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Care Planning and MTM 2008

Care Planning and MTM 2008 - A Problem-Oriented Approach to...

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Unformatted text preview: A Problem-Oriented Approach to Patient Care Using Pharmaceutical Care Plans Damary C. Torres, Pharm.D., BCOP Associate Clinical Professor St. John’s University Winthrop University Hospital [email protected] Slides courtesy of Danielle Ezzo Objectives Upon completion of the discussion, the student should be able to utilize a systematic approach to evaluate and understand case studies using the following steps: 1. Identify potential & real drug-related problems 2. Determine desired therapeutic outcomes & alternatives 3. Understand how to design an optimal individualized pharmacotherapeutic plan 4. Understand how to identify appropriate monitoring parameters 5. Understand how to provide important patient counseling points 6. Communicate, document & implement the Why Make a Care Plan? Organize the overwhelming amount of patient-information that is available to identify problems that may exist Aid in the selection of appropriate therapies for patient-specific problems Monitor the patient’s response to the chosen therapies Offer alternative choices if the initial selection is not successful Help organize what must be communicated to appropriate personnel, either verbally or written 9 Steps to Pharmaceutical Care with patients 1. Develop a relationship 2. Collect relevant information – Drugs, disease, patient factors 3. 4. 5. 6. 7. 8. 9. Interpret information & identify problems Prioritize drug-related problems Identify those problems that pharmacist can address Identify outcomes Develop a therapeutic plan Develop a monitoring plan Implement care plan Knowledge of disease Drug information skills Knowledge of drug therapy Patient Care Therapeutic planning skills Patient monitoring skills Knowledge of non-drug therapy Knowledge of laboratory and diagnostic testing Communication skills Physical assessment skills Figure 1.1; Tietze K. page 2. Elements of the ProblemOriented Medical Record SOAP Note Subjective Objective Assessment Plan (recommendations) FARM Format Findings Assessment Recommendations (or Resolutions) Monitoring Systematic Approach to Pharmaceutical Care Plans (PCPs) Develop a relationship with patients Collect relevant information – Drugs, disease, patient factors – From chart, patient monitoring form, etc.. Interpret information & identify problems – Symptoms, labs, drug-related problems Systematic Approach to Pharmaceutical Care Plans (PCPs) 1. Prioritize drug-related problems – Assess Problems 2. 3. Evaluate problems and explain plan Severity of disease or drug related problem Controlled/uncontrolled disease Appropriate vs. inappropriate treatment Goals of therapy Identify those problems that pharmacist can address Identify outcomes 1. 2. Systematic Approach to Pharmaceutical Care Plans (PCPs) Develop a therapeutic plan – What are your recommendations? Develop a monitoring plan – Evaluate the Outcome / Monitor 3. How do you know your plan worked? Should be measurable Frequency and end points (goals) Implement care plan Talk to patient, other health care providers as needed Information gathered is either: Objective Subjective Information that is only able to be described (usually by the patient) Not measurable Often more difficult to identify abnormalities Ex: “I’m weak” Information that is quantitative (you can assign a value to it) Abnormalities fall outside a specified parameter Normal parameters that help Ex: measured blood pressure Subjective Findings CC (Chief HPI (History of Present illness) PMH (Past medical history) FH (Family History) Complaint) SH (Social History) Dietary History Medications Allergies ROS (Review of Systems) Other: – Pt description of ADRs (Adverse Drug Reactions) – Pain Scale Objective Findings Physical Exam Height Weight Vital Signs Laboratory values Serum drug levels (if applicable) Other: – – – – X-rays EKGs CT scans Etc… Specific Examples…….. Subjective Coughing, itching, tingling, chills, sweating, loss of appetite, headache, heartburn, pain, indigestion, nervousness, sneezing, diarrhea, etc… Objective Height, weight, vital signs (BP), labs (creatinine), cultures, urine output, # of loose