Preliminary Data from a Pharmacist-Managed Anticoagulation Clinic Embedded in a Multidisciplinary Patient-Centered Medical Home

A Coordinated Quality, Cost-Savings Model

Patient-centered, comprehensive, team-based, coordinated care models are a focal point of healthcare reform. The patient-centered medical home (PCMH) model aims to provide better primary care and health outcomes at a lower cost. To become a PCMH, a set of standards must be met that includes coordination of care transitions.

Coordinated care becomes especially important for individuals taking high-risk medications, such as anticoagulants. Warfarin and other anticoagulants are associated with risk of rehospitalization around transitions of care. Although professional organization accrediting bodies, and healthcare regulators emphasize appropriate care transitions, there are few best practice descriptions available for anticoagulation care transitions.

Although conditions warranting anticoagulation are more prevalent with older age, clinicians may opt not to anticoagulate elderly adults because of concerns about excess bleeding, risk of falls, cognitive impairment, or short life expectancy. Acknowledging these challenges, safety concerns, and susceptibility around transitions of care, an anticoagulation clinic model dedicated to addressing the needs of individuals aged 60 and older was designed, embedded within a geriatric primary and specialty care PCMH at the Rosa Parks Wellness Institute for Senior Health (RP-WISH).

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