness post COVID-19. Disclosures Hillary Spencer, MD, MPH, NIH (T32 grant support) (Grant/Research Support)
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Kielly, Jason, Deborah V. Kelly, Shabnam Asghari, Kim Burt, and Jessica Biggin. "Patient satisfaction with chronic HIV care provided through an innovative pharmacist/nurse-managed clinic and a multidisciplinary clinic." Canadian Pharmacists Journal / Revue des Pharmaciens du Canada 150, no. 6 (October 6, 2017): 397–406. http://dx.doi.org/10.1177/1715163517734236.
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Background: Pharmacist/nurse-led clinics are an established model for many chronic diseases but not yet for HIV. At our centre, patients with HIV are seen by a multidisciplinary team (physician, nurse, pharmacist, social worker) at least yearly. Some attend an HIV-specialist pharmacist/nurse clinic (or “nonphysician clinic,” NPC) for alternate biannual visits. Our objective was to assess patient satisfaction with care received through both clinics. Methods: The Patient Satisfaction Survey for HIV Ambulatory Care (assesses satisfaction with access to care, clinic visits and quality of care) was administered by telephone to adults who attended either clinic between January and July 2014. Descriptive statistics described patient characteristics and satisfaction scores. Fisher’s exact test compared satisfaction scores between the NPC and multidisciplinary clinic (MDC). Multivariate logistic regression examined associations between overall satisfaction with care and clinic type and patient characteristics (e.g., age, disease duration). Results: Respondents were very satisfied with the overall quality of HIV care in both the NPC and MDC (89% vs 93%, respectively, p = 0.6). Patients from both clinics expressed satisfaction with access to care, treatment plan input, their provider’s knowledge of the newest developments in HIV care and explanation of medication side effects, with no significant differences noted. Significantly more MDC patients reported being asked about housing/finances, alcohol/drug use and whether they needed help disclosing their status. Patient characteristics were not significantly associated with satisfaction with overall quality of care. Conclusion: Patients are satisfied with both clinics, supporting NPC as an innovative model for chronic HIV care. Comparison of outcomes between clinics is needed to ensure high-quality care.
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Lacro, Jonathan P., Angela B. Kodsi, and Patricia L. Gilbert. "Psychopharmacists' Role in Neuroleptic Therapy a Pharmaceutical Care Approach." Journal of Pharmacy Technology 10, no. 4 (July 1994): 164–68. http://dx.doi.org/10.1177/875512259401000407.
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Objective: To describe the roles of the psychopharmacist in the use of neuroleptic therapy. Setting: A geriatric psychiatry ambulatory care clinic in a 400-bed Department of Veterans Affairs Medical Center, San Diego, California. Conclusions: In the pharmaceutical care model, the pharmacist is involved in several important roles in the provision of neuroleptic therapy. In the ambulatory care program, psychopharmacists provide important drug-related information to patients and consultation regarding potential neuroleptic-induced adverse effects. In addition, psychopharmacists serve as consultants to other clinicians concerning the risks associated with the use of neuroleptics and participate in neuroleptic-discontinuation clinics. Morbidity associated with neuroleptic-induced tardive dyskinesia has exposed healthcare providers to legal repercussions; therefore, pharmacy intervention may aid in the reduction of legal liability.
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Milley-Daigle, Carissa, Celina Dara, Genevieve Bouchard-Fortier, Anet Julius, Vishal Kukreti, Ernie Mak, Lyndon Morley, et al. "Improving medication reconciliation in ambulatory cancer care." Journal of Clinical Oncology 38, no. 29_suppl (October 10, 2020): 224. http://dx.doi.org/10.1200/jco.2020.38.29_suppl.224.
