Devin Schmidt, Pharm.D., BCACP, ambulatory care pharmacist, Mercy Health Muskegon, Muskegon, Mich.
In 2014, the Pharmacists' Patient Care Process was created by the Joint Commission of Pharmacy Practitioners (JCPP) after a need was recognized for a consistent process in the delivery of patient-centered care across various practice settings of the pharmacy profession. Supported by 13 national pharmacy organizations, this process set out to engage patients and caregivers using effective communication to promote comprehensive approaches to deliver care in collaboration with other members of the healthcare team.1 Since the publication of this process, many pharmacists and student pharmacists have begun using these steps to employ consistent patient care to their practices.
Recently, the American Pharmacists Association (APhA) highlighted implementing this process in transitions of care.2 This guide serves to provide specific guidance, directly related to patient care during a healthcare transition, within each of the principles defined in the Pharmacists' Patient Care Process.
Collect - A pharmacist should collect the necessary subjective and objective information to enable safe and efficient care transitions. Collected information should include, but not be limited to, data to optimize medication reconciliation, medication counseling, medication delivery and/or dispensing, and post discharge follow up via telephone or face-to-face visit. Depending on the care transition, this would include a comparison of the existing and previous medication regimens, patient's personal medication list and patient provided history.
Assess - Using the information collected, assessment of the indication, efficacy, safety and ease of adherence for each medication should be performed at each care transition. Assessing both acute and chronic disease states is important during a care transition, even though it may have been an acute concern that lead to this change in level of care. Attention should also be given to health literacy, the patient's social support system, potential barriers, such as transportation or financial barriers, and the need for assistance in setting up follow up care.
Plan - When creating a care plan during various care transitions, each medication related problem needs to be addressed to optimize the patient's medication regimen, prioritizing resolving barriers and ensuring safety. Care plans should align with the therapy goals established by the healthcare team. Engaging the patient with effective communication is important to educate and empower the patient to self-manage their health when discussing the plan.
Implement - Effective collaboration between pharmacists and other members of the healthcare team is imperative to address identified barriers to safe and efficient transitions. Potential collaborations might include utilizing other disciplines to help address barriers with home health, transportation, insurance enrollment, culture, language differences or various levels of health literacy. Pharmacists are uniquely suited to provide patient specific education on their complete medication list at transitions and empower self-management. Providing information to other members of the healthcare team that were not involved in the care transition is also an integral component for implementing a successful plan.
Follow-up: Monitor and Evaluate - Once a patient completes a care transition, it is important that the implemented plans are monitored and evaluated to determine its efficacy, as well as providing effective hand-offs to ensure continuity of care throughout transitions. Follow up phone calls, home or office visits and medication reviews aide in the assessment of adherence and self-care of the implemented plan.
Overall, various care transitions can involve different disciplines, tasks and responsibilities depending on the location of transition. However, utilizing the five steps of the Pharmacists' Patient Care Process provides a framework by which a consistent level of care across the pharmacy profession is provided during healthcare transitions.
1. The Pharmacists' Patient Care Process [Internet]. JCPP. 2014 [cited 2019Feb23]. Available from: https://jcpp.net/patient-care-process
2. American Pharmacists Association. Applying the Pharmacists' Patient Care Process to Care Transitions Services. February 2019.