Pharmacist care planning services: What matters most.

Introduction

Care planning services integral to primary health care are accessible to patients in many community pharmacies across Canada. Medication reviews and medication management are relatively new services provided by pharmacists in community practice, with 8 out of 10 Canadian provinces currently providing remuneration for these activities.[1] The MedsCheck program in Ontario and the Saskatchewan Medication Assessment Program form the basis of care planning, including services such as medication reviews and medication therapy management.[2] Medication reviews involve a structured assessment of patients’ prescription and nonprescription medication to optimize use and adherence, as well as update medication records.[2] Medication therapy management aims to ensure patients receive the best medication to achieve pharmacotherapeutic outcomes, with a focus on patient-centred goals.[2,3] While there is overlap in these services, care planning represents a process to identify a patient’s personal needs and goals, discuss options and coordinate a plan for how these goals will be met.[4] The process involves a range of activities, including patient assessment, medication review, interventions to resolve drug therapy problems, patient education and follow-up to monitor progress toward achieving goals of care.[5] Care plans are developed cooperatively with the patient, usually on an annual basis, and are shared with the patient and the patient’s other health care providers.

Since 2012, community pharmacies in Alberta may receive remuneration for Comprehensive Annual Care Plans (CACP) for patients who meet eligibility criteria described in the compensation plan for pharmacy services.[6-8] Research on the care planning services provided by community pharmacists in Alberta explored how the service was implemented and the perceived value to patients, pharmacists and other health care providers.[9,10] Key findings revealed that successful implementation of care planning services required changing the status quo, which involved adjustments to workflow and utilization of technology.[10] Patients valued care planning in terms of their experience with the service, noting that accessibility to care, reduced wait times and the co-creation of individualized plans mattered the most. Physicians valued collaboration and information sharing, as well as different perspectives that pharmacists provided on patient care. Pharmacists, while also valuing collaboration with patients and other health care professionals, found a renewed sense of responsibility and meaning in their role.[9]

The purpose of this article is to provide the practical lessons gleaned from this research and share what mattered most to patients, pharmacists, pharmacy technicians and other health care providers. These practical lessons may enhance the impact of pharmacist care beyond a single annual CACP service and elevate care planning as a necessary tool to provide primary health care services in community pharmacies. Pharmacists who are implementing or wishing to enhance their care planning services may find this information useful (Table 1). While these lessons are informed by research of Alberta pharmacists’ care planning services, there is a universality to them that may resonate with pharmacists from other jurisdictions.

Table 1

Care planning: What matters most

Develop your expertise	Participate in professional development to further develop expertise. Recognizing an area of expertise supported pharmacists in gaining confidence and a sense of contributing more to patient care.
Optimize roles and workflow	Optimize roles, workflow and space for pharmacists and pharmacy technicians to support implementation of the care planning service.
Customize the documentation	Develop a care plan template that supports the care planning process and facilitates sharing information that is clear, concise and consistent.
Schedule time for care planning	Schedule time for care planning with consideration to the time needed to prepare before seeing the patient, time with the patient, time to document/share information and time for follow-up.
Promote the service	Develop a standard description of the service, verbal and written, and share it with patients, members of the pharmacy team and others involved in the patient’s care to promote the service.
Involve the patient in the care planning process	Involve patients in every step of the care planning process and provide education and information in plain language to support engagement.
Outline responsibilities	Document and communicate specific responsibilities and actions in the care planning process.
Share information in a timely manner	Share care plan documentation with patients. Include a current medication list, concise action plan outlining patient’s goals, any health behaviour changes to implement and instructions for monitoring and follow-up.
Monitor progress and revise the care plan as needed	Revisit the care plan regularly to determine if specific goals are being achieved and goals revised based on new information, new drug therapy problems identified and new action plans to be implemented.
Explore possibilities for shared care plans	Strive to develop and implement shared care plans with other members of the health care team.

Develop your expertise

Professional development, both formal and informal, plays a role in helping pharmacists develop expertise and increase their confidence in providing care planning services. Pharmacists may provide care planning services initially in areas where they have more knowledge and experience. Formal certification, in areas such as diabetes or other specialties, shares a role in building confidence and recognition of pharmacists’ expertise by others.[10] Identifying learning gaps and learning by doing are also key strategies to expand care planning services. Pharmacists may also engage with peers to learn from each other and hone their skills related to care planning.

Optimize roles and workflow

Implementing care planning services “changes the status quo,” requiring thoughtful adjustments to workflow for pharmacists and pharmacy technicians.[10] Optimizing and defining team member roles, including the use of pharmacy technicians to identify potential patients eligible for the service and assist with the preparation of care plan documentation by preparing templates and medication lists, are common approaches.[10] Successful implementation also involves having a space to interview patients and to write up and document care plans, which means pharmacists moving out of the dispensary. The use of technology supports care planning services by enabling prompts that can flag eligible patients for care plans and follow-ups, accessing laboratory values via the provincial electronic health record and for documenting the care plan.

Customize the documentation

Customizing the care plan documentation to meet the needs of the intended audience is important. In sharing information, the care plan document itself represents pharmacists’ work previously not visible to others. The document itself is important in terms of content, format and appearance. Care plan documents can be tailored to reflect the pharmacist’s practice and to share information. There is no standard format or preferred approach to the care plan document. However, consistency and clarity are key features.