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224 Background: Adverse drug events are common in ambulatory oncology where care spans multiple providers and medication documentation is often poor. We undertook a QI project with the aim of having 30% of patients have a best possible medication history (BPMH) or medication reconciliation (MedRec) documented within 30 days of starting systemic therapy. Methods: An Electronic Medical record-Integrated Tool (EMITT) was developed to facilitate documentation. 2 Plan-Do-Study-Act (PDSA) cycles have been completed to date; PDSA 1 consisted of piloting EMITT in 3 clinics run by physician champions. PDSA 2 which consisted of expanding pharmacy support and addition of a 4th clinic was impacted by care changes related to COVID. The proportion of patients with BPMH/MedRec documented in EMITT was calculated monthly for each period (PDSA 1, PDSA 2 pre-COVID and PDSA 2 post-COVID). The balancing measure of time to complete an entry was evaluated through a time motion study. Results: Between 9/9/2019 and 31/5/2020, 9.4% (233/2488) of patients had BPMH/MedRec completed; Table shows proportion of patients by month. BPMH and MedRec were most frequently performed by pharmacists followed by pharmacy students and nurses. On average, it took 5.5 minutes to complete an entry (n = 10; median number of medications per patient = 12.3). Conclusions: BPMH was documented more often than MedRec. While some usage was sustained, the changes to care as a result of COVID-19 negatively impacted ambulatory medication reconciliation. Future PDSA cycles will involve engaging patients in MedRec and extending EMITT to all ambulatory cancer clinics where medication management is a major component of care. [Table: see text]
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Lari, S., A. M. S. Thompson, V. Spilchuk, M. Afanasyeva, and D. L. Holness. "Patient-centred care in an occupational medicine clinic." Occupational Medicine 69, no. 6 (August 2019): 441–44. http://dx.doi.org/10.1093/occmed/kqz092.
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Abstract Background Patient-centred care (PCC) has been associated with improved patient satisfaction outcomes in a variety of clinical settings. There is a paucity of research addressing the concept of PCC in an occupational medicine context. Aims To assess patient perception and compare physician and patient perceptions of patient centredness of the care at a specialty occupational medicine clinic. Methods An observational study design using the Patient Perception of Patient Centeredness Questionnaire (PPPC) at an ambulatory tertiary care occupational health clinic. Results were analysed using a standardized coding system. Summary scores were compared to results reported in a primary care setting. Patient and physician scores were compared to detect physician–patient differences in perceived patient centredness of care. Results Of 47 eligible patients 37 consented to participate and seven were excluded due to incomplete data. Summary scores of patient perceptions of patient centredness were similar but somewhat better than scores reported in a primary care setting. Perceived patient centredness of care was high and there was minimal discordance between patient and physician scores. Conclusions This study demonstrated that PCC can be measured in an occupational health setting. In an ambulatory tertiary care occupational health clinic there was a high degree of patient centredness of care which may be explained by a variety of factors. Future research should consider whether similar findings exist in other occupational medicine practice settings.
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Foy, John L., Richard C. Eastman, Reggie C. Nealon, Patty M. Bowen, Mary L. Pengelly, Jan A. Drass, Thomas E. Dorworth, and Frank Pucino. "Automated Therapeutic Drug Monitoring in an Ambulatory Care Endocrine Clinic." Annals of Pharmacotherapy 26, no. 5 (May 1992): 675–78. http://dx.doi.org/10.1177/106002809202600513.
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OBJECTIVE: To develop and implement an automated therapeutic drug monitoring system for accessing data from endocrine clinic patients who had been prescribed insulin, oral hypoglycemic agents (OHA), or levothyroxine. DATA SOURCES: We designed a computer system to retrieve clinical data from the Medical Information System (MIS), a centralized hospital computer system, and import this information directly into a Macintosh personal computer. Physician entry of prescriptions for insulin, OHA, or levothyroxine into MIS formed the basis for a computer program to retrieve daily diagnostic and prescription information, demographics, and laboratory analyses, including blood glucose and glycosylated hemoglobin for insulin and OHA orders and free and total thyroxine, total triiodothyronine, and thyroid stimulating hormone for levothyroxine orders. The information was imported into a database program (4th Dimension). RESULTS: The system identifies laboratory values outside of predetermined therapeutic ranges, maintains an up-to-date patient profile, and edits and generates reports. Preliminary experience suggests that automation eliminates 75–90 percent of the time required to manually collect the same information, and improves the accuracy, comprehensiveness, and utility of reports. CONCLUSIONS: Automated therapeutic drug monitoring minimizes the time required to collect clinical data, alerts clinicians to potential problems, and provides a means to assess overall therapeutic management. Our methodology can be used to evaluate other medications in a variety of general or specialty clinics.
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Raney, Erin C. "Assessment of Anticoagulation Management in a Simulated Ambulatory Care Clinic." American Journal of Pharmaceutical Education 71, no. 5 (September 2007): 97. http://dx.doi.org/10.5688/aj710597.
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Wayland, M. T., and M. B. Hardwicke. "Residentsʼ diagnosis of alcohol abuse in the ambulatory-care clinic." Academic Medicine 66, no. 7 (July 1991): 426. http://dx.doi.org/10.1097/00001888-199107000-00017.
