2024 T02 McCarthy Ch 02 HC professional care PDF

Topic # 2: KP2: Health Care Professionals & Interdisciplinary Care What is a profession? ❑ Not all health care occupations are necessarily deemed professions ✓Pharmacy was one of those health care occupations. ❑Professions exist to serve society. ✓However, mere...

Topic # 2: KP2: Health Care Professionals & Interdisciplinary Care What is a profession? ❑ Not all health care occupations are necessarily deemed professions ✓Pharmacy was one of those health care occupations. ❑Professions exist to serve society. ✓However, merely providing services that meet the public’s needs does not 1  Characteristics of a profession ❑Research has identified five generally recognized characteristics of a profession. ✓ determined by evaluating agreed-upon professions ❖ e.g., medicine, law, & clergy ❑Characteristics include: 1): systematic theory & body of knowledge, 2): professional authority & special privileges, 3): community sanction & social utility, 4): ethical codes & internal control, & 5): professional culture & organizations 2  Systematic theory & body of knowledge ❑ important first distinction between profession & public: ✓ results from didactic education received in professional schools ✓ continues throughout the life of the professional as (s)he is required to maintain competence through continuing education. ❑ members of professions providing service to society are expected: ✓ to have extensive theoretical knowledge ✓ to use that knowledge & associated skill 3  Professional authority & special privileges ❑ Refers to professional: ✓ ability to practice in his or her area of expertise ✓ being afforded opportunity to provide services to public ❑ HC services that members of public cannot presumably perform for themselves. ❑ client surrenders a portion of his or her autonomy to the professional: ✓ client acknowledges the superior competence of the professional to do the job that the client cannot do ✓ client trusts the professional’s judgment about which course of action will best meet the client needs 4  Social utility & community sanction ❑ professions: ✓ serve a socially necessary function (social utility) ✓ provides a service that is of great importance to society. ❑ Function of profession is sanctioned (community sanction) ✓ by society in a number of different ways ❖ system of licensure o Licenses granted by various professional boards ▪ boards exist to protect society ▪ incl members of society in addition to members of profession ❖ restriction on the use of a professional title. 5  Ethical codes & internal control ❑ professional: ✓ accepts responsibility ✓ is accountable through law & his or her profession ❖ through formal & informal internal controls eg codes of ethics ❑ profession accepts responsibility to maintain a standard of conduct beyond law (ethical codes & internal control) ✓ most difficult part about codes of ethics is enforcement. ✓ code of ethics inclusion weakest part of attribute theory ✓ effective technique to avoid public (external) control: ❖ maintain strong control over members ❑ Members enjoy relative freedom from direct on-the-job supervision & from direct public scrutiny. ✓ when supervision does exist: ❖ supervisor of professional is member of same profession 6  Professional culture & organizations ❑ profession’s culture is made up of: (1): values; (2): norms; (3): symbols. (1): Values: ✓ central beliefs of a profession ✓ incl belief in imp & merit to society of profession’s expertise ❖ belief: service cannot be better provided by other occupation ❖ belief: service provided is essential ❖ belief: society would suffer if service was withdrawn (2): Norms: ✓ accepted ways of social behavior within profession (3): Symbols: ✓ used to identify the calling of the profession: ❖ incl specific insignia, vocabulary & dress (eg white lab coat) 7  Individualized, unstandardized service directly to clients ❑ Efforts made by the various HC professions to improve quality of the services provided through standardization does not mean that HC providers do not meet this criterion. ✓ patient safety revolve around creating processes such that errors may be reduced or eliminated: a laudable goal ✓ patients present with almost infinite number of signs, symptoms, & personal characteristics that require that these processes be executed in the patient’s best interest in mind. ✓ best interest ❖ determined by thorough understanding of pt’s needs & wants ❖ requires flexibility of provider to change as pt’s needs &/or wants change. ❑ nature of HC makes requirement of providing individualized & unstandardized service to clients seem logical ✓ HC providers sometimes fail to treat patient as an individual. 