The Anticoagulation Clinic(AC Clinic) is a service staffed by pharmacists and nurses with specific knowledge in anticoagulation therapy. Anticoagulation care is managed under the supervision of the AC Clinic Medical Director and the patient’s physician.
I. Goals and Objectives
A. To provide services to physicians initiating anticoagulation therapy and assist physicians
in the management of oral and parenteral anticoagulants.
B. To provide consistent management and follow-up care for patients receiving
anticoagulation therapy by evaluating patient-specific data and pertinent laboratory tests
dependent upon the anticoagulant regimen.
C. To provide consistent education to the patient and/or family members about warfarin
and other anticoagulant therapy. To make them aware of potential problems during therapy
and the signs and symptoms of bleeding, embolic events and other adverse effects.
D. To consistently identify patients who are non-adherent with the anticoagulation care plan
and provide education to improve adherence and reduce the potential for adverse events
and maximize the benefits of treatment.
E. To maintain an anticoagulation flowsheet for each patient and provide complete
documentation of the care provided in the patient’s electronic medical record.
F. To consult with other providers involved with the patient’s care when needed.
II. Scope of Care
A. Patient Referral
1. Patients may be referred to the AC Clinic if they have demonstrated the capability to
self-administer medication, or have a responsible caregiver who can supervise the
medication administration, or other acceptable process in place to ensure adherence to
the treatment plan. A reliable method of communication must exist for the
patient to be enrolled in the AC Clinic. The AC Clinic is unable to manage the
b. underlying psychiatric problems hindering adherence to program expectations
c. inability to adhere to care plan
d. patients with no reliable means of communication
Patients may be referred to the AC Clinic at any point during anticoagulation therapy
provided that a collaborative care agreement exists between the AC Clinic and
the supervising physician (See below: Collaborative Care Agreement). The patient
must be assessed by the supervising physician periodically to determine need for
further anticoagulation therapy.
Dean Anticoagulation Clinics
COLLABORATIVE CARE AGREEMENT I, __________________________________ MD / DO, acknowledge that I have read and approve the Guidelines of the Dean Anticoagulation Clinics (AC Clinic). My signature on this document authorizes the AC Clinic clinician to monitor my patients’ anticoagulation therapy. This collaborative agreement may be terminated at any time for an individual patient either by me or the AC Clinic clinician for any reason including: anticoagulation therapy is discontinued, patient desires to be followed by the primary physician alone, or the patient misses 3 consecutive appointments, blood draws or other laboratory test used to maintain control of the anticoagulation therapy without contacting the AC Clinic staff.
Check all of the following that apply:
___ It is not necessary for the AC Clinic clinician to call me for routine changes in
___ The AC Clinic clinician may authorize prescriptions for warfarin to the
conditions relating current medication regimen, surgical history, and hospitalizations.
f. indication for anticoagulation therapy
g. target INR range and planned duration of therapy
h. if already receiving anticoagulation therapy include: start date, current dose
i. history of bleeding including major and minor (dates and outcomes)
j. physician name, direct office telephone number, pager number, and fax number
Dean Anticoagulation Clinics
INDICATIONS AND THERAPEUTIC RANGES Unless the desired INR range is specified by the primary physician on the patient referral form, the AC Clinic will use ranges for the corresponding indications below as recommended by the Commitee on Antithrombotic Therapy of the American College of Chest Physicians.
c. there is evidence suggestive of gross hematuria, gastrointestinal, or other bleeding
d. there is evidence suggestive of worsening thromboembolic disease
e. assessment of continuing need for anticoagulation is warranted
9. Discontinuation of anticoagulation therapy will only occur by physician order. When the
desired length of treatment has been reached, the the AC Clinic clinician will refer the
patient back to the primary physician to evaluate the need for continued
anticoagulation. Discharge from the AC Clinic will occur by physician order when:
a. anticoagulation therapy is discontinued
b. the patient desires primary physician to manage anticoagulation
c. the primary physician decides to manage anticoagulation
d. the patient violates adherence policy (see B.3)
10. The AC Clinic clinician must provide consultation only with the patient via an inclinic appointment,
the telephone, US mail or MyChart. The AC Clinic clinician can leave a message on the patient’s
voice mail or answering machine or speak with a family member, activated power of attorney for
healthcare, or other designated person provided that the patient completes and signs the AC Clinic
verbal permission form (see below). The completed and signed formed must be scanned into Epic
by Medical Records.
PERMISSION FOR VERBAL COMMUNICATIONS
(print name of patient or place patient label here) (birthdate)
(street address) (city, state, zip code)
I permit Dean Health Systems, Inc. Anticoagulation (AC) Clinic personnel (“Health Care Providers”) to leave information regarding ongoing anticoagulation therapy on my voice mail or answering machine.
In addition this authorization allows the AC personnel to discuss health information, in person or by telephone with the following family members or friends involved in my medical care: (List family members/friends and state the person’s relationship to the patient).
Patient’s Signature: Date:
If this Release is signed by a representative on behalf of the patient, complete the following:
Representative’s Name: Relationship to Patient: If, at any time, I do not want this information to be left on my answering machine or I want to change the names of the people listed above, I must notify the Anticoagulation (AC) clinic:
by telephone at 608-252-8060, or
by mail at the address listed below, or
in person at the Anticoagulation Clinic at Dean Clinic.
INSTRUCTIONS: Please sign this form and send to the following location:
Attention: Anticoagulation Clinic
1313 Fish Hatchery Road
Madison, WI 53715
Clinic Procedures - AC Clinics: For Dean Fish Hatchery Road AC Clinics see visio below;
For Riverview and Stoughton AC Clinic, see attached guidelines.