Ochsner Clinic Foundation Program New Orleans La Internal Medicine

• He went on to finish a Family Medicine Residency at the University of Mississippi in 2004. He started his surgical career at Ochsner Clinic Foundation in New Orleans LA. He completed General Surgery training at Ochsner in 2012. He then did a Vascular Fellowship at Ochsner in 2012.
• Ochsner Clinic Foundation Orthopaedic Surgery Residency Program. Program Director: Mark S Meyer, MD. Ochsner Clinic Foundation - New Orleans, LA. Ochsner Clinic Foundation Orthopaedic Surgery Residency Program. OrthopaedicsOne Residency.

• Ochsner Cardiology New Orleans
• Ochsner Clinic Foundation Program New Orleans La Internal Medicine Hospital
• Ochsner Clinic Foundation Hospital
• Ochsner Medical Center New Orleans La

Ochsner Clinic Foundation Program, New Orleans, Louisiana 140-21-22-146, Internal Medicine,. Ochsner Clinic Foundation Program, New Orleans, Louisiana 140-21-22-146, Internal Medicine,. Sponsored Links. Ochsner Clinic Foundation Internal Medicine Pgm BH 629 1514 Jefferson Hwy New Orleans, LA 70121. Tel: (504) 842-0450.

Abstract

The impact of managed care in the 1990s and the need for more broadly trained primary care physicians led the American Board of Internal Medicine and the American Board of Family Practice to explore ways to collaboratively train primary care physicians. One proposed solution was a combined residency incorporating the training curriculums of both boards in an integrated fashion. In 1995, the Alton Ochsner Medical Foundation Combined Family Practice and Internal Medicine Residency Program was one of the first to be approved by the two boards. The first residents began training in July 1996. Due to overlap in curriculums, completion for both boards is possible in 48 months as opposed to the 72 months a consecutive approach would require. The first graduates completed the program in July 2000.

The combined residents rotate on both the Family Practice inpatient service and the General Internal Medicine wards and participate in continuity care clinics and precepting in both core programs. Facilities for the program involve only existing clinics and administrative personnel. Residents serve as primary care physicians for a mixed ethnic, middle-class patient population atOchsner's New Orleans East satellite clinic, provide longitudinal obstetric and pediatric care at an inner city clinic, and complete a rural primary care rotation. Inservice examination scores have been consistently high with several combined residents scoring at the top United States level on both examinations. The program has matched with our highest ranked students over each year of the program despite a marked decline in US graduates entering primary care fields. Graduates of the combined program are ideal staff for either medical schools or residency programs of either core program.

While this residency is in its early stages, both boards have mandated an indepth evaluation to determine the quality and outcomes of training. The results of a recent survey of current Ochsner residents assessing their perceptions of the combined program were encouraging. We plan to track our graduates and compare them with recent graduates of the two core programs in order to document long-term impact.

During the 1990s, the impact of managed care and the emphasis on the need for more broadly trained primary care physicians led the American Board of Internal Medicine and the American Board of Family Practice to explore ways to collaboratively train primary care physicians (). Several board members strove to create a training process that contained the comprehensiveness of family practice while maintaining a disease-specific, subspeciality-based Internal Medicine focus. The goal was to most cost-effectively train the best prepared primary care physicians. A combined residency incorporating the training curriculums of both boards in an integrated fashion was one option .

The Alton Ochsner Medical Foundation and the Eastern Virginia Medical School were the first two programs to be approved to help meet these goals in 1995 . A 48-month curriculum was developed to meet the specific objectives of this unique training program. The first residents were taken in the March 1996 match and began training in July 1996.

The goals of the combined program are to:

1. Provide residents with enhanced generalist training

2. Provide additional training in a variety of communities (rural, inner-city, etc.)

3. Improve training resource efficiency

4. Increase the attractiveness of primary care

5. Improve communication between Internal Medicine and Family Practice

6. Increase the number of effective faculty role models for medical students and residents.

The curriculum of the Alton Ochsner Medical Foundation's 4-year integrated program is outlined in Appendix 1.

Administration

Monthly meetings with core faculty and the chief residents provide an opportunity for comanagement of the residency. Combined residents are given a faculty advisor in Internal Medicine for quarterly reviews of Internal Medicine academic performance and undergo quarterly reviews in Family Medicine with the Family Medicine program director. An annual faculty retreat is held to review the entire program along with the core Family Medicine program.