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Huntzinger, Paul E. "Establishing an Ambulatory Care Clerkship at a Coast Guard Clinic." Journal of Pharmacy Practice 13, no. 5 (October 2000): 392–99. http://dx.doi.org/10.1106/mgd2-3lcu-bx8c-wlv8.
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This paper describes the experience and benefits of establishing a pharmacy student clerkship program with the University of California, San Francisco (UCSF) at a U.S. Coast Guard (USCG) ambulatory care clinic. The goal of the paper is to provide pharmacists with information that can be used to institute a clerkship program. The implementation of the clerkship at the Integrated Support Command Alameda (ISCA) pharmacy involved an uncomplicated, step-wise approach that can be readily emulated. The clerkship provided the ISCA pharmacy with several benefits, including the opportunity for the pharmacist to mentor, that clearly outweighed the challenges.
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Holtby, CE, F. Amoozegar, and LJ Cooke. "P.144 Health care utilization by patients seen at a tertiary headache clinic." Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques 45, s2 (June 2018): S22. http://dx.doi.org/10.1017/cjn.2018.85.
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Background: Multidisciplinary treatment programs benefit headache patients. No evidence exists as to whether they change resource use. A historical prospective cohort study was performed to compare the frequency of ambulatory care and emergency department visits for the purposes of headache by patients seen at the Calgary Headache Assessment and Management Program (CHAMP) in the three years before, and after, their first appointment. Methods: Administrative data from Alberta Health was used. All patients seen by a physician at CHAMP from 2003-2013 were included. Sample characteristics were described and the Wilcoxan signed rank sum test was used to compare the number of ambulatory care and emergency department visits in the three years before and after each patient’s first physician appointment at CHAMP. Follow-up visits at CHAMP were excluded from analyses. Results: The median number of ambulatory care visits over three years changed from 4 to 2 (p<0.001). The median number of emergency department visits was zero before and after assessment at CHAMP. The mean number of emergency department visits changed from 1.5 to 1.2 (p<0.0001). Conclusions: Enrollment in a multidisciplinary headache program reduces the number of ambulatory care visits and emergency department visits for purposes of headache.
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Jun, Jeany K. "Establishing Clinical Pharmacy Services With Prescribing Privileges in a Federally Qualified Health Center Primary Care Clinic." Journal of Pharmacy Practice 31, no. 5 (July 18, 2017): 434–40. http://dx.doi.org/10.1177/0897190017718752.
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Objectives: To describe the process and cost of establishing clinical pharmacy services with prescribing privileges in a federally qualified health center (FQHC) primary care clinic. Setting: The primary care clinic was located in a low-income area of Southern California and served patients with Medicaid and Medicare. The primary care clinic had preventive medicine and family medicine physicians, a family medicine residency program, behavioral health services, and a registered dietician. Practice Innovation: New clinical pharmacy services were established at this FQHC primary care clinic. The medication assistance program was a stepping stone to establish rapport with the physicians. Credentialing and privileging was implemented for clinical pharmacists. An open protocol collaborative practice agreement was developed to allow clinical pharmacists to manage ambulatory patients. Results: From August 2014 to June 2015, the clinical pharmacist interacted with 392 patients and spent 336 hours educating patients and providing disease state management. The pharmacist also provided consults to residents and providers. Diabetic patients made up 76% of all clinical pharmacy encounters. There were 86 face-to-face clinical pharmacy appointments with the pharmacist. The average time for clinical pharmacy appointments was 77 minutes. Conclusion: By describing ways to develop rapport with providers, how to credential and privilege pharmacists, and explain resources and costs of setting up a service, the hope is that more clinical pharmacists will be able to incorporate into independent or FQHC primary care clinics for improved management of ambulatory patients.
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Williamson, Keenan, Chad Douglas Nix, and Molly Hale. "Application of an Outpatient CLABSI Surveillance Definition: Results and Lessons From 7 Infusion Clinics." Infection Control & Hospital Epidemiology 41, S1 (October 2020): s124. http://dx.doi.org/10.1017/ice.2020.634.
