8/6/18 - cdn.ymaws.com · MANAGEMENT (CMM) ©UNIVERSITY OF UTAH HEALTH, 2018 CMM PHILOSOPHY OF PRACTICE A shared philosophy of practice is an attitude or a mindset held by clinical
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8/6/18
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©UNIVERSITY OF UTAH HEALTH, 2018
UTILIZING COMPREHENSIVE MEDICATION MANAGEMENT (CMM) AS
A CONSISTENT CARE PROCESS IN PHARMACY PRACTICE
KYLE TURNER, PHARMD, BCACP ASSISTANT PROFESSOR (CLINICAL)
NICK COX, PHARMD, BCACP
CLINICAL PHARMACIST ©UNIVERSITY OF UTAH HEALTH, 2018
CONFLICT OF INTEREST
• The presenters have no COI to disclose
©UNIVERSITY OF UTAH HEALTH, 2018
WARNING – ALPHABET SOUP
©UNIVERSITY OF UTAH HEALTH, 2018
OBJECTIVES
• Pharmacist & Technician – Identify the three elements of comprehensive
medication management (CMM) – Recognize the role of CMM to identify and
resolve medication-related problems (MTPs) – Identify a plan to implement CMM into current
pharmacy practice
©UNIVERSITY OF UTAH HEALTH, 2018
THE NEED FOR A CONSISTENT CARE PROCESS
©UNIVERSITY OF UTAH HEALTH, 2018
BACKGROUND
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THE NEED FOR A CONSISTENT CARE PROCESS
AHRQ Effective Health Care Program MTM Interventions in Outpatient Settings Systematic review of 44 studies
Conclusion: The evidence base offers low evidence of benefit for a limited number of intermediate and health utilization outcomes. We graded the evidence as insufficient for most outcomes because of inconsistency in direction, magnitude and precision, rather than lack of evidence. Wide variations in populations and interventions, both within and across studies, likely explain these inconsistencies…. New research, regardless of specific focus, will likely continue to find inconsistent results until underlying sources of heterogeneity are accounted for.
AHRQ Publica2on No. 14(15)-‐EHC037-‐EF. Rockville, MD: Agency for Healthcare Research and Quality; November 2014. www.effec2vehealthcare.ahrq.gov/reports/final.cfm. ©UNIVERSITY OF UTAH HEALTH, 2018
THE PHARMACIST PATIENT CARE PROCESS
https://jcpp.net/patient-care-process/
©UNIVERSITY OF UTAH HEALTH, 2018
MEDICATION MANAGEMENT SERVICES (MMS)
Medication Management Services are a spectrum of patient-centered, pharmacist-provided, collaborative services that focus on medication appropriateness, effectiveness, safety, and adherence with the goal of improving health outcomes.
©UNIVERSITY OF UTAH HEALTH, 2018
COMPREHENSIVE MEDICATION MANAGEMENT (CMM)
©UNIVERSITY OF UTAH HEALTH, 2018
CMM PHILOSOPHY OF PRACTICE
A shared philosophy of practice is an attitude or a mindset held by clinical pharmacists and other health care providers that serves to guide ones actions and behaviors and instill trust in the care delivered. Without a philosophy of practice, it is unclear what the clinical pharmacist values and, therefore, how the clinical pharmacist will behave toward the goals of optimizing medication use for patients.
Pestka DL, Sorge LA, Mcclurg MR, Sorensen TD. The Philosophy of Practice for Comprehensive Medication Management: Evaluating Its Meaning and Application by Practitioners. Pharmacotherapy. 2018;38(1):69-79.
©UNIVERSITY OF UTAH HEALTH, 2018
CMM PHILOSOPHY OF PRACTICE FIVE CORE TENETS
• Mee#ng a societal need • Assuming responsibility for op#mizing medica#on use
• Embracing a pa#ent-‐centered approach • Caring through an ongoing pharmacist-‐pa#ent rela#onship
• Working as a collabora#ve member of the health care team
Pestka DL, Sorge LA, Mcclurg MR, Sorensen TD. The Philosophy of Practice for Comprehensive Medication Management: Evaluating Its Meaning and Application by Practitioners. Pharmacotherapy. 2018;38(1):69-79.
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©UNIVERSITY OF UTAH HEALTH, 2018
CMM PRACTICE MANAGEMENT PRINCIPLES
• Care team engagement • CMM program evaluation • Care delivery process • Organizational support • Ensuring consistent and quality care
©UNIVERSITY OF UTAH HEALTH, 2018
CMM PATIENT CARE PROCESS (PCP)
[The CMM PCP] ensures each patient's medications are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended.
Patient‐Centered Primary Care Collaborative (PCPCC). The patient‐centered medical home: integrating comprehensive medication management to optimize patient outcomes resource guide, 2nd ed. Washington, DC: PCPCC, 2012.
