Photo by Larisa Birta |
Over the past many years, organizations and providers have made concerted efforts to improve medication safety and ensure optimal therapeutic benefit for their patients. Patients, families, and caregivers have played a vital role in these efforts.
While work remains to improve key medication safety processes, such as medication reconciliation, the concept of medication optimization is starting to take hold as health care providers envision a more comprehensive goal for patient care that involves decisions and processes related to medication. This new goal would collect those key processes which are often approached as individual improvement projects, into a coordinated system of care related to medications.
Medication Optimization describes “an approach to medication management that focuses on all aspects of the patient’s journey from initiation of treatment (or decisions to forego treatment), to follow-up, to ongoing review and support of their medication treatment plan.”
As part of an initiative funded by Pfizer Global Medical Grants, IHI developed a draft theory of change for medication optimization and recruited seven primary care practices to learn together what it takes put the theory into action. The following practices joined the Medication Optimization in Primary Care Learning & Action Network (LAN): Advocate Care Center/Advocate Charitable Foundation, Heartland Health Centers, Larkin University and Borinquen Medical Centers of Miami Dade, NorthShore University Health System, University of North Texas Health Science Center, Vanderbilt Health, Providence Visiting Nurses Association/Washington State University. Key drivers included: Medication Management Systems; Primary Care Teams; Patient, Family, and Caregiver; and Learning System, Context, and Culture.
Given the complexity of the processes involved in each of the primary drivers — each topic could have a fully built out driver diagram and change package of its own — participating teams were not able to test the proposed set of interrelated processes for all drivers in their individual practices. Across the LAN, however, teams did test changes related to all primary and most secondary drivers.
Engage the Full Team and Leverage the Role of Pharmacists — Each participating organization had a multidisciplinary team engaged in the Learning & Action Network. This was typically some combination of a doctor, nurse practitioner, nurse, social worker, and pharmacist. It was recommended that teams include a patient on their core team, and while teams did engage patients in the work in various ways, they found it difficult at this stage to include a patient on the core team. A key takeaway from the LAN was the importance of bringing all skills to bear across the clinic, including those roles not represented in the core LAN team, such as front desk staff, pharmacy residents, and patients. Engaging the full team — and sharing how their individual efforts can accrue to improved processes, increased reliability, better workflow, and better lives for patients — is imperative.
The role of the pharmacist bears special mention. LAN teams tested referring patients to pharmacists for one-on-one consults or group teaching about newly prescribed medications to improve patients’: 1) ability to make informed decisions about their treatment; and 2) to improve adherence to agreed-upon treatment regimens. Early results are promising and teams report an improved appreciation among leadership and across the organization regarding the value pharmacists can bring when their role is leveraged to include patient education and consultation in the clinic.
Create Opportunities for Shared Decision Making and Patient, Family, and Caregiver Engagement — LAN teams tested several changes to engage patients and their families and caregivers in their care, including around shared decision making. Tests included:
- Use of a medication decision-making tool to facilitate discussions with the patient regarding the effectiveness, impact on daily routine, side effects, and costs of common drugs used to treat a given disease (see: Mayo Clinic Shared Decision Making National Resource Center);
- Development of education videos for patients in the waiting area;
- Pharmacist-led appointments;
- Group education visits with a clinician;
- Use of glucose and medication adherence logs by patients;
- Text messages to patients disengaged in care requesting they call for an appointment; and
- Collection of a patient-reported measure of shared decision making (see: CollaboRATE)
One team tested the usefulness and feasibility of collecting and sharing monthly HBa1c data with patients with diabetes to provide regular feedback about their disease, engage patients in care, and drive recommended changes in lifestyle and medication adherence. Initial results are encouraging and the team continues to test the change idea.
Tailor Office Processes to Promote Medication Optimization — Other areas of learning concerned adapting processes and supports in the office practice to promote medication optimization.
- One team developed a decision support tool for resolving medication discrepancies identified during medication reconciliation in home health care visits and set up standard work for notifying clinicians of unreconciled medications.
- Another team tested ways to incorporate the collection of data related to social determinants of health during the office visit and strategies for meeting needs identified in those interviews.
- Teams also helped each other identify ways in which the electronic health record could be adapted to assist their work in improving medication processes and documentation.
- Participants agreed that adopting quality improvement methods across the practice would help them to continue this work and tackle challenging quality issues in the future.
Next Steps for Testing Medication Optimization
More work is needed to understand how the proposed drivers and associated change ideas might work together to create medication optimization. At the conclusion of the LAN, we have determined that the theory of change, with some modest changes based on LAN team testing, warrants continued testing. In addition, we have identified the conditions we believe are necessary for more comprehensive testing of the theory for further proof of concept.
IHI’s recommendation for a next phase of study is to identify a large integrated health system interested in testing the draft theory of change for medication optimization. We believe such an organization would: 1) have the ability to allocate resources necessary to simultaneously test multiple change ideas associated with each driver, ideally one improvement team for each of the four primary drivers; and 2) have data systems in place to efficiently and effectively track process, outcome, and balancing measures over time to better understand the cumulative impact of changes tested. A goal of future testing should include identification of meaningful measures of medication optimization which would be useful to teams without the benefit of comprehensive data systems and a focus on the sequencing or prioritization of change ideas to further inform the work across a range of organization types.
Joelle Baehrend, MA, is an IHI director.
Sessions about Patient Safety and Person-Centered Care are part of IHI’s National Forum this December.