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Optimizing Medication

Use in Patient-Centered,

Team-Based Care Settings

The Patient Care Process for Delivering

Comprehensive Medication Management (CMM)

Acknowledgements

Funding for this research was provided by The American College of Clinical Pharmacy (ACCP), the American College of Clinical Pharmacy Research Institute, and the UNC Eshelman Institute for Innovation.

Citation for this Document

The Patient Care Process for Delivering Comprehensive Medication Management (CMM): Optimizing Medication Use in Patient-Centered, Team-Based Care Settings. CMM in Primary Care Research Team. July 2018. Available at http://www.accp.com/cmm_care_process

CMM in Primary Care Research Team Co-Principal Investigators

• Mary Roth McClurg, PharmD, MHS, Professor and Executive Vice Dean, UNC Eshelman School of Pharmacy
• Todd D. Sorensen, PharmD, Professor and Associate Department Head, University of Minnesota College of Pharmacy
• Jennifer Carroll, MD, MPH, Director, American Academy of Family Physicians National Research Network and Associate Professor of Family Medicine, University of Colorado

We would like to acknowledge the following members of the CMM in Primary Care Research team who contributed significantly to the development of this document:

• UNC Eshelman School of Pharmacy: Carrie Martin Blanchard, PharmD, MPH; Melanie Livet, PhD; Mary Yannayon, MA; Caryn Ward, PhD
• University of Minnesota College of Pharmacy: Debbie Pestka, PharmD; Lindsay Sorge, PharmD, MPH.; Caity Frail, PharmD, MS; and Kylee Funk, PharmD

We would like to acknowledge and thank the clinical pharmacists affiliated with the 35 primary care practice sites located in Minnesota, North Carolina, New York, and New Mexico for engaging in multiple interviews and assessments that led to the development of this document. Their insights were invaluable in both the creation and refinement of this common language.

We also thank members of our Grant Steering Committee and our Payer and Policy Advisory Board for insights provided over the past two years that have helped shape our thinking around this document. A very special thank you to Candace Dematteis, Managing Director with Policy Breakthroughs, LLC and Jon Easter, Director, Center for Medication Optimization (CMO) at the UNC Eshelman School of Pharmacy for their thoughtful review and insights into the positioning and dissemination of this document.

4 • CMM IN PRIMAR Y CARE RESEARCH TEAM

A Framework for Comprehensive Medication

Management

C

omprehensive medication management (CMM) is a patient-centered approach to optimizing medication use and improving patient health outcomes that is delivered by a clinical pharmacist working in collaboration with the patient and other health care providers. This care process ensures each patient’s medications (whether prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication has an appropriate indication , is effective for the medical condition and achieving defined patient and/or clinical goals, is safe given the comorbidities and other medications being taken, and that the patient is able to take the medication as intended and adhere to the prescribed regimen.^6 As part of the CMM service, the clinical pharmacist develops an individualized medication therapy care plan in collaboration with the patient and the health care team that achieves the intended goals of therapy with appropriate follow-up to ensure optimal medication use and outcomes. This all occurs because the patient understands, agrees with, and actively participates in the process.^6 Comprehensive medication management is framed conceptually around three core components of care:^9

• A Shared Philosophy of Practice: A set of professional values and beliefs held within a discipline that serve to guide an individual practitioner’s actions and behaviors and serve to instill trust in the care delivered. Having a shared philosophy is foundational to any patient-centered care practice. For CMM, the philosophy of practice establishes the values and beliefs that guide the clinical pharmacist’s action and behaviors as a member of an interdisciplinary, patient-centered care team and serves to foster a pharmacist-patient and pharmacist-physician relationship that is built on trust. Appendix A outlines the core tenets of a Philosophy of Practice for CMM.^10
• The Patient Care Process: The nature of work that occurs when a clinical pharmacist, working in collaboration with the patient and the healthcare team, provides care to an individual patient with the goal of optimizing medication use and improving the quality of their health care. Establishing a common language for this process is essential to ensure that the service is understood and valued as distinct from the care delivered by the patient’s primary care provider, yet is complementary. It also allows the interdisciplinary team of health care providers and staff to understand the ways in which various members of the team contribute to the patient care process for optimizing medication use.
• Practice Management: The structural and system level supports within a practice related to practice management and operations that enable the efficiency, effectiveness, and sustainability of CMM services. For a service to be delivered consistently and produce expected outcomes, essential components for managing the practice must be in place.

