a process for performing medication assessments

A Process for A Process for Performing Performing Medication Medication

AssessmentsAssessments

A Process for A Process for Performing Performing Medication Medication

AssessmentsAssessmentsDerek Jorgenson, BSP, PharmD, Derek Jorgenson, BSP, PharmD,

FCSHPFCSHPCollege of Pharmacy and Nutrition College of Pharmacy and Nutrition

University of SaskatchewanUniversity of Saskatchewan

Objectives Objectives Objectives Objectives

1. Learn an overview of a medication

assessment process (with a focus on key

messages/tips and providing access to

resources for more in-depth learning)

2. Apply this process to a sample patient

case with diabetes (focus on process

NOT therapeutics)

MavisMavisMavisMavis• 77yo, lives alone and 77yo, lives alone and

independently independently • Referred by family doc Referred by family doc

for medication for medication assessmentassessment

• MD questionMD question: Do I need : Do I need to adjust gliclazide dose to adjust gliclazide dose for renal function (stable for renal function (stable slowly declining chronic slowly declining chronic kidney disease, CrCl = kidney disease, CrCl = 50 ml/min)50 ml/min)

MavisMavisMavisMavisMedication list (from Medication list (from dispensing system):dispensing system):1.1. Gliclazide MR 30 mg Gliclazide MR 30 mg dailydaily

2.2. Metformin 500 mg BIDMetformin 500 mg BID

3.3. Omeprazole 20 mg Omeprazole 20 mg dailydaily

4.4. Citalopram 20 mg dailyCitalopram 20 mg daily

5.5. Ramipril 5 mg HSRamipril 5 mg HS

6.6. Amlodipine 2.5 Amlodipine 2.5 mg dailymg daily

7.7. HydrochlorothiazHydrochlorothiazide 12.5 mg dailyide 12.5 mg daily

8.8. Salbutamol MDI Salbutamol MDI prnprn

What is a Medication What is a Medication Assessment?Assessment?

What is a Medication What is a Medication Assessment?Assessment?

“A structured, critical examination of a

patient’s medications with the objectives of

reaching an agreement with the patient about

their treatment and optimising the impact of

medications on the patient’s health”

Hatah E, et al. Br J Clin Pharmacol. 2013

Who will benefit from a Who will benefit from a medication assessment with a medication assessment with a

pharmacist?pharmacist?

Who will benefit from a Who will benefit from a medication assessment with a medication assessment with a

pharmacist?pharmacist?No clear guidelines or evidenceNo clear guidelines or evidence……

• Multiple medicationsMultiple medications

• Recent hospitalization/new diagnosis Recent hospitalization/new diagnosis

• High risk medications (insulin, sulfonylureas, High risk medications (insulin, sulfonylureas,

anticoagulants…esp soon after initiation)anticoagulants…esp soon after initiation)

• All people with diabetes??All people with diabetes??

• Can use a screening tool available at: Can use a screening tool available at:

www.usask.ca/pharmacy-nutrition/primarycarewww.usask.ca/pharmacy-nutrition/primarycare

Medication Assessment Medication Assessment Process: THREE STEPSProcess: THREE STEPSMedication Assessment Medication Assessment Process: THREE STEPSProcess: THREE STEPS

1.1. Interview the patient Interview the patient (collect info from (collect info from

the patient the patient andand their profile/chart) their profile/chart)

2.2. Systematically identify drug therapy Systematically identify drug therapy

problems (DTPs)problems (DTPs)

3.3. Create a care plan Create a care plan to resolve problems to resolve problems

(now) and follow up / monitor (in the (now) and follow up / monitor (in the

future)future)Cipolle, Strand, Morley. Pharmaceutical Care Practice, Cipolle, Strand, Morley. Pharmaceutical Care Practice, 2012.2012.

Step 1Step 1: The Patient : The Patient InterviewInterview


PURPOSE:PURPOSE:

Collect the relevant information that you Collect the relevant information that you

will need to complete your assessmentwill need to complete your assessment

o Are MavisAre Mavis’’ drug therapy needs being drug therapy needs being

met?met?

o Are there any drug therapy problems?Are there any drug therapy problems?• Does her gliclazide dose need to be Does her gliclazide dose need to be

adjusted?adjusted?