8  RPhs Defined ❑ RPhs ✓ distribute prescription drugs to individuals ✓ advise patients, MDs & other health practitioners on: ❖ selection, dosages, interactions & side effects ❖ monitor health & progress of patients o to ensure they are using meds safely & effectively ❑ Compounding: ✓ actual mixing of ingredients to form medications ✓ small but important part of a RPh's practice. 9  Education & training ❑ Early edn of RPhs occurred as result of apprenticeship ❑ Formal education began in the late 19th century. ✓ No state required a pharmacy degree until 1910. ✓ Early degree-granting pharmacy education was 2-years in length (Ph.G.) ❑ 3 years – standard in 1925 ❑ 4-years – standard in 1932 ❑ 5-years – standard in 1960 10  Education & training ❑1915: Abraham Flexner declared pharmacy was not a profession ❑1915: US War Dept decided that registered RPhs would not routinely receive commissions because their professional edn was minimal ❑1928: AACP adopts min. 4-yr B.S. in Pharmacy; goes in effect 1932 ❑1940s: Increased to 5-yrs ❑1992: 6-yr Pharm.D. started as entry-level degree; CA since the 50s. 11  Education & training ❑ Doctor of Pharmacy (PharmD) education: ✓ minimum requirement for pharmacy practice ✓ pre-professional coursework of at least two years. ✓ final four years (or its equivalent) of pharmacy education MUST be attained in a college/school of pharmacy. ❑ Mix of didactic (classroom) & experiential learning 12  Residency training ❑ organized, directed, postgraduate training program in a defined area of pharmacy practice. ❑ PGY1 residencies : ✓ enhance general competencies of resident in managing medication use ✓ supports optimal medication therapy outcomes for patients ✓ usually housed in hospitals ✓ residencies in other area increased significantly over last decade o eg community pharmacies; home care; long-term care facilities; ambulatory care settings; managed care facilities ✓ number of pharmacy graduates seeking PGY1 residencies has been increasing. 13  Residency training ❑ PGY2 residencies are available for those who have completed a PGY1 residency ✓ ambulatory care, cardiology, critical care, drug information, emergency medicine, geriatrics, infectious diseases, informatics, oncology, internal medicine, medication safety, pediatrics, nuclear medicine, nutrition support, psychiatry, pharmacotherapy, solid organ transplant managed care pharmacy systems, health-system pharmacy administration 14  Fellowship training ❑ is a directed, highly individualized, postgraduate program designed to prepare participant to become independent researcher ❑ http://www.fda.gov/aboutfda/workingatfda/fellowshipinternshipgraduatefacultyprograms/def ault.htm 15  Licensure ❑ To practice pharmacy in US, DC, Guam, Puerto Rico or U.S Virgin Islands, one must possess a pharmacy license. ✓ licensure is predicated on successful completion of North American RPh Licensure Examination (NAPLEX) ✓ to sit for this exam: ❖ must graduate from accredited college/school of pharmacy ❖ graduates from foreign schools of pharmacy: o suitable score on Foreign Pharmacy Equivalency Examination (FPGEE) ✓ In addition to NAPLEX: ❖ RPhs must successfully complete Multistate Pharmacy Jurisprudence Exam (MPJE) or a state- 16 level equivalent law examination.  Continuing education [CE] ❑ All 50 states & territories require CE credits for continued licensure (specific requirements vary by locale). ❑ CE for the profession of pharmacy is a structured process of education designed or intended to support the continuous development of RPhs to maintain & enhance their professional competence. ❑ CE should promote problem-solving & critical thinking & be applicable to the practice of pharmacy. 17  Practice Environment ❑ In spite of many advances in pharmacy practice, RPhs continue to have the distribution of medications to patients as a primary responsibility. ❑ Along with this responsibility over distributive tasks, RPhs serve as a valuable source of medication-related information for patients & healthcare providers. 18 ❑ RPhs devote time: ✓ 55% to medication dispensing ✓ 16% to patient care services ✓ 14% to business/organization management ✓ 5% to education ✓ 4% to research ✓ 5% to other activities. ❑ proportions vary significantly based on practice setting: ✓ community pharmacies spend at least 70% in dispensing-related activities. ✓ hospital RPhs & those engaged in pt care roles spend less than half their time to medication dispensing. ✓ both community & hospital RPhs spending 27% of their time on direct patient-care activities 19 Figure 2-1 Pharmacy Staff & Mean Hourly Wage. Source: National Center for Health Statistics. (2010). Health, United States, 2009: With special feature on medical technology. Hyattsville, MD: National Center for Health Statistics. 