Patient-centered Medication Management: A Proposed ......Canada 2013). Medication administration is...
Transcript of Patient-centered Medication Management: A Proposed ......Canada 2013). Medication administration is...
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Patient-centered Medication Management: A Proposed Model
Jane D. Prestie Quality Consultant
Alberta Health Services
Edmonton, Alberta, Canada
Abstract
Aim. This paper’s aim is to introduce a patient centered medication management model for
nurses and their patients.
Background. The patient centered medication management (PCMM) model includes self
administration as one element but patient participation is throughout the continuum of acute care
(Prestie & Koch, 2011). The key elements include health professional role, patient’s status and
medication requirement. Self administration of medication processes have been utilized and
presented in the literature since 1959 (Lam 2011, Wright et al. 2006). PCMM was developed
during the commissioning phase of a new hospital.
Data Sources. The patient centered medication management model was developed based on
research around best medication administration practice and patient centered care philosophy.
Search sources included CINHAL, Pro-quest, and Google Scholar for articles regarding
medication management, self administration of medication, medication administration and
patient centered care from 2000 to current day. Review of related Alberta Legislation, Alberta
Professional Colleges was also undertaken.
Discussion. The goal of PCMM is to allow the acute care patient to be involved in managing
their medication so that the medication administration prior to discharge will resemble the
management of medications in the community.
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Implications for nursing. By utilizing the PCMM process it is hypothesized that medication
management will be done transparently, involve and empower the patient, and improve patient
and staff satisfaction.
Conclusion. PCMM is an alternative to traditional medication management that involves the
acute care patient, nurses, physicians, pharmacists, pharmacy technicians and health care aides.
Keywords: Self Administration of Medication, Patient Centered Care, Medication
Management, Medication Administration, and Quality Improvement
The purpose of this paper is to introduce an innovative, patient focused approach to
medication management. The Patient Centered Medication Management (PCMM) model is
focused on administration of non-parenteral medications and insulin in acute care settings (See
supporting information in file figure 1) (Prestie & Koch 2011). PCMM is an expansion of the
self administration process which involves the patient throughout their hospital stay. It contains
the elements of flexible medication times, health care aides (HCA) assistance and patient self
administration of medication. PCMM is intended to increase transparency among the health care
team, improve patient empowerment, encourage the patient to participate in their own health care
and improve staff and patient satisfaction. Nurses, registered nurses and licensed practical
nurses, are the primary medication administrators in acute care but support from physicians,
pharmacists, healthcare leaders, other health professionals, patients and families would be
necessary for acute care medication management to evolve to a patient centered approach.
The PCMM model was developed during the commissioning phase of a new hospital,
South Health Campus, in Alberta. Its design was based on applicable; federal and provincial
legislation, health professionals’ standards and Alberta Health Services governance documents.
It aligns with the hospital’s foundational pillars of patient and family centered care, collaborative
care, innovation and wellness (Alberta Health Services 2013).
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Background
Definitions
To understand the PCMM model it is important to have clear definitions of terms that are
associated with it. Medication management is the broadest view health professionals can take in
regards to medication. It involves procurement, storage, prescription, preparation, dispensing,
administering, patient monitoring, patient education and evaluation of the medication
management process (Accreditation Canada 2013). Under medication management a health
professional has a variety of specific activities, for example; performing medication
reconciliation, researching medications, adjustment of medication schedules, providing patient
education, monitoring of the medication effect, and evaluation of the medication regimen. Many
health care professionals; pharmacist, pharmacy technicians, physicians and nurses, as well as
other healthcare workers; unit clerks and pharmacy aides, are involved in acute care medication
management.
Medication administration is one aspect of medication management (Accreditation
Canada 2013). Medication administration is a cognitive and interactive aspect of patient care and
is more complex than the simple task of giving a medication to a patient. The process includes
providing medication to a patient for the purpose of immediate use and includes patient
assessment, preparation of medication, calculation and verification of medication dose, patient
education and the monitoring of the medication effects. (CARNA 2007). Historically nurses
have been given the task of medication administration in acute care (Manias et al. 2004).
There are numerous definitions of patient centered care in the literature (Kitson et al.