Curriculum

The curriculum, submitted to both boards and approved in 1994, was developed to meet the 36-month requirements of both boards. Due to overlap in curriculums, completion for both boards is possible in 48 months as opposed to the 72 months a consecutive approach would require. It was essential during the development of the program that no “short cuts” were taken, but that combined training fulfilled the requirements of both core programs.

Generalist Training

The first goal of the combined program was to enhance generalist training. The combined resident rotates on both the Family Practice inpatient service and the General Internal Medicine wards. This allows for precepting on inpatient issues by both family and internal medicine physicians. The combined residents also have continuity care clinics and precepting in both Internal Medicine and Family Practice. The total ambulatory experience is approximately 50% of the residency, as opposed to the ∼30% ambulatory requirement of the Internal Medicine program.

Care was taken to avoid disrupting ward responsibilities with this increased ambulatory curriculum. The number of clinics are adjusted based on the intensity of the rotation (i.e. medicine wards vs.consult rotations). Continuity clinics are provided in the family practice residency model clinic for all 4 years. Originally, residents also had Internal Medicine continue in the third and fourth years, but the requirement was recently changed to start in the second year of training. Now the residents spend a day every other week in the Internal Medicine clinic (just as the categorical Internal Medicine residents) alternated with a day-long clinic every other week in the Family Practice model clinic. This gives the residents at least 1 day per week in either Internal Medicine or Family Practice clinic. Residents meet the 24-month continuity care requirement defined by both boards of Internal Medicine and Family Practice.

Care To Differing Communities

Caring for differing communities is a strong aspect of the Ochsner combined program. Ochsner residents serve as primary care physicians for a mixed ethnic, middle-class patient population at the Ochsner's New Orleans East satellite clinic, which is ∼95% managed care. Residents also provide longitudinal obstetric and pediatric care at the inner city St. Thomas Clinic providing indigent care.

A rural Family Practice rotation is also included. Residents perform a 1-month rotation through Chabert Medical Center, approximately 30–40 miles from the main Ochsner campus, providing care for an uninsured (and largely Cajun) population. This includes rotations in Internal Medicine, ICU, OB/GYN, and newborn nursery, and provides a community experience as opposed to the tertiary referral experience obtained at the main Ochsner campus.

Efficiency of Training Resources

Program efficiency is improved in several ways. Facilities involve only existing clinics and administrative personnel. The continuity clinics are provided in the existing Family Practice Residency model clinic and one of the Internal Medicine clinics used by the Internal Medicine Residency. In addition, Family Medicine participation in Internal Medicine morning report includes twice-monthly cases presented by the Family Medicine hospital service. Geriatrics lectures are also provided for both Internal Medicine and Family Practice residents once-monthly. Noon conferences and Internal Medicine Grand Rounds are open to all house staff.

Attractiveness of Primary Care

Medical students have found the combined residency attractive, as denoted by a significant number of high-quality students applying and accepting appointments to the residency. Of the original five matching residents appointed to the residency, all completed the residency in June 2000. The program has matched with our highest ranked students over each year of the program despite a marked decline in US graduates entering primary care fields.

Interdepartmental Communication

Monthly curriculum meetings between the core departments enhance communication on a departmental level. Resident-level interaction on the Internal Medicine ward and consult rotations have also enhanced communication between the departments of Internal and Family Medicine. Combined residents are constantly interacting with residents of both core programs and have fostered more interactions between these residency groups. Both programs' faculty and residents have noted that the combined program has served to improve the core programs from which it derives.

More Role Models

Once several combined residents have completed the residency, they become ideal staff for either medical schools or residency programs of either core program. Their added training is invaluable both in the clinic and on inpatient ward services for either Family or Internal Medicine. We plans to use our graduates as faculty for the combined program in the future. To date, two Ochsner graduates have become staff of the Ochsner Clinic.

Evaluation

There is currently not a separate Residency Review Committee to evaluate combined programs, which can only be carried out when both core programs are accredited. While this residency is in its early stages, both boards have mandated an indepth evaluation to determine the quality and outcomes of training. Although many of the day to day details of the program have been satisfactorily resolved at this point, the program has now changed its focus to a more long-term assessment.