20  Specialization ❑ varieties of specialties available for pharmacy practitioners. ✓ Specialization achieved after one is eligible to practice, not before. ✓ practitioners have the ability to advance their abilities such that they can seek recognition of that training through specialization. ❑ Initially Board of Pharmacy Specialties (BPS ) recognized 5 areas of pharmacy specialization 1) nuclear pharmacy, 2) pharmacotherapy, 3) nutrition support pharmacy, 4) psychiatric pharmacy, 5) oncology pharmacy. ✓ Beginning in 2011, Board of Pharmacy Specialties began recognizing specialization in ambulatory care pharmacy. 21  RPhs Practice: Specializations ❑Ambulatory care ❑Managed care ❑Pharmacy admn ❑Long-term care ❑Drug info ❑Internal medicine ❑Community practice ❑Psychiatry* ❑Industry ❑Pharmacokinetics ❑Geriatrics ❑Oncology* ❑Nuclear medicine* ❑Nutrition support* ❑Pharmacotherapy* * Certification available. 22  Pharmacy technicians Defined “an individual working in a pharmacy [setting] who, under the supervision of a licensed RPh, assists in pharmacy activities that do not require the professional judgment of a RPh”. 23  Pharmacy technicians Education & training ❑ State level requirements for pharmacy technicians vary greatly. ✓ Age minimums, educational minimums, & training requirements exist. ❑ Of the 50 states, the District of Columbia, Puerto Rico, & Guam, 34 government bodies have established technician training requirements. 24  Pharmacy technicians Licensure ❑ Currently, 39 states regulate pharmacy technicians in some manner (certification, licensure, or registration). ❑ National certification examinations are available from the Pharmacy Technician Certification Board & the Institute for the Certification of Pharmacy Technicians. ✓ The certification examinations cover a broad range of topics related to aspects of pharmacy technician practice. 25  Pharmacy technicians: Practice environment ❑ number of pharmacy technicians has increased dramatically since 1999 ✓ It is estimated that in 2008, there were 326,300 active pharmacy technicians. ❑ Pharmacy technicians work in a variety of settings ✓eg community pharmacies; hospitals; branches of the military; mail order pharmacies ✓ Most (more than 75%) are employed by retail pharmacies. 26 ❑ Pharmacy technicians assist RPhs ✓ preparation of Rx medications ❖ eg computer entry; counting medications; labeling Rx bottles ✓ assisting customers ✓ performing administrative duties within pharmacy ❖ eg record keeping; insurance claims; prescription inventory control ✓ Activities prohibited include at a minimum: ❖ drug regimen review; clinical conflict resolution; therapy modification; pt counseling; receipt of new Rx drug orders; Rx transfer; dispensing process validation; 27 prescriber contact concerning Rx drug order clarification  Pharmacy technicians Practice environment ❑ While there exists a general understanding of the nature & scope of pharmacy technician practice, the specific duties that are able to be performed by pharmacy technicians vary by state & practice setting ✓ eg retail versus institutional practice ❑ Each of the duties of the pharmacy technician is performed under the direct supervision of a licensed RPh. 28  Physicians ❑ Demand for physician services is highly sensitive to changes in consumer preferences, HC reimbursement policies, & legislation. Bureau of Labor Statistics (BLS), 2006. Defined ❑ Physicians are concerned primarily with maintaining or restoring health of their patients through the diagnosis & treatment of disease or injury. ❑ For pharmacy, physician holds an important position as it is physician who prescribes the most & as such, creates majority of demand for pharmacy products & services. 29  Education & training ❑ Formal medical education is thought to have started in the middle to late 18th century. ✓ This early education focused on didactic training; however, this changed quickly. ✓ As such, this earliest formal medical education resembles modern-day medical education, namely a combination of didactic & experiential learning. 30  Education & training ❑ Flexner Report (1910) ✓ critical evaluation of medical education. ✓ made recommendations that included: ❖ minimum educational standards for admission to medical schools ❖ minimum length of medical school education of 4 yr ❖ closure (or combination with universities) of the proprietary medical schools that existed at the time 31  Education & training ❑ Today medical edn is post-baccalaureate 4-yr program ✓ 2 years (M1 & M2) are didactic primarily. ❖ Courses in: o anatomy; biochemistry; genetics; immunology; microbiology; pathology; pharmacology; physiology; public health sciences ✓ 2 years (M3 & M4) are clerkships (experiential learning) ❖ Required rotations o eg internal medicine; surgery; pediatrics; family medicine; neurology; electives obstetrics & gynecology; psychiatry 32  Education & training ❑ MD vs DO ✓ Doctor of Osteopathy ❖ 26 such schools in US ❖ “osteopathic medical education emphasizes hands-on diagnosis & treatment through a system of therapy known as osteopathic manipulative medicine” ✓ DO curricula are very similar to that of students studying in MD schools. 