MavisMavisMavisMavis

What additional What additional information did information did you decide you you decide you needed from needed from

Mavis during your Mavis during your small group small group discussion?discussion?






6.6. Amlodipine 2.5 Amlodipine 2.5 mg dailymg daily

7.7. HydrochlorothiazHydrochlorothiazide 12.5 mg dailyide 12.5 mg daily

8.8. Salbutamol MDI Salbutamol MDI prnprn



KEY MESSAGE:KEY MESSAGE:

Use a Use a structuredstructured and and logicallogical approach approach

to the patient interview to ensure an to the patient interview to ensure an

efficientefficient and and comprehensivecomprehensive data data

collectioncollection

Organizing an Organizing an interviewinterview

Organizing an Organizing an interviewinterview

A structured and logical approach:A structured and logical approach:1.1. Introduction and setting the stageIntroduction and setting the stage

2.2. Determine pts’ main concernDetermine pts’ main concern

3.3. Gathering informationGathering information

4.4. Conclude the interview Conclude the interview

Be flexible…while maintaining controlBe flexible…while maintaining control

A structured & logical A structured & logical approachapproach


1. Introduction and setting the stage1. Introduction and setting the stageo Who are you and what is your role?Who are you and what is your role?o Purpose of the interview Purpose of the interview o Process of the medication assessmentProcess of the medication assessmento Estimate of time requiredEstimate of time requiredo Ensure privacy understoodEnsure privacy understood



2.2. Determine patient’s main Determine patient’s main

concerns (if any)concerns (if any)

““What is your biggest concern about What is your biggest concern about

the medications that you are the medications that you are

currently taking?”currently taking?”



3.3. Information gatheringInformation gathering• Start with getting a good medication Start with getting a good medication

historyhistoryo What are they taking and what are the What are they taking and what are the

indicationsindications

• Next go through each condition one at a Next go through each condition one at a timetime……o ask questions to get a detailed history of ask questions to get a detailed history of

the management / control of the management / control of eacheach condition condition

Use ‘lines of Use ‘lines of questioning’questioning’Use ‘lines of Use ‘lines of questioning’questioning’• Tell me about...Tell me about...

• Where is the symptom?Where is the symptom?• What is it like?What is it like?• How severe is it? (e.g. use a 1-10 scale)How severe is it? (e.g. use a 1-10 scale)• How long or how often has it been present?How long or how often has it been present?• How did it happen?How did it happen?• What makes it worse?What makes it worse?• What makes it better?What makes it better?Lots of examples available at: Lots of examples available at: www.usask.ca/pharmacy-nutrition/primarycarewww.usask.ca/pharmacy-nutrition/primarycare



Gather any other relevant info Gather any other relevant info (depending on (depending on case) case)

o allergies and intolerancesallergies and intoleranceso other medical conditions or symptoms other medical conditions or symptoms

• Consider ‘head to toe’ approach/review of systems Consider ‘head to toe’ approach/review of systems o family/social historyfamily/social historyo caffeine/alcohol/smoking/other drug usecaffeine/alcohol/smoking/other drug useo immunizationsimmunizationso compliance aids and devicescompliance aids and deviceso Cognitive and functional statusCognitive and functional status



4. Conclude the interview 4. Conclude the interview

o Summarize any issues identified or Summarize any issues identified or

actions that pt needs to takeactions that pt needs to take

o Next steps for the pharmacist and the Next steps for the pharmacist and the

patientpatient

o Ask pt if they have any additional Ask pt if they have any additional

questions or concernsquestions or concerns

Patient Interviewing: Patient Interviewing: Extra tipsExtra tips

Patient Interviewing: Patient Interviewing: Extra tipsExtra tips

• Takes time to get good at thisTakes time to get good at this

• 95% of DTPs can be ID95% of DTPs can be ID’’d from the pt interviewd from the pt interview

• Video on pt interview process in more detail: Video on pt interview process in more detail:

www.youtube.com/watch?v=Ec2bFjCsR0gwww.youtube.com/watch?v=Ec2bFjCsR0g

• For more information, tips, suggestions: For more information, tips, suggestions:


