Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2593_Библиотеки_им_академика_М_И_Перельмана
.pdf
5
6
7
8
social histories, and must be provided in
a culturally sensitive manner.
A successful MTMS encounter must be
well documented following the problemoriented medical record (POMR).
Documentation involves collecting
subjective and objective data to identify
the primary problem.
Case 1-2 (Question 1)
Case 1-3 (Question 1)
Case 1-4 (Question 1),
Table 1-4
The clinician must assess the drug
therapy or disease-specific problem and
create a treatment plan.
Case 1-4 (Questions
1, 2)
The final step in documenting the
MTMS encounter is developing the
medication action plan and processing
any billing requirements.
Case 1-4 (Questions
1, 2, 4)
Accurate and complete communication
of the MTMS encounter to the patient’s
health care team is vital.
Case 1-4 (Question 3)
INTRODUCTION
This chapter discusses medication therapy management services
(MTMS) with a focus on the assessment of drug therapy. The
illustrations in this chapter primarily focus on the pharmacist;
however, the principles used to assess patient response to drug
therapy are of value to all health care providers.
As defined by the American Pharmacists Association (APhA),
medication therapy management (MTM) is a term used to describe a
broad range of health care services provided by pharmacists, the
medication experts on the health care team. A consensus definition
created by 11 national pharmacy associations, adopted by the
https://t.me/medicina_free
pharmacy profession in 2004, defines MTM as a service or group of
services that optimize therapeutic outcomes for individual patients.
1
Pharmacists provide MTM to help patients get the best benefits from
their medications by actively managing drug therapy and identifying,
preventing, and resolving medication-related problems.
When practiced in the outpatient setting, MTMS can be used to
assess patient adherence to medications, identify potential drug
duplications, and provide an overall counseling service for
medication therapy. MTM allows pharmacists to decrease
medication-related errors while also educating patients on their
medication regimens. A pharmacist plays a vital role in a patient’s
therapy management and can help relay information to a physician.
During MTMS services, a pharmacist has the opportunity to confirm
the potential use and appropriateness of medication in relation to a
specific disease state. The Pharmacists Patient Care Process
(PPCP) may be utilized in such instances. The process’s five steps
include collect, assess, plan, implement, and follow-up: monitor and
evaluate. By utilizing the PPCP tool, a pharmacist can provide wellrounded care to each individual based on their specific conditions
and needs.
2
MTMS provide a significant opportunity to optimize drug regimens
and create patient-centered care. The utilization of such services is
crucial to a pharmacist’s role in the health care system. In addition to
the therapeutic outcome benefits, there is the potential for a
considerable financial benefit from conducting MTMS because these
services are primarily focused on patients with multiple chronic
conditions, which can pose a significant burden on our health care
system. According to a study evaluating MTMS, it was observed that
a 31% reduction in total health care expenditures occurred, resulting
in a 12:1 savings to cost ratio.2 Therefore, MTMS are a valuable tool
that all pharmacists should utilize when necessary because they can
provide a great therapeutic benefit and a potential reduction in health
care costs.
MTM has a direct relationship to pharmaceutical care.
Pharmaceutical care has been described as the responsible
provision of drug therapy to achieve definite outcomes that are
https://t.me/medicina_free
intended to improve a patient’s quality of life.
3,4
In fact, MTM has
been described as a service provided in the practice of
pharmaceutical care.5 However, unlike pharmaceutical care, MTM is
recognized by payers, has current procedural terminology (CPT)
codes specifically for pharmacists, and has several clearly defined
interventions. Therefore, MTMS will be the term used to describe the
activity of MTM in various patient populations.
With the passage of the Patient Protection and Affordable Care
Act and the Health Care and Education Reconciliation Act of 2010,
pharmacists have tremendous opportunities in the implementation of
health care reform.