33  Licensure ❑ Regardless of training (MD or DO) licensure involves a three-step process ✓ Step 1 exam for licensure: ❖ taken during second year of medical school. ✓ Step 2 exam for licensure: ❖ taken during fourth year of medical school ❖ comprised of two parts: o clinical knowledge o clinical skills o use of “standardized patients” ✓ Step 3 exam for licensure: ❖ taken during first year of residency. ❖ assess resident’s suitability for unsupervised medical practice 34  Licensure ❑ Continuing medical edn is required by 62 medical boards. ❑ number of hours needed varies by state ❑ in some states varies by degree type (MD vs. DO) ❑ majority require between 20 & 50 hours per year. ✓ some states ALSO require specific continuing medical education content each license cycle e.g., error prevention, infection control ✓ some states accept certificates/awards eg from American Osteopathic Assn & American Board of Medical Specialties ✓ documentation of continued competence. 35  Specialization ❑ voluntary process. ❑ License examination is NOT specialty-specific. ✓ American Board of Medical Specialties is the umbrella organization of 24 member boards that offer certification in more than 145 specialties & subspecialties. ✓ American Osteopathic Association, Bureau of Osteopathic Specialists offers certification in any of 18 specialty areas to doctors of osteopathic medicine. 36  Practice Environment ❑ Number of physicians practicing in US has been on rise. ✓ there continue to be fears that rate of increase has not kept pace with the rate of increase in US population. ✓ there are concerns that as baby boomers begin to populate the ranks of the elderly ✓ may experience greater shortage (hyper-demand) of physicians; ✓ increased demand is est to be 22% by 2020 over 2005. 37  Figure 2-2 Active Doctors of Medicine. 38 Source: National Center for Health Statistics. (2010). Health, United States, 2009: With special feature on medical technology. Hyattsville, MD: National Center for Health Statistics. ❑ number of primary care providers increased dramatically ❑ largest increases in primary care providers: ✓ in nurse practitioners ✓ in physician assistants ✓ increase in number of physicians in primary care: ❖ result of foreign medical graduates ✓ specialist & subspecialist can & do provide primary care ✓ trend toward more specialist less primary care providers ❖ implications on future of practice of pharmacy ❖ increased demand for primary care ❖ RPhs have increased role in meeting needs of pts ❖ Collaborative Drug Therapy Management: o RPh fulfill responsibility to provide patient-centered care 39 o expanded responsibilities in states where allowed  Figure 2-3 Doctors of Medicine in General Primary Care. 40 Source: National Center for Health Statistics. (2010). Health, United States, 2009: With special feature on medical technology. Hyattsville, MD: National Center for Health Statistics.  Nurses ❑ Defn: “the protection, promotion, & optimization of health & abilities, prevention of illness & injury, alleviation of suffering through the diagnosis & treatment of human response & advocacy in the care of individuals, families, communities, & populations.” RN & LPN ❑ RN more advanced of two nursing designations owing to requirements for more education. ✓ result: scope of practice for RN is broader than for LPN ✓ LPN works under supervision of registered nurse 41  APN ❑ In addition to LPN & RN: nurses have opportunities for advanced practice roles. ❑ designations used by advanced practice nurses (APNs): ✓ nurse practitioner; clinical nurse specialist; certified registered nurse anesthetist; certified nurse midwife ❑ have prescriptive authority in most jurisdictions ❑ in some jurisdictions: ✓ APNs may practice independently without physician collaboration or supervision. 42  Education & training ❑ educational reqts for RN & LPN differ in scope & length. ✓ LPN: ❖ 1-year of study; ❖ attain diploma or certificate. ✓ RN: ❖ requisite education diverse as career opportunities in nursing ✓ three recognized educational pathways for RN: (1): bachelor’s degree (2): associate’s degree (3): diploma from an approved nursing program. 43 ❑ APN designation requires additional edn beyond that reqd for licensure as RN. ❑ APNs have at least 2 years of graduate edn (eg MS degree) ✓ new standard for qualification as APN: ❖ doctor of nursing practice o advanced-level practice degree focuses on clinical aspects of nursing o not focus on academic research (PhD in nursing). ❑ In addition to holding licensed as RNs: ✓ some states require APNs to submit: ❖ evidence of advanced edn ❖ evidence of certification through organizations such as American Nurses Credentialing Center, American Academy of Nurse Practitioners 44  Licensure ❑ to enter practice: graduate nurses must pass National Council Licensure Examination (NCLEX) ✓ NCLEX recognized by boards of nursing in US ❖ NCLEX divided into two separate exams: