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There are two aspects that typically differentiate a profession-specific process of care. First, the application of the care process is defined within the context of the profession's knowledge and expertise. For pharmacy, the patient care process is focused on a patient's medication-related needs and their experience with medication therapy.3 Dentists and dental hygienists employ a patient care process that is focused on a patient's oral health needs.16 The nursing care process is applied to provide a holistic approach to a patient's health needs and include physical and mental health, sociocultural issues, spirituality, as well as economic and life-style factors.4 The general approach to providing care to an individual patient in each of these disciplines is similar, however the focus of the process is distinct.
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The second way in which each profession uniquely addresses a patient's needs is the manner in which patient-specific information is assessed. When assessing information collected from a patient (e.g., history of present illness, physical examination, laboratory data), physicians employ a clinical reasoning process called "differential diagnosis" to weigh the probability of one disease versus other diseases that possibly account for the patient's signs and symptoms. In the case of dental hygienists, the American Dental Hygienists Association notes that an assessment not only includes a health history and clinical assessment, but also a "risk assessment" that includes 11 areas of evaluation.5 For pharmacists providing comprehensive medication management, the assessment step involves a systematic examination of the indication, effectiveness, safety, and convenience of each of the patient's medications. This is a unique way of approaching a patient's health needs. No other discipline applies a systematic assessment process to a patient's medications and their medication experience in this manner.
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Several publications and resources have outlined elements of the patient care process to deliver comprehensive medication management services.2,6,12,17 There is relative consistency between these sources regarding the core elements. What varies is the specificity of the operational definition of each of the process components. Detailed operational definitions help to establish consistency across all practitioners applying the patient care process. It is important to note that this care process is not specific to a care setting – the process can be applied in any setting when providing comprehensive medication management. What often varies is the information collected and its source as well as the duration of time to complete the process. For example, in an ambulatory care clinic the patient is often the most important source of information but in a critical care unit of a hospital there is a greater reliance on laboratory tests and special diagnostic studies. Similarly, the process of care unfolds in hours or days in acute care settings, but may extend over weeks or months in chronic care environments.
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When initiating the patient care cycle, a practitioner assures the collection of the necessary subjective and objective information about the patient and is responsible for analyzing the data in order to understand the relevant medical needs, medication-related problems, and clinical status of the patient. In some cases, this information will be directly collected by interviewing the patient or reviewing a medical record. In other cases, the practitioner may rely on other personnel to collect the information that will be used in the assessment. This may include a blood pressure determined by a clinical assistant or a list of active medications recorded by a nurse. However, it is ultimately the practitioner's responsibility to assure that all of the necessary information is collected and that the data is accurate, regardless of the source. This information is critical to the ability of the practitioner to complete an assessment that will appropriately address all of a patient's medication-related needs. (See Table 2.)
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Assess Information and Formulate a Medication Therapy Problem List
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Once all of the information deemed necessary to conduct a comprehensive assessment of the patient and their medication-related needs has been collected, the assessment is organized into a problem list consisting of the patient's active medical problems and medication therapy problems. Once identified, problems are prioritized to make decisions regarding the patient's medication therapy in order to offer the best opportunity to achieve the patient's overall health goals. In doing so, the practitioner reviews each medical condition and medication to make sure that each current medication is indicated (or necessary) for the condition for which it is being taken and that each condition that requires drug therapy is being appropriately treated. Then the practitioner determines whether each medication the patient is taking is effective, achieving the intended outcome. This includes assuring the medication is the most appropriate option for the patient and is at a dose that is expected to achieve the intended effect. Next, the practitioner considers the safety of each medication, assuring that the patient is not experiencing or being exposed to an unnecessary risk for adverse effects or an unintended interaction. Finally, the practitioner then evaluates each medication for convenience. This includes assuring the patient can take the medication as intended, considering issues such as access and affordability as well as sufficient knowledge and ability to appropriately administer the medication. Throughout the assessment process, practitioners must keep the patient's goals for therapy at the forefront of their decision-making. Table 3 outlines the forms of assessment applied when optimizing pharmacotherapy.
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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. For example, there is a great deal of emphasis placed on improving patient adherence to medications, with non-adherence rates reported to range from 28 to 65%.18,19 However, if a patient is prescribed a medication that is not indicated or is causing an adverse effect, focusing time and attention toward improving medication adherence is misguided and does not address the most important medication therapy problem. Similarly, a patient who is prescribed a medication which they cannot afford when there is an affordable alternative is not experiencing an adherence issue.
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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.20
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When this assessment approach is applied, a relatively consistent pattern of medication therapy problems emerges.21–23 The categories identified with the greatest frequency are "needs additional therapy" and "dose too low" followed by "adherence." The other categories are observed less frequently. 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.
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Develop the Care Plan
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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.
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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.
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Implement the Care Plan
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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.)
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There are many tools and resources that may be used to support a patient and/or their caregivers to successfully implement the care plan. 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.
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Follow-up with the Patient
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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.)
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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.