©UNIVERSITY OF UTAH HEALTH, 2018
CMM PATIENT CARE PROCESS (PCP)
Goal = identify and resolve medication therapy problems (MTPs)
Indica2on Effec2veness Safety Adherence
©UNIVERSITY OF UTAH HEALTH, 2018
MEDICATION THERAPY PROBLEMS (MTPS)
©UNIVERSITY OF UTAH HEALTH, 2018
CASE #1
BC is a patient who presents to your pharmacy and asks “What are your thoughts on my medications?” The patient is frustrated by her medications. She feels like she is on too many, thinks she’s experiencing side effects, and wants to know if you “see any problems.” She plans to take your recommendations to her next doctor’s appointment.
©UNIVERSITY OF UTAH HEALTH, 2018
Age: 34 Race: White Allergies: NKDA CASE #1
BC’s MEDICATIONS Medica4ons Fill History Notes
Omeprazole 20 mg daily Last filled 04/18/18 Aspirin 81 mg daily Picks up OTC Trazodone 100 mg daily Last filled 04/18/18 Harvoni 90/400 mg PO daily Last filled 04/18/18 Morphine 15 mg Q6H Last filled 04/18/18 (#120 for 30 days) Albuterol 90 mcg/act: 2 puffs Q4-‐6H prn Last filled 05/02/18, 04/18/18, 03/30/18 Sertraline 50 mg daily Last filled 03/10/18
BC’s MEDICAL CONDITIONS Chronic back pain Chronic hepa22s C Asthma Depression/anxiety Insomnia
What “problems” do you no4ce? How many “problems” did you no4ce? How many “problems” did you consider? Did you consider the 33 poten4al “problems”? What ques4ons can we ask to assess INDICATION? What ques4ons can we ask to assess EFFICTIVENESS? What ques4ons can we ask to assess SAFETY? What ques4ons can we ask to assess ADHERENCE? What ques4ons can we ask to assess UNTREATED INDICATIONS? What other things can we consider?
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©UNIVERSITY OF UTAH HEALTH, 2018
CASE 1 How can we classify/document the “problems”?
Problem I / E / S / A Category Ra4onale
Aspirin – why is pa2ent taking?
Albuterol – 3 fills in 2 months
Morphine -‐ >50 MED’s
©UNIVERSITY OF UTAH HEALTH, 2018
CASE 1 How can we classify/document the “problems”?
Problem I / E / S / A Category Ra4onale
Aspirin – why is pa2ent taking? Indica2on Unnecessary medica2on therapy
No medical indica2on
Albuterol – 3 fills in 2 months Indica2on Adherence
Needs addt’l med therapy Adherence
Synergis2c therapy Can’t swallow/administer
Morphine -‐ >50 MED’s Safety Dosage too high Dose too high
©UNIVERSITY OF UTAH HEALTH, 2018
APPLICATION TO PRACTICE
©UNIVERSITY OF UTAH HEALTH, 2018
How can CMM be applied to your pharmacy practice?
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OPTIMAL REGIMEN MEETS OPTIMAL USE
https://www.accp.com/news/index.aspx?i=48
©UNIVERSITY OF UTAH HEALTH, 2018
UTAH COMMUNITY PHARMACY ENHANCED SERVICES NETWORK (CPESN)
Mission Statement: Develop, implement, and maintain a network of community pharmacies that provide high quality enhanced services to patients to improve patient clinical out comes and utilization of healthcare resources by working collaboratively with other healthcare providers, health systems, accountable care organizations, and other key stakeholders.
https://utah.cpesn.com/
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©UNIVERSITY OF UTAH HEALTH, 2018
UTAH CPESN MINIMUM SERVICE SETS
• Adherence support services • Comprehensive medication management • Immunizations • Medication synchronization • Medication reconciliation
©UNIVERSITY OF UTAH HEALTH, 2018
UTAH CPESN MINIMUM SERVICE SETS
• Adherence support services • Comprehensive medication management • Immunizations • Medication synchronization • Medication reconciliation
©UNIVERSITY OF UTAH HEALTH, 2018
CMM FOR COUNSELING?
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CASE #2
DK is a patient who presents to your pharmacy to pick up a new prescription for “Sertraline 50 mg PO daily”. You, the pharmacist, are about to counsel her on this new medication. . . How can CMM be utilized in this scenario? How does CMM enhance the counseling?
©UNIVERSITY OF UTAH HEALTH, 2018
PRACTICE – SMALL GROUPS
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CASE #3
Using your handouts, answer the following…. • Using the CMM framework (I/E/S/A), what
medication “problems” can you identify?
• Using the PQA document, how would you classify your identified “problems”?
• What actions can you take with the patient or provider to resolve these “problems”?