o NCLEX-RN is for registered nurses o NCLEX-PN for vocational/practical nurses. ✓ While there are different examinations for registered nurses & for vocational/practical nurses, there is no separate NCLEX-RN examination or passing standard for associate degree, baccalaureate degree, or diploma 45 nursing school graduates. ❑ requirements for evidence of continued competence differs across states & across nurse type. ✓ 75% of states require continuing competence for nurses. ✓ continued competence requirements include: ❖ continuing education; minimal practice; peer review; refresher courses; competency examinations; continued competency assessment ✓ all states require continued competence for APNs ❖ requirements vary by state & by APN designation: o include recertification; CE beyond that required for RN licensure; practice requirements; pharmacology course work. 46  Specialization ❑ Certification programs are available for RNs in over 20 different area including ✓ ambulatory care nursing; ✓ general nursing practice ✓ pediatric nursing ✓ psychiatric & mental health nursing ❑ 355,000+ nurse practitioners (NPs) licensed in U.S. ❑ 36,000+ new NPs completed academic programs 2019–20 ❑ 88.9% of NPs certified in primary care, ❑ 70.2% of all NPs deliver primary care. 47  Practice Environment ❑ There were more than 750,000 LPNs in US in 2008. ✓ LPNs work nights, weekends, & holidays depending on the setting ✓ LPNs assist patients with activities of daily living ✓ LPNs employed by nursing homes, home HC, & hospice, office-based practices of physicians & hospitals. ✓ roles of LPNs vary by state. 48 ❑ majority of nurses (62.2%) work in hospital setting ❑ notable opportunities for RNs: ✓ ambulatory care (10.5%) public health (7.8%). ❑ APNs work in a variety of healthcare settings ✓ level of practice independence & prescriptive authority differs by: ❖ state independent practice collaborative agreements/protocols practice under physician supervision ✓ APN designation ❖ eg nurse practitioner clinical nurse specialist, certified nurse midwife, certified nurse anesthetist 49  Physician Assistants Defined ❑ PA’s role in health system is unique ✓ practice medicine in a team environment under direction of a physician. ❑ As part of comprehensive responsibilities: ✓ conduct physical exams, diagnose & treat illnesses, order & interpret tests, assist in surgery, counsel on preventive HC prescribe medications. ❑ specific duties determined by supervising physician & by state law 50  Education & training ❑ PAs educated in programs accredited by Accreditation Review Commission on Education for Physician Assistant. ❑ programs housed in community & post-4-year colleges ❑ PA curriculum averages 26 months. ✓ trained to diagnose & treat medical problems ✓ curriculum consists of: ❖ didactic instruction in basic medical & behavioral sciences ❖ experiential learning ❖ clinical rotations in later portions of PA edn ❑ there are 149+ accredited physician assistant programs ❑ PAs require continuing medical education (100 hrs/2yrs) ✓ PAs retested on clinical skills (every 6 years). 51  Licensure ❑ All States & DC have legislation governing practice of PA ❑ All jurisdictions require: ✓ PAs to pass Physician Assistant National Certifying Examination ❖ administered by National Commission on Certification of Physician Assistants (NCCPA) ❖ open only to graduates of accredited PA education programs. 52  Practice Environment ❑ 2021: ~112,216 Certified Physician Assistants employed ✓ 64.4% women ✓average age is 38 years old. ❑ greatest percentage of PAs report being employed in a group medical practice (44.2%). ✓ Almost one quarter of all clinically practicing PAs are employed in hospitals ✓ 11.6% in solo physician practices. 53 OTHER ALLIED HEALTH PROFESSIONALS 54 Occupation Education Degree(s) Roles Optometrists 7–9 yrs OD ✓ primary providers of vision care ✓ examine eyes to diagnose vision problems ✓ prescribe eyeglasses & contact lenses ✓ diagnose diseases of eye (eg glaucoma) ✓ may have limited prescriptive authority. Social 4– 6 yrs BSW, MSW ✓ assist people by helping them solve issues in everyday lives workers ❖ eg family & personal problem; deal with relationship ✓ help disability, life-threatening disease or social problem ❖ eg inadequate housing, unemployment, substance abuse; assist with serious domestic conflicts, involving child or spousal abuse. Podiatrists 9 yrs DPM ✓ diagnose & treat disorder, disease & injury of foot & lower leg ✓ prescribe medications ✓ perform physical therapy ✓ fit orthotics ✓ set fractures 55 ✓ perform surgery.  