2012). Some common themes associated with patient centered care include: patient participation,
clinician-patient relationship, and clinical care environment (Kitson et al. 2012). The PCMM
model of patient centered care is defined as inclusion of the patient perspective in planning,
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delivering and evaluating their health care (IPFCC 2011). Concepts associated with patient
centered care that are necessary in the PCMM model include patient/health care team
collaboration, active patient participation, information sharing and respect.
Literature Review
Currently there is no literature on patient centered medication management therefore a
review of self administration of medication literature was undertaken. Self administration of
medication processes have been utilized and presented in the literature since 1959 (Lam et al.
2011, Wright et al. 2006). The self administration models presented previously in the literature
focuses on the patient administering their own medications (Lam et al. 2011, Manias et al. 2004,
Murray 2006, Wright et al. 2006). Some of these models include a phased approach that included
direct and indirect supervision by a nurse (Lam et al. 2011, Murray 2006, Wright et al. 2006).
Primary reasons for introducing self administration programs where to determine the
patient’s ability to manage their medication regimen, to teach a patient how to administer their
medications, or to encourage patient independence (Manias et al. 2004, Wright et al. 2006). Self
administration of medications in acute care has been associated with patient empowerment,
patient satisfaction, increase patient knowledge of medications, and increase patient’s self
confidence regarding managing medication (Lam et al. 2011, Manias et al. 2004, Murray 2006,
Wright et al. 2006). Many studies hypothesized that adherence to medication regimens in the
community would improve if self administration occurred in acute care but this has not been
satisfactorily proven partially due to the short time frame of the follow up in the studies post
discharge, small study size and no verified compliance measurement tool (Lam et al. 2011 ,
Wright et al. 2006).
Numerous studies on self administration of medication have focused on the complex
patients (Manias et al. 2004, Murray 2006). Complex patients have been the focus of self
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administration since they tend to have more complex medication regimens, physical limitations
and decrease cognitive functions that impact their ability to manage their medications in the
community settings (Manias et al. 2004, Murray 2006). Self administration has been used with
the complex patient population to improve compliance with their medication regimen and to
assess their physical and cognitive ability to manage their medications correctly (Manias et al.
2004, Murray 2006).
Hospital medication administration times contrast greatly with home medication
administration times and can change the therapeutic effect of the medications (Jarman et al.
2002). Patient centered medication times have been shown to improve sleep, decrease
medication errors and improve patient satisfaction (ISMP 2011, Manias et al. 2004). When
instituting patient centered medication administration times nursing workload did not increase
but the work may have moved to a different nurse due to work shifts.
Most studies stress the importance of assessing patients by utilizing a standardized
assessment tool. Common elements include assessment of competence, mental status, physical
characteristics and willingness to participate (Fuller & Watson 2005, Manias et al. 2004, Murray
2011, Wright et al. 2006). The studies designated the assessment as a nursing activity but
cautioned regarding the increase in workload (Fuller &Watson 2005).
For self administration models to be effective tools to assist the patient have been
employed. Medication storage tools include blister packs, dosettes, or medication bottles (Lever
et al. 2008). Once a patient medication storage tool has been selected it is imperative to identify
the health professional responsible for the set up and replenishment of the tool (Lever et al.
2008).
Patient medication administration records are necessary for the patient to record their
ingestion of medications, to ensure communication with the health care team and to ensure
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monitoring of the effects of the medication (Manias et al. 2004). Ideally the patient medication
administration record should be an easy to use standardized form to ensure easy transitions
throughout the hospital (Manias et al. 2004).
Benefits
Self administration of medication benefits specific to the patient described in the
literature include promoting independence, enhancing knowledge, fostering confidence,
elevated competence in medication management, improved understanding of their medication
regimen and increased satisfaction in hospitalization (Grantham et al. 2006 , Lam et al. 2011,
Manias et al. 2004, Murray 2011). The large majority of patients who participated in a self
administration of medication programs in acute care stated they would participate again if
hospitalized (Manias et al. 2004, Murray 2011). Another benefit for patients participating in
PCMM is the medication administration schedule is personalized to integrate with the patient
lifestyle (Jarman et al. 2002).
Hospital benefits include decreased length of hospital stay, decrease in medication errors,
lower readmission rates, increase self care in the community and improved health care team
medication knowledge (Grantham et al. 2006, Lam et al. 2011, Manias et al. 2004, Murray
2011).
