With the passing of the Affordable Care Act (2010), the U.S. government was tasked with identifying priorities to improve health care. One priority was to promote care coordination and effective communication (U.S. Department of Health and Human Services, 2011). Health care models have been evolving to place greater emphasis on these aspects through the use of health information technology (HealthIT) and integration of care coordinators into primary care and other practice settings (Lipson, Rich, Libersky, & Parchman, 2011). Care coordinators often develop and manage patient-centered care plans. It is important for individuals who provide and coordinate care to effectively communicate information as well as use the information contained in the care plan to best serve patients across the continuum of care. However, one of the current barriers to coordination of care is timely and effective communication. Electronic infrastructure to support communication and information transfer is critical to ensuring care coordination across diverse settings and patient populations. The sector of health care that handles this issue (i.e., HealthIT) plays a central role in coordinating care.
The U.S. government formed the Office of the National Coordinator (ONC) for HealthIT in 2004 and charged the federal entity with the responsibility of coordinating HealthIT development nationwide. The ONC (2015) issued a draft report, “Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap,” in which coordinated care is touted for its ability to improve patient outcomes and health care affordability. Furthermore, care planning is described as an important part of the process of providing coordinated care. Within the report, a call to action is issued, stating, “Individuals and their extended care teams (including family and caregivers) should utilize care planning to capture individual goals and preferences as part of longitudinal health information used across care settings” (ONC, 2015, p. 47). Through the implementation of a comprehensive HealthIT infrastructure, care planning can be a powerful tool in coordinating patient care and addressing medication management issues.
Care Planning: Definition, Purpose, and the Role of HealthIT
According to the ONC (2015), a care plan is a dynamically updated patient record that captures patients’ goals and preferences in a format readily accessible by care team members across disciplines and settings. Studies have shown that when patients set goals and are actively involved in treatment strategies, clinical outcomes (e.g., medication adherence rates, disease state control) improve and drug costs decrease (Kuntz et al., 2014; Shimp et al., 2012; Wilson et al., 2010; Wolever et al., 2010).
In specific patient populations, such as older adults, these considerations become even more important due to multiple comorbidities, medical complexity, and treatment burden (American Geriatrics Society, 2012). To determine realistic goals, the clinical value of a medication (i.e., benefit weighed against risk) must be assessed alongside the desired health and quality of life outcomes. A care plan that allows for easy documentation and communication of this information serves many purposes, such as in the nursing home, where an interdisciplinary team provides care. Nursing home residents often undergo transitions in care, which necessitate timely updates to care plans.
Fortunately, with increasingly widespread development and implementation of HealthIT and web-based applications designed specifically for care planning (i.e., e-care planning), the issue of accessibility may soon be diminished. Such is the vision for the future of health care in the United States (ONC, 2015) and, although the journey has begun toward reaching the goal of coordinated care through easily accessible and navigable health information across care settings, there is still much to be done before the vision is fully realized and implemented.
Medication use and Management: A Case for E-Care Plans
Care planning has the potential to improve patient care and outcomes in a variety of ways, including medication use and management. A complete care plan must contain an up-to-date list of medications. It has been well-documented in the medical literature that medication lists derived from provider records or claims data are prone to errors due to the use of medication products not captured in these records (e.g., over-the-counter [OTC] medications, vitamins, supplements, herbal therapies, medication samples), as well as stopped medications or dose changes (Bedell et al., 2000; Orrico, 2008; Roane, Patel, Hardin, & Knoblich, 2014; Stewart & Lynch, 2014). These factors make a patient-reported medication list documented in the care plan exceedingly valuable for medication-related applications, such as comprehensive medication management (CMM), medication therapy management (MTM), and medication regimen review (MRR).
The ONC (2015) describes CMM as a process in which the appropriate, safe, and effective use of medications is evaluated along with patient adherence. Pharmacists use a five-step, patient-centered approach to provide care as shown in Figure 1 (Joint Commission of Pharmacy Practitioners, 2014), which addresses medication-related problems and coordination of care. The care plan is an essential information source for efficiently completing these steps.
During the collection of information, the pharmacist develops or reconciles a current medication list and history for prescription and OTC medications, including vitamin and mineral supplements and herbal therapies. The assessment includes patient-centered, medication-related goals. To collaboratively implement the plan, as well as monitor and evaluate the resolution of medication-related concerns, effective documentation systems and communication vehicles are necessary.
Currently, documentation of CMM or MTM services typically occurs externally to patients’ medical records or care plans when conducted by pharmacists. In the future, pharmacists will likely be able to access medication lists documented in patients’ care plans, giving them a good starting point for conducting medication review. Pharmacists may then update medication lists and document medication-related problems, thereby enhancing other care team members’ awareness and promoting resolution of the issues.
