Lorent, J. Pharmacie clinique ; Lelubre, O. Clerc, M. Grosjean, K. De Vriese, O. Hamdani, C. Senterre, K. Amighi, M. Peres, M. Schneider, O. Bugnon, C. De Vriese, Pharmacoepidemiology and drug safety , Jun;27 6 Biset, M. Lelubre, C. Amighi, O. Bugnon, M. Schneider, C. De Vriese, Patient preference and adherence, , Jan 19; Berger, N. Bawab, J.
De Mooij, D. Sutter Widmer, N. Szilas , C. Labranche, C. Formulate a medication therapy problem list, classifying the patient's medication therapy problems based on indication, effectiveness, safety, and adherence. It is critical that the practitioner completes their assessment and defines a problem list considering indication, effectiveness, safety, and convenience in this order. This order of assessment ensures that the most relevant issue affecting the patient is identified.
Similarly, a patient who is prescribed a medication which they cannot afford when there is an affordable alternative is not experiencing an adherence issue. The output of the assessment is a medication therapy problem list, prioritized in the order of importance from both the patient's and practitioner's perspective.
Typically, the problem list is framed in a categorical system of medication therapy problems. A nationally recognized system for categorizing the output of a practitioner's assessment is now recognized by the Pharmacy Quality Alliance. See Table 4. There are nine medication therapy problem categories and these align with the four areas of medication use assessment. When this assessment approach is applied, a relatively consistent pattern of medication therapy problems emerges.
It should be noted that these reported trends all come from application of this assessment process in ambulatory care settings. It is likely that the distribution of medication therapy problems would differ in acute care settings. Upon completion of the assessment and establishing a prioritized list of medication therapy problems, an individualized patient-centered care plan that is evidence-based and as affordable as possible for the patient is created.
The plan should be developed in collaboration with the patient or caregiver to ensure that it meets with the patient's expectations and priorities.
It also should be developed in collaboration with other health care professionals to ensure that all health care providers involved with the patient's care agree and support the plan. The care plan will include goals of therapy and outline contingencies to adjust medications, doses, or delivery as well as monitoring parameters.
It will establish time frames for follow-up and clearly state who will be responsible for each component of the care plan. The steps for developing a patient-centered care plan are outlined in Table 5. The practitioner develops an individualized patient-centered care plan, in collaboration with other health care professionals and the patient or caregiver that is evidence-based and as affordable as possible for the patient. Operational Definition Develop a care plan to manage the patient's active medical conditions and resolve the identified medication therapy problems.
Coordinate care with the primary care provider and other health care team members to reach consensus on the proposed care plan, when needed. Identify the monitoring parameters important to assess ongoing effectiveness, safety, and adherence, including frequency of follow-up monitoring. Review and reconcile all medication lists e. Determine who will implement components of the care plan i. Once a care plan is established, the real work begins.
The practitioner works to prevent and resolve medication therapy problems. The care plan will likely include activities that the patient and other health care providers will be responsible; however, it is the duty of the practitioner to ensure that each of the elements of the plan have been implemented in a time frame that is reasonable and effective.
See Table 6. The practitioner implements the care plan in collaboration with other health care professionals and the patient or caregiver. Operational Definition Discuss the care plan with the patient. Implement those recommendations that you have the ability to implement in your scope of practice.
If the practitioner cannot independently implement a recommendation s , communicate the care plan to the rest of the care team, indicating where implementation of the plan is required by another member of the team.
Document the encounter in the electronic health record e. Communicate instructions for follow-up with the patient. Determine the appropriate mode for follow-up i.
It is in this part of the patient care process where practitioners will employ strategies such as patient education, motivational interviewing techniques, tools that support medication adherence, and patient self-monitoring technologies.
Each of these tools and resources are approaches to best meet the needs of the patient and their medication-related goals. After the initial implementation of a care plan, ongoing monitoring and follow-up to evaluate the effectiveness and safety of the plan are essential. The plan should be modified as needed in collaboration with other health care professionals and the patient or caregiver.
This process of follow-up is critical and demonstrates the practitioner has assumed responsibility for the patient's medication-related needs. While a practitioner who serves as a consultant may not follow up to determine if the problem has been resolved, this is inconsistent with the expectations of a comprehensive medication management practice or the patient care process.
As a health care practitioner who has assumed an important role in a patient's care, it is a responsibility of the practitioner to determine the outcome of drug therapy and take additional action if necessary. This process of follow-up can occur through a variety of mechanisms including face-to-face encounters, phone calls, electronic health record messaging, and telehealth technologies. See Table 7. The practitioner provides ongoing monitoring and follow-up to evaluate the effectiveness and safety of the care plan, and modifies the plan, when needed, in collaboration with other health care professionals and the patient or caregiver.
Repeat a comprehensive medication management CMM follow-up visit at least once within 1 year of the CMM initial visit, whereby all steps of the CMM Patient Care Process are repeated to ensure continuity of care and ongoing medication optimization. Refer the patient back to the provider and document accordingly if all medication therapy problems identified on previous visits have been resolved, no new problems are identified, and it is determined that the patient no longer needs CMM services.
The frequency to which follow-up occurs varies from setting to setting. A practitioner practicing in an acute care environment will possibly transfer responsibility for follow-up to other providers, including another pharmacist, when the patient transitions to another setting. In the ambulatory care setting, a practitioner should ensure that a patient has a comprehensive evaluation of their medications and health status, at a minimum, annually.