Monthly evaluations of the residents on their rotations are generally highly satisfactory. Inservice examination scores have been consistently high with several combined residents scoring at the top US level on both examinations. Combined residents also have biannual meetings with the program directors to discuss evaluations and problems with the residency.

Resident Survey

A recent survey of all current residents assessing their perceptions of the combined program was encouraging. All 16 residents, 66% male and 33% female, completed the survey. Ninety-one percent (91%) said they would choose the combined residency again—this is especially encouraging since all four levels (years) of training are represented. When specifically asked to rank their level of satisfaction, 9% were “extremely satisfied,” 64% were “mostly satisfied,” and 27% responded with “average satisfaction.” When asked why they chose the residency, “broader training” and “dual boarding” were the top two reasons. The residents identify general Internal Medicine and ambulatory clinics as their residency's strongest area. Forty-five percent (45%) reported a lack of general inpatient Pediatrics as the residency's weakest area.

When interviewing for residencies, 55% interviewed primarily for Family Practice and 27% interviewed primarily for Internal Medicine with the remaining 18% of residents interviewing for both residencies. Both groups indicated that the leastinfluential factors leading to the choice of the combined program was “could not decide between Family Practice and Internal Medicine” and “unsure of future job requirements.” The potential future benefits of the combined residency training were ranked as follows: 45% “more knowledge,” 27% “more opportunity for jobs,” 18% “aid in becoming a hospitalist,” and 18% “other.” Most residents found the combined program through literature and “other” means.

Information was obtained regarding planned practice patterns, but no specific trends could be concluded at this early date. Antivirus software made in usa. We plan to track our graduates and compare them with recent graduates of the two core programs in order to document long-term impact.

Challenges

In this time of diminishing resources for graduate medical education, it remains a challenge to justify new and unique programs. The success of combined programs depends on the strength of the two core programs. At a time when fewer US medical students are choosing primary care, recruitment remains difficult. Extra effort in communication is necessary to maintain integration, and it will be critical to get the word out to potential applicants about this innovative program.

Conclusion

The Alton Ochsner Medical Foundation's Combined Internal Medicine and Family Practice Residency is now well established and accepted by both core programs and is fulfilling the goals set forth by both boards. The residency has attracted many students to interview and match for the program and continues to do so.

By balancing inpatient and ambulatory education in many different patient encounter settings, the combined residency is enhancing the medical education of the residents. The combined residents are generally accepted by both Internal Medicine and Family Medicine staff and residents, which enhances communication between these departments. Most importantly, the residents appear to be satisfied with their training.

Nonetheless, these programs remain controversial and their necessity is questioned by many leading physicians within both core programs. It will be important to demonstrate an added benefit for this type of training in a more long-term fashion. We plan to track graduates of the combined and core programsto more accurately evaluate the impact of the combined program.

Appendix 1

Alton Ochsner Medical Foundation Combined Family Practice and Internal Medicine Curriculum

Dr. Murphee is a staff internist at Ochsner Clinic Baton Rouge

Dr. Brandon is the Co-Director of Ochsner's Family Practice Residency Program and is on staff at Ochsner Clinic New Orleans East

References

• Kimball H. R., Young P. R. A statement on the generalist physician from the American Boards of Family Practice and Internal Medicine. JAMA. 1994;271:315–316. (commentary) [PubMed] [Google Scholar]
• Kimball H. R., Young P. R. Educational resource sharing and collaborative training in family practice and internal medicine: a statement from the American Boards of Internal Medicine and Family Practice. JAMA. 1995;273:320–322. [PubMed] [Google Scholar]
• Chapman R., Nuovo J. Combined residency training in family practice and other specialties. Family Medicine. 1997;29:715–718. [PubMed] [Google Scholar]
• Dixon J. G., Barnes H. V., Davies T. C. A combined residency in family medicine and internal medicine at Eastern Virginia Medical School. Acad Med. 1999;74(1):121–127. suppl. S. [PubMed] [Google Scholar]

