November/December 2017

Medication Monitor: Transdisciplinary Professionalism Improves Medication Management — An Urgent Call for Heightened Awareness
By Mark D. Coggins, PharmD, BCGP, FASCP
Today's Geriatric Medicine
Vol. 10 No. 6 P. 5

Navigating today's health care system is complex due to fragmentation between settings and providers that results in increased costs, lower quality, and higher rates of preventable hospitalizations.1 The patient-centered medical home (PCMH) is a model of care that places patients at the forefront of care and aims to build relationships between patients and their clinical care teams.2

PCMHs have been shown to produce the following results3:

• Improve quality. Patients receive the treatment they need when they need it.

• Reduce costs. They prevent expensive and avoidable hospitalizations, emergency department visits, and complications, especially for patients with complex chronic conditions.

• Improve the patient experience. They provide the personalized comprehensive coordinated care patients want.

• Improve staff satisfaction. Their systems and structures help staff work more efficiently.

Opportunity for Improvement
Improving the collaboration between members of the health care team is difficult. In order to improve patient-centered care we must overcome challenges that impede collaboration, including the following:

• dysfunctional behaviors (professional and ethical), both from individual team members and resulting from historical negative perceptions between disciplines;

• inadequate communication skills;

• health literacy challenges of the public;

• exclusion of patients from their own care;

• lack of accountability for patients' overall care outside of a member's functional area of expertise; and

• lack of accountability for patients' overall care as they transition through the continuum of care.

Need for a New Professionalism
In recent years, the need for a "new professionalism" referred to as Transdisciplinary Professionalism (TDP) has been proposed to help meet the challenges facing today's health system.4 TDP may be defined as an approach to create and carry out a shared social contract that ensures multiple health disciplines working in concert are worthy of the trust of patients and the public in order to improve the health of patients and their communities.4 Additionally, TDP recognizes that patients have a corresponding accountability for their own care and can help make their health care experiences safer by becoming active, involved, and informed members of the team.

While PCMHs provide a model-of-care template to improve care, TDP involves a set of shared values that all health care disciplines on the team profess collectively to uphold. Through adherence to TDP, it is believed that the team's shared values, including increased accountability (both individually and as a whole) between various disciplines will result in increased quality of care and positive health outcomes. Furthermore, for the team to meet its obligations as part of the "social contract," members of the team regardless of discipline must hold each other accountable for actions and behaviors that would prevent the team from being found worthy of the trust of patients and society.

TDP to Improve Medication Management
Bringing the problem into focus requires acknowledging that a problem exists as the first step to working toward patient-centered care and fulfilling TDP. Consider the following statistics:

• In 2019, across the United States an estimated 4.83 billion prescriptions will be filled.5

• Medications are involved in more than 75% of all treatments.6

• Four out of five patients who visit a physician receive at least one prescription.6

• The United States claims less than 5% of the world's population, yet consumes roughly 80% of the world's opioid supply.7

• Adherence to therapy for chronic diseases in developed countries averages 50%.8

• Drug-related morbidity and mortality costs exceed $200 billion annually in the United States, exceeding the amount spent on the medications themselves.9

• Medicare beneficiaries with multiple chronic illnesses are 100 times more likely to have a preventable hospitalization than those with no chronic conditions.10

• The Institute of Medicine notes that while only 10% of total health care costs are spent on medications, their ability to control disease and impact overall cost, morbidity, and productivity—when appropriately used—is enormous.11

A new culture of accountability for preventing medication-related problems (MRPs) could significantly improve health care outcomes. Studies show that 50% of all MRPs could be avoided with improved medication management.12 And although older adults are more prone to adverse effects from medications, nearly 90% of adverse drug events are thought to be preventable in older adults (compared with 24% in younger patients).12

Preventable causes of medication-related problems include drug interactions, inadequate monitoring, inappropriate drug selection, inappropriate treatment, lack of patient adherence, overdosage, poor communication, underprescribing, and untreated medical problems.12

Health Care Teams Must Own the Problem
Once there is agreement that the problem exists, a more painful step must occur due to the need for inward evaluation of the current problems. This requires health care teams to acknowledge and take ownership for a failure to adequately meet patient needs related to medication management.