Note: There are three core components of CMM, as described above. Through our research, we have studied and operationally defined each of these areas. This document articulates a common language for the Patient Care Process for Delivering Comprehensive Medication Management. Appendix A outlines the core tenets of the CMM Philosophy of Practice. The remaining core component (i.e., Practice Management Systems) has been the focus of recent work, with learnings forthcoming. In addition, electronic self-assessment tools for each of the three components are under development.

Comprehensive Medication Management

CMM IN PRIMARY CARE RESEARCH TEAM • 5

The Patient Care Process: A Common

Language for Delivering Comprehensive

Medication Management

E

stablishing a common language for the delivery of CMM is important to ensure a consistent approach to optimizing medication use to improve patient care. Articulating a consistent approach helps one to recall key steps in a process that could otherwise be easily overlooked, and it makes explicit the minimum, expected steps in a comprehensive process. To arrive at a common language for the CMM patient care process, we relied on a rigorous research methodology that sought to define a “usable innovation” for optimizing medication use in patients with multiple chronic conditions using multiple medications.^11 The concept of a “usable innovation” is derived from the implementation science literature, which establishes that for an innovative intervention or service to be consistently implemented and reliably produce outcomes, it must include:

1. A clear description of the guiding principles or philosophy of practice,
2. A clear description of the “essential functions” that frame the service,
3. A clear description of the “operational definitions” that explicitly define how each essential function will be operationalized, and
4. A practical assessment of the performance of practitioners who are delivering the service (i.e., fidelity, which helps to ensure that the intervention is being implemented as intended). An extensive literature search was conducted as part of this research to understand the nature of existing definitions of the patient care process for optimizing medication use as well as the essential components of comprehensive medication management. Briefly, this research builds on existing frameworks and standards of practice.6-7, 12-13^ Findings from this research validate the essential functions articulated in existing frameworks and standards of practice, but, importantly, enhance and extend prior work by explicitly defining how each essential function should be operationalized at a level where the service can be replicated and practitioner performance assessed. For example, the five essential functions derived through our research validate the core steps of the Joint Commission of Pharmacy Practitioner’s Pharmacists’ Patient Care Process (PPCP) ; however, our work extends the PPCP by explicitly defining each of the essential functions and clearly articulating how each should be operationalized. This is key to ensuring consistent implementation, replication, and scale of an intervention or service. Finally, it is important to note that the common language for the patient care process was the result of research conducted in the outpatient, ambulatory, team-based care setting for the delivery of comprehensive medication management, as defined above. Although it was developed in this setting, it is likely that the patient care process for delivering CMM can be easily adapted depending on context (e.g., acute care, care transitions, community-based pharmacy, targeted disease management). It is expected that this process is generally related to the clinical work of pharmacists, not specific to a single setting.

CMM IN PRIMARY CARE RESEARCH TEAM • 7

Essential Functions Operational Definitions+

Essential Function 1

Collect and Analyze

Information

The clinical pharmacist assures the collection of the necessary subjective and objective information about the patient and is responsible for analyzing information in order to understand the relevant medical/medication history and clinical status of the patient.

1a. Conduct a review of the medical record to gather relevant information (e.g., patient demographics, active medical problem list, immunization history, admission and discharge notes, office visit notes, laboratory values, diagnostic tests, medication lists).

1b. Conduct a comprehensive review of medications and associated health and social history with the patient. You or a member of the interdisciplinary health care team member should:

• Inquire as to whether the patient has any questions or concerns for the visit.
• Review social history (e.g., alcohol, tobacco, caffeine, other substance use).
• Review social determinants of health relevant to medication use (e.g., can the patient afford his/her medications, does the patient’s education level, housing arrangements, or means of transportation affect his/her ability to use medications as intended).
• Review past medication history, including allergies and medication adverse effects.
• Obtain and reconcile a complete medication list that includes all current prescription and nonprescription medications as well as complementary and alternative medicine the patient is taking (e.g., name, strength and formulation, dose, frequency, duration).
• Review the indication for each medication.
• Review the effectiveness of each medication.
• Review the safety of each medication.
• Review the patient’s adherence to his/her medications using available resources (e.g., ask the patient about adherence to each of his/her medications, claims data, pharmacy fill history).
• Review the patient’s medication experience (e.g., beliefs, expectations, and cultural considerations related to medications).
• Determine the patient’s personal goals of therapy.

The Patient Care Process for Comprehensive

Medication Management

8 • CMM IN PRIMAR Y CARE RESEARCH TEAM

Essential Functions Operational Definitions+

Essential Function 1 (Continued)

Collect and Analyze

Information

• Review how the patient manages his/her medications at home (e.g., independently or with help, pill boxes, calendars, reminders).
• Gather any additional information that may be needed (e.g., information from physical assessment and/or review of systems, home monitored blood glucose readings, blood pressure readings, and/or relevant laboratory parameters).