6,7
One of the hallmarks of this law is delivery
system reform. As health care delivery systems change, pharmacists
have an opportunity to improve overall quality of care, to become
involved in coordinated health care approaches such as medical
home teams and accountable care organizations, and to collaborate
to improve care for high-risk patients and those with chronic
conditions in primary care settings. Chronic diseases are prevalent
and costly in the United States. Approximately 133 million (or 45%)
of all Americans suffer from at least one chronic condition, and the
number is increasing. According to the Centers for Disease Control
and Prevention (CDC), in the United States, chronic diseases
account for 75% of health care spending, or $5300 per person
annually.8 These chronic conditions are often not singular in nature,
with one in four adults having two or more chronic conditions,
making treatment efforts even more challenging, and with that
number expected to continue to rise over the next several years
through the end of 2029.
9
Pharmacists have additional opportunities because hospitals have
financial incentives to improve quality, reduce costs, and decrease
hospital-acquired conditions.
6,7
Both patient self-care and medication
reconciliation are critical aspects of any MTMS encounter regardless
of the setting (ie, inpatient, community, ambulatory, or institutional).
Patient self-care requires the patient to take responsibility for the
illness; however, the help of a professional to structure healthy selfcare is important. For example, patients with diabetes who monitor
their blood glucose levels regularly and adjust their diet according to
https://t.me/medicina_free
the guidelines published by the American Diabetes Association
(ADA) would be practicing self-care. Self-care is often the work that
the patient performs between visits with the provider. The patient
should be involved in their own care to ensure the best outcomes.
Medication reconciliation is the comprehensive evaluation of a
patient’s medication regimen any time there is a change in therapy in
an effort to avoid medication errors such as omissions, duplications,
dosing errors, or drug interactions, as well as to observe compliance
and adherence patterns. This process should include a comparison
of the existing and previous medication regimens and should occur
at every transition of care in which new medications are ordered,
existing orders are rewritten or adjusted, or when the patient has
added nonprescription medications to their self-care.10 Although not
a new concept to the profession of pharmacy, there has been
heightened awareness and intensified effort in this area of practice
as a result of the Joint Commission. In 2005, the Joint Commission
announced its National Patient Safety Goal (NPSG) 8A and 8B to
accurately and completely reconcile medications across the
continuum of care. This goal requires institutions to develop and test
processes for medication reconciliation in ambulatory and acute care
settings.11 In 2015, the Joint Commission’s NPSG 3 continued its
focus on improving the safe use of medications, in particular by
maintaining and communicating accurate patient medical
information.12 In 2020, the Joint Commission’s NPSG 3 refined its
focus even further, emphasizing recording and passing along correct
information about a patient's medications, comparing past and
present medication lists, providing written information about the
patient’s medications, and bringing up-to-date medication lists to all
physician appointments.
13
The Centers for Medicare & Medicaid Services (CMS), the largest
purchaser of health insurance in the United States, is directly
connecting reimbursement for Medicare services to patient
outcomes. CMS developed star ratings as a means to move away
from the pay-for-service model of health care and move toward a
new quality-based model. CMS annually rates Medicare health plans
on a scale of 1 to 5 stars, with 5 stars representing the highest
https://t.me/medicina_free
quality. The star ratings include measures across five broad
categories: outcomes, intermediate outcomes, patient experience,
access, and process.14 For specific details and updates, visit
https://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/Downloads/2020-Star-RatingsFact-Sheet-.pdf.
It is important for pharmacists to realize that MTMS are integral to
improving health outcomes and are continuing to gain acceptance
from payers, in both the private and public sectors. The opportunity
for pharmacists to continue to expand their role, while offering highlevel care, along with the potential for improvement in pharmacy
compensation is in line with the CMS star ratings.
The general approach to an MTMS patient encounter in various
clinical settings is discussed in the next sections. Figure 1-1
provides a visual representation of a systematic process for a
comprehensive and effective approach for delivering MTMS.