Occupation Education Degree(s) Roles Dentists 6–10 yrs DDS, ✓ diagnose & treat problems with teeth & tissues in mouth DMD ✓ prescribe medications, perform surgery, & extract teeth. Psychologists 6+ yrs Specialist, ✓ assess, diagnose, treat, & prevent mental disorders ✓ advise on how to deal with problems of everyday living incl MS, PhD, ❖ problems in home, place of work, or community, to help PsyD improve their quality of life. Dieticians/ 4 yrs BS, MS ✓ plan food & nutrition programs ✓ supervise meal preparation & oversee serving of meals nutritionists ✓ illness prevention activities occur by promoting healthy eating habits & recommending dietary modifications. Occupational 4–6 yrs MS ✓ help patients improve perform tasks in living & work place ✓ work with individuals who suffer from mentally, physically, therapists developmentally, or emotionally disabling condition ✓ goal: help clients have independent, productive & satisfying lives 56  Occupation Education Degree(s) Roles ✓ provide activities Recreational 4 years BS ❖ arts & crafts, playing with animals, sports, games, dance & movement, drama, music, & community outings therapists ✓ serve individuals with disabilities or illnesses ✓ goal: to improve & maintain their physical, mental, & emotional well-being. ✓ work with patients who have limitations in their ability to Physical 4+ yrs MS, DPT move & perform functional activities therapists ✓ examine patients ✓ develop plan using treatment techniques ✓ goal: promote ability to move, reduce pain, restore function, & prevent disability. Source : "Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2010- 11 Edition, Retrieved from http://www.bls.gov/oco/ 57  Collaboration with health care providers Pharmacy role ❑ primary role of RPh is focused on medication consumption ✓ e.g ❖ screen for contraindications & drug–drug interaction ❖ serve as physician’s resource for information about medical therapies ❖ provide patient education about medications ❑ For high-risk disease states: ✓ RPhs play more important role as a part of medication management team 58  Multidisciplinary Care ❑ Many different professionals working together for the good of the patient Interdisciplinary Care ❑Many different professionals, independent of each other, working for the good of the patient 59  Commitment to the relationship Stage 4 Relationship expansion Stage 3 Individual characteristics Contextual factors Exploration &trial Exploration & Trial Stage 2 Exchange characteristics Professional recognition Stage 1 Professional awareness Stage 0 60  Commitment to the relationship Relationship expansion Individual characteristics Contextual factors Exploration &trial Exploration & Trial Exchange characteristics Professional recognition Professional awareness Stage 0 61  Stage 0: professional awareness ❑ description: traditional RPh–physician working relationship ❑ At this stage: ✓ exchanges between RPh & physician discrete & minimal ❑ interactions: ✓ are short in duration ✓ no attempt to change the existing relationship. ✓ “are considered professionally safe, routine, & defined by well-established expectations” 62  Commitment to the relationship Relationship expansion Individual characteristics Contextual factors Exploration &trial Exploration & Trial Exchange characteristics Professional recognition Stage 1 Professional awareness 63  Stage 1: professional recognition ❑ involves exclusively RPh’s effort to establish relationship with physician ❑ RPh informs physician of the services that RPh can provide. ✓ important step in establishment of collaborative relationship ❖ because RPh’s role definitions & role boundaries have been established by past experiences that MD has had with RPhs. ❑ goal: trust. ✓ RPhs are working to enhance their own attractiveness or usefulness to the physician during stage 1 interactions. 64  Commitment to the relationship Relationship expansion Individual characteristics Contextual factors Exploration &trial Exploration & Trial Stage 2 Exchange characteristics Professional recognition Professional awareness 65  Stage 2: exploration & trial ❑ requires some low level commitment on part of physician ✓ above & beyond what has been demonstrated in first two stages ✓ RPh remains the primary initiator of interaction. ❑ trial may involve physician referring patient(s) ✓ physician can assess ❖ RPh’s ability to deliver both quantity & quality of services as promised ❖ risks & benefits associated with collaborative relationship. 66  Commitment to the relationship Relationship expansion Stage 3 Individual characteristics Contextual factors Exploration &trial Exploration & Trial Exchange characteristics Professional recognition Professional awareness 67  Stage 3: professional relationship expansion ❑ natural progression of activities undertaken in earlier stages. ❑ RPh’s expectation: ✓ physician initiates the exchange ✓ exchange efforts remain unbalanced ❖ RPh still has more responsibility as initiator ❑ content of RPh-initiated communication center on: ✓ benefits derived RPh’s services ✓ seeking feedback on past performance. ❑ exchange represents some level of commitment on part of physician toward the collaborative relationship ✓ RPh can & should expect that professional conflict will occur in this fine-tuning of the relationship. 