Challenges
Challenges described in the literature can be categorized as patient safety, professional
accountability and resource availability (Wright et al. 2006). Patient safety concerns include
clear and timely communication between patients and the health care team and safe secure
storage of medication (Manias et al. 2004). Another patient safety concern is difficulty ensuring
the patient achieves independent self administration during the hospital stay due to the trend to
shorten the length of hospitalization (Lam et al. 2011, Manias et al. 2004, Murray 2011).
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Additional resources required for successful self administration implementation include a patient
medication administration record and written patient education (Lever et al. 2008).
Professional accountability in regards to self administration include resistance to move
away from the exiting medical model (Grantham et al. 2006 , Lam et al. 2011, Murray
2011).The medical model focuses on the responsibility of the health professionals and many are
reluctant to relinquish control. As well, the patient roll traditionally is the sick roll or subject and
they are not normally engaged as an active participant in their own treatment regimen (Lever et
al. 2008, Manias et al. 2004).
Under Alberta legislation, oral medication administration is not a restricted activity,
meaning it does not carry significant risk when performed and does not need advanced skills to
complete. (Province of Alberta, 2005) Both Registered Nurses and Licensed Practical Nurses
include medication administration in their list of competencies (Province of Alberta, 2005).
Within their scope of practice nurses can indirectly supervise HCA performing medication
assistance (CARNA et al. 2010).
The HCA is an unregulated health care worker who can take additional education to gain
an advanced competency in medication assistance, which teaches the five rights of medication
administration; right patient, right drug, right time, right route and right dose. (Alberta Health &
Wellness, 2001) The nurse is accountable for; appropriately assigning the task according to the
HCA’s competence, determining the level of supervision required, overseeing the delivery of
medication by the HCA and monitoring patient outcomes (CARNA et al. 2010). The HCA
would be assisting with medications specifically for competent, stable patients. Medication
assistance involves delivery of medications, identification of proper patient, identification of
correct medication, assistance with accessing the medication and properly documenting the
delivery and ingestion of the medication (Alberta Health and Wellness 2001).
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Resource availability includes limitations on health care team time and storage devices
availability (Murray 2011, Wright et al. 2006). Time for patient assessment and preparation of
the patient specific storage devices would need to be allocated to the nurses and pharmacy
technicians responsible for completing these tasks (Lever et al. 2008). This time may be gained
from having other health care professionals increase their scope of practice which would permit
nurses and pharmacy technicians time to accomplish these additional tasks (Manias et al. 2004,
Wright et al. 2006). Budget to purchase the patient storage devices would also need to be in
place for a successful implementation (Lever et al. 2008, Wright et al. 2006).
PCMM Model
The PCMM model embraces patient participation throughout the continuum of acute care
and incorporates the elements of self administration. The vision is that all patients will
participate in PCMM within the hospital. The key elements of PCMM include health care team
roles, the patient’s status and medication requirement. In PCMM medication administration can
take one of three pathways; nurse administration, collaborative administration and self
administration.
Initiation
PCMM is initiated when the patient is being admitted into acute care for a period greater
than 24 hours. Key nursing activities that occur during initiation of PCMM are; adjusting the
medication schedule to reflect the patient’s home schedule, completing the patient medication
assessment tool, identifying any chronic medications that the patient can self administer and
determining if the current medication regimen is stable or unstable. The outcome of these
activities is the nurse assigning the patient to the appropriate administration pathway; nurse
administration, collaborative administration, or self administration.
Nurse Administration Pathway
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Complete medication administration will be done by a nurse in the nurse administration
pathway because; the patient oral medication regimen is not stable, the patient is not cognitively
intact, the patient is receiving narcotics, or the patient does not wish to participate in taking their
medications independently. In this pathway the nurse continues to provide education when a new
medication is introduced or the dosing is changed. As well the nurse continues to assess the
patient’s physical and cognitive abilities using the assessment tool.
If the patient was designated to this pathway because the patient does not wish to
participate in taking their medications independently it is important for the health care team to
explore the patient’s belief around the sick role (Manias et al. 2004). This exploration will allow
the nurse to identify points where the patient can participate in their care.
Collaborative Administration Pathway
The requirements for the collaborative administration pathway is that the patient has
been; deemed cognitively intact, is not utilizing narcotics for pain management, and is willing to
participate in medication administration. This pathway encompasses the nurse administering
medications that have not been stabilized and parenteral medications. The nurse would be
responsible for patient assessment, preparation of medication, calculation and verification of
medication dose, patient education, monitoring of effects pertaining to all medications and
documentation of these activities.
