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Episode 38 - June 2022: BBCH Gender Clinic & Annual Synchronized Subscribing

June 2022

MMP's Caitlin Costigan on using annual synchronized prescribing to improve med adherence; Toni Eimicke and Erin Belfort from the BBCH Gender Clinic discuss care for transgender youth and LGBTQ+ patients.

Additional Information

Julie: This is BACON brief ACO news from the MaineHealth Accountable Care Organization, a fricasseed monthly podcast for health care providers. I'm Julie Grosvenor.

Mike: And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO.

Julie:
So just saying that makes me want to say, Mike, what's up, doc?

Mike: Yeah, yeah, I hear you.

Julie: So Mike, we have two discussions this month. As you know, in our Sizzle segment, we're going to mark Pride Month with the team at MaineHealth's Gender Clinic.

Mike: That's right. But at first, first we are in our Meaty Topic segment. We'll introduce a method of prescribing that has shown to improve medication adherence and reduce cost.

Julie: Well, those both sound like really good things, so let's get to it.

Mike:
Our management of many chronic conditions depends heavily on medications, for better or for worse, but even more importantly, on patients actually taking their medications. Research suggests, however, that around 50% of patients don't take their medications as prescribed.

Julie:
50%? Five zero?

Mike: Five zero. That's what it says.

Julie:
Oh, well, that's a sobering statistic.

Mike: Sure is. But, you know, I got good news. There is a proven technique that providers and care teams can use to boost med adherence. To learn about it, our producer Paul Santomenna talked to Caitlin Costigan. She's the lead APP for Maine Medical Partners’ Primary Care Practices.

Paul: Caitlin, there's evidence to suggest that these annual synchronized prescribing practices improve med adherence and also reduce costs. So can you talk about this technique or this sort of body of prescribing?

Caitlin: There is a really interesting calculator on the American Medical Association web page, The Step Forward Module, and what it looked at was averaging the amount of time spent per refill prescription. And if they estimated about ten refill encounters per day in a provider's time, it would take about two and a half hours per week that we spend performing refills. So, in our care team redesign, which we've been working at, at the primary care level, we've been looking at ways to find workflows to decrease time spent in the in-basket for all care team members. So there's this technique called synchronized prescription renewal. It also goes by 90 by four. And it really is the process of renewing all of the patient's long-term medications on the same date. As a note, as of 2020, Maine does allow for prescription duration of 15 months. So, Maine allows these longer-term prescriptions. The process ideally takes place during a routine annual wellness visit or a physical, and when the process is implemented, the goal is that fewer trips to the pharmacy for the patient, reduced duplicate medications, and a lower likelihood of running out of these medications. It also improves satisfaction within the office as less time is being spent reviewing medications for the provider as well as the staff that we work with.

Paul: So I assume that there are certain types of patients that this might be most appropriate for. Can you talk about if you're starting out with this process, which patients, maybe to focus on?

Caitlin:
Yeah. So, typically these are patients who are stable, they have chronic medications or conditions that they are in long term. These medications may experience medication adherence challenges due to transportation barriers, language barriers, financial barriers, but they're patients who have medication prescriptions that don't change frequently and that they are on long-term. It is important to note that these long-term prescriptions don't necessarily prevent patients from coming back into the office, and there's a lot of evidence that we shouldn't use them, shorter-term prescriptions to hook the patient to return, so that if we continue to provide long-term prescriptions, that we can still see patients at the intervals that we typically would every 3 to 6 months.

Paul: What steps would a practice need to take to start implementing this?

Caitlin: So, really we should look at the opportune visits. And these visits are usually visits such as wellness visits, physical exams, chronic follow-up opportunities. And at those visits, we should really plan to renew all long-term medications together. You can create a smart phrase in Epic, which is primarily what we use in the MaineHealth system. And you can actually write a smart phrase such as renew these chronic medications for one year, 90 times four, and you can add a note in the pharmacy and all prescriptions are able to add a note to the pharmacist that that would state renew these chronic meds for one year and delete prior prescriptions for these meds. You can also ask that they synchronize, so they come to you the same day every three months. It's also recommended that these medication orders are pended during pre-visit planning, so asking our staff to pend these orders will help to streamline the process at that time. And then at the time of the visit, we can review the medications, verify them, and then e-prescribe them.

Paul:
You've been doing this for a while, right? What advice do you have for folks who might want to start doing this?

Caitlin: So, the one thing would be to communicate that it is important that the patient continues to see the provider at the provider's discretion. Again, this is not the hook to bring them back in, and that, if we start this today, that we will see a change in six months. Patients will call us for refills. The work requires the provider to have a per-patient approach as well. There are going to be patients who it just doesn't work for, they tend to not be coming into their visits. You may not see them in follow-up. So this isn't a one size fits all, but for the majority of patients, this can be really effective in helping us save time.