68  Commitment to the relationship Stage 4 Relationship expansion Individual characteristics Contextual factors Exploration &trial Exploration & Trial Exchange characteristics Professional recognition Professional awareness 69  Stage 4: commitment to collaborative working relationship ❑ achieved when physician convinced that benefits > risk ❑ for commitment in relationship to exist: ✓ relationship needs to be relatively: ❖ lengthy; consistent; high level of input from all parties. ❑ commitment reached: ✓ if there is equity in effort toward maintaining relationship ❑ after commitment is achieved: work remains to be done ❑ failure to attend to relationship by both parties: its demise ❑ collaborative working relationship is in every sense of the word ❑ unlike earlier stages, RPh cannot be sole source of relationship effort 70 ✓ physician must also attend to relationship’s needs.  Continuity of care: background ❑ in old days: one doctor with help of nurse provided all HC needed. ❑ common for patients to see several HC practitioners. ✓ Pts receive care from: doctors, nurses, nurse practitioners, physician assistants, RPhs, dietitians, physical or occupational therapists, social workers, & nurse’s aides. ✓ Pts have several doctors: specialize in one organ system/disease ✓ as people age : move from one place of care to another. ❖ receive care in: doctor’s office, hospital, rehabilitation facility, board-&-care facility, assisted living facility, nursing home, or at home ❖ At the end of life, they may receive hospice care ❑ Two core concepts or aspirations of continuity: : continuity is about care of a single patient. ✓ continuity not attribute of provider/organization 71 : element is that care is provided over time.  Informational continuity ❑ Consistent & coherent approach to the management of a health condition that is responsive to a patient’s changing needs ✓ need: established plan of care to meet patient needs Management continuity ❑ use of information on past events & personal circumstances ✓ to make current care appropriate for each individual. ✓ focus of information: [a] disease; [b] patient ❑ transfer of patient information reqd to make HC decisions 72  Relational continuity ❑ ongoing therapeutic relationship ✓ between patient & one or more providers ✓ trust & loyalty = personal relationship between pt & clinician ❖ aka interpersonal continuity ❑ Higher levels of continuity of care = fn[higher levels of satisfaction] ❑ fosters improved: ✓ communication ✓ trust ✓ sustained sense of responsibility. 73  Medical home ❑ refers to partnership approach in the provision of primary HC ✓ accessibility; family centered; coordinated; comprehensive; continuous; compassionate; culturally effective ❑ patient-centered primary HC to improve: ✓ patient’s health ✓ across continuum of referrals & services ❑ based on relationship between patient & physician: ✓ to improve patient’s health ✓ via open communication within team care framework ❑ primary focus: ✓ to have one central clearinghouse ❖ all patient medication records kept up to date ✓ embraces idea for shared info among HC professionals ✓ facilitates continuity of care. 74  Pharmacy role: medical home model ❑ requires team-based approach to patient care. ❑ requires multidisciplinary approach from entire HC team ✓ includes nurses, RPhs, physicians, therapists & other health professionals. ❑ RPhs should & can have a: ✓ role in medication therapy management ✓ open shared communication with physicians. ❑ RPhs have been typically underused in this role ✓ have great potential to demonstrate professional expertise 75  Defining quality ❑ Quality means: ✓ different things to different people ✓ based on involvement, need, price, & experience. ❑ Institute of Medicine (IOM) defined quality: ✓ “the degree to which health services for individuals & populations increase likelihood of desired health outcomes & are consistent with current professional knowledge” ❑ Agency for Healthcare Research & Quality (AHRQ ): ✓ “doing right thing for right patient, at right time, in right way, to achieve best possible results”. 76 77  How is quality assessed? ❑ HC quality may be measured in any of a number of ways including: (1): clinical performance measures of how well providers deliver specific services needed by specific patients ✓ most valued from clinician’s perspective: ❖ most directly influence clinical outcomes of the patient (2): assessments by patients of how well providers meet HC needs from patient’s perspective ✓ most important to patient: ❖ how (s)he perceive his or her treatment to be ❖ measured with patient report cards & quality (3): outcome measures ✓ eg mortality rates from cancers preventable by screening that may be affected by quality of HC received. ✓ interest to researchers, policy makers, & administrators: ❖ to objectively review trends or take macro perspective 78  Accreditation ❑ Joint Commission ✓ performance standards serve as indicator of quality ❖ to those unfamiliar with HC organization ❑ Possessing accreditation means: ✓ HC organization has met national standards ❖ incl clinical performance measures. ❑ Joint Commission presides over a growing, national, comparative performance measurement database inform ✓ internal HC organization quality improvement activities external accountability; pay-for-performance 79 advance research.  