Medication Review Unit 2 PDF

College of Nursing Pharmacy & Medication Review Allied Health Sciences Presented by: Mary Angelique C. Banogon, RPh Instructor I Department of Pharmacy TOPICS Overview of Medication Review...

College of Nursing Pharmacy & Medication Review Allied Health Sciences Presented by: Mary Angelique C. Banogon, RPh Instructor I Department of Pharmacy TOPICS Overview of Medication Review Goals of Medication Review Composition of Medication Review − Medication Assessment − Care Plan − Follow-up Evaluation Department of Pharmacy Objectives Describing medication review Identifying and describing the components of a Care Plan and a follow up evaluation. Develop a written Care Plan for a patient scenario including solution focused suggestions, monitoring, and a follow-up plan. Department of Pharmacy Medication Review A structured, critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimizing the impact of medicines, minimizing the number of medication-related problems and reducing waste. Department of Pharmacy Goals of a Medication Review Department of Pharmacy International Pharmaceutical Federation (FIP). Medication review and medicines use review: A toolkit for pharmacists. The Hag ue: International Pharmaceutical Federation; 2022. Department of Pharmacy Department of Pharmacy Medicines Use Review a subtype of MR describes pharmacists partnering with patients to improve their medicines use, consider their preferences, and ultimately optimize medication adherence This service is particularly relevant for patients with polypharmacy, especially treated for chronic conditions, as well as for those with identified adherence issues MR type 2a comprises MUR 10/31/2024 Department of Pharmacy Medication Review (MR) Medicines Use Review (MUR) MR aims primarily at MUR is a service improving clinical exclusively designed to outcomes and thus improve medication contributes to system- adherence. level efficiency in addition to encompassing medication adherence goals Department of Pharmacy Applications of MR and MUR Pharmacists can take on a leading role by identifying patients at greater risk of medication errors, such as those with polypharmacy or taking high risk medicines, and by conducting MR for such patient groups Following their analysis, pharmacists may discuss their findings with prescribers or, in contexts where the legislation permits, optimise pharmacotherapy by their own initiative within their own scope of practice Department of Pharmacy Applications of MR and MUR In the Community Setting pharmacists can— meet with their patients in dedicated consulting rooms or ambulatory clinics review Px’s medicines consult available clinical data communicate with Px’s prescriber to suggest changes to their pharmacotherapy develop and propose strategies to improve patients’ use and understanding of their medicines as well as their adherence to treatments. Department of Pharmacy Applications of MR and MUR In the in healthcare establishments and hospitals— Can take into account the patient’s chief complaint, history of present illness, current investigations (laboratory tests, microbial cultures, pathology, imaging) and medication prior to admission, among other clinical information, to ensure safe and effective pharmacotherapy during their hospital stay MUR and medicines reconciliation should also be conjointly conducted to gain an accurate description of a patient’s current pharmacotherapy, including prescribed, non-prescription (over-the-counter) and traditional, complementary and integrative medicines Department of Pharmacy Role of Pharmacists in Medication Review Pharmacists can: address practical medicines optimization address medicines adherence issues thereby improving the clinical effectiveness of medicines taken by patients Many problems with medicines usage can be avoided by: monitoring the effects of therapy making recommendations to change therapy modifying medication where necessary Department of Pharmacy Conditions and requirements for MR I. Data Access and Information Access to the necessary information to adequately analyse medication therapy, identify actual and potential medication-related problems, and suggest the necessary interventions is critical. Three information sources should be consulted: Medication history Clinical data Patient information (interview). Department of Pharmacy Conditions and requirements for MR I. Data Access and Information Medication history Information on active and previous medication is essential and should include, but is not limited to, the following elements: 1. Medicine names 2. Formulations 3. Doses 4. Regimens 5. Route(s) of administration 6. Duration of treatment (with start and end dates) 7. Name and specialisation of prescriber Department of Pharmacy Conditions and requirements for MR I. Data Access and Information Clinical Data include information on: current investigations (laboratory results, microbial cultures and antimicrobial sensitivity tests, and imaging and pathology reports), past medical and surgical history, family history, current health conditions recent hospital admissions Department of Pharmacy Conditions and requirements for MR I. Data Access and Information Patient information (interview) Through patient interviews, pharmacists can obtain information that is not routinely documented, which includes— side effects medication adherence medication preferences lifestyle habits the use of non-prescription (over-the-counter), traditional, complementary and integrative medicines Department of Pharmacy Conditions and requirements for MR II. Resources