stools/day, etc… How do we write a SOAP note? Problem SOAP Note list – Number each problem consecutively (1, 2, 3…) – List problems in order of importance Most serious least serious Acute chronic Problem #1 may be the patient’s chief complaint Subjective information pertinent to problems Objective information pertinent to problems Assessment of problems Plan for problems Subjective Document PERTINENT subjective findings for each drug-related problem listed Can be found through communication with patient Information that the patient describes Objective Document PERTINENT findings for each drug-related problem listed Can be found in chart, computer system, physical assessment… Information that can be measured Assessment Pharmacists evaluation: nature, extent, type and clinical significance Describes the thought process involved with concluding a problem does/does not exist and whether active intervention is necessary If additional information necessary to assess the problem(s) than the case must be discussed with additional healthcare personnel and/or patient Assessment (continued…) State severity or urgency of a problem; indicate when intervention(s) should be made (immediately, within a few days, 1 week, etc…) – If a disease state can be staged, you should state this here (ex: asthma, CHF) Assessment (continued…) State desired therapeutic outcomes (short and long term goals) – Outcomes Cure disease Reduce symptoms Slow progression of disease Prevent disease/symptoms – Short term goals Ex: eliminate symptoms – Long term goals Ex: cure infection Assessment Format Should be paragraph format Aim for 3 sentences First sentence: Summary of description of the patient and problems Second sentence: Supporting sentence; list a few symptoms that support your conclusion of the patients problem and severity/stage, controlled or not, explain plan Third sentence: State goals; try to state short and long term goals Example of an Appropriate Assessment Lisa Loeb is a 55 yo female with HTN, HF, DM and hyperlipidemia who arrives to clinic complaining of shortness of breath upon exertion. Symptoms are consistent with having an exacerbation of HF, due to her increased shortness of breath and recent noncompliance with her Lasix. Goals are to immediately restart LL’s Lasix and eliminate all symptoms of HF. Plan List what your action will be to help correct the patient’s problem – Therapeutic – pharmacologic and nonpharmacologic – Don’t forget MONITORING action plan When will you follow up with the patient Goals for outcomes!!! – Patient Counseling points AKA: – Recommendations or Resolutions Monitor Outcomes [as part of your plan] Efficacy Resolution of signs, symptoms, & laboratory abnormalities Toxicity Document potential toxicity along with specific method of monitoring Monitor signs, symptoms, lab values & drug serum levels Important note: ** Frequency, duration and endpoint/goal for each monitoring parameter must be documented ***Recommend the point at which changes in the plan may be necessary Checklist I have made a problem list All subjective and objective information listed is pertinent to the problem My assessment is in paragraph format My plan includes monitoring and has set goals – I have listed all my recommendations to discontinue and start medications – I have not forgotten to recommend to Sample Case Hypoglycemia Sample Case CC: “I have been feeling very dizzy lately.” HPI: Robert Kerzon is a 47 yo male who arrives at your clinic stating that he has had multiple (3) episodes of dizziness over the past 1 week. He has a history of HTN, DM type II, and hyperlipidemia. He is an obese male weighing 250 lbs at a height of 5’11”. He states that 2 weeks ago he started the “South Beach Diet” and is still continuing Phase I (No carbs, no sugar) because he is having successful weight loss. (He lost 10 pounds so far.) Sample Case HPI, cont’d: – He is compliant with all his medications, which include medications to control HTN, DM and cholesterol. He also is compliant with the monitoring of his symptoms. He presents to you a log of his daily BP values and glucose levels (fingersticks). Sample Case PMH: – – – FH: – – HTN x 8 years DM type II x 5 years Hyperlipidemia x 10 years Mother ↑, DM type II x 25 years Father ↑, MI x 3 years ago SH: – (-) illicit drug use – social