Abstract

Clinical privileging of pharmacists and the effective use of support staff and information technology have helped create an efficient pharmacist-operated anticoagulation clinic at Ochsner Clinic Foundation that will support future growth efforts for improved patient care. Developed by Ochsner's Department of Cardiology, the pharmacist-operated anticoagulation clinic cares for 2000 patients with a clinical pharmacist, staff pharmacist, registered nurse, and medical assistants. Patients are managed by face-to-face and telephone encounters. The pharmacists are privileged by medical staff to write prescriptions for warfarin, adjust warfarin doses, and conduct appropriate laboratory monitoring. Patients attend a mandatory initial visit where they are given medication instructions and educational materials. The pharmacist determines the treatment dose and schedules follow-up appointments. A software system developed by Ochsner's Information Services Department imports patient data from the institution's central computer system, allowing for a limited electronic patient record. Once fully implemented, this program will allow for more specific patient tracking and assist with quality improvement efforts. At present, approximately 68% of our patient population is within therapeutic range.

Numerous descriptions of anticoagulation clinics are available in the literature. Most of these describe clinics with moderate patient enrollment (50–250 patients) in which various methods of management are used. There are essentially two categories that comprise most clinical management strategies. The first is made up of point of care services where laboratory tests are performed and patients are seen in person at each visit for consultation. The other is to manage laboratory values and consultations via telephone.

Clinical pharmacist- or nurse-managed clinics have been proven to be cost-effective and comparable to usual care by physicians . The Ochsner Clinic Foundation Anticoagulation Clinic is a pharmacist-operated, high-volume anticoagulation clinic (>1000 patients) that has integrated both methods of management and the development of a software system designed to streamline and optimize workload. This system has resulted in increased efficiency over standard anticoagulation management.

Clinic Staffing

Ochsner Clinic Foundation operates several pharmacistmanaged clinics, one of which is the anticoagulation clinic located on the Ochsner main campus in New Orleans (expansion to satellite clinics in the greater metropolitan area is expected in the near future). Prior to the development of the clinic in 1997, anticoagulation patients were followed by their prescribing physician; only a small percentage of internal medicine patients were followed by a staff registered nurse. The anticoagulation clinic was developed to service cardiology patients but soon expanded to provide service to internal medicine patients whose primary care physicians were located on the Ochsner main campus. The clinic was originally staffed with a clinical pharmacist, a licensed practical nurse, and one medical assistant and provided care for approximately 700 patients. After 3 years of operation, the clinic's current enrollment exceeds 2000 patients. A clinical pharmacist serves as the director of the clinic, and staffing includes a full-time staff pharmacist, a registered nurse, five medical assistants, and a data entry clerk. Pharmacy residents and students also provide staffing assistance on a rotational basis. One pharmacist and the registered nurse carry a pager in order to make a clinician available to patients and staff throughout the clinic's hours of operation.

The medical assistants help manage the patients who obtain their laboratory values from Ochsner's satellite clinics. These patients are managed using telephone care only, as they seldom visit our main campus to receive face-to-face consultations. Approximately two-thirds of our patient population is handled by this method with each medical assistant having a distinct patient population that they speak with on a consistent basis. The other third of our population uses our main campus to obtain laboratory values and are then seen by a pharmacist or nurse for consultation.

Pharmacists practicing in the anticoagulation clinic are privileged by the medical staff and the institution to write prescriptions for anticoagulation therapy (warfarin, low molecular weight heparin [LMWH]), adjust medication dosages, and order appropriate laboratory tests. Dosage adjustments and follow-up visits are scheduled at the discretion of the pharmacist. A cardiologist serves as the administrator for the clinic and reviews all decisions made by the pharmacist by receiving an electronic progress note for each patient at the end of the day. Each internal medicine physician whose patient is followed in the anticoagulation clinic is available at any time for discussion concerning his or her patient's care. Pharmacy residents, students, and new staff members train with the existing staff and cosignature of an experienced pharmacist is required for all clinical decision making and documentation until competency is demonstrated to the director of the anticoagulation clinic.