Schedule time for care planning

Care planning is time and resource intensive and should be reserved for patients most likely to benefit.[11] Pharmacists may schedule more time with patients, anticipating the time it requires to complete the care plan. Patients highly value the time pharmacists spend with them to discuss their medications and medical conditions and to explain the plan to them. The value of the care plan is associated with reduced waiting time to see a health care professional and convenient access to care.[9]

Promote the service

There is a need to communicate consistently to patients about care planning services. Patients are often not familiar with the term care plan, and many pharmacists use terminology such as medication reviews to refer to the service, which leads to confusion among patients. Some patients are not aware of whether they have received a care plan prepared by a pharmacist.[9] Providing information to patients about care planning services, including purpose, the patient’s role, pharmacist’s role, physician’s role, goal setting, action plans and responsibilities, may further enhance patient engagement and the ability to meet the goals of care.

Involve the patient in the care planning process

Collaborating with patients to co-create care plans may represent a paradigm shift for some pharmacists. Care planning services require pharmacists to listen to patients, understand their priorities and develop health goals that are important to them. Patient-centredness is integral to the care planning process. The process includes developing a shared understanding of what matters to the patient, setting goals collaboratively and creating an action plan together using shared decision making.[10,12] This is particularly important for patients with chronic medical conditions or multimorbidity who self-manage their conditions on a daily basis. Traditionally, pharmacists have been trained to provide patient education and “tell” patients about the importance of adherence. However, collaborative care planning requires a shift in mind-set.[13] Positive interactions with health care providers have been shown to be central to successful self-management.[14] Patients value pharmacists explaining their medical conditions and medications, as well as changes in medication, to them in a way they can understand.[9] Deprescribing provides additional opportunities for pharmacists to engage patients in setting health priorities and goals.

Outline responsibilities

Once the care plan is documented, specific actions and responsibilities need to be understood by all who are involved in care, including the patient. Consider the “5 Ws” of the care plan:

Who will be involved in enacting the plan? Patient or family member, pharmacist and/or physician?

What will be the specific action plans/recommendations? What will the pharmacist do? What will the patient be responsible for? What will the physician be responsible for? What questions does the patient have about the care planning process?

When and how often will follow-up occur?

Where and how will follow-up and monitoring occur? Who will be responsible for follow-up?

Explain the “why” to the patient. Why are you recommending changes to drug therapy? Why are you ordering lab tests? Patients will be more likely to remember what to do if they understand why it is important.

Share information in a timely manner

Sharing information is a vital component of the care planning process. While the care plan document itself serves an important role in facilitating information sharing to support collaboration with physicians,[9] both pharmacists and physicians may appreciate engaging in real-time information sharing (electronic communication, telephone or in person). In particular, communication at the initial stages of care planning to gather additional information and perspectives can assist in making informed drug therapy decisions. While care plans should be co-developed with patients, patients may not routinely receive a copy of the detailed care plan document. Pharmacists may wish to investigate and implement mechanisms to share care plans with patients when the care plan is created to further support patients achieving their health goals.[14]

Monitor progress and revise the care plan as needed

The care plan is a living document, and the process of care planning is dynamic. Monitoring and follow-up are critical to assessing patient response and relationship building. The care plan document can serve as a tool for clinicians and patients to set goals and to implement and measure progress over time.[11] Timely patient follow-up provides the opportunity to assess a patient’s care, support self-management activities, clarify possible misunderstandings, provide additional information such as test results and determine with the patient if adjustments in the plan are needed. Follow-up is also an opportunity to build interpersonal relationships and trust between patients and the pharmacist. This is critical as it is widely recognized that relationships are key to the provision of quality health care and lead to improved patient satisfaction and better health outcomes for chronic disease management. Care plan documents should include patient preferences regarding follow-up (e.g., over the phone or face to face when they come to the pharmacy).

The importance of close follow-up was highlighted by Necyk et al.[15] Their recent research in Alberta looked at the impact of a pharmacist CACP provided in the first few years (July 1, 2012, to March 31, 2015) on patient outcomes as well as physician visits, hospitalizations and emergency department visits.[15] While limited impact on health care use was noted, these authors conclude that further investigation is needed how to better operationalize CACP provided by pharmacists in order to affect health care use.

Explore possibilities for shared care plans

Finally, it is important to highlight the potential for shared care plans that support pharmacists’ contribution to team-based, person-centred care as primary health care providers.[16,17] Shared care planning is a strategy to improve patient engagement and coordination among providers in multidisciplinary teams across time and practice settings.[18] While shared care planning was not commonly seen in this study, care plans that are co-developed by the pharmacist, patient, physician and other health disciplines allow for timely interventions and follow-up for patients in the primary care setting.[9,10] Evidence suggests that shared care planning not only improves symptoms and clinical outcomes but also contributes to an improvement in adherence, screening rates and lower health care utilization.[19-23]

Conclusion

Care planning places the focus on patients and involves them in the care process. Remuneration of care planning services provides opportunities for pharmacists to use their knowledge and skills to address the health needs of Canadians. This requires changing the status quo not only in terms of organizational structures and roles of pharmacy team members but also in terms of how pharmacists engage and work with patients and other health care professionals. While the CACP is the end product of care planning by pharmacists, it may be the process of care, including the involvement of patients, ongoing monitoring and follow-up and collaboration with others that has the greatest impact on patients’ health. Sharing experiences and building on lessons learned are critical to ensuring pharmacists continue to move forward, address what matters most and show how they can make a difference as primary health care providers.