Paul: Yeah. Where can people go to get more information?

Caitlin: So they can go right to the AMA Steps Forward website and they have modules online. If you search for “90 times four” or “extended prescription,” it will pull up the module about — there are some really great articles about this and then there are also some playbooks and ways to roll this out across your practices in a step-by-step approach. And it gives a step-by-step approach in terms of providers, how you can adopt the prescription renewals, create an accurate list, review the medication list, determine if patients are adhering to medications, and then streamline the prescription drug prior to the authorization process. And then you can use your electronic medical record, use Epic to help confirm the refill data and save time and then also coordinate with our pharmacy colleagues as well.

Julie: To help Mark Pride Month, we reached out to The Gender Clinic at The Barbara Bush Children's Hospital. We wanted to understand some of the challenges transgender youth face when seeking health care, and we wanted to find out what providers can do to reduce barriers to health care access for transgender people.

Mike: Our producer, Paul Santomenna talked to members of The Gender Clinic team.

Paul:
So, I'm joined by two members of The Gender Clinic, Toni and Erin, who are going to talk with me today, somewhat in honor of Pride Month, at least that was our motivation. So first, please introduce yourselves and tell us who you are.

Erin: Sure. So, I'm Erin Belfort. I'm a child and adolescent psychiatrist at Maine Med, and I've been here since 2012, and I'm our fellowship training director. So I do a fair bit of teaching and training of fellows, and my clinical work is in our pediatric gender clinic.

Toni: And I'm Toni Eimicke. I'm a pediatric nurse practitioner. I've been with Maine Medical Partners since 2009. I work both in The Gender Clinic and also in pediatric endocrinology.

Paul: Okay. Great. Well, thanks for joining us. First, a really broad question. What is The Gender Clinic? What does it do?

Toni: So, The Gender Clinic, it's a multidisciplinary clinic—and that's a major focus of our clinic, the aspect of being multidisciplinary. We started seeing patients around 2009 or so. Prior to seeing patients, The GeMS clinic at Boston Children's Hospital, they started their transgender clinic in about 2007 or so and reached out to us in about 2009 with some patients who were living in Maine but seeking care in Boston. And so our clinic started out as sort of like an outreach clinic with a few patients initially seen at Boston Children's, and then it grew from there. Our clinic is made up of specialists from pediatric endocrinology, child and adolescent psychiatry, adolescent medicine, social work, medical ethics, spiritual care, and I'm sure missing some others. But we meet as a team weekly, which is an integral part of our clinic running as successfully as it does.

Paul: Erin, do you want to add anything?

Erin:
Yeah. I would just kind of echo Toni's piece about how important a multidisciplinary clinic is in this work, that this is really complex and nuanced work. And I've been involved since 2013, and I almost feel like the more I do it, the more complicated it feels. And so, really having a whole team of experts to bounce ideas off of is really valuable, especially in the current sociopolitical climate that we're in. We want to make sure we're doing this work well and we're doing it right and taking care of the population in Maine and northern New England.

Toni: And I'll add to that as well, the WPATH, which stands for World Professional Association for Transgender Health Standards of Care, and the Endocrine Society Guidelines both advocate for multidisciplinary care when caring for transgender youth. So as Erin pointed out, not only do we find it so helpful to us, it is the standard of care to provide a multidisciplinary clinic in which to see these patients.

Paul: So tell me a little bit about the unique needs of the patients, of transgender and gender-diverse patients. And how does the clinic address those?

Erin: Yeah, I can start with maybe the mental health side, and then, Toni, I'll turn it to you for the medical side. We have kind of evolved our model over time, but now all patients coming into our clinic start on the mental health side of our team with an assessment. And we're really trying to get to know the youth and their family to determine if they meet criteria for a diagnosis called gender dysphoria, to learn about their treatment goals within the clinic, to identify any mental health comorbidities that might exist. And then we kind of develop the initial treatment plan on our side before we send folks over to the medical side. And some folks never, never need nor want medical treatment. Really, they need mental health support, work with families around family acceptance. But I would say our youth are pretty marginalized in their communities and their families in our country. And as a result of that marginalization, many of them have a lot of mental health symptoms and concerns when we meet them. And we know that LGBT folks of all ages have many more health disparities than other populations, both more medical diagnoses and certainly more mental health diagnoses. So, the majority of kids that we see do meet criteria for other mental health conditions like depression or anxiety. And so we really see our job as kind of assessing and treating the whole child really in the context of their family and their community. So that's kind of what we do on the mental health side. And Toni can speak to once they get sent over to the medical side of our team.