Mavis – Key info that Mavis – Key info that needed to be collectedneeded to be collectedMavis – Key info that Mavis – Key info that

needed to be collectedneeded to be collected• Very adherent overallVery adherent overall• Pt main concernPt main concern –on –on ““too many medstoo many meds””• MedsMeds: : Also on ASA 81 mg daily, Vit D 1000 IU daily, Also on ASA 81 mg daily, Vit D 1000 IU daily,

Valerian 150 mg HSValerian 150 mg HS• DiabetesDiabetes: :

o Diagnosed 10 yrs ago, never tried other medsDiagnosed 10 yrs ago, never tried other medso Home glucose AM fasting 3.8 – 7.0 mmol/LHome glucose AM fasting 3.8 – 7.0 mmol/Lo No hypoglycemia episodes (she knows Sx to watch No hypoglycemia episodes (she knows Sx to watch

for)for)o Does not know her A1c, urine albumin/creatinine Does not know her A1c, urine albumin/creatinine

ratioratioo No complications (other than CrCl=50ml/min)No complications (other than CrCl=50ml/min)


needed to be collectedneeded to be collectedIndication for omeprazole?Indication for omeprazole?• She doesnShe doesn’’t remember, but has no t remember, but has no GERD / dyspepsia symptoms. GERD / dyspepsia symptoms. • Reports having a bleeding ulcer ~15 Reports having a bleeding ulcer ~15 years agoyears ago• Taking omeprazole every day for 5-6 Taking omeprazole every day for 5-6 yearsyears• No side effects, covered by drug planNo side effects, covered by drug plan


needed to be collectedneeded to be collected

Indication for citalopram?Indication for citalopram?• Depression x 5 years ago (when Depression x 5 years ago (when husband died)husband died)• Working great – no concerns with Working great – no concerns with mood or tearfulness in last few yearsmood or tearfulness in last few years• No history of suicidal ideationNo history of suicidal ideation• No side effects, taking every dayNo side effects, taking every day


needed to be collectedneeded to be collectedIndication for ramipril, hydrochlorothiazide, Indication for ramipril, hydrochlorothiazide, amlodipine?amlodipine?• Hypertension for many yearsHypertension for many years• No history of vascular diseaseNo history of vascular disease• Does not remember any recent med changesDoes not remember any recent med changes• Home BP: 120/80 mmHgHome BP: 120/80 mmHg• BP in your pharmacy: 115/78 mmHgBP in your pharmacy: 115/78 mmHg• Some light-headedness every AM but no fallsSome light-headedness every AM but no falls• Taking all of them regularly, no side side Taking all of them regularly, no side side effectseffects



Indication for salbutamol?Indication for salbutamol?• Asthma x decadesAsthma x decades• Uses salbutamol 1-2 times week during Uses salbutamol 1-2 times week during allergy season, but no inhaled allergy season, but no inhaled corticosteroidcorticosteroid• No severe exacerbations, no ER visitsNo severe exacerbations, no ER visits• Has detailed asthma action planHas detailed asthma action plan• Inhaler technique excellentInhaler technique excellent



Indication for ASA and herbals?Indication for ASA and herbals?• ASA – her son told her to take it for ASA – her son told her to take it for her hearther heart• Vit D – doc told her to take it for Vit D – doc told her to take it for “health”“health”• Valerian – her son told her to take it Valerian – her son told her to take it for her depression years agofor her depression years ago

Medication Assessment Medication Assessment Process: Process: Three StepsThree Steps


1.1. Interview the patient Interview the patient (and collect info (and collect info

from the patient profile/chart)from the patient profile/chart)


problemsproblems




MavisMavisMavisMavis

What are MavisWhat are Mavis’’ drug therapy drug therapy

problems problems (DTPs)?(DTPs)?