1c. Analyze information in preparation for formulating an assessment of medication therapy problems.

Essential Function 2

Assess the

Information and

Formulate a

Medication Therapy

Problem List

The clinical pharmacist assesses the information collected and formulates a problem list consisting of the patient’s active medical problems and medication therapy problems in order to prioritize recommendations to optimize medication use and achieve clinical goals.

2a. Assess and prioritize the patient’s active medical conditions taking into account clinical and patient goals of therapy. 2b. Assess the indication of each medication the patient is taking by considering the following:

• Does the patient have an indication for the medication?
• Is the medication appropriate for the medical condition being treated?
• Does the patient have an untreated medical condition that requires therapy, but is not being treated or prevented?

Intentionality of “IESA” in Patient Assessment

The order of the medication assessment (i.e., indication, effectiveness, safety, adherence

or IESA) is intentional and is outlined sequentially to guide the clinical pharmacist and

the health care team through essential questions that must be considered in determining

the appropriateness of each medication. In other words, one must determine whether

an indication is correct for a medication before effectiveness, safety and adherence are

considered. Ensuring adherence becomes a final step in the assessment. It is important to

assess adherence once you know that a medication is indicated, is working and prescribed

at a dose likely to achieve clinical goals, and is not causing an adverse effect. Therefore, the

order of the assessment, while not intended to be prescriptive, is intentional.

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Essential Functions Operational Definitions+

Essential Function 3

Develop the Care Plan

The clinical pharmacist develops an individualized, evidence-based care plan in collaboration with the healthcare team and the patient or caregiver.

3a. Develop a care plan in collaboration with the patient and the patient’s health care providers to address the identified medication therapy problems.

3b. Identify the monitoring parameters important to routinely assess indication, effectiveness, safety, and adherence.

3c. Review all medication lists to arrive at an accurate and updated medication list.

3d. Determine and coordinate who will implement components of the care plan (i.e., patient, clinical pharmacist, other health care provider).

3e. Determine the type of follow-up needed.

3f. Determine the appropriate timeframe for patient follow-up.

3g. Determine the appropriate mode for follow-up (e.g., in person, electronically, by phone).

Essential Function 4

Implement the

Care Plan

The clinical pharmacist implements the care plan in collaboration with the healthcare team and the patient or caregiver.

4a. Discuss the care plan with the patient.

4b. Ensure patient understanding and agreement with the plan and goals of therapy.

4c. Provide personalized education to the patient on his/her medications and lifestyle modifications.

4d. Provide the patient with an updated, accurate medication list.

4e. Implement those recommendations that you as the clinical pharmacist have the ability to implement.

4f. Communicate the care plan to the rest of the care team. If you cannot implement a recommendation(s) on your own, reach consensus on where implementation is required by another member of the team.

4g. Document the encounter in the electronic health record (e.g., summary of relevant patient information, assessment, and plan, including rationale, monitoring, and follow-up).

4h. Arrange patient follow-up.

4i. Communicate instructions for follow-up with the patient.

CMM IN PRIMARY CARE RESEARCH TEAM • 11

Essential Functions Operational Definitions+

Essential Function 5

Follow up and

Monitor

The clinical pharmacist provides ongoing follow-up and monitoring to optimize the care plan and identify and resolve medication therapy problems, with the goal of optimizing medication use and improving care.

5a. Provide targeted follow-up and monitoring (e.g., in person, electronically, or via phone), where needed, to monitor response to therapy and/or refine the care plan to achieve patient and clinical goals of therapy. Targeted follow-up includes, but is not limited to, quick check-ins to assess general status of care, monitor blood sugar or blood pressure, adjust insulin, check INRs, provide education.

5b. Repeat a comprehensive medication management visit at least annually, whereby all steps of the Patient Care Process are repeated to ensure continuity of care and ongoing medication optimization.

5c. If the patient is no longer a candidate for CMM, ensure that a plan is in place for continuity of care with other care team members.

• (^) It is well accepted that some steps (e.g., reviewing the medical record, physical assessment, inquiring about immunizations, alcohol, tobacco, caffeine) may not be necessary to carry out at each encounter, but are important steps in the process that should be operationalized, where and when appropriate, over the course of the longitudinal relationship with the patient.

