Patient-centered Medication Management: A Proposed Model

Jane D. Prestie Quality Consultant

Alberta Health Services

Edmonton, Alberta, Canada

Abstract

Aim. This paper’s aim is to introduce a patient centered medication management model for

nurses and their patients.

Background. The patient centered medication management (PCMM) model includes self

administration as one element but patient participation is throughout the continuum of acute care

(Prestie & Koch, 2011). The key elements include health professional role, patient’s status and

medication requirement. Self administration of medication processes have been utilized and

presented in the literature since 1959 (Lam 2011, Wright et al. 2006). PCMM was developed

during the commissioning phase of a new hospital.

Data Sources. The patient centered medication management model was developed based on

research around best medication administration practice and patient centered care philosophy.

Search sources included CINHAL, Pro-quest, and Google Scholar for articles regarding

medication management, self administration of medication, medication administration and

patient centered care from 2000 to current day. Review of related Alberta Legislation, Alberta

Professional Colleges was also undertaken.

Discussion. The goal of PCMM is to allow the acute care patient to be involved in managing

their medication so that the medication administration prior to discharge will resemble the

management of medications in the community.

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Implications for nursing. By utilizing the PCMM process it is hypothesized that medication

management will be done transparently, involve and empower the patient, and improve patient

and staff satisfaction.

Conclusion. PCMM is an alternative to traditional medication management that involves the

acute care patient, nurses, physicians, pharmacists, pharmacy technicians and health care aides.

Keywords: Self Administration of Medication, Patient Centered Care, Medication

Management, Medication Administration, and Quality Improvement

The purpose of this paper is to introduce an innovative, patient focused approach to

medication management. The Patient Centered Medication Management (PCMM) model is

focused on administration of non-parenteral medications and insulin in acute care settings (See

supporting information in file figure 1) (Prestie & Koch 2011). PCMM is an expansion of the

self administration process which involves the patient throughout their hospital stay. It contains

the elements of flexible medication times, health care aides (HCA) assistance and patient self

administration of medication. PCMM is intended to increase transparency among the health care

team, improve patient empowerment, encourage the patient to participate in their own health care

and improve staff and patient satisfaction. Nurses, registered nurses and licensed practical

nurses, are the primary medication administrators in acute care but support from physicians,

pharmacists, healthcare leaders, other health professionals, patients and families would be

necessary for acute care medication management to evolve to a patient centered approach.

The PCMM model was developed during the commissioning phase of a new hospital,

South Health Campus, in Alberta. Its design was based on applicable; federal and provincial

legislation, health professionals’ standards and Alberta Health Services governance documents.

It aligns with the hospital’s foundational pillars of patient and family centered care, collaborative

care, innovation and wellness (Alberta Health Services 2013).

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Background

Definitions

To understand the PCMM model it is important to have clear definitions of terms that are

associated with it. Medication management is the broadest view health professionals can take in

regards to medication. It involves procurement, storage, prescription, preparation, dispensing,

administering, patient monitoring, patient education and evaluation of the medication

management process (Accreditation Canada 2013). Under medication management a health

professional has a variety of specific activities, for example; performing medication

reconciliation, researching medications, adjustment of medication schedules, providing patient

education, monitoring of the medication effect, and evaluation of the medication regimen. Many

health care professionals; pharmacist, pharmacy technicians, physicians and nurses, as well as

other healthcare workers; unit clerks and pharmacy aides, are involved in acute care medication

management.

Medication administration is one aspect of medication management (Accreditation

Canada 2013). Medication administration is a cognitive and interactive aspect of patient care and

is more complex than the simple task of giving a medication to a patient. The process includes

providing medication to a patient for the purpose of immediate use and includes patient

assessment, preparation of medication, calculation and verification of medication dose, patient

education and the monitoring of the medication effects. (CARNA 2007). Historically nurses

have been given the task of medication administration in acute care (Manias et al. 2004).

There are numerous definitions of patient centered care in the literature (Kitson et al.

2012). Some common themes associated with patient centered care include: patient participation,

clinician-patient relationship, and clinical care environment (Kitson et al. 2012). The PCMM

model of patient centered care is defined as inclusion of the patient perspective in planning,

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delivering and evaluating their health care (IPFCC 2011). Concepts associated with patient

centered care that are necessary in the PCMM model include patient/health care team

collaboration, active patient participation, information sharing and respect.

Literature Review

Currently there is no literature on patient centered medication management therefore a

review of self administration of medication literature was undertaken. Self administration of

medication processes have been utilized and presented in the literature since 1959 (Lam et al.

2011, Wright et al. 2006). The self administration models presented previously in the literature

focuses on the patient administering their own medications (Lam et al. 2011, Manias et al. 2004,

Murray 2006, Wright et al. 2006). Some of these models include a phased approach that included

direct and indirect supervision by a nurse (Lam et al. 2011, Murray 2006, Wright et al. 2006).

Primary reasons for introducing self administration programs where to determine the

patient’s ability to manage their medication regimen, to teach a patient how to administer their

medications, or to encourage patient independence (Manias et al. 2004, Wright et al. 2006). Self

administration of medications in acute care has been associated with patient empowerment,

patient satisfaction, increase patient knowledge of medications, and increase patient’s self

confidence regarding managing medication (Lam et al. 2011, Manias et al. 2004, Murray 2006,

Wright et al. 2006). Many studies hypothesized that adherence to medication regimens in the

community would improve if self administration occurred in acute care but this has not been

satisfactorily proven partially due to the short time frame of the follow up in the studies post

discharge, small study size and no verified compliance measurement tool (Lam et al. 2011 ,

Wright et al. 2006).