6.6. Amlodipine 2.5 mg Amlodipine 2.5 mg dailydaily

7.7. Hydrochlorothiazide Hydrochlorothiazide 12.5 mg daily12.5 mg daily

8.8. Salbutamol MDI prnSalbutamol MDI prn

9.9. ASA 81mg QDASA 81mg QD

10.10. Vit D 1000 IU QDVit D 1000 IU QD

11.11. Valerian HSValerian HS

Step 2Step 2: Identifying drug : Identifying drug therapy problemstherapy problems

Step 2Step 2: Identifying drug : Identifying drug therapy problemstherapy problems

KEY MESSAGE:KEY MESSAGE:

o If you donIf you don’’t use a t use a systematicsystematic

(thought) process to identify DTPs in (thought) process to identify DTPs in

complex patients complex patients you WILL make you WILL make

mistakes, you WILL miss problems mistakes, you WILL miss problems

and you WILL NOT optimally care and you WILL NOT optimally care

for your ptsfor your pts

How to identify DTPs…How to identify DTPs…How to identify DTPs…How to identify DTPs…

1.1. Pattern recognitionPattern recognition

2.2. Therapeutic thought processTherapeutic thought process

3.3. Pharmacotherapy work-upPharmacotherapy work-up

Therapeutic thought Therapeutic thought process process FOUR questions to FOUR questions to

ask yourself regarding the pt ask yourself regarding the pt data you collecteddata you collected

Therapeutic thought Therapeutic thought process process FOUR questions to FOUR questions to

ask yourself regarding the pt ask yourself regarding the pt data you collecteddata you collected

1.1. Are the pts’ undesirable Are the pts’ undesirable signs/symptoms/ conditions being signs/symptoms/ conditions being causedcaused by drug therapy? by drug therapy?

2.2. Is drug therapy needed?Is drug therapy needed?

3.3. Is the patient taking the best Is the patient taking the best drug(s)?drug(s)?

4.4. Why is/are the drug(s) not Why is/are the drug(s) not working?working?Adapted from Winslade and Bajcar. Therapeutic Thought Adapted from Winslade and Bajcar. Therapeutic Thought

Process (1991)Process (1991)

Pharmacotherapy WorkupPharmacotherapy Workup: : FOUR STEPSFOUR STEPS

Pharmacotherapy WorkupPharmacotherapy Workup: : FOUR STEPSFOUR STEPS

1.1. Evaluate Evaluate appropriateness ofappropriateness of

indicationindication

2.2. Determine drug Determine drug effectivenesseffectiveness

3.3. Establish Establish safetysafety of the drug regimen of the drug regimen

4.4. Ensure patient Ensure patient

adherenceadherence/compliance/complianceCiplolle et al. Pharmaceutical Care Practice, 2Ciplolle et al. Pharmaceutical Care Practice, 2ndnd Ed (2004) Ed (2004)

For more For more information…information…

For more For more information…information…

www.usask.ca/pharmacy-nutrition/www.usask.ca/pharmacy-nutrition/primarycareprimarycare

BOTTOM LINEBOTTOM LINE: : Do not rely on Do not rely on pattern recognition alone…use a pattern recognition alone…use a systematicsystematic thought process when thought process when dealing with complex pts.dealing with complex pts.

MavisMavis’’ DTPs DTPsMavisMavis’’ DTPs DTPs



1.1. Interview the patient (and collect info Interview the patient (and collect info

from the patient profile/chart)from the patient profile/chart)


problemsproblems




Step 3:Step 3: Create a care Create a care planplan

Step 3:Step 3: Create a care Create a care planplan

• What is the purpose of a care plan?What is the purpose of a care plan?

• Can be formal (using standard forms) or Can be formal (using standard forms) or

notnot

What is in a care planWhat is in a care plan??

1.1. Need to define goals of therapyNeed to define goals of therapy

2.2. Need to make solution focused Need to make solution focused

interventions (if DTPs were identified) interventions (if DTPs were identified)

3.3. Need a monitoring planNeed a monitoring plan

1. Sample goals of 1. Sample goals of therapytherapy

1. Sample goals of 1. Sample goals of therapytherapy

Purpose of goals of therapy?Purpose of goals of therapy?