A foundational element in the success of our comprehensive medication

management program in the Fairview Health System is our expectation

that all of our pharmacists deliver care using this patient care process. This

ensures a level of consistency that builds trust with our medical staff, produces

predictability in our data and allows us to establish recognition of the value

our pharmacists contribute to our organization and the patients we serve. This

is also paired with the accountability that our pharmacists have for ensuring

that a patient’s medication-related needs are met as a part of this process.

Amanda Brummel PharmD, BCACP Director, Clinical Ambulatory Pharmacy Services Fairview Pharmacy Services

CMM IN PRIMARY CARE RESEARCH TEAM • 13

Appendix A. The Philosophy of Practice for

Comprehensive Medication Management

10

Core Tenets

Meeting a societal need

Professions exist for the purpose of serving society, and thus it is important to consider how pharmacists are meeting the needs of society and our communities. As health care professionals highly trained in the science and application of medications, pharmacists serve a unique role of improving patient care by optimizing medication use for patients and populations.

Assuming responsibility for optimizing medication use

If pharmacists are to meet the needs of patients and society, they must assume responsibility for all of a patient’s medication-related needs. This means delivering CMM consistently and holistically to assure that patients are taking appropriate, effective, and safe medications and that they are taking them as intended. This is achieved through identification, prevention, and resolution of medication therapy problems and empowering patients to improve their health. Applying a consistent approach to the CMM patient care process includes collecting and analyzing relevant patient information, formulating an assessment and plan for optimizing medication use, implementing the patient care plan, and providing ongoing follow-up and monitoring.

Embracing a patient-centered approach

Patient-centered care is defined as “providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” This also includes being mindful and respectful of cultural beliefs as well as advocating for the patient to ensure their needs are met. Pharmacists should keep individual patient preferences at the center of their decisions and the care they provide.

Caring through an ongoing patient-pharmacist relationship

The patient-pharmacist relationship is a partnership between the patient and the pharmacist that is built on trust and formed for the purpose of optimizing the patient’s medication experience. This involves relating to individuals through active listening and with understanding, respect, and warmth. It is an ongoing relationship of trust between the patient and the pharmacist.

Working as a collaborative member of the health care team

The provision of high-quality, team-based care to individuals involves collaborating with members of the health care team on shared goals in and across care settings. Consistently meeting the medication- related needs of patients cannot occur without collaboration among the health care professionals engaged in a patient’s care. Therefore, it is essential that the pharmacist demonstrate a spirit of collaboration and embrace a team-based approach to care.

14 • CMM IN PRIMAR Y CARE RESEARCH TEAM

• Cipolle RJ, Strand LM, Morley PC, Pharmaceutical Care Practice: The Patient-Centered Approach to Medication. Management. 3rd ed. New York, NY: McGraw-Hill 2012, p 157. ** Although the medication therapy problem rationale, more cost-effective medication available, is placed under the medication-related need of adherence, it may not necessarily relate to adherence directly or represent a patient-focused medication therapy problem.

Medication Related Needs Medication Therapy Problem Category Medication Therapy Problem Rationale Indication Unnecessary medication therapy Duplicate Therapy No medical indication at this time Nonmedication therapy more appropriate Addiction/recreational medication use Treating avoidable adverse medication reaction Needs additional medication therapy Preventive therapy Untreated condition Synergistic therapy Effectiveness Ineffective medication^ More effective medication available Condition refractory to medication Dosage form inappropriate Dosage too low Dose too low Frequency inappropriate Incorrect administration Medication interaction Incorrect storage Duration inappropriate Needs additional monitoring (^) Medication requires monitoring Safety Adverse medication event Undesirable effect Unsafe medication for the patient Medication interaction Incorrect administration Allergic reaction Dosage increase/decrease too fast Dosage too high Dose too high Frequency Inappropriate Duration inappropriate Medication interaction Needs additional monitoring (^) Medication requires monitoring Adherence Adherence Does not understand instructions Patient prefers not to take Patient forgets to take Medication product not available Cannot swallow/administer medication Cost More cost-effective medication available** Cannot afford medication product

The Medication Therapy Problem (MTP) Categories Framework is a consensus-based document developed by the Pharmacy Quality Alliance’s (PQA’s) Measure Development Team (MDT), to provide a framework for development of measures involving MTPs. The framework is intended to standardize how MTPs identified during Medication Therapy Management (MTM) encounters are categorized within measures. The MDT incorporated input from numerous MTM providers and practices, and referred to MTP categories established in the literature.* This standard framework for use within measures will promote consistent categorization and coding of MTPs and the related actions/recommendations to resolve the MTPs.

Appendix B. Medication Therapy Problem

Categories Framework

14