Within the framework of TDP, all health care team members are ultimately accountable for patient care and its outcomes, including MRPs. This requires the team to collaborate and work together so that the needs of the patient are truly placed first. Too often, nonprescribing health care professionals, health care organizations, and payers have not stood up against poor prescribing habits that go against best practice guidelines and are widely known to be dangerous. Poor communication, lack of respectful relationships between team members, egos, an antiquated health care system based on hierarchy depending on team members' positions and professional status, and the overall lack of accountability have in large part allowed poor medication management practices to flourish, including the following:

• inappropriate opioid prescribing, which is now a national epidemic;

• inadequate antimicrobial stewardship and the emergence of strains of deadly antibiotic treatment-resistant organisms;

• inappropriate use of antipsychotics in persons with dementia despite the risks of significant harm including death;

• widespread use of benzodiazepines despite numerous guidelines advising against the practice, in addition to use of benzodiazepines with opioids despite black box warnings;

• decades of dangerous and ineffective sliding-scale insulin use; and

• prescribing cascades, polypharmacy, and failure to implement appropriate deprescribing initiatives.

Responsibility Goes Beyond Prescribers
Of course, prescribers have significant accountability for these issues. However, pharmacists, along with other health care professionals who have either not pushed back or have not been supported by organizational leadership in demanding improved prescribing behaviors, must also own the problem. Over the years, unprofessional and disruptive behaviors by physicians have often been allowed to continue without repercussion to offenders. Allowing comments such as "If you wanted to be a doctor, then you should have gone to medical school" have not only damaged the integrity of the team, resulting in lower team member effectiveness and satisfaction, but have also allowed diminished patient care.

Disruptive behaviors are not limited to physicians alone, as disrespectful relationships also occur between other professionals within the same discipline as well as between disciplines. Additionally, over the years, nonprescribing professionals such as nurses and others have insisted on deflecting their own professional and ethical responsibilities either due to knowledge deficits, ignorance, or fear of repercussion by using the default comment, "The doctor ordered it, so it must be right" when relevant concerns are identified.

Solving the Problem
Once all members of the team acknowledge their roles in improving medication management, then meaningful steps to develop and implement sustainable solutions through transdisciplinary professionalism can take place.

According to one comprehensive national study, only 12% of US adults have proficient health literacy, and more than one-third have difficulty with common health tasks, such as following directions on a prescription drug label or adhering to a childhood immunization schedule. Information on health topics from health professionals is one of the most important sources of information for patients, regardless of their respective health literacy levels.13

Ultimately, TDP results in a meaningful collaborative approach that places the needs of the patient first while also taking steps to help patients become more engaged in their own care. Accountability among all team members for patients' medication can help to minimize many of the current breakdowns that occur as patients transition through settings.

Engaging more team members and raising awareness of the implications caused by MRPs greatly expands the ability to improve the health literacy of the public. Patients would be more readily identified as needing additional education offerings, including the use of teach-back methods, which can be provided by multiple team members including nurses, pharmacists, physicians, and others. Increased coordination of care also allows patients' individual needs to be better met, such as referring patients with more complex medication regimens and those with multiple chronic diseases to pharmacists for comprehensive medication management reviews.

Enhanced communication between providers at the time of discharge from hospitals and other settings for patients returning to the community would also improve adherence and reduce medication errors that commonly occur during transitions, such as missed medications and medications not being appropriately stopped.

Additionally, we know that cost concerns reduce patient treatment adherence. Improved coordination helps identify those patients who have specific needs in that vein, so that social workers and pharmacists can work on solutions to improve patient access to services and medications.