and Logistics Adequate time: specific time should be scheduled by employers to ensure proper execution of an MR. Resources and Logistics: Clinical tools, interaction detection software, databases, clinical decision support systems and guidance documents — such as the Medication Appropriateness Index, Beers criteria, and STOPP/START criteria as well as deprescribing algorithms and local, regional, national or international guidelines — may be useful resources to guide pharmacists in carrying out MR A dedicated physical area to conduct patient interviews to complete MR is also necessary Department of Pharmacy Conditions and requirements for MR II. Resources and Logistics Professional Training: pharmacists should receive the necessary training to optimally conduct this service. Appropriate remuneration scheme would not only compensate for the time, effort and tools required to conduct proper MR, but also to recognise the pharmacist’s expertise and experience and the savings generated by this service. Awareness will be required among stakeholders to ensure appropriate compensation for the service Department of Pharmacy Conditions and requirements for MR III. Collaborative Efforts Healthcare professionals as medicines experts and key members of the healthcare team, pharmacists are responsible and accountable for making recommendations and interventions to optimise their patients’ medication therapy. Department of Pharmacy Conditions and requirements for MR III. Collaborative Efforts Healthcare professionals In the community setting, collaborative approaches with general practitioners and other members of ambulatory clinics are necessary necessary for solving pharmacotherapeutic problems and optimising medication therapy between prescribers and pharmacists Ensuring excellent communication channels, clear and concise documentation, and shared access to information are important features to ensure proper collaboration. Department of Pharmacy Conditions and requirements for MR III.Collaborative Efforts Healthcare professionals In the healthcare facilities and hospitals, collaboration between prescribers, nursing staff and other healthcare practitioners is also essential to ensure recommendations made regarding medication therapy are carried out Transitional care is also necessary to ensure MR efforts are maintained throughout transitions of care, such as following hospital discharge or transfers to residential care. Department of Pharmacy Conditions and requirements for MR III. Collaborative Efforts Patient a relationship of trust with the patient is equally important Being open-minded and attentive to patients’ concerns regarding their medication therapy is essential when analysing medication profiles, and patients’ preferences can directly affect which interventions pharmacists make. Promoting patient-centered care by taking the time to adequately interview the patient and by explaining the rationale behind recommendations and choices is necessary. Department of Pharmacy The MR Process Department of Pharmacy The MR Process Department of Pharmacy The MR Process Department of Pharmacy The MR Process Department of Pharmacy SUMMARY OF MR PROCESS Department of Pharmacy SUMMARY OF MR PROCESS Department of Pharmacy MR template form Department of Pharmacy MR template form Department of Pharmacy MR template form Department of Pharmacy Patient Care Process 1) the assessment of the patient, his or her medical problems, and drug therapies leading to drug therapy problem identification 2) care plan development 3) follow-up evaluations Department of Pharmacy Process Patient Care Department of Pharmacy 1. The Assessment The purpose of the assessment is threefold: 1) to understand the patient and the patient's medication experience well enough to make rational drug therapy decisions with and for him or her; 2) to determine if the patient's drug therapy is appropriate, effective, and safe, and if the patient is compliant with his or her medications; 3) identify drug therapy problems. Department of Pharmacy 1. The Assessment There are essential clinical skills that each practitioner must develop in order to conduct a productive assessment: Inquiry Listening Observational skills Department of Pharmacy 1. The Assessment ACTIVITIES RESPONSIBILITIES ❖ Meet the patient Establish the therapeutic relationship ❖ Elicit relevant information from the Determine who your patient is as an patient and other health records individual by learning about the reason for the encounter, the ASSESSMENT patient’s demographics, medication experience, and other clinical information ❖ Make rational drug therapy Determine whether the patient's decisions drug-related needs are being met (indication, effectiveness, safety, adherence) Identify drug therapy problems Department of Pharmacy The Assessment Meeting the Patient Introducing Yourself create a positive experience for each patient Patients must feel that you are free to identify with the patient before the patient will feel free to identify with you as their pharmaceutical care practitioner. As patients and practitioners begin to develop a shared identity, that is the essence of a therapeutic relationship. patient's perception of your professional expertise is based on many factors, including your dress and demeanor, quality and relevance of your comments, your ability to elicit relevant information, your willingness to listen, your ability to provide meaningful information, feedback, and explanations, as well as your attitude and confidence. Department of Pharmacy The Assessment Meeting the Patient The