ETOH use – Smokes ½ PPD Sample Case Medications: – – – – Glyburide 5 mg po BID (for DM) Altace (ramipril) 10 mg po QD (for HTN) Lipitor 20 mg po HS (for hyperlipidemia) Tylenol 500 mg; 2 tabs po q4-6 hours prn pain – Saw palmetto; 1 tab po qd (pt. heard it’s good for a healthy prostate) Sample Case Allergies: – NKDA ROS: – Unremarkable except for 3 episodes of dizziness in the past week, and increase BP, Pt offers no other complaints. Sample Case PE: – Gen: WDWN mildly obese male with recent episodes of dizziness – VS: BP 130/80, P 75, RR 16, T 37º C Wt = 113 Kg, Ht 5’11” – Neuro: dizziness x 3 episodes in past 1 week – Labs: Na 142, K 4.6, Cl 101, CO2 22, BUN 22, SCr 1.1, Glu 68, Alb 4.1, TSH 5.4, Hgb 13.1, Hct 42%, Plt 324, WBC 9, HgA1c 6.3, LDL 95, HDL 48, TG 145 Sample Case Patient daily logs Blood Pressure Log (Optimal BP for a diabetic 125/75) Mon Wed Thurs Fri 128/80 Tues 124/80 128/82 130/78 139/84 Glucose Log (Normal glucose range 70 – 120) Mon Tues Wed Thur s Fri 72 65 69 75 63 Problem List for Sample Case 1. 2. 3. 4. 5. Dizziness secondary to hypoglycemia HTN Smoking Cessation Weight Management Hyperlipidemia SOAP note for Problem #1 Dizziness Secondary to Hypoglycemia Findings 46 yo male DM type II HTN Hyperlipidemia Mildly obese (Ht = 5’11” Smokes ½ PPD IBW= 75 kg, ABW = 113kg) Glyburide, altace, lipitor, tylenol, saw palmetto BP not optimal Multiple hypoglycemia episodes Phase 1 of South Beach Diet (no sugar, no carbs) Successful weight loss (- 10 lbs) Assessment RK is a 47 yo male with HTN, DM type II, and hyperlipidemia presenting to clinic with complaints of multiple episodes of dizziness x 1 week. Signs and symptoms are consistent with hypoglycemia and supported by low fingerstick readings. Immediate intervention is necessary to eliminate hypoglycemia and associated signs and symptoms. All problems should be assessed here Plan Change glyburide 5 mg po BID to 2.5 mg po BID D/C saw palmetto (patient shows no need for this) D/C ETOH use Ask patient if ready to stop smoking Increase fingersticks to BID (pre-breakfast and 2 hours post dinner) Glucagon emergency kit for hypoglycemia Keep sugar candies or glucose tablets on hand at all times (for emergencies) Maintain steady diet and exercise routine Follow phase 2 of ‘South Beach Diet’ (low Recommendations for all problems should be carbs) made here Plan Monitoring for Efficacy & Toxicity Elimination of dizziness Fingersticks BID for optimal glucose level 70 – 120 mg/dL. Carb intake per mealtime diary at every visit Weight loss in 1 month to achieve ~5 % weight reduction (12.5 lbs) Use of glucagon Monitoring for all problems/recommendations should be made here Conclusion Using pharmaceutical care plans (PCPs) is an organized process PCPs help us organize and prioritize patient problems and recommend appropriate therapy. PCPs help in setting goals to achieve optimal patient therapy! MTM: Medication Therapy Management Readings http://www.pharmacist.com/AM/Template.cfm? – http://www.pharmacist.com/AM/Template.cfm?Sect – http://www.pharmacist.com/AM/Template.cfm?Sect Robertson KE. Process for preventing or identifying and resolving problems in drug therapy. Am J Health Syst Pharm. 1996 Mar 15;53(6):639-50. Medication Therapy Management Communication service – enables the pharmacy profession to more rapidly expand its business model around delivering patient services Community pharmacists can provide patient services face-to-face, earn fees, and improve health outcomes. Working with a variety of program sponsors – Medicare Part D plans, commercial plans, selfinsured employers, manufacturers, government entities Pharmacists receive patient cases and supporting clinical and financial Medication Therapy Management Services that pharmacists will provide using MTM include: – – – – – – – medication therapy management adverse events tracking formulary management compliance disease management clinical trials specialty drug management Medication Therapy Management Pharmacists can deliver valuable services to their patients, document these sessions, and submit claims for payment. AKA: CDTM – Collaborative Disease Therapy Management Desired Goal of MTM Managed Care Perspective – Decrease healthcare costs Judicious use of medications Prevent hospitalizations – Customer satisfaction Patient education Pharmacy Perspective – Decrease patient cost – Improve patient’s quality of life – Prevent nonadherence – Reimbursement for patient education and clinical services The Big Picture MTM patients typically have several problems to resolve Consider the top 2 issues by – Severity to health – Patient-perceived interest Develop a comprehensive care plan that prioritizes each problem MTM Core Elements 2. 