Pharmacists Taking Over!

[Marty]

As most of my old friends know I have been working for Mid-Atlantic Kaiser since I retired from private practise in 1995. We have about 500,00 members.
When I first came to Kaiser, anticoagulation was mostly managed by individual doctors and nurses. Last week we received this message from regional headquarters.

CLINICAL PHARMACY SERVICES
ANTICOAGULATION

CPS staff are available for long term follow up of patients on anticoagulation therapy and for consultation as needed.

Clinical pharmacists will have a dedicated panel of patients to follow to ensure continuity and quality of care.

Clinical pharmacists will carry on-call pager on rotating basis.

PATIENT ENROLLMENT
Review new patient information sheets.
Research missing clinical information.
Educate patient and/or caregiver regarding anticoagulant therapy.
Coordinate Visiting Nursing services if necessary.

PATIENT CARE
Notify patient of INR results, adjust dose if necessary and schedule next INR appointment.
Facilitate management of anticoagulation therapy adverse events.
Facilitate management of anticoagulation drug interactions.
Notify patients who have missed INR appointments.
Answer physician questions regarding anticoagulation therapy.
In the the future with proper training and education, manage patients according to outpatient treatment of DVT guideline and design anticoagulation plans for patients undergoing invasive procedures.

I personally believe this plan will improve anticoagulation management.I'm interested to know what the folks who contribute to vr.com think.

 

[MelissaM]

Marty,

I don't know about anti-coagulation, but from my experience, Kaiser does a good job evaluating changes before implementation. They truly seem to want to balance the needs of the patient with the needs of running a big HMO.

Melissa

 

[ALCapshaw2]

My Anti-Coagulation Clinic has a PharmD Manager with a CRNP as the primary 'go to' person for dose management. The PharmD may get involved if the CRNP is out of the the office or for complex cases.

The finger sticking and record keeping is performed by Pharmacy Students. If the reading is out of range, then the CRNP is consulted by the student.

I've been very impressed with the CRNP's at this clinic.

I was less than pleased with the "Do as I say" attitude of the (young and not very experienced) nurse at my cardio's office. These YOUNG nurses were totally opposed to Home Testing or ANY form of patient management / involvement.

I guess we 'Old Geezers' just don't like being told what to do you by 'Young Whipper Snappers' Give me someone who's been 'around the block' a few times anyday!

'AL Capshaw'

 

[tobagotwo]

Of course they are, Al. It interferes with their sense of personal importance. Not to mention that, if you know what you're doing without their constant overlordship, others may figure out that they're not needed, too. Insurrection!

The problem with most of these health or even fitness programs (not just ACT) is that these "young whippersnappers" are often taught that there is one formula, and it works the same for everyone, common sense be darned. They're taught to push back on the patients, so they"ll "behave."

They come out of training thinking, "I'm a professional. I know: you don't." Too bad. They need to be taught to have a gozinta as well as a gozoutta.

Hopefully, the pharmacists will have a better take on how this works over time.

Best wishes,

 

[bvdr]

Marty, I think it is a very good idea. Maybe it will lead to anticoagulation management that is more carefully managed rather than by the seat of the pants which is so often seen.

Al, Bob, about the young nurses with attitudes.........what can I say but you are right. Give them some more time. What is right today may be wrong tomorrow. If they develop skills in observation and learn to really listen to their patients they may turn out alright. There is a learning curve....

 

[Barry]

My experience has been that pharmacists know more about drugs, and are much more forthcoming with information about drugs, than nurses or physicians.

 

[Karlynn]

My experience has been that pharmacists know more about drugs, and are much more forthcoming with information about drugs, than nurses or physicians.

My Mom always said - ask your pharmacist a question about a drug before your doctor.

 

[John & Joann]

We use a coumadin clinic that has pharmacist and students. The service, quality of testing, and management results are outstanding. Joann does NOT want to do home testing and this system works well. They utilize the finger prick and not the blood draw. Because of scar tissue, the blood draw is a real pain.

 

[tobagotwo]

I think that pharmacists are much better with understanding how drug actions affect patients than physicians are. And I think they are not as likely to take an "educated guess" that you may have to take the fall for.

They will probably spot cross-indications with other drugs in the process, as they will better understand what they're looking at when they see a list of your prescriptions. Not to mention that they're much more likely to look something up when they're usure.

Could be very good indeed.

 

[Rich]

Sounds like a good idea Marty.
I have to echo Barry's comment, our local pharmacist could put any of these doctors and their staff to shame.
My personal experience with a newcomer at my cardiologist's office was kind of funny.
She called with my INR results one day and told me she thought I needed a little adjustment.
I informed her that I had just made my own adjustment which did not agree with her direction.
She was very upset apparently and said quite loudly,'YOU MADE YOUR OWN ADJUSTMENT ? YOU CAN"T DO THAT, YOU HAVE TO DO WHAT I TELL YOU!
I responded with "NO I DON'T, I HAVE BEEN DOING THIS FOR NINE YEARS, PROBABLY WHILE YOU WERE STILL IN GRADE SCHOOL, I KNOW WHAT I"M DOING. And I do (with Al's help sometimes).
At my next appt. with my cardiologist he just laughed a little and said just keep doing it your way, she will eventually learn.
Rich

 

[Guest]

Kaiser in Denver has over 6,500 people in a clinic like this. They do not utilize fingersticks. The people go to the lab on the appointed day and have their blood drawn and then go about their business. Later that day, the pharmacists get the lab results and call the people. I asked the Kaiser people about privacy issues leaving messages on answering machines. The answer was that it is not a problem. Almost 100% of the people enrolled with Kaiser have a cell phone.