In some cases, the nature of the patient's medication therapy problems may be resolved to the degree to which the patient no longer requires ongoing monitoring. In such cases, the patient is referred back to the primary care provider for ongoing follow-up and monitoring. The third critical element of practice is a practice management system. The specifics of any practice management system are based on fundamental business principles and the requirements of the particular type of health care setting where the practice exists.
Avedis Donabedian, considered the father of quality improvement in health care, defined standards as the desired and achievable performance related to a given parameter — an objective, definable, and measurable characteristic of the structure, the process, or the outcome of the care.
The patient care process sets a standard of achievable performance by defining the parameters of the process that can be measured. With the fast-paced movement toward outcome-based health care models and associated quality-based payments, it is critical to objectively measure the impact patient care services have on patient outcomes.
This allows the linkage from the standard process, such as what health problems were identified and how they were addressed during the patient encounter, to desired outcomes. The quality of performance will determine their value and continued adoption. For the process to be measurable, each of the elements must be clearly defined and performed in a similar manner during each patient encounter. The lack of clarity and consistency has been the Achilles heel in the evidence to support the value of pharmacist patient care services.
The generation and analysis of data regarding the care provided and the resulting health outcomes are becoming increasingly important not only to organizations but to individual providers as well. Health care systems are rapidly embracing the power of technology to analyze information to gain important insights.
This technology is only useful if clinical care is robustly documented, collected, and managed. Data is optimally collected as part of the workflow process using IT tools. Creating the requisite tools, however, requires a standard process to build cohesive systems with uniform data sets. This allows the reporting of comparable information to providers and others.
The uniform patient care process sets a standard for the workflow that allows IT systems to capture and extract data for analysis and sharing. Imagine a patient encounter with a practitioner in any setting.
The practitioner often has some patient information available prior to encounter; however, the practitioner will most likely collect new information. This work can now be captured in the collect phase of the workflow. The practitioner will then assess the information and identify new or unresolved medication-related problems. This work can be captured in the assessment phase of the visit. The practitioner will then update or add to the team's plan of care for the patient and the information can be captured in the planning phase.
During the encounter, the practitioner may be able to implement some or all of the plan, and this data will be captured from the implementation phase. Follow-up will capture the resolution of the identified problems over time and measure the results.
The information collected can now be exchanged, extracted, and analyzed at the provider, population, organizational, and payer levels because it is defined and collected in a uniform manner. The ability to capture clinical data is currently available through a number of coding systems. See Table 8. The Pharmacy Health Information Technology Collaborative has been at the forefront in assuring pharmacist patient care services are part of the IT systems being developed for the health care system in the United States.
It is not necessary for practitioners to know each of the codes, but to understand how they operate behind the scenes when performing and documenting their clinical activities. This will enable practitioners to assist information technologists to effectively design systems to accurately document the elements of the process which can produce the data on medication-related outcomes. Payment to health care providers for patient care services in the United States has traditionally been based on the documentation and reporting of standard processes of care.
Rules and guidance from Medicare and the Center for Medicare and Medicaid Services CMS are considered the billing and payment standard for health care providers both for governmental and commercial payers. Eligible Medicare Part B providers such as physicians, nurse practitioners, and physician assistants must follow standards set forth in the CMS Documentation Guidelines for Evaluation and Management Services.
Built on top of the standard documentation requirement are the reporting of levels of decision-making and complexity of care. The added layer of documentation is determined by the number of required elements in each documentation domain. A billing code can then be assigned to that patient care encounter which, in turn, equates to the amount of payment commensurate with the level of care provided.
While this process is the basis for the current fee-for-service payment structure, it is likely the general format that will remain in any new payment model. Similarly, other providers such as dieticians and physical therapists have standard processes, workflow, and documentation that enable the payment structures in their practice model. Pharmacists have traditionally used the SOAP note format when documenting care for patients.
This is particularly appropriate when providing services incident to an eligible Medicare Part B provider. It is the standard documentation required in that circumstance. However, some elements for the SOAP note, which are required when using certain billing codes, are not routinely performed by pharmacists e.
Thus, the pharmacist patient care process sets a standard that reflects the pharmacist's work, makes documentation more efficient, and enables appropriate billing and attribution in new models of care. A standard process of care provides the structure that all practitioners should follow and, when implemented correctly and consistently, can improve the quality of care. It provides a common language that defines roles, responsibilities, and expectations. Comprehensive medication management involves a five-step process: collect, assess, plan, implement, and follow-up.
A standard process of care informs the creation of quality metrics and is the foundation of practitioner workflow, the structure of health information systems, and billing for patient care services. This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.
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Next Chapter. Haines S. When defining clinical pharmacy and pharmaceutical care, pharmacists long ago recognized the need to improve the safety and effectiveness of drug therapy.
Objective: To describe how clinical pharmacy and pharmaceutical care, closely related concepts, can contribute to a strategy for improving the quality of drug therapy. Design: Commentary and review of selected publications. Conclusion: Pharmacists can improve the quality of drug therapy by improving the organizational structures through which drug therapy is provided, specifically by creating medications use systems and by regularly evaluating their performance.
As envisaged by the Institute of Medicine, these systems must be patient centered, cooperative, and interprofessional.
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