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Background: The NHSN does not have a published surveillance definition for central-line–associated bloodstream infections (CLABSIs) related to healthcare in ambulatory settings. With the increasing reliance on services involving central-line care in the ambulatory setting, there is opportunity to improve healthcare performance by developing standardized surveillance. Methods: Chart review was performed on 320 patients who had a visit at an infusion clinic and a positive blood culture in 2018. A qualifying infusion clinic visit involved accessing of the central line during the encounter. Ambulatory-associated cases were defined as having a qualifying infusion clinic encounter within 7 days prior to blood culture collection. Cases were excluded if the patient’s central line had been accessed in an inpatient setting between the positive blood culture and infusion clinic visit. All other criteria were based on the NHSN inpatient CLABSI case definition. Results: Application of the proposed surveillance definition revealed 17 of 320 (5.3%) patients who met criteria for an ambulatory CLABSI. All 16 patients who met criteria (94%) had an inpatient hospital stay within 7 days of the qualifying infusion clinic encounter, for an average of 8.8 hospital days (range, 2–20). Positive blood cultures were collected on average 3.2 days after the patient’s qualifying infusion clinic encounter (range, 0–7). Moreover, 20 causative organisms were identified: 6 common commensals, 2 Staphylococcus aureus, and 12 gram-negative bacteria. Also, positive blood cultures for 7 patients (41%) were collected in ambulatory clinics. Patients reported symptom onset on average 1.2 days prior to telling a healthcare professional (range, 0–5) and an average of 2 days from their last qualifying infusion clinic visit (range, 0–6). In addition, 1 patient (6%) met for a site-specific infection outside of the defined window period during their subsequent admission. Conclusions: Application of the surveillance definition resulted in the identification of 17 CLABSIs. These results highlight important limitations in ambulatory CLABSI surveillance: Patients who access emergency services closer to their residence may have had their bloodstream infection (BSI) identified elsewhere. Ensuring comprehensive interfacility communication would increase the value of an institution’s surveillance. Additionally, ambulatory surveillance for BSI should include all possible collection locations. Although subject to recall bias, the event date could be based on symptom onset to allow for variation in healthcare-seeking behavior. In the ambulatory setting, because diagnostics are not readily available, delayed diagnosis of site-specific infections could result in an inflated ambulatory CLABSI rate.Funding: NoneDisclosures: None
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Francis, Maureen D., Mark L. Wieland, Sean Drake, Keri Lyn Gwisdalla, Katherine A. Julian, Christopher Nabors, Anne Pereira, et al. "Clinic Design and Continuity in Internal Medicine Resident Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative." Journal of Graduate Medical Education 7, no. 1 (March 1, 2015): 36–41. http://dx.doi.org/10.4300/jgme-d-14-00358.1.
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Abstract Background Many internal medicine (IM) programs have reorganized their resident continuity clinics to improve trainees' ambulatory experience. Downstream effects on continuity of care and other clinical and educational metrics are unclear. Methods This multi-institutional, cross-sectional study included 713 IM residents from 12 programs. Continuity was measured using the usual provider of care method (UPC) and the continuity for physician method (PHY). Three clinic models (traditional, block, and combination) were compared using analysis of covariance. Multivariable linear regression analysis was used to analyze the effect of practice metrics and clinic model on continuity. Results UPC, reflecting continuity from the patient perspective, was significantly different, and was highest in the block model, midrange in combination model, and lowest in the traditional model programs. PHY, reflecting continuity from the perspective of the resident provider, was significantly lower in the block model than in combination and traditional programs. Panel size, ambulatory workload, utilization, number of clinics attended in the study period, and clinic model together accounted for 62% of the variation found in UPC and 26% of the variation found in PHY. Conclusions Clinic model appeared to have a significant effect on continuity measured from both the patient and resident perspectives. Continuity requires balance between provider availability and demand for services. Optimizing this balance to maximize resident education, and the health of the population served, will require consideration of relevant local factors and priorities in addition to the clinic model.
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Shea, Christopher M., Kristin L. Reiter, Mark A. Weaver, and Jordan Albritton. "Quality improvement teams, super-users, and nurse champions: a recipe for meaningful use?" Journal of the American Medical Informatics Association 23, no. 6 (April 23, 2016): 1195–98. http://dx.doi.org/10.1093/jamia/ocw029.
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Abstract Objective This study assessed whether having an electronic health record (EHR) super-user, nurse champion for meaningful use (MU), and quality improvement (QI) team leading MU implementation is positively associated with MU Stage 1 demonstration. Methods Data on MU demonstration of 596 providers in 37 ambulatory care clinics came from the clinical data warehouse and administrative systems of UNC Health Care. We surveyed the 37 clinics about champions, super-users, and QI teams. We used generalized estimating equation methods with an independence working correlation matrix to account for clustering within clinics and to weight contributions from each clinic according to clinic size. Results Having a QI team lead MU implementation was significantly associated with MU demonstration (odds ratio, OR = 3.57, 95% CI, 1.83-6.96, P < .001, Table 2 ). Having neither a nurse champion nor an EHR super-user was significant. Conclusion Our findings support the alignment of MU with QI efforts by having the QI team lead MU implementation.