 

[SHerrin Hutt]

They have to betr at it than any Dr. I have had. Since I got my protime machine from QAS my daughter & I have did a better job than any of my Dr's ever did.

 

[Marge]

Marty, I'm a Kaiser patient -- this sounds pretty much like what Kaiser does in the district where I am (the Diablo Valley region -- Northern CA).

I was on warfarin for three months after my valve repair surgery last year & now I am on it again due to atrial flutter. It is all managed by a centralized anti-coagulation clinic, headed by a Pharm D. I have talked to the head and to one other Pharm D, so I know there are at least two Pharm Ds on the staff. I can go to any Kaiser lab for testing. (There is one about 10 minutes drive from my home.) At first I was going once a week; after I was in range they started having me go every three weeks. They want me to go as early in the a.m. as possible so the lab can get the results to the anti-coagulation clinic and they can contact me, if necessary, that same say. If I'm not in range, they are supposed to call me the same day, and the one time I was not in range they did. If I'm in range they send me a letter which I usually get the following day.

I can call them to check about the INR, or anything else. There is a list of things that I am supposed to call the anti-cogulation clinic about if they occur: any illnesses, any new prescription drugs, etc. I have called them a few times to check on things. It is reassuring that there is someone competent to call whenever I feel the need. I am pretty comfortable with the procedures so far. I would be happier if the Kaiser in my region had fingerstick facilities, because it has not been that easy to do blood draws, but I think between the lab techs and me, we have worked that out fairly well.

So far my cardiologist has been only minimally involved in all this: just to tell me that I should start warfarin again & to refer me to the anti-coagulation clinic, once he had determined I was in atrial flutter. I assume the anti-coagulation clinic coordinates with the cardio, but I don't know what procedures they follow.

 

[Marty]

Thanks for the feed back!

Thanks for the feed back!

All the comments were interesting and educational. Thank you. My only gripe with my own clinic in Falls Church is the lab will only test with vein draws using a somewhat imposing large machine to measure the INR and PT. I discussed finger stick monitors with the chief lab tech and she essentially said Kaiser does not trust the accuracy of devices like the Coaguchek or Protime. I believe they are dead wrong but getting Kaiser to change a procedure is not easy. One would need to go through several thick layers of administration. Al, what do you know about the relative accuracy of testing venous vs. capillary blood?

 

[Guest]

The logic behind a variation in capillary vs venous blood in INR testing is false. In blood sugar testing there is a difference because every cell in the body is taking sugar from the blood. So the farther away from the heart the blood gets, the less sugar threre will be. However, with warfarin, only the liver is trying to get warfarin out of the blood. Therefore, there is no difference between the INR in capillary vs venous blood.

The real logic is that it would cost a lot of money for an outfit the size of Kaiser to change. If they have 6,500 people on warfarin in Denver and they could get the CoaguCheks at a discount of $1,000 each, it would cost $6,500,000 to switch just the people in Denver to home testing.

So if somebody asks why Kaiser doesn't use CoaguCheks which would you expect to get for an answer - "we can't afford it" or "we have doubts about the accuracy"

 

[Marty]

Another question for Al?

Another question for Al?

Good answer to the capillary question. Thanks Al. Now it brings up the next
question. Wouldn't it be cheaper for Kaiser to let the pharmacists test each patient in their own office area with a capillary monitor instead of sending patients to register at the busy central lab, veinstick,store the blood, and then test it hours later in that big expensive looking box called Sysmex CA-1000 Coagulation Analyzer? This brings in all the problems with citrate,clotting,centrifuge, etc. Lets face it Kaiser could never aforrd to give each patient a capillary monitor but they could give one to each pharmacy, speed the whole test up, and save money.

 

[Guest]

I think that they will eventually go to finger sticks, but it will be quite some time before they do.

 

[KristyW]

I think that they will eventually go to finger sticks, but it will be quite some time before they do.

Marty & Al,

This is a timely discussion as I have been way out of range for a week. ( 6.8 on Wednesday, 8.8 on Thursday...hold 2 days...2.2 on Monday) I have Kaiser. I had a nice discussion with the person assigned to me at the Coag Clinic. I had 3 venous punctures in less than a week & they can only use my right arm to draw blood. When I was whining about it, my coag person asked right away if I had Medicare because medicare would pay for a Coaguchek/ProTime machine. I told him no & asked why Kaiser doesn't use these at the lab. He said that Kaiser Denver is planning to test it very soon, but it would only be available in one of their facilities (not one in the center of town either).

This guy is very informed. He did question the accuracy of the fingerstick machines, but I reminded him that it was easier to mess up a test in a lab. He agreed. I believe that the time is coming when Kaiser will use these machines, but it will not be clinic-wide for quite some time.

 

[Marty]

Thanks, Kristy. This is the kind of information I need. I hope to see Falls Church doing finger stick before I retire again.

 

[Guest]

Marty,

The guy "in the know" in Denver is Daniel Witt. He is a pharmacist and was in charge of their Coumadin Clinic but has moved into another administrative position now. I saw him last month in Orlando at the Anticoagulation Forum meeting. About this time there was another thread (Marge I believe) who was a Kaiser person and wondering about their procedures. I asked him about this and said that I would not use his name. But he said, "It's OK to use my name". So I assume that if you want to contact him it would be OK.

If anyone else wants to know more about Medicare and self-testing, please send me a private message or e-mail.