US Pharm. 2016;41(8)55-57.
As healthcare continues to evolve with advances in technology and increasingly effective pharmaceuticals, the population is living longer with chronic diseases such as cancer, coronary artery disease, diabetes, congestive heart failure (CHF), atrial fibrillation, rheumatoid arthritis, and chronic obstructive pulmonary disease (COPD). Pharmacists provide ongoing support, helping patients to manage their conditions on a long-term basis. Yet, to date, pharmacists and other healthcare professionals have not fully explored how best to promote effective lifestyle interventions to help manage chronic conditions—diseases that significantly burden the healthcare system.
In the United States, approximately 1 in 4 people has multiple (two or more) chronic conditions.1 This disease burden increases with age, with multiple chronic conditions occurring in 3 of 4 individuals aged >65 years.1 Multiple chronic conditions are associated with substantial healthcare costs in the U.S.1 Even though effective medications exist to manage most of these conditions, 20% to 50% of them are not taken as prescribed. This figure takes into consideration that 20% to 30% of prescriptions are never filled, and 50% are not continued as prescribed.2
Furthermore, access to primary care in the U.S. and elsewhere is becoming increasingly constrained because of the large number of patients and the aging of the population. Surveys in the U.S. reveal that average wait time for an appointment with a primary care physician is 19.5 days (range, 5-66 days).3 Wait times for access to specialist clinicians can extend to weeks.4 If this current trajectory is not redirected, patients may be denied needed medical interventions simply owing to lack of timely access to the healthcare system.
Allowing and encouraging patients to participate more directly in monitoring their health is one possible solution to this problem; however, it requires the creation of an environment where high-quality healthcare outcomes are attainable and sustainable, with an empowered healthcare consumer at the center of the process.
To attain this goal, the consumer needs to have a certain level of health literacy and disease knowledge, and possess the ability, skills, and technology necessary to easily monitor a chronic health condition, as well as the means to share this information with family members and others providing care. Ideally, this monitoring would be facilitated by an environment that is supportive and nonjudgmental.5
The creation of a supportive culture requires collaboration between the patient and his or her healthcare providers, including pharmacists. It is not enough to supply a technology to execute such a feat; organizations need to create environments that encourage collaboration. This may include redesigning current systems and processes and managing them so as to create positive experiences, thereby improving outcomes. Pharmacists can play a pivotal role in these efforts given the many possible points of contact they have with healthcare consumers.6 Pharmacists provide interventions daily when speaking with, serving, or engaging patients. These interactions, together with providing appropriate technologies and services, can foster true collaboration between the patient and the healthcare team.
A prerequisite for effective collaboration between patients and their caregivers is the correct technological infrastructure, in particular a longitudinal electronic health record (EHR) that is shared by individuals as well as all care-team members.7 The record must contain all data elements that are critical for quality care delivery, including medication history, medication therapy management (MTM) documentation, laboratory and imaging results, immunization and public health data, clinician notes, case management notes, administrative data, and patient-generated data. Data should be gathered from all sources, including point-of-care measurements, retail pharmacy measurements, and patient-generated home measurements.7 Unfortunately, robust and practical data for consumer reaction are often not available in a consumer-friendly format. This problem can be remedied if the right technologies are in place and aligned with the concept of personalized healthcare.8
In addition to health information technology, patient-facing e-health tools are another innovation that allows more patients to actively participate in maintaining their health and supports collaborative care with providers. For example, the collaborative-care model is emerging as a viable approach to leveraging expertly trained clinical pharmacists as active team members in renal clinics, where management of blood pressure (BP) in patients with chronic kidney disease and a renal transplant is enhanced by engaging patients in a home-monitoring setting using web-enabled telehealth.9
The use of remote patient home-monitoring devices also shows promise for chronic conditions such as diabetes, coronary heart disease, CHF, COPD, and atrial fibrillation. Examples of such technologies are devices that allow patients to monitor BP, weight, blood glucose, oxygen saturation, activity level, and international normalized ratio (INR).10
Educating and Engaging Patients
How can pharmacists really motivate the healthcare consumer who visits the pharmacy? Engaging patients in self-management programs depends largely on a communication process that builds successful rapport.11 As pharmacists have long known, the key to a good counseling session is communicating on a level that is understandable and practical, yet impactful for the patient.11 A strong clinician-patient relationship is the cornerstone to any successful patient engagement and therapeutic paradigm, including participation in the decision-making process and patient adherence to treatment recommendations.