New Patient Enrollment

Ochsner Cardiology New Orleans

Any staff cardiologist or internal medicine physician whose practice is housed on the Ochsner main campus can enroll patients into the anticoagulation clinic. The new patients are called to inform or remind them of their initial appointment date and time. The laboratory appointment is scheduled before the pharmacist consultation appointment so the International Normalized Ratios (INRs) are available when the patient sees the pharmacist. Each new patient is given extensive education material, which begins with a 10-minute video presentation about warfarin or LMWH. Patients are encouraged to bring spouses or family members to this appointment where the video is used to help stimulate questions from the patient concerning their new drug therapy. The educational content of the visit includes the rationale of drug therapy; the mechanism of action of warfarin; monitoring of warfarin therapy (including an explanation of the INR); what to do in the event of missed doses; the influence of diet, illness, and changes in concomitant medications (including nonprescription items, vitamins and herbals); a description of the signs and symptoms of bleeding and clotting and appropriate actions to take if symptoms occur; the necessity of drug monitoring; and a description of clinic procedures. This appointment typically lasts 30–45 minutes (depending on the prior knowledge of the patient) and is documented in the chart that the patient received education and instructions.

Once the information is presented to the patient, the pharmacist addresses all questions and concerns. A brief medical history is obtained including a list of all concurrent medications, diet, and history of complications that may be aggravated by anticoagulation therapy. The clinical pharmacist determines the therapeutic range and duration of therapy on the basis of established guidelines if they are not specified in the chart. The patient is given the INR results from that day and instructed on an appropriate dose of warfarin and a follow-up visit scheduled. Logistic issues are addressed for patients who live long distances from the Ochsner main campus. These patients often have blood drawn for INRs at either the satellite clinics or at other local hospitals and outlying laboratories. These patients are given a standing laboratory order that contains instructions for faxing or telephoning INRs to the clinic.

Patient Population

All anticoagulation patients are treated with warfarin (Coumadin®, DuPont Pharma, Willmington, DE); some patients enrolled in the outpatient deep vein thrombosis protocol are given LMWH. The average age of the patients is 67.4 years (range, 14–100 years). Sixty-six percent (66%) have their blood drawn at an outside laboratory. Indications for anticoagulation are atrial fibrillation (58%), heart valve replacements (15%), thromboembolism (9%), cerebral vascular accident or transient ischemic attack (8%), congestive heart failure (5%), coronary artery disease or myocardial infarction (2%) among others (2%).

Anticoagulation Clinic Operations

Ochsner Clinic Foundation has developed a computer program called Coumasoft that imports laboratory data from the hospital mainframe system and links the information to the appropriate patient. Each patient enrolled in the anticoagulation clinic has an electronic file. The medical assistants input all information such as patient demographics, enrolling diagnosis, therapeutic endpoints, and concurrent medications. The data entry clerk, in addition to her daily computer duties, answers the telephone, takes messages, and forwards calls to the appropriate medical assistant.

Ochsner Clinic Foundation Program New Orleans La Internal Medicine Hospital

Coumasoft looks for lab results based on the patient's appointment date, and each patient's electronic file is automatically sent to the appropriate medical assistant or pharmacist. If the PT/INR falls within therapeutic range, the electronic chart is automatically sent to the pharmacist for dosage instructions. If the PT/INR is outside of the therapeutic range, the electronic chart automatically appears on the computer of the corresponding medical assistant who will then call the patient to inquire of any changes. Once the patient whose PT/INR is out of range is questioned and adequate information is obtained, the chart (which includes all information obtained by the medical assistant) is then sent to the pharmacist for dosage instructions. Figure 1 shows the questionnaire that all medical assistants use as a guide to troubleshoot for patient changes. Once the pharmacist reviews the chart and documents their recommendations, the patients are then called and given the pharmacist's instructions.

Electronic patient questionnaire used by medical assistants to troubleshoot individual patient warfarin dosage requirements

The same procedure is followed for patients who receive face-to-face consultation, except the pharmacist or nurse completes all steps in the software program. Review of the laboratory results and dosage adjustments are made at the time the patient is seen in clinic. The number of patients who have laboratory tests completed for warfarin monitoring can range from 170–200 per day. By using this program, the clinic has the opportunity to simplify and track patients more effectively for quality initiatives and improvements.

The frequency at which patients are followed varies from twice a week to once every 8 weeks depending on the clinical judgment of the pharmacist. Patients are encouraged to report any changes in their medications or medical care (e.g. procedures, hospital admissions, etc.) at any time between appointments. Patients with acute problems are referred to the emergency department or their primary care provider.