A Call for TDP — Final Thoughts
MRPs unfortunately are common, jeopardize patient care and safety, add tremendous unnecessary cost to the entire health care system, and demand increased attention as a national priority. Health care providers and all health care professionals owe it to patients and society to address MRPs with an adequate level of urgency reflective of the risks posed to patients due to years of medication management neglect.

No single health care discipline alone can reverse the widespread issues seen today that are associated with MRPs. A radical change in culture is needed. Transdisciplinary professionalism with shared accountability by all team members to improve all aspects of patient care, including medication management, must become part of the solution. Everyone can do more to improve medication-related outcomes. This includes a shared accountability by health care organizations whose teams provide care to patients. Organizational leadership can best serve patients and ultimately their respective organizations by clearly defining each team member's accountability for appropriate collaboration and taking prompt action when any team member, including physicians, is unwilling to practice collaboratively.

Pharmacists, who by definition and training are medication experts, have an even greater obligation surrounding the effort to improve medication management. We must be willing to provide authentic leadership and to increase efforts to help improve knowledge related to medications and acceptable medication-related principles among all members of the care team as well as patients. Offering to provide counseling to patients is insufficient. There must be increased questioning and dialogue with patients to understand their unique needs and perspectives. The failure of pharmacists to lead this effort will jeopardize the respect and trust the pharmacy profession has earned. Ultimately, the failure of all health care team members to change and accept greater responsibility for medication management will result in the lost trust of patients and society.

— Mark D. Coggins, PharmD, BCGP, FASCP, is vice president of pharmacy services and medication management for Diversicare, which operates skilled nursing centers in 10 states. He was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.

References
1. Frandsen BR, Joynt KE, Rebitzer JB, Jha AK. Care fragmentation, quality, and costs among chronically ill patients. Am J Manag Care. 2015;21(5):355-362.

2. Shih A, Davis K, Schoenbaum S, Gauthier A, Nuzum R, McCarthy D. Organizing the U.S. health care delivery system for high performance. The Commonwealth Fund website. http://www.commonwealthfund.org/publications/fund-reports/2008/aug/organizing-the-u-s--health-care-delivery-system-for-high-performance. Published August 2008.

3. Edwards ST, Bitton A, Hong J, Landon BE. Patient-centered medical home initiatives expanded in 2009-13: providers, patients, and payment incentives increased. Health Aff (Millwood). 2014;33(10):1823-1831.

4. Global Forum on Innovation in Health Professional Education; Board on Global Health; Institute of Medicine. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, D.C.: National Academies Press; 2014.

5. Total number of retail prescriptions filled annually in the United States from 2013 to 2022 (in billions). Statista website. https://www.statista.com/statistics/261303/total-number-of-retail-prescriptions-filled-annually-in-the-us/

6. National Association of Chain Drug Stores. The Chain Pharmacy Industry Profile. National Association of Chain Drug Stores Foundation: 2001.

7. Nowak L. America's pain points. Express Scripts website. http://lab.express-scripts.com/lab/insights/drug-safety-and-abuse/americas-pain-points. Published December 9, 2014.

8. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: The Clinician's Guide. New York, NY: McGraw-Hill Medical; 2004.

9. Johnson JA, Bootman JL. Drug-related morbidity and mortality. A cost-of-illness model. Arch Intern Med. 1995;155(18):1949-1956.

10. The future of Medicare: recognizing the need for chronic care coordination. U.S. Government Publishing Office website. https://www.gpo.gov/fdsys/pkg/CHRG-110shrg38617/html/CHRG-110shrg38617.htm  

11. Institute of Medicine. Informing the Future: Critical Issues in Health. 4th ed. Washington, D.C.: National Academy of Science; 2007.

12. Ruscin JM, Linnebur SA. Drug-related problems in the elderly. Merck Manuals website. http://www.merckmanuals.com/professional/geriatrics/drug-therapy-in-the-elderly/drug-related-problems-in-the-elderly

13. Quick guide to health literacy. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion website. https://health.gov/communication/literacy/quickguide/factsbasic.htm