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Young, Richard A., Sandra K. Burge, Kaparaboyna A. Kumar, Jocelyn M. Wilson, and Daniela F. Ortiz. "A Time-Motion Study of Primary Care Physicians’ Work in the Electronic Health Record Era." Family Medicine 50, no. 2 (February 2, 2018): 91–99. http://dx.doi.org/10.22454/fammed.2018.184803.
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Background and Objectives: Electronic health records (EHRs) have had mixed effects on the workflow of ambulatory primary care. In this study, we update previous research on the time required to care for patients in primary care clinics with EHRs. Methods: We directly observed family physician (FP) attendings, residents, and their ambulatory patients in 982 visits in clinics affiliated with 10 residencies of the Residency Research Network of Texas. The FPs were purposely chosen to reflect a diversity of patient care styles. We measured total visit time, previsit chart time, face-to-face time, non-face time, out-of-hours EHR work time, and total EHR work time. Results: The mean (SD) visit length was 35.8 (16.6) minutes, not counting resident precepting time. The mean time components included 2.9 (3.8) minutes working in the EHR prior to entering the room, 16.5 (9.2) minutes of face-to-face time not working in the EHR, 2.0 (2.1) minutes working in the EHR in the room (which occurred in 73.4% of the visits), 7.5 (7.5) minutes of non-face time (mostly EHR time), and 6.9 (7.6) minutes of EHR work outside of normal clinic operational hours (which occurred in 64.6% of the visits). The total time and total EHR time varied only slightly between faculty physicians, third-year and second-year residents. Multivariable linear regression analysis revealed many factors associated with total visit time including patient, physician, and clinic infrastructure factors. Conclusions: Primary care physicians spent more time working in the EHR than they spent in face-to-face time with patients in clinic visits.
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Jun, Jeany Kim. "The Role of Pharmacy Through Collaborative Practice in an Ambulatory Care Clinic." American Journal of Lifestyle Medicine 13, no. 3 (February 8, 2017): 275–81. http://dx.doi.org/10.1177/1559827617691721.
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Pharmacists have been practicing in ambulatory care environments managing patients with chronic illnesses since the 1970s. The US Surgeon General and the Centers for Disease Control and Prevention support pharmacists working in collaboration with physicians to optimize medication outcomes, improve patient satisfaction, and lower health care costs. Through collaborative practice agreements, pharmacists are able to work as part of a health care team with access to electronic health records, and they assist busy physicians manage patients with chronic diseases such as diabetes. This article will review the different types of ambulatory care practice settings, what is included in a collaborative practice agreement, the credentialing and privileging of pharmacists working in such environments, the qualifications of pharmacists, the scope of practice, and some challenges for reimbursement.
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Wong Quiles, Chris Ivette, Marie D. Desrochers, Riley M. Mahan, Kristen Graham, Margaret Brill-Conway, Kelly Eng, and Amy Billett. "Feasibility of a clinic-based central line care teach-back program for pediatric oncology families." Journal of Clinical Oncology 35, no. 8_suppl (March 10, 2017): 183. http://dx.doi.org/10.1200/jco.2017.35.8_suppl.183.
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183 Background: Pediatric oncology (PO) patients with central lines (CLs) are at high risk for CL associated bloodstream infections (CLABSI), which increase morbidity, mortality, and costs. A large portion of ambulatory CL care in the home is provided by families who often have limited opportunities to develop the needed skills and adhere to best practice line care. Methods: A pilot quality improvement initiative was undertaken from 5/2015-6/2016 to develop a coaching program for families to demonstrate external CL care with a nurse during a routine clinic visit (teach-back), either on a simulation model or the patient. Tests of change were implemented to add teach-backs during routine clinic visits and ensure teach-back documentation in the medical record. Initial steps included assessing family interest in teach-backs by conducting surveys about CL care at home and unstructured incorporation into routine care by existing clinic nursing staff. After assessment of the pilot phase, targeted interventions started April 2016 including dedicated staff for scheduling, tracking, and performing teach-backs during routine clinic visits; culture change including an expectation that all families would participate and on-going staff education about the program; language change to increase participation by avoiding family perception of being tested; and incentives (gift-card raffle) for nurses to provide coaching. Results: Before April 2016, less than 25% of families participated due to a combination of family refusal; lack of nursing availability, space, or time; and inability to approach prior to line removal. In April 2016, 52% of families participated, reaching 90% by June 2016. Informal feedback from both staff and patient/family participants suggested increased job satisfaction by nurses and wide acceptance by all. In addition, many families participated in multiple teach-back sessions to improve line care skills. Conclusions: A CL teach-back program in a busy ambulatory PO clinic is feasible, but requires dedicated resources and culture change. Ongoing improvements are in place to ensure sustainability of the program and measure the impact on ambulatory CLABSI rate and family distress and line care skills.