Educating patients on how to take care of their health and imparting health information is also important to successful patient engagement. Ideally, patients should be approached at their current level of health literacy, with sensitivity to cultural traditions.12 Patients with health literacy deficits may be embarrassed to reveal that they have a limited understanding of their condition; therefore, it is reasonable for the pharmacist and staff to assume that all patients will have gaps in health literacy. This assumption allows the conversation to take place at the appropriate level while maintaining a supportive and non-judgmental environment.
Care should be taken by the pharmacist and pharmacy staff to ensure that patients are thoroughly familiar with their chronic medications, including when and how to take the drugs, what dose has been prescribed, whether the medication should be taken with food or on an empty stomach, what drugs (including herbal and OTC products) can interact, what side effects are possible, and how side effects can be recognized.13
Patient satisfaction with the encounter and treatment plan will be reflected in patients’ overall understanding of their situation, as well as their proactive engagement in decision making. In this scenario, as the patient modifies behavior to become more accountable in following through with medical interventions, primary medical outcomes will improve. For example, pharmacist-led chronic disease management has been shown to improve glycemic, BP, and lipid goal attainment.14
Pharmacists can play an important role in giving patients information about self-management and in enhancing motivation and self-efficacy.14 Current evidence suggests that patients who are engaged in their healthcare in a pharmacist-led program will realize measurable improvements in quality.14 Table 1 presents key concepts for involving patients developed by the Agency for Healthcare Research and Quality.15
In addition, pharmacists can take the following steps to enhance patient-engagement opportunities3:
• Identify individuals at risk for poor health outcomes, whether due to poorly managed disease states, a lack of supportive care, or noncompliance with medication instructions
• Help patients manage their medications with appropriate education and reminder alerts. Whether in the form of an app on a mobile device or e-mail on a computer, reminders can support and educate the patient by alerting them at the appropriate times to take medications, by providing correct dosage information, and by properly instructing them on how to take the medications based on clinician-specific directions
• Use patient portals to foster medication adherence. A patient portal is a secure website that allows a patient to access his or her medical records. MinuteClinic, a division of CVS Caremark, is one example of a healthcare provider that it is adopting an electronic health record that will feature advanced patient-portal capabilities to enable information sharing with its patients.16 Answers to patient questions can also be provided through portals, resulting in a speedy resolution of queries, while providing real-time education to enhance a patients’ understanding of their medications and disease states.
For example, providing patients with a portal to view their BP readings over time can promote self-management and increase medication adherence. By reviewing fluctuations in BP, patients are able to associate undesirable increases in BP to changes in medication use and lifestyle indiscretions. This process can enhance awareness of factors that influence BP and potentially enhance personal accountability for improved BP management.17
As healthcare continues to evolve, having concrete, data-driven strategies for engaging patients is becoming increasingly important.18 Easy access to practical data allows patients to better manage their health. Pharmacists can take an active role in this effort by using technological innovations, such as EHRs, reminder alerts, and secure patient portals to help patients manage their medications and to engage them in their care.
1. U.S. Department of Health and Human Services. About the multiple chronic conditions initiative. www.hhs.gov/ash/about-ash/multiple-chronic-conditions/about-mcc/index.html. Accessed July 9, 2016.
2. CDC. Noon conference. March 27, 2013. www.cdc.gov/primarycare/materials/medication/docs/medication-adherence-01ccd.pdf. Accessed July 17, 2016.