3. 4. 5. 6. Medication Therapy Review (MTR) Personal Medication Record (PMR) Medication Action Plan (MAP) Intervention and / or Referral Documentation and Follow-Up 1. Medication Therapy Review (MTR) Like a traditional “Brown Bag” session or “Medicine Check-Up” for a patient Sets up a standardized system and makes the process more systematic Allows the pharmacist to use medication and clinical skills/judgment Conducting a Medication Therapy Review (MTR) Conducting MTR Step 1: Prepare for the visit Get a history of the medications dispensed by the patient’s pharmacy Review the patient’s medical conditions Review the patient’s prescription medications ***Get as much information as you can to make appropriate conclusions Conducting MTR Step 2: Collect a Thorough Medical History Verify patient demographics – Address, DOB etc… Assess the patient’s physical and overall health status – – – – Social history Current and previous diseases Family medical history Patient assessment or lab values Personal Medication History (PMH) Form Link to multilanguage form http://www.hhs.gov/pharmacy/pdf/att1.p Conducting MTR Step 3: Collect a Thorough Medication History Ask about medication allergies and reactions Determine adherence to medications and barriers to adherence Assess patients knowledge of medication purpose and directions Good communication skills are key – Eye Contact – Layman’s terms – Why are you asking them these questions? Medication Information Form Conducting MTR Step 4: Assess Medication Therapy Review the Drug Related Problem (DRP) categories: – Drug without an indication – Indication without a drug – Dose too high – Dose too low – Drug-drug interactions – Adverse drug event – Suboptimal compliance Common DRPs Encountered by Pharmacists’ Monitoring Untreated condition Improper drug selection Underdose Overdose Failure of patient to receive drug Adverse drug reaction Drug-drug interaction Drug-food interaction Non-adherence Duplication of therapy Allergies Requiring renal or hepatic adjustments Conducting MTR Step 5: Develop a Plan to Address Problems Correct any medication misinformation and address patient concerns Provide the patient with needed educational materials as well as a personal action plan (MAP) Develop a plan to be shared with the patient’s physician Personal Medication Record (PMR) PMR is an up-to-date medication list The patient should receive a PMR at the end of a comprehensive MTR The patient should be instructed to: – Share the PMR with health care provider by bringing it to each physician / specialist visit, hospital admission and pharmacy visit – Keep their PMR up-to-date What I’m taking Form (pill, injection, liquid, patch, etc.) Dosage How Much and When Use (regularly or occasionally) Start/Stop Dates (1/5/08 - 3/5/08) (1/5/08 ongoing) Notes, Directions, Reasons for Use * Be sure to include ALL prescription drugs over-the-counter drugs, vitamins, and herbal supplements. 1 2 3 4 5 6 7 8 9 Medication Action Plan (MAP) MAP is a patient focused document containing information the patient can use to improve medication selfmanagement The patient can share the MAP with caregivers and/ or other health care providers Intervention and / or Referral The pharmacist assumes the responsibility to address any potential or actual medicationrelated problems identified Must follow-up Documentation and FollowUp “If you didn’t document, it didn’t happen” The pharmacist must document services in a manner appropriate for evaluating patient progress and billing and should schedule a followup visit – Billing codes: 0115T – initial encounter 0116T – subsequent counter Communicating the plan With the patient prior to the end of the appointment, or within 2 weeks of the appointment With the appropriate prescriber – Note any specialists (e.g. endocrinologists) and send specific doctor letters to them Questions??? ...
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