Report Cards ❑ quality initiative involves: ✓ development of quality indicators & measures ✓ providing audiences with report cards ✓ assess: : orgn; : HC plan; : HC provider ❑ summary of key indicators used by: ✓ variety of audiences; consumers ; employers ❑ National Committee for Quality Assurance (NCQA): ✓ produces report cards for physicians & HC plans. ❑ Managed care orgns share NCQA accreditation & report card with pt ❑ accreditation is voluntary: ✓ plans promote themselves on basis of the grades ❑ HC Effectiveness Data & Information Set (HEDIS ): ✓ used by > 90% of health plans 80 ✓ measure performance on imp dimensions of care & service.  Patient Ratings ❑ organizations evaluate themselves: quality care measures ❑ patients evaluate the orgns. ❑ quality initiatives have developed surveys (paper or internet) for patients to complete in order to rate these orgns ✓ aggregate information published: ❖ for others to see ❖ use in evaluating providers & orgns. ❖ patients use these resources: o making choices about providers o report on their experiences with a provider. 81  Important trends affecting HC professionals: Patient-focused care ❑ “characterized by decentralization of services, cross-training of personnel from different departments to provide basic care, interdisciplinary collaboration, various degrees of organizational restructuring, simplification & redesign of work to eliminate steps & save time, & an increased involvement of patients in their own care” ❑ to improve patient care by organizationally & physically moving service functions, to patient care areas to effect orgnl restructuring: ✓ viz basic laboratory, pharmacy, admitting/discharge, medical records, housekeeping, & material support services ❑ Health professionals work in teams to increase & improve communication among themselves & with the patient. 82  TeamSTEPPS: Team Strategies & Tools to Enhance Performance & Patient Safety ❑ is comprehensive set of ready-to-use materials & training curriculum ❑ integrate teamwork principles into any HC system. ✓ developed jointly by Dept of Defense & Agency for Healthcare Research & Quality (AHRQ) ✓ built a national training & support network called National Implementation of TeamSTEPPS Project ✓ currently conducting training sessions throughout the country ❑ Facilitating pt-focused care requires reengineering of HC systems ✓ Hammer & Champy (1993) defined reengineering as: ❖ fundamental re-thinking & radical redesign of business processes to achieve dramatic improvements in critical, contemporary 83 measures of performance viz quality, cost, service & speed.  Critical care pathways ❑ represent comprehensive management plans ✓ plans that aim to optimize & streamline patient care ❑ plans define: ✓ key steps in management of patient: ❖ to improve quality of health care ❖ to reduce resource utilization ❑ is an “optimal sequencing & timing of interventions by HC professionals for a particular diagnosis or proc designed: ✓ to minimize delays ✓ to minimize resource utilization ✓ to maximize the quality of care 84  Continuous quality improvement ❑ aka total quality management or total quality improvement. ❑ CQI ✓ enables cross-functional, interdisciplinary team to examine processes that could or should be improved. ✓ brings together a team of healthcare workers ✓ team know a particular procedure well ✓ advantage: employees more receptive to change when active participants in the change process. 85  FOCUS-PDCA ❑ F: Find a process to ❑ P: Plan the improvement. improve. ❑ D: Do the improvement, ❑ O: Organize a team collect data & analyze that knows the process. data ❑ C: Clarify current knowledge of process ❑ C: Check & study results. ❑ U: Understand sources ❑ A: Act to hold the gain & of process variation. to improve the process further ❑ S: Select the process 86 improvement.  Pay for performance (P4P) ❑ Defn:... quality based purchasing... the use of payment methods & other incentives to encourage high quality, patient-focused, high value care. ✓ model built on defined measures, data collection, & public reporting ✓ includes payment incentives aimed at quality, efficiency, & patient satisfaction. ❑ P4P programs increasingly are focusing their efforts on outcome & cost-efficiency measures, rather than clinical process measures alone. 87 Technological advances ❑ Handheld devices ❑ E-prescribing ❑ EHR/EMR.. 88