Figure 1-1 General approach to a medication therapy management
services (MTMS) patient encounter. (Reprinted from American
Pharmacists Association; National Association of Chain Drug Stores
Foundation. Medication therapy management in pharmacy practice:
core elements of an MTM service model (version 2.0). J Am Pharm
Assoc (2003). 2008;48(3):341–353. © 2008 American Pharmacists
Association, with permission.)
https://t.me/medicina_free
SOURCES OF PATIENT INFORMATION
Successful patient assessment and monitoring requires gathering
and organizing relevant information.
4,15
The patient, family member,
or caregiver is always the primary source of information. The
provider asks the patient a series of questions to obtain subjective
information that is helpful in making a diagnosis or evaluating
ongoing therapy. Likewise, providers without direct access to patient
data must also obtain subjective data or measure objective physical
data to guide recommendations for therapy and to monitor previously
prescribed therapy.
Data-Rich and Data-Poor Environments
In a “data-rich environment,” such as a hospital, long-term facility, or
outpatient medical clinic, a wealth of information is available to
practitioners from the medical record, pharmacy profile, and
medication administration record (MAR). In these settings,
physicians, nurses, other health care providers, and patients are
readily available. This facilitates timely, effective communication
among providers involved in the drug therapy decision-making
process. Objective data (eg, diagnosis, physical examination,
laboratory and other test results, vital signs, weight, medications,
medication allergies, intravenous flow rates, and fluid balance) are
readily available. The patient record provides information that is
needed to identify and assess medical problems, which is necessary
to design patient-specific care plans and document MTMS. In some
settings, patient insurance information is important to help
understand the formulary choices and access to medications.
In a “data-poor environment,” such as a community pharmacy,
clinicians are often required to make assessments with limited
information. Although the information may be limited to (a) the
medication profile, (b) patient demographic data, (c) medication
allergy history, and (d) the patient’s insurance coverage, it is still
valuable.
https://t.me/medicina_free
The information in Table 1-1 is an illustrative summary of sources
of patient information.
Table 1-1
Sources of Patient Information
Data-Rich Environment Data-Poor Environment
Paper Charts
Decreasing use across the
practice continuum
Limitations
Not consistent from site to site
Difficult to access if more than
one user
Delays in data entry
Electronic Health Record (EHR)
Electronic version of a paper chart
Differs across practice settings
One of the most complete sources
of reliable information
Can interface with other software
systems in the pharmacy,
laboratories, etc
Data shared between systems in
real time
Pharmacy Information Systems (PIS)—
Outpatient and Inpatient
Mainly focus on pharmacy billing,
inventory management, production of
medication labels
Limited documentation of clinical
pharmacy
Pharmacy information systems (PIS) are generally considered
data poor. Early PIS were established for pharmacy billing and
inventory management. These initial systems provided medication fill
lists, generated patient profiles, and produced medication labels that
were valuable to institutional pharmacies as the profession moved
toward a unit-dose medication distribution system. More modern
functionalities allow for some limited documentation of clinical
pharmacy activities, but the PIS are still considered to be data poor.
An initiative by the U.S. Department of Health and Human
Services, called the EHR Incentive Program, exemplifies the
importance of the integration of PIS with other computerized
systems.16 This initiative, the “Meaningful Use of an EHR,” allows
https://t.me/medicina_free
Medicare and Medicaid to provide incentive payments to providers
and hospitals for the “meaningful use” of certified health information
technology products. Eligibility for these incentive payments involves
transitioning PIS to a more data-rich clinical information system
(CIS), which includes direct computerized physician order entry,
clinical decision support, an electronic health record (EHR), an
electronic medication administration record (eMAR), and integration
of various information systems such as pharmacy and laboratory
services. Additional functionality incorporates the use of barcode
technology, which allows the ability to track and promote quality
assurance during the medication administration process. Information
generated by the CIS is electronically transmitted to the pharmacy in
real time, eliminating lost, illegible, or incomplete medication orders.