One of the quality measures (i.e., 0553) states that there is a need for all patients 66 and older to receive a medication review annually and have a medication list documented in the medical record (National Quality Forum, 2012). Although this quality measure reflects the importance of an annual medication review for older adults, coverage for medication management services is complex. The Centers for Medicare and Medicaid Services requires Part D plans to offer certain MTM services, such as an annual comprehensive medication review to eligible Part D beneficiaries. In addition, criteria for payment for services billed under the Medicare transitional care management billing codes 99495 and 99496 require that medication reconciliation, along with an assessment of medication regimen understanding, be completed within 2 business days of discharge (Pincus, 2013).
The value of a perpetually updated, patient-reported, e-care plan medication list is perhaps not as apparent anywhere in health care as it is in the patient population undergoing care transitions. Repeatedly, the literature has documented the propensity of medication lists at transitions of care to be discrepant, potentially resulting in medication errors and adverse events if the discrepancies are not caught and resolved (Armor, Wight, & Carter, 2014; Kilcup, Schultz, Carlson, & Wilson, 2013; Kramer et al., 2014; Peterson et al., 2010). In fact, nurse-documented preadmission medication lists, physician-documented medication lists within admission history and physical examination notes, and electronic medical record medication lists updated at each inpatient or outpatient visit were all found to be discrepant when compared to a pharmacist-obtained medication history, reconciled with pharmacy fill records (Peterson et al., 2010). In comparing these medication lists, a median of 10 discrepancies per patient was found among 43 of 48 patients included in the study (Peterson et al., 2010). Discrepancies judged to be serious medication errors (i.e., high potential for harm of serious or life-threatening severity) accounted for 7% to 18% of discrepancies found. Another study of 44 patients undergoing 132 care transitions (e.g., hospital admission, hospital discharge, skilled nursing facility admission and discharge) found an average of seven to eight medication discrepancies per transition (Sinvani et al., 2013).
The Joint Commission (2015) dictates that organizations must have a system in place that offers at least a good faith effort to conduct medication reconciliation at transitions of care points. This standard is reflected in National Patient Safety Goal 03.06.01—maintain and communicate accurate medication information (The Joint Commission, 2015). However, as e-care planning becomes more ubiquitous, access to care plan medication lists should facilitate effective medication history taking and simplify the medication reconciliation process.
Nevertheless, barriers to achieving this vision exist. Although many health care provider organizations are diligently working on implementing tools such as electronic health records, computerized physician order entry, as well as e-care planning, software applications used for doing so are often dramatically different from organization to organization and, consequently, are unable to fully communicate between systems or present information in a meaningful manner (ONC, 2015). Even software applications within the same organization may not be able to interface and exchange information fully. A model for standardizing electronic medical records, the continuity of care record (CCR), is designed to enable transfer of meaningful information to other health care providers. A conceptual model of the core data elements of a CCR put forth by the American Society for Testing and Materials (Braithwaite, 2004) and other stakeholders is presented in Figure 2. The CCR is an “organized and transportable core data set of the most relevant and timely facts about a patient’s health information and healthcare” (Braithwaite, 2004, p. 3). The mandated core elements are in the box on the left with extensions on the right. Extensions offer options for tailoring the CCR to inform in specific categories.
Conceptual Model of the Continuity of Care Record (CCR; Braithwaite, 2004). Reprinted with permission from Health Level Seven® International (HL7).
Geriatric Nursing Implications
In settings where a formal role exists, such as within a care coordination program, nurses often fill the role of care coordinator and care plan developer. However, even in a more traditional nursing role (e.g., at the patient’s bedside), care coordination activities constitute the majority of nursing time (Storfjell, Ohlson, Omoike, Fitzpatrick, & Wetasin, 2009). Nurses are critical in (a) ensuring ongoing updates are made to medication lists and (b) engaging key team members, such as the patient, family, caregiver(s), and pharmacist. Pharmacists can assist development of a comprehensive medication list and in conducting medication reconciliation at pre-specified time points or during transitions in care. Nurses can engage pharmacists to perform medication reviews (e.g., CMM, MTM, MRR) with expectations that pharmacists will identify and resolve patients’ medication-related concerns. Pharmacists providing these services have been shown to improve medication management and safety as well as optimize disease state control (Lee, Grace, & Taylor, 2006). Nurses must effectively communicate care plans with other members of the care team. HealthIT is expected to facilitate the development and communication of care plans to achieve patient-centered goals.
The coordinated efforts of the U.S. government and several key professional organizations have allowed the country to make substantial progress toward providing more coordinated care to patients through the advent and development of HealthIT. Care planning has become an important tool in facilitating care coordination, but without the necessary HealthIT infrastructure to make care plans accessible across health care settings, the information contained in care plans (including medication lists) has limited impact. With many professional and regulatory organizations pushing for medication reviews for patients with multimorbidity and taking multiple medications, having a perpetually updated, patient-reported medication list accessible across care settings is invaluable.
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