Physical Environment A semiprivate or private space must be provided for you to conduct an assessment of your patient's drug-related needs. Keep the area where you meet with patients clean and organized. Only have materials available that you intend to use to help patients such as informational brochures, patient records, and access to the Internet, or samples of products or drug administration devices for demonstration. Keep in mind that most of these items are new to your patients and can be distracting during the assessment interview Department of Pharmacy The Assessment Meeting the Patient Taking Notes At times you may want to record the patient's words verbatim as he or she describes the medication experience. Documentation is an essential standard of practice that you must meet. It is important that your patient feels comfortable with this. Take the time to explain how essential it is for your records to reflect what is truly happening with the patient and his or her medications. Assure your patient that all records you make are considered confidential. Department of Pharmacy The Assessment Eliciting Information from Patient Reason for the Encounter The patient's primary reason(s) for the encounter anchors and directs the practitioner’s assessment process. The primary reason for the encounter can be variable and may be an illness that must be managed with drug therapy, a disease, a complaint, a question, a concern, or a new condition that has developed. The wealth of information that can be contained in your patient's story of the present problem includes its severity, context, location, quality, timing, modifying factors, and associated signs and symptoms. Department of Pharmacy The Assessment Eliciting Information from Patient Reason for the Encounter You will need to determine when it began, previous attempts to treat it, and the results or outcomes of any previous therapeutic approaches. You will always need to explore fully what selfcare steps your patient has taken in an attempt to control or resolve his or her problem. Department of Pharmacy The Assessment Eliciting Information from Patient Reason for the Encounter If your patient has had limited success in the past, you will want to discover how much faith your patient has in drug therapy, so you can determine if you can confidently recommend continuation. On the other hand, if your patient has attempted to treat his or her condition with little or no positive results, you must recognize that repeating this same drug therapy or recommending continuation of that same medication will have a negative influence on the therapeutic relationship and probably result in poor compliance Department of Pharmacy The Assessment Eliciting Information from Patient Department of Pharmacy The Assessment Eliciting Information from Patient Pregnancy and Breastfeeding Department of Pharmacy Department of Pharmacy Department of Pharmacy Department of Pharmacy The Assessment Eliciting Information from Patient Medication Experience The medication experience includes the patient's preferences, attitudes, general understanding of his or her drug therapy, concerns about it, expressed expectations of desired outcomes, and the patient's medication taking behavior. An initial objective of the assessment is to understand your patient's preferences and attitudes concerning medications and to what extent they influence the decision making process. Your patient will ultimately decide if and how to use medications. Department of Pharmacy The Assessment Eliciting Information from Patient Medication Experience During the assessment, you will need to inquire and make judgments about the following questions: What is your patient's level of understanding of his or her disease or illness, drug therapies, and therapeutic instructions? What concerns does your patient have about his or her health in general or medical conditions and drug therapies in particular? What concerns does your patient have about side effects, toxicities, adverse events, or allergies? What does your patient dislike about his or her drug therapies? What unique preferences about drug therapies does your patient have? Are your patient's expectations and goals realistic and achievable? To what extent does your patient want to be an active participant in his or her care? To what degree is the cost of drug therapy, clinic visits, hospitalizations, or treatment failures, a concern for your patient? Department of Pharmacy The Assessment Eliciting Information from Patient The three components of your patient's medication experience are (1) the patient’s description of his or her wants, needs, concerns, understanding, and beliefs about health in general and drug therapies specifically, (2) the patient's medication history (3) the patient's current medication record. Department of Pharmacy The Assessment Eliciting Information from Patient Elements for Current medication record for all medical conditions Indication: The active medical condition, illness, disease, signs, and/or symptoms being treated or being prevented by the use of medications. The drug Product your patient is taking. The Dosage regimen your patient is actually using. Outcome: How your patient is responding to the medication—what progress toward desired goals of therapy has been achieved to date. Department of Pharmacy Indication vs Diagnosis The concept of indication for drug therapy is intended to encompass all of the clinical reasons that a patient might require drug therapy. The concept of indication is broader than simply a diagnosis or a disease. A diagnosis is