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©UNIVERSITY OF UTAH HEALTH, 2018
TAKEAWAYS
©UNIVERSITY OF UTAH HEALTH, 2018
ADVICE FROM COMMUNITY PHARMACY ADVICE & LESSONS LEARNED GOODRICH PHARMACY (MINNESOTA)
1. Get the tools and master them 2. Develop a patient care culture 3. Develop a patient care culture 4. Start soon 5. Perseverance is required: It can take a while to get
a program up to speed 6. Pharmacists like CMM: CMM creates job
satisfaction for pharmacists
McInnis, T. Capps, K. Get the medications right: a nationwide snapshot of expert practices—Comprehensive medication management in ambulatory/community pharmacy. Health2 Resources, May 2016
©UNIVERSITY OF UTAH HEALTH, 2018
ADVICE FROM COMMUNITY PHARMACY WHAT WORKS GOODRICH PHARMACY (MINNESOTA)
• A culture that supports the pharmacist as a patient care professional.
• Read-and-write access to the EHRs – His team doesn’t always have that access, but it makes a
difference in patient care.
• Broad collaborative practice agreements. – “Doctors don’t want you to bring them a problem you
can’t fix,”he said. Pharmacists need to have the authority to fix the problems they find.
McInnis, T. Capps, K. Get the medications right: a nationwide snapshot of expert practices—Comprehensive medication management in ambulatory/community pharmacy. Health2 Resources, May 2016
©UNIVERSITY OF UTAH HEALTH, 2018
BIG PICTURE
What can you apply to your practice TODAY? • CMM as a framework for. . . – Counseling – Medication regimen reviews – Identification of drug-related problems
• Increased ownership of “optimal use”
What does CMM look like in the future? • CPESN • Building into PharmD curriculum • National adoption – “What does a
pharmacist do?”
©UNIVERSITY OF UTAH HEALTH, 2018
QUESTION 1
What is the correct order of the assessment steps of the CMM care process? A. Adherence, Safety, Indication, Effectiveness B. Effectiveness, Indication, Safety, Adherence C. Indication, Effectiveness, Safety, Adherence D. Safety, Effectiveness, Indication, Adherence
©UNIVERSITY OF UTAH HEALTH, 2018
QUESTION 1
What is the correct order of the assessment steps of the CMM care process? A. Adherence, Safety, Indication, Effectiveness B. Effectiveness, Indication, Safety, Adherence C. Indication, Effectiveness, Safety, Adherence D. Safety, Effectiveness, Indication, Adherence
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QUESTION 2
Which of the following is NOT a key component of CMM? A. Patient care process B. Philosophy of practice C. Personal practice style D. Practice management systems
©UNIVERSITY OF UTAH HEALTH, 2018
QUESTION 2
Which of the following is NOT a key component of CMM? A. Patient care process B. Philosophy of practice C. Personal practice style D. Practice management systems
©UNIVERSITY OF UTAH HEALTH, 2018
QUESTION 3
According to published reports, what was a key reason MTM demonstrated little evidence of benefit? A. Too few studies have investigated the topic B. Too few patients included in studies C. Inconsistency in practice, strategy, and
heterogeneity of studies D. No benefit likely exists
©UNIVERSITY OF UTAH HEALTH, 2018
QUESTION 3
According to published reports, what was a key reason MTM demonstrated little evidence of benefit? A. Too few studies have investigated the topic B. Too few patients included in studies C. Inconsistency in practice, strategy, and
heterogeneity of studies D. No benefit likely exists
©UNIVERSITY OF UTAH HEALTH, 2018
QUESTION 4
Which is NOT an example of CMM applied to community pharmacy practice?
A. Utilization of CMM as framework when counseling about new medications
B. Provision of a CMM “med review” C. Establishment of broad collaborative practice
agreements D. Presence of an automated blood pressure
monitor at pharmacy
©UNIVERSITY OF UTAH HEALTH, 2018
QUESTION 4
Which is NOT an example of CMM applied to community pharmacy practice?
A. Utilization of CMM as framework when counseling about new medications
B. Provision of a CMM “med review” C. Establishment of broad collaborative practice
agreements D. Presence of an automated blood pressure
monitor at pharmacy
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©UNIVERSITY OF UTAH HEALTH, 2018
QUESTION 5
Which principle of optimal care are pharmacists and technicians ideally positioned to impact?
A. Optimal regimen B. Optimal use C. Optimal diagnosing D. Optimal monitoring
©UNIVERSITY OF UTAH HEALTH, 2018
QUESTION 5
Which principle of optimal care are pharmacists and technicians ideally positioned to impact?
A. Optimal regimen B. Optimal use C. Optimal diagnosing D. Optimal monitoring
©UNIVERSITY OF UTAH HEALTH, 2018
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