Psychometric evaluation of a comprehensive medication management service experience instrument.

BACKGROUND: The Health-Systems Alliance for Integrated Medication Management (HAIMM) instrument was developed to estimate patient experience following pharmacist-delivered comprehensive medication management (CMM). OBJECTIVES: The objective of this paper was to assess the psychometric properties and factor structure of the HAIMM instrument. METHODS: Data were collected from 5 members of the HAIMM collaborative. A one-factor confirmatory factor analysis (CFA) model was used to assess instrument dimensionality. A partial-credit item response theory model was used to assess the psychometric properties of the ten-item HAIMM patient experience instrument, consisting of tests for rating scale functioning, person and item fit, and content validity. RESULTS: Among 516 respondents, there was a strong skew toward high satisfaction, including a strong ceiling effect. CFA results suggest a unidimensional construct. Item difficulty was spread across a low range and content redundancies were identified. The mean-square values for both infit and outfit all fell within the recommended range, whereas the z-standard fit was within the recommended range for most items. The 5-point Likert scale used in the HAIMM instrument did not distinguish between participants' level of experience following the pharmacist-delivered CMM service. CONCLUSION: The psychometric analysis showed the HAIMM survey tool does not cover all of the content that should be assessed to fully evaluate CMM experiences. In its current form, the HAIMM instrument should not be used to make comparisons about the quality of CMM services provided, although it may be useful to monitor patient satisfaction for quality improvement purposes. Further research is required to develop an improved instrument that contains expanded content coverage, response options, and aspects of CMM to be useful by health care providers, health systems, and other decision makers.

Leveraging quality improvement principles in comprehensive medication management pharmacy practice: A case example.

OBJECTIVE: To maximize the time pharmacists providing comprehensive medication management (CMM) services spend providing direct patient care by tracking their time spent on various activities. SETTING: Fifteen primary care clinics within an integrated health care system in Minnesota. PRACTICE DESCRIPTION: Eleven pharmacists provide comprehensive medication management services in 15 clinic sites; 12 primary care clinics, 1 family medicine residency training clinic, and 2 specialty clinics. PRACTICE INNOVATION: A team of pharmacists providing CMM developed and completed a self-reported workload sheet to document how much time they spent on various activities. These sheets were completed at 4 different points over 6 years to guide efficiency efforts to increase pharmacists' time spent in value-added activities such as direct patient care. EVALUATION: Beginning in 2014, each CMM pharmacist was asked to complete the workload tally sheet to track the time they spent on all their daily activities for a 5-day period. The workload sheets were collected in 2014, 2016, 2017, and 2019 and represent a snapshot of activity at 1 point during each year. Workload sheets from each pharmacist were compiled and analyzed each year to assess time spent in direct patient care and other value-added activities. RESULTS: From 2014 to 2019, CMM pharmacists increased their time providing value-added services from 47.1% to 72% and increased time in direct patient care from 26.7% to 52.5%. This was achieved through a number of workflow optimization strategies, including appropriation of staff to schedule and recruit CMM patients, developing expanded collaborative practice agreements, and creating documentation efficiencies. CONCLUSION: Collecting CMM pharmacist workload data across the years demonstrated the amount of time pharmacists were spending on various clinic-related activities and served to identify areas where workflow and processes could be improved to increase the time pharmacists spend in value-added services. As CMM practices continue to develop and expand, tracking and optimizing pharmacists' time is essential to leverage efficiency and value of pharmacy services.

Seeing the Forest Through the Trees: Improving Adherence Alone Will Not Optimize Medication Use.

Medication adherence is a problem that has received widespread attention in the medical literature and health policy circles. With the increased emphasis on recognizing and rewarding quality in the U.S. health care system, medication adherence measures are increasingly being adopted to assess quality of medication use. However, when adherence is discussed in the literature or evaluated via quality measures, there is rarely any dialogue surrounding adherence in the context of patient-centered issues such as clinical status, individualized medication needs, or personal expectations and social situation. When nonadherence is identified via a comprehensive assessment of all of a patient's medication-related issues, it typically is recognized as only the third most frequent type of medication-related problem. Issues such as requiring a medication that has not been prescribed or receiving a medication prescribed at a dose too low to achieve the intended clinical goal are more frequently experienced. Furthermore, if a patient is nonadherent to a medication because of adverse effects or if the medication prescribed is not appropriate considering the patient's individual clinical situation, promoting adherence can create unintended harm. Therefore, achieving medication adherence as typically evaluated via existing quality metrics such as proportion of days covered is only valid if the medication is first deemed to be indicated, effective, and safe for the patient. Medications are the most common medical intervention for chronic illnesses. As a result, success in achieving the Triple Aim of health care is highly dependent on optimizing medication use. When quality measures for medication use narrowly focus on measuring adherence, the resulting programs of payers and providers will likely ignore the most frequent types of medication problems that prevent improved health, create unnecessary costs, and could negatively impact patients' experience with the health care system. Strong leadership and advocacy on the part of agencies in the position to influence the quality measurement landscape in the U.S. health care system will be critical to achieve widespread awareness of medication nonadherence in the context of the full scope of medication-related problems in health care. DISCLOSURES: No outside funding supported this research. Brummel provides consulting services to other health systems; has received grants from Sanofi and speaking fees from AMCP, APhA, and ASHP; and is on the faculty at the University of Minnesota and employed by Fairview Pharmacy Services. Ekstrand provides consulting services for Alliance for Integrated Medication Management and has received speaking fees from International Diabetes Center and MN Alliance of Physician Assistants. The authors report no other conflict of interest, potential or otherwise. Study concept and design were contributed primarily by Sorensen, Brummel, and Rehrauer, along with the other authors. Rehrauer, Brummel, and Ekstrand collected the data, which were interpreted by Sorensen, Brummel, Rehrauer, and Ekstrand. Pestka and Sorensen wrote and revised the manuscript, with assistance from the other authors.