a medicolegal term used primarily by physicians to describe his or her best medical judgment describing the patient's pathology or illness. A diagnosis is established after the medical practitioner meets with the patient, conducts an interview, history and physical examination, collects and interprets all relevant laboratory test results, and sometimes confers with colleagues. We use drugs in a much broader scope within the health care system. Department of Pharmacy Indication In pharmaceutical care practice, the term indication refers to the clinical reason the patient is taking or needs to take a medication. This is often different from the FDA use of the term indication. The FDA and therefore the pharmaceutical industry restricts the use of the term indication to refer only to the approved labeling and marketing of a product based on data submitted by the industry and reviewed by the FDA. In fact, when a product is used for a clinical condition that the FDA has not approved, it is termed “off-label” use. This should not be confused with the clinical use of the term indication. In practice, the term indication is used for the clinical condition for which the practitioner, prescriber, and/or patient have decided to use the product. (Note: This use may or may not be FDA approved and therefore may or may not be “off label.”) Department of Pharmacy The Assessment Make Rational Drug Therapy Decisions Major Decisions that the pharmaceutical care practitioner makes during the assessment: whether the patient's drug-related needs are being met at this time whether the patient is experiencing Drug Therapy Problems Department of Pharmacy The Assessment Make Rational Drug Therapy Decisions Always assess the patient's drug-related needs in the same systematic order. 1. First determine if the indication is appropriate for the drug therapy. 2. Second, evaluate the effectiveness of the drug regimen for the indication. 3. Third, determine the level of safety of the drug regimen. Only after determining that the drug therapy selected or being used by the patient is appropriately indicated, effective, and safe do you logically evaluate the patient's adherence to the medication regimen. Department of Pharmacy The Assessment Make Rational Drug Therapy Decisions Assessment of Drug Related Needs Department of Pharmacy Drug Therapy Problems are undesirable events or risks experienced by the patient that involve or are suspected to involve drug therapy, that inhibit or delay him or her from achieving the desired goals of therapy, and require professional judgment to resolve. Department of Pharmacy Department of Pharmacy CATEGORIES OF DRUG THERAPY PROBLEMS Department of Pharmacy Department of Pharmacy Department of Pharmacy Department of Pharmacy Department of Pharmacy 2. Care Plan The purpose of the care plan is to organize all of the work agreed upon by the practitioner and the patient to achieve the goals of therapy. In pharmaceutical care, care plans are organized by indications for drug therapy (i.e., pain management, sinusitis, prevention of osteoporosis). This structure allows the practitioner to constantly be aware of the indications the patient has for drug therapies and how best to manage each of them. Department of Pharmacy 2. Care Plan ACTIVITIES RESPONSIBILITIES ❖ Establish goals of therapy Negotiate and agree upon ❖ Select appropriate interventions to: endpoints and time frame for ✓ resolve drug therapy problems pharmacotherapies with the ✓ achieve goals of therapy patient and other providers ✓ prevent drug therapy problems Consider therapeutic CARE PLAN ✓ schedule follow-up evaluation alternatives Select patient-specific pharmacotherapies Consider non-drug interventions Education of the patient Department of Pharmacy Department of Pharmacy Department of Pharmacy Three Steps in constructing a Care Plan 1) Establishing goals of therapy 2) Selecting appropriate individualized interventions 3) Scheduling the next follow-up evaluation Department of Pharmacy 1. Establishing goals of therapy consist of a parameter, a value, and a time frame used to describe the future desired endpoints guide all subsequent decisions, actions, interventions, and patient education Therefore, goals of therapy must be explicitly stated, consistent with the patient's preferences and desires, clinically sound, and observable or measurable in a stated time frame. Department of Pharmacy The goals of drug therapy can be to: 1. Cure a disease 2. Reduce or eliminate signs and/or symptoms 3. Slow or halt the progression of a disease 4. Prevent a disease 5. Normalize laboratory values 6. Assist in the diagnostic process Department of Pharmacy Examples of the Goals of Therapy for Common Medical Conditions Department of Pharmacy 1. Establishing goals of therapy Goals of therapy have a specific structure and always include the following components: 1. clinical parameters (signs and symptoms) and/or laboratory values that are observable, measurable, and realistic; 2. a desired value or observable change in the parameter; 3. a specific time frame in which the goal is to be met. Example: “The patient's diastolic blood pressure will be reduced to between 75 and 85 mmHg within 30 days,” “The patient's elbow pain will be eliminated within 24 hours,” Department of Pharmacy Department of Pharmacy 2. Selecting appropriate individualized interventions Care plans contain interventions designed to: Resolve drug therapy problems initiate new drug therapy discontinue drug therapy increase dosages decrease dosages provide patient-specific education, refer the patient to another