A “contract for care” has been developed to help illustrate to the patients the necessity of anticoagulation monitoring and how imperative their involvement and cooperation is. The contract states that the patient will take responsibility for their care by assisting our communication either by phone or by being compliant with their regularly scheduled appointments. If patients become noncompliant with their appointment date, a letter, generated by Coumasoft, will be sent to the patient to remind them of the appointment. In the event that the patient still chooses to miss his or her appointment, another letter is generated explaining the necessity of proper monitoring. The last step with noncompliant patients takes them back to their enrolling physician who is then responsible for following the patient. Our current noncompliance rate is approximately 10%.

Due to the nature of the drug, most warfarin patients are taking a very precise dose that can vary from day to day. We attempt to keep patients on one strength of warfarin and instruct them to change their dose by taking fractions or multiples of the one tablet strength. Multiple tablet strengths could easily lead to confusion and, ultimately, poor patient outcomes. Due to the intricate dosing scheme most patients require, we have developed a dosing card (Figure 2) that illustrates the patient's dose on a daily schedule. The card has become a very handy tool for the patients to reference. We encourage them to keep it near their medications and to follow the directions on the card only (and not their prescription bottle, which may be outdated). The dosing cards also have the phone number to the clinic to improve accessibility.

Patient dosing card

Coumasoft facilitates management of the clinic by compiling quality assurance (QA) reports. Patient data can be sorted by location of laboratory, diagnosis, medical assistant, and physician. Summaries of growth and target INR goal attainment are printed quarterly for review. A detailed patient report has been made available that compiles all data recorded that may have been related to out-of-range INRs. This report alone will help create quality improvement initiatives and avenues for future research.

Outcomes

Quarterly QA reports are compiled that detail the percentage of patients within therapeutic range as of their most recent INR. Approximately 68% of patients are within therapeutic range, including face-to-face visits and telephone-managed patients. As of the date of this writing, we have not comparatively studied the different patient groups for variances in outcomes; however, most literature suggests that in-person consultations produce the best outcomes. Further studies are currently underway including one investigation assessing the variances among patient outcomes between patients enrolled in the anticoagulation clinic compared with those that are not. The purpose of the study is to illustrate how pharmacist operated anticoagulation clinics are superior in improving patient outcomes by reducing hospital admissions, avoiding emergency room visits and preventing adverse drug reactions. This will be the first such study using an Ochsner Clinic Foundation patient population.

Historically, and regardless of the provider status (pharmacist vs. physician), telephone-managed patients have always resulted in a financial deficit. There is no process established to bill Medicaid or any other insurance plan for a telephone consult. In fact, the only patients the Ochsner Anticoagulation Clinic can receive payment for are those patients who have been counseled in person (one-third of the clinic's total patient population). In order to increase efficiency (income received can help with expansion, which will allow us to access the 5000 patients—or 60% of all warfarin patients—who are not yet enrolled), the institution is interested in placing a PharmD in each of Ochsner's satellite clinics in order to remove the telephone-managed component of the clinic. This process will allow for increased face-to-face patient consultations, more revenue, and perhaps increased compliance—all resulting in improved patient outcomes.

Ochsner Clinic Foundation Hospital

Conclusion

Several factors contribute to the quality of care, efficiency, and productivity of the Ochsner Anticoagulation Clinic. These include the effective use of clinical pharmacists and supporting staff, the development and implementation of a locally designed computer software program, use of patient contact by phone and in person, and quality assessment and improvement. All of these components help provide the type of comprehensive care that comprises the philosophy of the Ochsner Clinic Foundation.

Annette Barrios manages the Ochsner Clinic, Foundation Coumadin Clinic

References

• Conte R. R., Kehoe W. A., Nielson N. Nine-year experience with a pharmacist-managed anticoagulation clinic. Am J Hosp Pharm. 1986;43:2460–2464. [PubMed] [Google Scholar]
• Wilt V. M., Gums J. G., Ahmed O. I. Outcome analysis of a pharmacist-managed anticoagulation service. Pharmacotherapy. 1995;15:732–739. [PubMed] [Google Scholar]
• Krokosky N. J., Vanscoy G. J. Running an anticoagulation clinic. Am J Nurs. 1989;89:1304–1306. [PubMed] [Google Scholar]
• Ansell J., Hirsch J., Dalen J. Managing oral anticoagulant therapy. Chest. 200;119:22–38. (suppl) S. [PubMed] [Google Scholar]

Ochsner Medical Center New Orleans La