Development and Validation of a Patient Satisfaction Survey for Comprehensive Medication Management.

BACKGROUND: Comprehensive medication management (CMM) services are a relatively new standard for clinical practice. A patient satisfaction tool for pharmacists providing comparable pharmacy services is essential for measuring quality and sustainability. OBJECTIVE: To develop a psychometrically valid questionnaire for measuring patient satisfaction for CMM services. METHODS: A patient satisfaction survey tool was developed through a multiphase development process. Validation studies were conducted across 2 urban ambulatory care health system settings providing CMM services. The survey consisted of 10 items related to 3 domains: medication-related needs, pharmacist-patient engagement, and overall satisfaction. Using a 4-point scale, the surveys were mailed, collected, and analyzed for descriptive statistics, internal consistency, and factorial composition. RESULTS: Total surveys returned for analysis numbered 195, with an overall survey response rate of 19.2%. Factor analysis and item analysis identified 1 factor of pharmacists' patient care services. The factor was named "patient satisfaction." CONCLUSIONS: The instrument that was developed provided 1 factor of CMM services. This brief patient satisfaction tool appears to be reliable and valid and may serve other CMM providers to assess 1 measure of quality assurance upon further evaluation.

Preventing and resolving drug therapy problems by understanding patients' medication experiences.

OBJECTIVES: To provide tools for pharmacists to uncover patients' medication experiences and to discuss strategies that medication therapy management (MTM) pharmacists use to prevent and resolve drug therapy problems rooted in patients' medication experiences. DESIGN: Qualitative study. SETTING: Health care delivery system in the Minneapolis/Saint Paul, MN, area from January to October 2010. PARTICIPANTS: 10 MTM pharmacists. INTERVENTION: Thematic analysis of data from a focus group of MTM pharmacists and an MTM pharmacist's practice diary. RESULTS: Patients' medication experiences were revealed as a foundational aspect of MTM pharmacists' daily practices because they had to take these experiences into consideration to be effective practitioners. According to MTM pharmacists, patients express attitudes toward drug therapy in many different ways, thereby affecting how each patient takes his/her medications. Patients' medication experiences often were at the root of drug therapy problems (DTPs). From MTM pharmacists' examples, we identified DTPs at the root of patients' medication experiences and several strategies used by pharmacists to address patients' needs and concerns regarding medications. MTM pharmacists approached patients in a nonjudgmental way so that patients would feel comfortable sharing their perspectives and goals. After understanding patients' motivations and the basis of their attitudes and decision making, pharmacists could negotiate the process of behavioral change, if needed. CONCLUSION: If pharmacists understand patients' medication experiences, they may be able to address and resolve DTPs to ultimately improve therapeutic outcomes and reduce adverse events.

The medication experience: preliminary evidence of its value for patient education and counseling on chronic medications.

OBJECTIVE: To describe medication therapy management (MTM) pharmacists' encounters with patients' medication experiences, to examine the utility of the medication experience in practice, and to explore the value of the medication experience in patient education and counseling on medications. METHODS: A focus group of 10 MTM pharmacists, and 1 pharmacist's 9-month practice diary were analyzed to reveal patients' medication experiences and the utility and value of the medication experience in practice. RESULTS: MTM pharmacists commonly encountered patients' medication experiences in their practices. The medication experience was often at the root of drug therapy problems (DTPs) the practitioners identified. The pharmacists identified several examples of drug therapy problems with an associated medication experience at the root. The medication experience was a meaningful construct to guide patient education and counseling on new chronic medications to ultimately prevent DTPs, and valuable for tailoring patient education and counseling on medications to resolve DTPs. CONCLUSION: Our study provides preliminary evidence of the value of the medication experience for patient education and counseling on chronic medications in practice. PRACTICE IMPLICATIONS: The medication experience is a valuable tool for practitioners to understand patients' needs, identify and resolve DTPs, and tailor patient education and counseling for chronic medications.