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Francis, Maureen D., Kris Thomas, Michael Langan, Amy Smith, Sean Drake, Keri Lyn Gwisdalla, Ronald R. Jones, et al. "Clinic Design, Key Practice Metrics, and Resident Satisfaction in Internal Medicine Continuity Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative." Journal of Graduate Medical Education 6, no. 2 (June 1, 2014): 249–55. http://dx.doi.org/10.4300/jgme-d-13-00159.1.
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Abstract Background Internal medicine programs are redesigning ambulatory training to improve the resident experience and answer the challenges of conflicting clinical responsibilities. However, little is known about the effect of clinic redesign on residents' satisfaction. Objective We assessed residents' satisfaction with different resident continuity clinic models in programs participating in the Educational Innovations Project Ambulatory Collaborative (EPAC). Methods A total of 713 internal medicine residents from 12 institutions in the EPAC participated in this cross-sectional study. Each program completed a detailed curriculum questionnaire and tracked practice metrics for participating residents. Residents completed a 3-part satisfaction survey based on the Veterans Affairs Learners' Perception Survey, with additional questions addressing residents' perceptions of the continuous healing relationship and conflicting duties across care settings. Results Three clinic models were identified: traditional weekly experience, combination model with weekly experience plus concentrated ambulatory rotations, and a block model with distinct inpatient and ambulatory blocks. The satisfaction survey showed block models had less conflict between inpatient and outpatient duties than traditional and combination models. Residents' perceptions of the continuous healing relationship was higher in combination models. In secondary analyses, the continuity for physician measure was correlated with residents' perceptions of the continuous healing relationship. Panel size and workload did not have an effect on residents' overall personal experience. Conclusions Block models successfully minimize conflict across care settings without sacrificing overall resident satisfaction or resident perception of the continuous healing relationship. However, resident perception of the continuous healing relationship was higher in combination models.
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Fragala, Guy, Manon Labreche, and Patti Wawzynieki. "Benefits Achieved for Patients Through Application of Height-Adjustable Examination Tables." Journal of Patient Experience 4, no. 3 (May 9, 2017): 138–43. http://dx.doi.org/10.1177/2374373517706835.
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Objectives: Ambulatory care is a rapidly growing segment of overall healthcare delivery and populations seen in ambulatory care settings are aging resulting in many patients with mobility limitations. Mounting a fixed height examination table can present a challenge to a patient with mobility limitations and may be somewhat difficult for the general patient population. This study sought to investigate potential benefits to the patient which might be achieved through introduction of height adjustable examination tables. Methods: A data collection tool was administered to patients at the time of a regularly scheduled clinic visit intended to measure exertion required, level of difficulty and feeling of safety. Results: Both patients requiring assistance and independent patients reported higher exertion, more difficulty and feeling less safe when mounting higher fixed height versus height adjustable examination tables. Conclusions: Height adjustable examination tables provide benefits to patients and should be considered when seeking furnishings for ambulatory care clinics.
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Shah, Mansi, Jessica Tilton, and Shiyun Kim. "Factors Influencing Enrollment in the Medication Therapy Management Clinic at an Academic Ambulatory Care Clinic." Journal of Pharmacy Practice 29, no. 2 (August 3, 2014): 106–9. http://dx.doi.org/10.1177/0897190014544791.