Short term goal example:Short term goal example:

• Reduce fasting glucose to 5-7mmol/L Reduce fasting glucose to 5-7mmol/L

within 1 monthwithin 1 month

Long term goals:Long term goals:

• Reduce A1c to <7% within 6 monthsReduce A1c to <7% within 6 months

• Prevent long term diabetes complicationsPrevent long term diabetes complications

2. Solution focused 2. Solution focused recommendationsrecommendations

2. Solution focused 2. Solution focused recommendationsrecommendations

• For when you find DTPs…For when you find DTPs…

• If you cannot make the change If you cannot make the change

independently, it is vital to provide independently, it is vital to provide specificspecific

recommendations (to physician, NP and the recommendations (to physician, NP and the

patient) re: patient) re: WHAT needs to be done, by WHAT needs to be done, by

WHOM and WHENWHOM and WHEN

• ““Suggest that the family doctor writes a new Suggest that the family doctor writes a new

prescription today to stop the gliclazide and prescription today to stop the gliclazide and

continue with metformin 500mg BIDcontinue with metformin 500mg BID””• NOT:NOT:

o ““Suggest physician start metformin todaySuggest physician start metformin today””o ““Suggest physician switch glyburide to Suggest physician switch glyburide to

alternate diabetes medicationalternate diabetes medication””

Example: GeneralExample: GeneralExample: GeneralExample: General

• Suggest reducing omeprazole for 20mg Suggest reducing omeprazole for 20mg

every other day for 2 weeks then stopevery other day for 2 weeks then stop

• Stop ASA todayStop ASA today

• Many others for Mavis…Many others for Mavis…

• Also need to consider how you would Also need to consider how you would

prioritize implementing multiple prioritize implementing multiple

changes (since Mavis has MANY changes (since Mavis has MANY

recommendations)recommendations)

Some examples: Some examples: MavisMavis

Some examples: Some examples: MavisMavis

3. Monitoring plans3. Monitoring plans3. Monitoring plans3. Monitoring plans

• ““If you donIf you don’’t follow up – you dont follow up – you don’’t caret care””

• Key is to define WHAT needs to be Key is to define WHAT needs to be

monitored, by WHOM and WHENmonitored, by WHOM and WHEN

• Be specificBe specific

• Consider effectiveness, safety, Consider effectiveness, safety,

adherence adherence

Sample Diabetes Monitoring Sample Diabetes Monitoring Plan: MavisPlan: Mavis

Sample Diabetes Monitoring Sample Diabetes Monitoring Plan: MavisPlan: Mavis

What Who WhenHome glucose Mavis Once daily variable

times

Hg A1c Family doc Every 3 months

Complications (feet, vascular, eyes)

Family doc Every 3 months

Urine albumin creatinine ratio

Family doc Annual

Serum creatinine Family doc Every 3 months

Hypoglycemic events

Pharmacist To ask at Rx refills

Metformin side effects

Pharmacist To ask at Rx refills

Serum electrolytes (K, Mg, Na)

Family doc Every 3 months

Medication adherence

Pharmacist To ask at Rx refiils

Step 3: Care PlansStep 3: Care PlansStep 3: Care PlansStep 3: Care Plans

KEY MESSAGES:KEY MESSAGES:

• Importance of clear, specific goals of therapyImportance of clear, specific goals of therapy

• Importance of specific, solution focused Importance of specific, solution focused

recommendations recommendations

• Importance of good monitoring & follow up Importance of good monitoring & follow up

planplan

Sample standardized forms available at: Sample standardized forms available at:


Additional ResourcesAdditional ResourcesAdditional ResourcesAdditional Resources

Medication Medication Assessment Video Assessment Video

Mini-SeriesMini-Series

Medication Medication Assessment Video Assessment Video

Mini-SeriesMini-SeriesBrought to you by the Medication Assessment Brought to you by the Medication Assessment

CentreCentre

www.youtube.com/user/MrPharmacistderek

http://www.youtube.com/user/MrPharmacistderek

More LIVE Sessions…More LIVE Sessions…More LIVE Sessions…More LIVE Sessions…

Day-long workshops:Day-long workshops:

o CPhA Conference May 31/14CPhA Conference May 31/14

o Can be specially organized for Can be specially organized for your staffyour staff

Want even more??Want even more??Want even more??Want even more??

QUESTIONSQUESTIONS

Derek JorgensonDerek [email protected]@usask.ca

QUESTIONSQUESTIONS

Derek JorgensonDerek [email protected]@usask.ca

a process for performing medication assessments

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medication assessment

interview process

patients medications

daily metformin

daily ramipril

daily citalopram

patient interviewpurpose

impact of medications