Anticoagulation Management Service (AMS)
A. Mission and Goal
a. Mission Statement
b. Benefits of a pharmacy managed anticoagulation clinic
c. Value
i. Improved patient care
ii. Decreased ER and Readmission rates
iii. Increased revenue
B. Personnel
a. Job Description and Responsibilities
b. Personnel needs per patient
C. Protocols
a.
b.
c.
d.
e.
f.
g.
Patient admission criteria
Dosing guidelines
INR testing
Return visits
Communicating results
Critical values
AWOL patients
D. Continuity of Care
a. Inpatient education and testing
b. Patient discharge
c. Admission
i. Scheduled
ii. Emergent
E. Patient Education
a. Initial visit
b. Compliance and follow-up
F. Testing
a.
b.
c.
d.
Point of Care testing
CLIA
Quality control
Outside labs
G. Information Management
a. Visit scheduling
b. Visit documentation
c. Billing
H. Anticoagulation Management
a.
b.
c.
d.
Target INR
Warfarin, LMWH, Anti Xa Inhibitors, etc.
Bridge Therapy
Reversal Treatments
I. Quality Assurance
a. Efficacy of therapies
b. Effectiveness of clinic
c. Patient satisfaction
Mission and Goals
A. Mission Statement:
Provide the optimal care for patients on difficult to manage anticoagulants such as
warfarin utilizing patient education and Point of Care testing as the hallmarks of the
program.
B. Studies have shown consistently better outcomes through pharmacy managed
anticoagulation clinics than traditional programs.
C. These studies have demonstrated longer durations in the therapeutic range and decreased
bleeding complications. Also, readmission and emergency room visits were reduced.
Patient visits can be billed for at the low intensity visit rate as well as the INR test
through Medicare and other insurance providers.
Personnel:
A. A clinical pharmacist with additional training in anticoagulation management, following
medical staff approved guidelines, will primarily manage patient care. Responsibilities
will include; determine visit schedule, INR testing, dosage adjustment and patient /
caregiver education. The primary care physician will be updated on every visit and every
dosage change. The pharmacist will also consult the primary care physician when
needed.
B. Each patient will average 2 visits per month at 15 minutes per visit.
For 250 patients = 500 visits/month = 7500 minutes or 125 hours = 20 X 6 hour days per
month or one FTE. Education for the initial appointment will increase initial visit time to
30 minutes. Complimentary staff will decrease 15 minute per visit time. i.e. time spent
for scheduling, tracking, billing, paperwork.
C. Medicare pays $50 per lowest intensive visit (99211 code) (“incident to” rule) plus $15
per INR test. 500 visits per month = $32,500 per month. One FTE expense =
$10,800/month.
Protocols: see attached.
Continuity of Care:
A. Patient education will optimally be started in the hospital. Patients being discharged to
the AMS will be scheduled for an appointment before discharge. There will be
communication between the primacy care physician and the AMS on all admissions and
discharges including ER visits.
Patient Education:
A. All patients will have the option of viewing the warfarin video. All patients will be
educated on warfarin, its use and goals, side effects, precautions, testing and schedule.
The primary objective is to ensure that every patient understands the correct dosing
schedule prior to leaving after each visit. Each patient will be given a dosing calendar to
help keep track of doses and schedule.
B. Each patient will be instructed on the importance of compliance with drug and INR
testing.
Testing:
A. A Point of Care (POC) device will be used primarily for INR determinations. This will
allow immediate feedback to patient to ensure correct understanding and instant
gratification.
B. The hospital’s CLIA license for waved testing can be used if appropriate quality
assurance protocols are followed.
C. Prior to use and periodically, the POC device will be compared to standardized tests
and/or actual patients to ensure accurate readings.
D. Utilizing of outside labs will be minimized if possible due to un-reimbursable follow-up.
Information Management:
A. A schedule will be maintained on future patient visits.
B. Each visit will be documented either in the chart or computer including a brief report on
any side effects, compliance, INR, any medication additions, deletions or changes plus
additional relevant information. The warfarin dose will be trended along with the
corresponding INR. The next scheduled visit will be documented.
C. Each visit and test will be coded and billed according to Medicare guidelines.
Anticoagulation Management: see protocols
Quality Assurance:
A. Quality assurance parameters may include treatment and clinic effectiveness,
complication rate, and patient satisfaction surveys.
Financial Assessment:
500 visits/month
Revenue:
Patient charge per visit
Estimated annual gross revenue
Bad Debt (10%)
Estimated annual net clinic revenue
Revenue increases as visits increase
$51.47 (lowest intensity visit)
$398,820
($39,000)
$359,820
Expenses:
Annual Wages and Benefits
Supply Costs
($150,000)
($39,344)
Net Profit
$170476
Supply Costs:
Hemochron Elite POC
$0
600 cuvettes
$1944
FAX machine
$300*
Computer
$2000
Patient education
$2000
CLIA & Quality Assurance
$1100**
Room & Equipment
$30,00*
Misc.
$2000
TOTAL
$39,344
* May be able to use current space and supplies.
**If use current CLIA will be less.