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Purpose: In 2001, the University of Illinois Hospital and Health Sciences System (UI Health) established a pharmacist-run, referral-based medication therapy management clinic (MTMC). Referrals are obtained from any UI Health provider or by self-referral. Although there is a high volume of referrals, a large percentage of patients do not enroll. This study was designed to determine the various factors that influence patient enrollment in the MTMC. Methods: This study was a retrospective chart review of demographic and patient variable data during years 2010 and 2011. Disabilities, distance from MTMC, mode of transportation, past medical history, and appointment dates were extracted from the medical records. Results were analyzed using descriptive statistics and logistic regression analysis. Results: A total of 103 referrals were made; however, only 17% of patients remain enrolled in MTMC. The baseline demographics included a mean age of 63 years, 68% female, 70% African American, and 81% English speaking. Patients lived an average of 8 miles from MTMC; most utilized public or government-supplemented transport services; 24% of patients reported some type of disability, most commonly utilizing a walker or a wheelchair. On average, patients were prescribed 13 medications with hypertension (70%), diabetes (56%), and hyperlipidemia (48%) being the most common chronic disease states. The reason for referral included medication management, education, medication reconciliation, and disease state management. Five patients were unable to be contacted to schedule an initial appointment. Additionally, 18 patients failed their scheduled initial appointment and did not reschedule. Logistic regression analysis demonstrated distance traveled for clinic visit, age, and history of hypertension affected the probability of patients showing for their appointments (chi-square = 19.7, P < .001). Conclusion: This study demonstrated that distance from MTMC is the most common barrier in patient enrollment; therefore, strategies to improve patient access are necessary.
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Wong, Roberta J., and Paul A. Volberding. "Providing Clinical Pharmacy Services in an AIDS—oncology Ambulatory-care Clinic." American Journal of Health-System Pharmacy 45, no. 11 (November 1, 1988): 2351–54. http://dx.doi.org/10.1093/ajhp/45.11.2351.
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Perry, Brian A., Andrew O. Westfall, Elizabeth Molony, Rodney Tucker, Christine Ritchie, Michael S. Saag, Michael J. Mugavero, and Jessica S. Merlin. "Characteristics of an Ambulatory Palliative Care Clinic for HIV-Infected Patients." Journal of Palliative Medicine 16, no. 8 (August 2013): 934–37. http://dx.doi.org/10.1089/jpm.2012.0451.
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Kuo, David, and Mark J. Fagan. "Satisfaction with methods of spanish interpretation in an ambulatory care clinic." Journal of General Internal Medicine 14, no. 9 (September 1999): 547–50. http://dx.doi.org/10.1046/j.1525-1497.1999.07258.x.
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Stahl, James E., Mark S. Roberts, and Scott Gazelle. "Optimizing management and financial performance of the teaching ambulatory care clinic." Journal of General Internal Medicine 18, no. 4 (April 2003): 266–74. http://dx.doi.org/10.1046/j.1525-1497.2003.20726.x.
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Parsons, Katelyn A., and Anthony E. Zimmermann. "Impact of an ambulatory care pharmacist in an occupational health clinic." Journal of the American Pharmacists Association 59, no. 1 (January 2019): 64–69. http://dx.doi.org/10.1016/j.japh.2018.09.003.
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Pendergrass, John C., and Ranganathan Chandrasekaran. "Key Factors Affecting Ambulatory Care Providers’ Electronic Exchange of Health Information With Affiliated and Unaffiliated Partners: Web-Based Survey Study." JMIR Medical Informatics 7, no. 4 (November 7, 2019): e12000. http://dx.doi.org/10.2196/12000.
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Background Despite the potential benefits of electronic health information exchange (HIE) to improve the quality and efficiency of care, HIE use by ambulatory providers remains low. Ambulatory providers can greatly improve the quality of care by electronically exchanging health information with affiliated providers within their health care network as well as with unaffiliated, external providers. Objective This study aimed to examine the extent of electronic HIE use by ambulatory clinics with affiliated providers within their health system and with external providers, as well as the key technological, organizational, and environmental factors affecting the extent of HIE use within and outside the health system. Methods A Web-based survey of 320 ambulatory care providers was conducted in the state of Illinois. The study examined the extent of HIE usage by ambulatory providers with hospitals, clinics, and other facilities within and outside their health care system–encompassing seven kinds of health care data. Ten factors pertaining to technology (IT [information technology] Compatibility, External IT Support, Security & Privacy Safeguards), organization (Workflow Adaptability, Senior Leadership Support, Clinicians Health-IT Knowledge, Staff Health-IT Knowledge), and environment (Government Efforts & Incentives, Partner Readiness, Competitors and Peers) were assessed. A series of multivariate regressions were used to examine predictor effects. Results The 6 regressions produced adjusted R-squared values ranging from 0.44 to 0.63. We found that ambulatory clinics exchanged more health information electronically with affiliated entities within their health system as compared with those outside their health system. Partner readiness emerged as the most significant predictor of HIE usage with all entities. Governmental initiatives for HIE, clinicians’ prior familiarity and knowledge of health IT systems, implementation of appropriate security, and privacy safeguards were also significant predictors. External information technology support and workflow adaptability emerged as key predictors for HIE use outside a clinic’s health system. Differences based on clinic size, ownership, and specialty were also observed. Conclusions This study provides exploratory insights into HIE use by ambulatory providers within and outside their health care system and differential predictors that impact HIE use. HIE use can be further improved by encouraging large-scale interoperability efforts, improving external IT support, and redesigning adaptable workflows.
