How do we achieve optimal results for patients? This vision includes strategies and steps for a broader system of care based on the premise that health care professionals cannot go it alone.
When pharmacists speak about medication management, we often refer to the activities associated with medication therapy management conducted by a community pharmacist, or perhaps the activities of a pharmacist to manage a patient’s medications in a particular setting.
While buzz words like “care coordination” are tossed into conversations, rare are the occasions when you hear “medication management” discussed in a way that describes both
the interaction of multiple types of health care professionals and
collaboration across care settings. Yet, this is what both experience and common sense would tell us is needed for patients with multiple comorbidities and complex medication regimens.
Let’s consider the surgical intervention as a comparison. While the surgeon could be considered someone who largely completes the intervention him or herself, the reality is that the surgeon has a specific focus and expertise. He or she is the leader of the intervention, but many other professionals surround the surgeon to make the intervention a success. The anesthesiologist, surgical nurse, surgical technician, physical therapist, nurse, and pharmacist all contribute their various knowledge and skills during the pre- and post-op window. And more notably, because all of their interactions with the patient are over a relatively short time horizon with an intensive follow-up period, the intervention is more likely to be a success. In addition, the contributions of these team members span multiple care settings—ambulatory surgery center and home at a minimum, with ambulatory clinics, hospital, and rehabilitation as other common settings.
Although success over several months could be viewed as relatively easier than success over many years, it may be worth examining what we could learn from the surgical intervention’s success rates. Through this lens, we would—and should—still be focusing on care transitions. But the most challenging piece may be considering how to support the optimal medication-taking behavior of patients across the long time horizon of chronic disease management.
In the surgical intervention, we know that 2 things occur: 1) each health care professional involved focuses on his/her areas of expertise and optimal contributions to the overall intervention, and 2) they interact with patients at different points in time, all reinforcing different aspects of the same care plan. These areas alone represent huge opportunities for improvement with medication management interventions. The critical need for both of them cannot be overlooked when we consider, for example, the average chronically ill Medicare beneficiary who receives 50 unique prescriptions yearly from 13 different prescribers.
The Map from Good to Great Medication Management
Author Jim Collins described the notion of getting the right people on the bus, and in the right seats on the bus, in his top-selling book Good to Great
(Harper Business, New York, 2001). This same principle undoubtedly applies to medication management. First, we need to make sure that all of the right people (with the right skill sets and credentials) are interacting with the patient with specific focus on drug therapy. The first logical question is “Who are the right people to have on the bus?”
While the answer will be somewhat unique to each patient, a broad brush stroke may include the following health care professionals:
Physicians and/or extenders who are responsible for creating the patient’s comprehensive care plan(s).
Pharmacists, ideally involved with both dispensing the medication and regularly touching base with the patient to provide education and assess medication safety and efficacy, but potentially also to assist with reconciliation of care plans across multiple providers or settings.
Nurses, who have the training to provide medication education, conduct clinical assessments that allow for assessment of efficacy, and assist with reconciliation of care plans across multiple providers or settings.
Social workers, who can assist with removing barriers that prevent optimal medication use, including access to care or medications and adherence issues that are rooted in patient motivation.
Pharmacy technicians and nursing assistants, who can serve as information gatherers and help the other professionals work at the top of their license.
Once all of these types of care providers are working with the patient and his/her medication regimen, how do we achieve optimal outcomes? In considering this, we can recall the surgical intervention with intense follow-up. What does intense follow-up look like with medication management and chronic disease? One end of the spectrum could include where we are today—multiple health care professionals interacting with the patient with regard to their medications, but perhaps using different care plans to guide them and not necessarily being in concert with one another. The other end of the spectrum—an impossibility, but notable regardless—is the notion of being “omnipresent” for each medication use decision a patient makes. The optimal goal is somewhere in between these extremes, but it seems that continual reinforcement of a single care plan by multiple health care professionals across multiple settings is needed for a sustainable effect.
The Discharge Plan: What Would It Look Like?
Envision what this could look like even across a short time horizon—the 30-day period after hospital discharge. The patient receives the discharging physician’s instructions, which included recommendations made by any inpatient specialists, with supplemental education by an inpatient nurse and pharmacist. Then, when going to the pharmacy to fill the new prescriptions, the pharmacist has access to the discharge summary and/or instructions and can reinforce what the patient should stop taking and potentially put a note on those remaining refills in the computer system, and also provide education on the new medications.
A discharge planner and the community pharmacist both follow up with a telephone call to the patient a few days post discharge to see how he/she is doing. The pharmacist would focus on medication therapy and how well the patient is adhering to and clinically tolerating the changed regimen. Because the discharge care plan took into account all of the patient’s chronic medications (both those prescribed by specialists and the primary care physician (PCP), the follow-up visit with the PCP can focus on the stability of the medical issues that prompted the hospitalization, as well as how well those medical problems are being managed by medications and other treatments. The patient leaves his/her primary care visit with an updated care plan that is communicated to all of the specialists the patient sees in addition to the pharmacy and other health care professionals who are part of the medical neighborhood, such as home health.
Enabling Team-Based Medication Management
Clearly the scenario described here requires a robust means of sharing information among health care professionals in different settings, which largely does not exist today except within the Department of Veterans Affairs facilities or other self-contained systems. However, the advent of health information exchange will widely change the accessibility of pertinent administrative and clinical data and may well be the tool that is needed to enable health care providers to work in concert with each other, even if they are in different care settings or geographies.
While health care professionals working in concert with each other will never be paramount to the individual health care provider’s relationship with the patient, it is obvious that trusted inter-professional relationships are needed to optimize the patient’s use of medications over time. No 1 type of health care professional can take on medication management alone and expect to be successful.
The possibility of a broader system of care, regardless of who each health care professional is employed by, is still something we envision in the distance. While there is always a question of how to get from here to there, we have to start somewhere. Maybe that somewhere is a fairly simple place—hospital pharmacists talking with pharmacists based in the community, coordinating the patient’s medications across those settings, and attempting to create a bridge when the communication void still exists, regardless of how many years we have been talking about “med rec.”
Trista Pfeiffenberger is currently the Director of Network Pharmacy Programs and Pharmacy Operations for Community Care of North Carolina (CCNC). She obtained her Doctor of Pharmacy degree from West Virginia University in 2002, then completed a Pharmacy Practice Management Residency with Master of Science in Pharmacy Practice at the University of Kansas. Before joining CCNC in 2009, Trista held pharmacy leadership positions at both Duke University Hospital and UNC Hospitals. Trista is a member of the North Carolina Association of Pharmacists and the American Society of Health-System Pharmacists and currently serves on committees for both organizations.