Toni: Yeah, on the medical side, we provide gender-affirming hormone treatment. We provide other medical treatments that help support a person in their journey and help them meet their clinical—their goals for their body and their life. And I will say, as far as what I think is unique to this population of patients is the close coordination of care that is needed in many cases to help, really help that patient meet the goals and help them be happy and feel whole and feel satisfied with the care that we're providing. So I think that that's something that is unique to our population.

Paul: Yeah. And I would imagine, of course, that this population and really, you know, the larger LGBTQ+ population, really has to confront some barriers, right, to getting health care at all. So I know that's not specific to your work, but can you talk about that larger population and those kinds of barriers that they might see?

Erin:
Yeah. I think it's sadly pretty well documented in the literature that LGBTQ folks have more obstacles and difficulties getting medical and getting mental health care, and they experience bias and discrimination at all levels. So individual provider levels to systemic ways that bias is sort of embedded in our health care system and is not welcoming and affirming necessarily. So I think that's a real problem that we as individuals and as a health system need to really be mindful of overcoming some of those barriers. Randy Brown, our program manager, has been really integral in some of the Epic changes that have rolled out to sort of help us in the EMR, have sexual orientation and gender identity tools very easily accessible so that patients are less likely to be misgendered, for example, when they show up to a visit with their provider.

Toni: Yeah, I echo everything Erin said. I think stigma and access to care are major barriers. And as she said, we've seen, I've seen statistics quoting 70% of patients report they face health care discrimination, and feel unsafe or feel unwelcome and may defer care when needed. And I will also mention, just to add to the earlier question, about what our clinic is and who we are. We do see patients from every county in Maine and some from New Hampshire as well. So we're seeing a diverse population of patients geographically within Maine.

Paul: What advice might you have for the PCP in Franklin County who has transgender patients, to sort of, make care more accessible to them at the practice level?

Erin: I think starting with know thyself and sort of do a little self-reflection on one's own biases and one's own beliefs. I think it's important when working with marginalized populations of any kind. Avoiding making assumptions is really important. I think sometimes I'll hear pediatricians or primary care doctors say things like, Oh, "Do you have a boyfriend?" to an adolescent. And you've just made a really big assumption about who that kid is. And so, kind of keeping things open-ended. So in our clinic, it's pretty common for us to start our introductions with who we are and our discipline. And we include our pronouns, and we invite and offer for folks to include their pronouns when they introduce themselves to us. So, we work hard to really make space for people to show up and be themselves, and we try not to make assumptions about who they are. So, thinking about things like your paperwork and your forms and your EMR and how to be more inclusive, I think is really important for us all to think about in our clinical work.

Toni: Absolutely. That was, you touched upon many of the points I was thinking, and having open language regarding family structure, not assuming that, you know, asking about parents, not necessarily assuming there's a mom and dad and having open language, avoiding heteronormative assumptions, as Erin pointed out, is a good way to make someone feel like this is a safe space to talk about things and open up. And then again, I echo the inclusive forms, asking about pronouns, using a preferred name, or inviting someone to share that information.

Paul:
I wonder, though, too, if you have any advice for providers or anyone that it applies for, for anyone at all who say, makes a mistake, which I think might be a big fear that people have, is that, oh, they're well-meaning, but they're going to say something wrong.

Toni: Yeah. The advice I've always heard is apologize and move on and try not to make it about you. And not to make that person then have to guide you through your apology. And again, like Erin said, just know yourself. Be open and sincere and genuine. And I think that that comes through in your interaction and, if you have anything more to add, Erin.

Erin: Yeah. I think it's important to acknowledge that we all make mistakes and it's inevitable. And sometimes people get so paralyzed by that fear that it really prevents them from showing up and being present with a patient. And I think just recognizing our shared humanity is important. And I will often kind of preface when I'm getting to know somebody. If I ever make a mistake with my language, please catch me and please correct me. I'll just offer that invitation that I'm open to feedback. I'm open to updates over time as I get to know you, sometimes their preferred name or their pronouns change as I'm getting to know them. And so I just offer opportunities for corrections and updates along the way.

Paul:
Well, I think that's some good advice we can end with. So, thanks so much for taking the time to talk with us today.

Erin: Very welcome.

Toni: Great. Thanks for having us.

Julie:
Well, Mike, I think this was a great episode and I want to thank our listeners for listening to BACON this month. You can find all our episodes on your podcast app and at our web page, MaineHealthACO.org/BACON. And if you have questions, comments or suggestions, as always, we'd love to hear from you. Please email us at bacon@mainehealth.org. That's bacon@mainehealth.org.

Mike:
That's right. And BACON is produced with great care and brilliance by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. See you next month.

Julie: See you next month.