Patient Outreaches for Clinical Pharmacy Services: A Population Health Management Program Assessment

Abstract

Background: Pharmacists in ambulatory care can utilize population health approaches to identify patients needing disease management and improve outcomes. However, population health is only effective when identified patients are successfully outreached and show to appointments. Objective: Describe a population health approach utilized by pharmacists in primary care, report outcomes of outreach attempts and scheduled appointments, and determine whether patient and referral characteristics predict no-show appointments. Methods: Retrospective cohort study of patients referred for pharmacist management of hypertension or chronic pain through population health between 2013-2016. Outreach attempt and appointments outcomes were collected. Patient and referral characteristics were analyzed to determine whether predictive of no-show appointments using logistic regression. Results: Of 450 outreach attempts, 250 (56%) patients were not reached, 164 (36%) scheduled appointments, and 36 (8%) were reached but declined an appointment. Of 164 patients with appointments, 71 (43%) no-showed. Patients with higher systolic blood pressure were more likely to no-show (OR: 1.02, 95% CI: 1.00-1.04). Other characteristics were not predictive of no-show appointments. Conclusion: Successful outreach and showed appointments are essential components of successful population health programs. Using multiple outreach modalities and further identifying factors predictive of no-show appointments to refine the current approach may lead to increased efficiency.

Clinical Pharmacists in Chronic Care [Part 2]

“…Interventions that were most effective included combinations of more convenient care, information, reminders, self-monitoring, reinforcement, advocacy, family therapy, psychotherapy, crisis intercession, regular telephone follow-up, and supportive care [83]. Weight loss has been noted to modify risk factors via improving insulin sensitivity, reducing inflammation, decreasing BP and modifying the lipid profile [100]. It is astonishing that 7-28% of patients with coronary heart disease still smoke, but around half of smokers are planning to quit [101].…”