The HCA would assist patients that have been scored as cognitively stable either by
delivering the medication to the patient or assisting the patient in ingesting the medication. The
HCA would be responsible in documenting delivery of medications and communication with the
nurse when medications are not ingested.
The collaborative pathway will be the core pathway for patients that do not administer
their medications independently in the community.
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Self Administration Pathway
The self administration pathway would be utilized for patients that are; cognitively intact,
have the physical ability to administer their own medications, are willing to participate and who
manage their medications independently in the community. The pharmacy would support this
pathway by supplying the patient with a day’s worth of medications in a delivery device such as
a dosette or blister pack. A patient medication administration record would be given to the
patient for them to be aware of medication administration time and record their medication
administration.
The nurse would be responsible for; patient assessment, calculation and verification of
medication dose, patient education specific to their medications, monitoring of effects pertaining
to all medications and administration of any parenteral medications. The nurse also monitors the
patient medication self administration and discusses any concerns or issues with the patient and
health care team.
Discharge
The discharge activities related to the PCMM model are only enacted when patients have
limited or no contact with health professionals in the first 72 hours following discharge. On the
day of discharge medication reconciliation, any additional patient education, empting patient’s
storage device of any medication and returning the storage device to the patient for home use are
the tasks completed by a health professional.
The PCMM Models final steps are 48 to 72 hours post discharge. The primary activity
that an acute care nurse or pharmacist would perform is a telephone interview to determine the
patient’s adherence to the medication regimen. Additional medication education may be
provided at this time as well if required. If it is determined that there are difficulties in adherence
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to the medication regimen the patient would be referred to a community health professional for
further follow up.
PCMM Tools
Assessment Tool
The PCMM Assessment Tool (See additional information in file table 1) was adapted from the
Self-Medication Risk Assessment Instrument (Fuller & Watson 2005) and DRUGS (Lam et al.
2006). The PCMM assessment tool uses commonly agreed upon categories to assess cognitive
abilities and physical impairments. New categories included in the PCMM assessment tool are
the patient’s willingness to participate and whether pain control is required. Patients receiving
narcotics for pain control would be viewed as being potentially cognitively impaired and
therefore would revert to the nurse medication administration pathway.
The outcome of the assessment will place the patient in the appropriate pathway: nurse
administration if any criteria is present under this column, collaborative administration if no
nurse pathway criteria is present and at least one criteria in the collaborative column is present,
or self administration if all self administration column criteria are present.
The assessment tool was designed to be easily applied and accommodated the medication
assistant role that a HCA can fulfill in Alberta. The HCA can deliver oral medications to patients
that are unable to retrieve their medications and assist patients who are physically unable to
administer their own medications.
Documentation Records
To support the collaborative administration pathway the typical medication
administration records would need to be modified to include an area for documentation of nurse
administration, patient education, medication delivery and HCA assistance. In addition to
documentation of HCA assistance a communication process would need to be developed to
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notify the nurse if a patient did not receive a medication and the reason why the HCA assistance
was not completed.
A hospital approved patient medication administration record would also need to be
developed to ensure monitoring of patient medication management by the health care team when
the self administration pathway is being utilized. A patient medication administration record
should include areas to document delivery of medication, ingestion of medication and any
incidences where the patients medication regimen was not followed to ensure good
communication among the health care team.
Discussion
Benefits
By utilizing the PCMM model medication administration will be transparent throughout
the health care team, involve and empower the patient, and improve patient and staff satisfaction.
PCMM will promote a patient centered environment which has been shown to improve recovery
and decrease readmission rates (Murray 2011). By giving patients the responsibility of managing
their own medications when they are deemed capable promotes the idea of wellness and
minimizes the sick role that some patients perform when in acute care setting (Manias et al.
2004).
PCMM also promotes collaborative care among the health care team and patient. For
PCMM to be effective nurses, HCA, pharmacists, pharmacy technicians and physicians will need
to consult, strategize and formulate a plan of medication management working in partnership
with the patient. By collaborating health care professionals will increase their understanding of
each other’s roles, scopes of practice and exchange interprofessional knowledge within their
health care team (Orchard, et al. 2005).