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Namen, Andrew M., Antoinette Wymer, Douglas Case, and Edward F. Haponik. "Performance of Sleep Histories in an Ambulatory Medicine Clinic." Chest 116, no. 6 (December 1999): 1558–63. http://dx.doi.org/10.1378/chest.116.6.1558.
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Mwasongwe, Stanford E., Rikki M. Tanner, Bharat Poudel, Daniel N. Pugliese, Bessie A. Young, Marwah Abdalla, Solomon K. Musani, et al. "Ambulatory Blood Pressure Phenotypes in Adults Taking Antihypertensive Medication with and without CKD." Clinical Journal of the American Society of Nephrology 15, no. 4 (March 26, 2020): 501–10. http://dx.doi.org/10.2215/cjn.08840719.
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Background and objectivesRecent guidelines recommend out-of-clinic BP measurements.Design, setting, participants, & measurementsWe compared the prevalence of BP phenotypes between 561 black patients, with and without CKD, taking antihypertensive medication who underwent ambulatory BP monitoring at baseline (between 2000 and 2004) in the Jackson Heart Study. CKD was defined as an albumin-to-creatinine ratio ≥30 mg/g or eGFR <60 ml/min per 1.73 m2. Sustained controlled BP was defined by BP at goal both inside and outside of the clinic and sustained uncontrolled BP as BP above goal both inside and outside of the clinic. Masked uncontrolled hypertension was defined by controlled clinic-measured BP with uncontrolled out-of-clinic BP.ResultsCKD was associated with a higher multivariable-adjusted prevalence ratio for uncontrolled versus controlled clinic BP (prevalence ratio, 1.44; 95% CI, 1.02 to 2.02) and sustained uncontrolled BP versus sustained controlled BP (prevalence ratio, 1.66; 95% CI, 1.16 to 2.36). There were no statistically significant differences in the prevalence of uncontrolled daytime or nighttime BP, nondipping BP, white-coat effect, and masked uncontrolled hypertension between participants with and without CKD after multivariable adjustment. After multivariable adjustment, reduced eGFR was associated with masked uncontrolled hypertension versus sustained controlled BP (prevalence ratio, 1.42; 95% CI, 1.00 to 2.00), whereas albuminuria was associated with uncontrolled clinic BP (prevalence ratio, 1.76; 95% CI, 1.20 to 2.60) and sustained uncontrolled BP versus sustained controlled BP (prevalence ratio, 2.02; 95% CI, 1.36 to 2.99).ConclusionsThe prevalence of BP phenotypes defined using ambulatory BP monitoring is high among adults with CKD taking antihypertensive medication.
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Patel, Tammy L., Shelley Raffin Bouchal, Catherine M. Laing, and Stephanie Hubbard. "Reducing emergency department utilization for outpatient acute cancer symptoms: An integrative review on the advent of urgent cancer clinics." Canadian Oncology Nursing Journal 31, no. 1 (February 3, 2021): 22–35. http://dx.doi.org/10.5737/236880763112235.
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The purpose of this integrative literature review was to identify nursing research opportunities related to outpatient acute cancer symptom management within emerging urgent cancer clinics (UCCs). Patients with acute cancer symptoms (e.g., fevers, gastrointestinal disturbances, or uncontrolled pain) from ambulatory settings predominantly rely on emergency departments (EDs) for assessment and treatment. However, this model of care is no longer sustainable and emphasizes healthcare system inefficiencies. Urgent cancer clinics allow patients to have these symptoms treated by oncology experts within ambulatory cancer centres. Unfortunately, limited research on urgent cancer clinics both operationally and experientially makes it difficult for others to adopt this new model of care. The core questions that guided this integrative review were: 1) What is the state of the science regarding UCCs, and what differences exist when compared to EDs in the management of outpatient acute cancer symptoms? and 2) Where do UCCs exist around the world, and what is understood about UCCs related to clinic operations and staffing models?