health care practitioner with the expertise needed to solve the patient's health problem Department of Pharmacy 2. Selecting appropriate individualized interventions Care plans contain interventions designed to: Achieve the stated goals of therapy Interventions to achieve the goals of therapy can include— new drug regimen(s) the patient should receive, changes in drug therapy that are required, patient-specific education or information, referrals to specialists, instructions on how to properly use prescription drug products, nonprescription drug products, how to use other remedies, products, and devices. Department of Pharmacy 2. Selecting appropriate individualized interventions Care plans contain interventions designed to: Prevent new drug therapy problems from developing These interventions are especially important for patients who have a higher than normal probability of developing a drug therapy problem due to some identified risk factor(s). Example: -initiating antihypertensive therapy with a minimal dosage to prevent orthostatic hypotension -warning patients about drowsiness associated with some antihistamine products Department of Pharmacy 3. Scheduling the next follow-up evaluation Determines the outcomes of drug therapy During the follow-up evaluation, the results of care plan actions are judged as to their positive or negative impact on the patient Therefore, the decision regarding when to schedule the next follow-up evaluation needs to: Incorporate the timing of the expected positive outcomes Achievement of the goals of therapy Probable timing of any negative outcomes including side effects and/or adverse reactions from the medication Department of Pharmacy 3. Follow-up Evaluation ACTIVITIES RESPONSIBILITIES ❖ Elicit clinical and/or laboratory Evaluate effectiveness of evidence of actual patient outcomes, pharmacotherapy compare them to the goals of therapy Evaluate safety of to determine effectiveness of drug pharmacotherapy therapy Determine patient adherence ❖ Elicit clinical and/or laboratory Make a judgment as to the clinical FOLLOW-UP evidence of adverse effects to status of the patient's conditions EVALUATION determine safety of drug therapy being managed with drug ❖ Document clinical status of each therapies condition being managed with drug Identify any new drug therapy therapy problems and their cause ❖ Reassess patient for any new drug Provide continuous care therapy problems ❖ Schedule the next follow-up evaluation Department of Pharmacy 3. Follow-up Evaluation The purpose of the follow-up evaluation is to: determine the actual outcomes of drug therapy for the patient compare these results with the intended goals of therapy determine the effectiveness and safety of pharmacotherapy evaluate patient adherence establish the current status of the patient's medical conditions being managed with drug therapy Department of Pharmacy The specific activities performed at a follow-up evaluation are described as follows: Observe or measure the positive results the patient has experienced from drug therapies (effectiveness). Observe or measure any undesirable effects the patient has experienced that were caused by a drug therapy (safety). Determine the actual dosage of medication the patient is taking that is producing the results observed (adherence). Department of Pharmacy Evaluating Effectiveness of Drug Therapies Department of Pharmacy The specific activities performed at a follow- up evaluation are described as follows: Make a clinical judgment of the status of the patient's medical condition or illness being managed with drug therapy (outcomes). A clinical judgment is made as to the outcome status of each medical condition being treated with drug therapies. At each evaluation the status might be resolved, stable, improved, partially improved, unimproved, worsened, or failed. Each term has a specific meaning in practice and contains two items of important information: 1.the progress, or lack of progress, in achieving the desired goals of therapy at the time of the follow-up evaluation 2.the action, if any, taken to adjust the patient's drug therapies.. Department of Pharmacy INITIAL: describe the status of the patient’s medical condition at the time drug therapy is first initiated and goals of therapy are being established. This unique outcome term is reserved to note the time (day) when pharmacotherapy was initiated to manage a patient's medical condition. Noting the initial date allows calculation of the total length of therapy as well as the time to reach goal. Department of Pharmacy The specific activities performed at a follow- up evaluation are described as follows: Reassess the patient to determine if he or she developed any new drug therapy problems. Department of Pharmacy An important goal of completing the patient care process is to establish a meaningful, therapeutic relationship with the patient. This relationship is different from any other relationship you might develop with an individual. It involves a high level of trust, respect, and sharing. Without this relationship, the patient care process cannot be completed well and the quality of care will be compromised. It takes time to develop such a relationship and it is able to grow with each encounter. It is very difficult to provide pharmaceutical care without such a relationship. Department of Pharmacy Department of Pharmacy □ Current on all childhood immunizations Department of Pharmacy □ Current on all adult immunizations Department of Pharmacy Department of Pharmacy Department of Pharmacy Department of Pharmacy Department of Pharmacy