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For PCMM to be effective an increased focus on patient medication education is
necessary. Patient education may be provided by a variety of different health professionals but it
results in the patient and health care team gaining and sharing knowledge (Murray, 2011).
PCMM promotion of patient education will also result in meeting Accreditation Canada’s
standards (2013).
By involving the patient throughout their acute care hospital stay the patient will be more
informed of medication management and their specific medication regimen. Patients will take on
at least partial responsibility for their medications while in acute care and therefore be better
equipped to manage their medication regimen post discharge.
By creating and utilizing PCMM as a hospital wide process patients can expect to be
involved in medication management including administering their own medications when
appropriate (Wright et al, 2011). Tools that support safe storage and appropriate documentation
will be readily available to patients and the health care team. The goal is that patients will move
through the PCMM pathways with ease.
The medication administration record will need to be modified to ensure all members of
the collaborative health care team, including the patient, have an appropriate place to document
their role in medication management. Areas that are suggested for inclusion in a medication
administration record supportive of PCMM include; administration (nurse), education (nurse,
pharmacist) delivery (nurse, HCA, pharmacy technician) and ingestion (nurse, HCA, patient). By
developing the advanced medication administration record communication throughout the health
care team, which includes the patient, should improve from current practice.
Challenges
The major challenges arise during implementation of the PCMM model. The PCMM
model requires changes to the traditional roles played by the health care team and the patient in
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relation to medication management. One of PCMM objectives is to utilize all members of the
health care team to their full scope of practice or ability. For existing roles to change discussions
between the professional nursing colleges and institutions regarding the role of the HCA in
medication management need to be undertaken. Professional nursing colleges need to review and
update their definitions of medication administration and focus on the cognitive aspects of
medication administration that are the responsibility of the nurse, allowing others, the patient or
HCA, to assume responsibility for the psychomotor tasks of delivery and ingestion.
For the PCMM model to be implemented effectively specific members of the health care
team will need to be designated to ensure that the storage of patient specific medications is
secure and accurate. This role may be designated to or split between pharmacy services and the
patient care unit. Secure medication storage for self administered or assisted medication
pathways need to meet Accreditation Canada(2013) standards. As well, they need to be easily
accessible to the health care team and when necessary the patient. If a specific consumable
device, such as a dosette, is used in the process then budgeting for the device will need to be
included in the PCMM implementation plan.
Implications for nursing
PCMM is a model that nurses can embrace which supports the movement toward patient
centered care. By dividing some of the traditional roles of the nurse among the health care team
the patient will benefit from the nurses advanced knowledge and training. The lower risk roles
of delivery and ingestions of oral medications can be assigned to HCA or the patient when
appropriate. Nurses will be able to focus more of their time on the advanced cognitive functions
of assessment, preparation of medications, patient education and monitoring of effects. The
PCMM model provides the patient with the greatest opportunity to participate in their medication
management and be involved in their acute care experience. This will raise their satisfaction
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level as they are actively involved in their treatment and become more attuned to their health
care needs.
Conclusion
The PCMM model is a patient centered approach to medication management in acute
care. PCMM has expanded on the principles of self administration that have been discussed in
the literature for over 40 years. To overcome the traditional model of medication administration
PCMM involves the patient in their medication administration through the continuum of care
during a hospitalization.
The goal of PCMM is to ensure the medication management is transparent to the
healthcare team and patient throughout the hospital stay. Patients are empowered as they are part
of a collaborative team focussed on their healthcare needs. Health care roles are redefined to
utilize all staff to their full scope of practice. Nurses will be better able focus on the cognitive
tasks of medication administration: assessment, preparation, monitoring and education. The
psychomotor tasks of oral medication delivery and ingestion become the responsibility of the
HCA or patient when appropriate.
Additional tools need to be implemented to ensure successful transformation to the
PCMM model. For PCMM to be successful a medication administration patient assessment
needs to be completed and updated on a continual basis to ensure the patient is moving through
the PCMM model appropriately. In the self administration pathway, a bedside storage device and
medication delivery process will need to be developed to ensure that medication security is
maintained. Incorporation of an advanced medication administration record is required to ensure
the appropriate member of the health care team, including the patient, can document their role in
medication administration.
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PCMM is expected to allow members of the health care team to focus more on their
higher level competencies while engaging the patient in their own medication regimen. This will
increase the satisfaction of health care team members and patients and will enable better patient
outcomes.
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