3. Mazzolini C. Survey shows patients in many cities wait weeks for appointments. Medical Economics. February 24, 2014. http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/aca/survey-shows-patients-many-cities-wait-weeks-appointments. Accessed July 9, 2016.
4. Rosenthal E. The healthcare waiting game. New York Times. July 5, 2014. www.nytimes.com/2014/07/06/sunday-review/long-waits-for-doctors-appointments-have-become-the-norm.html?_r=0. Accessed July 9, 2016.
5. Advisory Committee on Training In Primary Care Medicine and Dentistry. Health literacy and patient engagement. Twelfth Annual Report to the Secretary of the United States Department of Health and Human Services and the Congress of the United States. September 2015. www.hrsa.gov/advisorycommittees/bhpradvisory/actpcmd/Reports/twelfthreport.pdf. Accessed July 9, 2016.
6. Agency for Healthcare Research and Quality. AHRQ health literacy tools for use in pharmacies. November, 2015. www.ahrq.gov/professionals/quality-patient-safety/pharmhealthlit/tools.html. Accessed July 9, 2016.
7. Angaran DM. Documentation. In: Angaran DM, Whalen KL, eds. Medication Therapy Management: A Comprehensive Approach. 2015. New York, NY: McGraw-Hill; 2015. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1079§ionid=61424182. Accessed July 13, 2016.
8. Tunnah P. Time for some healthcare New Year’s resolutions. December 30, 2015. www.socialmediatoday.com/social-business/time-some-healthcare-new-years-resolutions#sthash.bBNDxdZg.dpuf. Accessed July 9, 2016.
9. Aberger EW, Migliozzi D, Follick MJ, et al. Enhancing patient engagement and blood pressure management for renal transplant recipients via home electronic monitoring and web-enabled collaborative care. Telemed J E Health. 2014;20(9):850-854.
10. Figge H. Health information technologies in cardiology: mobile devices, home monitoring, and e-prescribing. US Pharm. 2015;40(2):58-60.
11. Hermansen-Kolbulnicky CJ. Oral and nonverbal communication in medication therapy management. In: Angaran DM, Whalen KL, eds. Medication Therapy Management: A Comprehensive Approach. New York, NY: McGraw-Hill; 2015. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1079§ionid=61424028. Accessed July 13, 2016.
12. Agarwal AK, Murinson BB. New dimensions in patient-physician interaction: values, autonomy, and medical information in the patient-centered clinical encounter. Rambam Maimonides Med J. 2012;3(3):e0017. www.ncbi.nlm.nih.gov/pmc/articles/PMC3678821. Accessed July 9, 2016.
13. Hardin H, Ferrer J, Mobley L. Conducting the comprehensive medication review. In: Angaran DM, Whalen KL, eds. Medication Therapy Management: A Comprehensive Approach. New York, NY: McGraw-Hill; 2015. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1079§ionid=61423929.Accessed July 13, 2016.
14. Greer N, Bolduc J, Geurkink E, et al. Pharmacist-led chronic disease management: a systematic review of effectiveness and harms compared with usual care. Ann Int Med. 2016;165(1):30-40.
15. Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research and Quality. June 2013. www.ahrq.gov/professionals/systems/hospital/engagingfamilies/guide.html. Accessed July 9, 2016.
16. Monegain B. MinuteClinic taps Epic for EMR. Healthcare IT News. March 10, 2014. www.healthcareitnews.com/news/minuteclinic-taps-epic-her.Accessed July 17, 2016.
17. CDC. Self-Measured Blood Pressure Monitoring: Action Steps for Clinicians. Atlanta, GA: Centers for Disease Control and Prevention, US Dept. of Health and Human Services; 2014.http://millionhearts.hhs.gov/files/MH_SMBP_Clinicians.pdf. Accessed July 9, 2016.
18. Underhill A. 5 proven ways to engage patients. Medical Practice Insider [e-newsletter]. September 15, 2014. www.medicalpracticeinsider.com/best-practices/5-proven-ways-engage-patients. Accessed July 9, 2016.
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