In a data-poor environment, the clinician must be a proactive
interviewer and may become an investigator. The investigative
approach is direct and requires strong problem-solving abilities and
active listening skills. Questions should be formulated to obtain
information such as the medication history, actual medication use,
patient perception of care, use of over-the-counter (OTC) and natural
or herbal products, and health beliefs (cultural or otherwise). This
approach can help verify and ensure the accuracy of other data
sources. Clinicians should be mindful that not all patients are reliable
historians, and some are poor sources of information. Even when the
patient is a poor historian, the interview provides critical information
(eg, indicator of poor adherence and need for a caregiver or
interpreter) that cannot be obtained from other sources.
EFFECTIVE COMMUNICATION AND THE
PATIENT INTERVIEW
The ability to use effective communication principles and historytaking skills is crucial to a successful patient interaction.
4,15
The
importance of interviewing the patient, how to set the stage for the
https://t.me/medicina_free
interview, general interview rules, and the essential information to be
obtained from the interview are outlined in Table 1-2. Information
obtained from the patient is critical for assessment and planning in
MTM.
Table 1-2
Interviewing the Patient
Importance of Interviewing the Patient
Establishes professional relationship with the patient to do the following:
Obtain subjective data on medical problems.
Obtain patient-specific information on drug efficacy and toxicity.
Assess the patient’s knowledge about, attitudes toward, and pattern of
medication use.
Formulate a problem list.
Formulate plans for medication teaching and pharmaceutical care.
How to Set the Stage for the Interview
Have the patient complete a written health and medication questionnaire, if
available.
Make the setting as private as possible.
Maintain eye contact.
Encourage the patient to be descriptive.
Clarify by restatement or patient demonstration (eg, of a technique).
General Interview Rules
Read the chart or patient profile first.
Ask for the patient’s permission to conduct an interview or make an
appointment to do so.
Begin with open-ended questions.
Move to close-ended questions.
Document interaction.
Information to Be Obtained
History of allergies
History of adverse drug reactions
Weight and height
Drugs: dose, route, frequency, and reason for use
Perceived efficacy of each drug
Perceived side effects
https://t.me/medicina_free
Adherence to prescribed drug regimen
Nonprescription medication use (including complementary and alternative
medications)
Possibility of pregnancy in females of childbearing age
Family or other support systems
Source: Teresa O’Sullivan, PharmD, University of Washington.
Motivational interviewing (MI) is another useful method created by
Miller and Rollnick that can be utilized during patient counseling to
improve patient adherence to therapy. It is an empathetic and
collaborative style of counseling based on five key principles:
expressing empathy, developing discrepancy, adapting to resistance,
avoiding arguments, and supporting self-efficacy, as seen in Table 1-
3. The basis of MI is aimed at improving a patient’s ambivalence to
drug therapy through behavioral changes. It should be noted that MI
does not require a long-standing pharmacist–patient relationship to
be effective, because individual sessions have been shown to be
helpful.
17,18
Table 1-3
Principles of Motivational Interviewing
Expressing
empathy
Convey to your patient that you understand their condition. This
will allow the patient to be more open minded.
Develop
discrepancy
Point out to the patient that there is a difference between current
behavior and being able to reach their goals.
Adapt to
resistance
Use different approaches to encourage the patient to channel
their resistance into positive change.
Avoid
arguments
Do not argue with your patient or force them to view things as you
do.
Support self-
efficacy
Assist the patient with believing that their own decisions will make
a difference to behavioral change. Instead of telling the patient
what to do, empower them to figure out what will be effective.
Sources: Adapted from Miller WR, Rollnick S. Motivational Interviewing: Preparing
People to Change Addictive Behavior. Guilford Press; 1991. Center for Substance
Abuse Treatment. Motivational interviewing as a counseling style. In: Enhancing
Motivation for Change in Substance Abuse Treatment. Substance Abuse and
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана