GP and LMC leader Dr John Allingham explains how to run your warfarin anticoagulation service efficiently
This article focuses on the provision of warfarin services for anticoagulation.
Enhanced services sometimes include the administration of low molecular weight heparin, such as enoxaparin (Clexane), and the prescribing of direct oral anticoagulants, but are usually specified under a separate service so are not considered in this article.
Monitoring of patients on warfarin should be in accordance with NICE guidance, and the clinical parameters clearly defined.
However, some commissioners add in their own criteria or Key Performance Indicators.
These are often around timescales or criteria that fall within Care Quality Commission requirements.
Ensure you read the contract carefully so you avoid any errors that could prove costly.
Ensure clinical conditions are coded correctly by the team or person responsible for data entry.
Annotating prescriptions allows patients requiring short-term anti-coagulation following a thrombotic episode to stop their course of medication at the right time.
The repeat medication can be labelled ‘take until’, so if an error occurs the pharmacist may see the note and act as a failsafe.
Throughout the process, keep a careful eye on the contraindications and any other treatment that may affect the International Normalised Ratio (INR) and require an extra test or dose change.
The risk of a patient slipping through the net and harm occurring is significant with this service, so all Did Not Attends (DNAs) must be tracked down and followed up. The use of telephone and especially text message reminders may prove useful.
Check that testing and dosing conform with both the guidelines and the specification of the contract. After all, there is no value in doing unfunded additional tests and reviews unless they’re clinically necessary.
Patients on warfarin will require regular monitoring of their renal and liver function, and a full blood count to monitor for anaemia. There must be a system in place to ensure this, and the clinical system must be coded.
Convenience will be appreciated by patients, so consider appointments at times that suit patients.
You could start this by gauging whether extended hours be utilised at times that cater to working- age patients.
With adequate training and computer programmes that can provide warfarin dose advice such as DAWN or INRStar, it’s possible to manage stable patients with a health care assistant (HCA).
Doing this will initially require high levels of support and governance – but once these are secured, running the service in this way is a sure-fire way of maximising profit.
Any service should be run by staff operating at the top of their licence or training – which is to say the least qualified and hence cheapest who can safely deliver the care contracted.
As with the introduction of any new service, staff training needs to be factored in on the cost of running it overall. Foremost, consider if there’s any cover in the event of staff sickness or absence, and whether succession planning has been given due attention.
The point of care testing (POCT) machines and the accompanying test strips are key costs that need to be considered.
The practice can be cost-efficient in this area – for instance, avoiding wastage by meticulous stock control and clarifying expiry dates.
Fortunately, the latest POCT machines are small and portable, which can help to deliver the service across multiple sites and at home.
Many patients qualifying for this service will be in care homes or housebound. Therefore, the pricing of the service normally incorporates those allocated to home visiting.
These patients have additional complex needs, so may require a nurse rather than HCA to provide for them. It’s good practice to use home visits to consider other activities that can generate income, save time and improve clinical care.
Examples of this ‘concurrent activity’ might be quality outcome framework reviews, giving flu jabs and writing or updating care plans.
Be sure that all necessary safety protocols are followed, which includes patients having ‘yellow booklets’ and alert cards and knowing to produce them at all appointments, regardless of the reason.
Staff delivering the service should have a competent understanding of when to refer for further help or to ask if warfarin should be discontinued.
Amidst this, computer software helps, but written protocols and training act as a failsafe.
It’s a good idea to run a reconciliation exercise monthly, so it’s easy to see how activity has been coded and financed.
On top of this, regularly review all costs, including DNAs and the maintenance costs of the practice to ensure the viability and preferably profitability of the service.
If the anti-coagulation service appears to be making a loss, don’t hesitate to raise the issue with your Local Medical Committee (LMC).
They may have advice on how others locally are managing, or can even take the shared problems to the commissioner with the goal of negotiating a better deal.
Dr John Allingham is medical secretary at Kent LMC
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