Numerous studies on self administration of medication have focused on the complex

patients (Manias et al. 2004, Murray 2006). Complex patients have been the focus of self

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administration since they tend to have more complex medication regimens, physical limitations

and decrease cognitive functions that impact their ability to manage their medications in the

community settings (Manias et al. 2004, Murray 2006). Self administration has been used with

the complex patient population to improve compliance with their medication regimen and to

assess their physical and cognitive ability to manage their medications correctly (Manias et al.

2004, Murray 2006).

Hospital medication administration times contrast greatly with home medication

administration times and can change the therapeutic effect of the medications (Jarman et al.

2002). Patient centered medication times have been shown to improve sleep, decrease

medication errors and improve patient satisfaction (ISMP 2011, Manias et al. 2004). When

instituting patient centered medication administration times nursing workload did not increase

but the work may have moved to a different nurse due to work shifts.

Most studies stress the importance of assessing patients by utilizing a standardized

assessment tool. Common elements include assessment of competence, mental status, physical

characteristics and willingness to participate (Fuller & Watson 2005, Manias et al. 2004, Murray

2011, Wright et al. 2006). The studies designated the assessment as a nursing activity but

cautioned regarding the increase in workload (Fuller &Watson 2005).

For self administration models to be effective tools to assist the patient have been

employed. Medication storage tools include blister packs, dosettes, or medication bottles (Lever

et al. 2008). Once a patient medication storage tool has been selected it is imperative to identify

the health professional responsible for the set up and replenishment of the tool (Lever et al.

2008).

Patient medication administration records are necessary for the patient to record their

ingestion of medications, to ensure communication with the health care team and to ensure

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monitoring of the effects of the medication (Manias et al. 2004). Ideally the patient medication

administration record should be an easy to use standardized form to ensure easy transitions

throughout the hospital (Manias et al. 2004).

Benefits

Self administration of medication benefits specific to the patient described in the

literature include promoting independence, enhancing knowledge, fostering confidence,

elevated competence in medication management, improved understanding of their medication

regimen and increased satisfaction in hospitalization (Grantham et al. 2006 , Lam et al. 2011,

Manias et al. 2004, Murray 2011). The large majority of patients who participated in a self

administration of medication programs in acute care stated they would participate again if

hospitalized (Manias et al. 2004, Murray 2011). Another benefit for patients participating in

PCMM is the medication administration schedule is personalized to integrate with the patient

lifestyle (Jarman et al. 2002).

Hospital benefits include decreased length of hospital stay, decrease in medication errors,

lower readmission rates, increase self care in the community and improved health care team

medication knowledge (Grantham et al. 2006, Lam et al. 2011, Manias et al. 2004, Murray

2011).

Challenges

Challenges described in the literature can be categorized as patient safety, professional

accountability and resource availability (Wright et al. 2006). Patient safety concerns include

clear and timely communication between patients and the health care team and safe secure

storage of medication (Manias et al. 2004). Another patient safety concern is difficulty ensuring

the patient achieves independent self administration during the hospital stay due to the trend to

shorten the length of hospitalization (Lam et al. 2011, Manias et al. 2004, Murray 2011).

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Additional resources required for successful self administration implementation include a patient

medication administration record and written patient education (Lever et al. 2008).

Professional accountability in regards to self administration include resistance to move

away from the exiting medical model (Grantham et al. 2006 , Lam et al. 2011, Murray

2011).The medical model focuses on the responsibility of the health professionals and many are

reluctant to relinquish control. As well, the patient roll traditionally is the sick roll or subject and

they are not normally engaged as an active participant in their own treatment regimen (Lever et

al. 2008, Manias et al. 2004).

Under Alberta legislation, oral medication administration is not a restricted activity,

meaning it does not carry significant risk when performed and does not need advanced skills to

complete. (Province of Alberta, 2005) Both Registered Nurses and Licensed Practical Nurses

include medication administration in their list of competencies (Province of Alberta, 2005).

Within their scope of practice nurses can indirectly supervise HCA performing medication

assistance (CARNA et al. 2010).

The HCA is an unregulated health care worker who can take additional education to gain

an advanced competency in medication assistance, which teaches the five rights of medication

administration; right patient, right drug, right time, right route and right dose. (Alberta Health &

Wellness, 2001) The nurse is accountable for; appropriately assigning the task according to the

HCA’s competence, determining the level of supervision required, overseeing the delivery of

medication by the HCA and monitoring patient outcomes (CARNA et al. 2010). The HCA

would be assisting with medications specifically for competent, stable patients. Medication

assistance involves delivery of medications, identification of proper patient, identification of

correct medication, assistance with accessing the medication and properly documenting the

delivery and ingestion of the medication (Alberta Health and Wellness 2001).

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Resource availability includes limitations on health care team time and storage devices

availability (Murray 2011, Wright et al. 2006). Time for patient assessment and preparation of

the patient specific storage devices would need to be allocated to the nurses and pharmacy

technicians responsible for completing these tasks (Lever et al. 2008). This time may be gained

from having other health care professionals increase their scope of practice which would permit

nurses and pharmacy technicians time to accomplish these additional tasks (Manias et al. 2004,

Wright et al. 2006). Budget to purchase the patient storage devices would also need to be in

place for a successful implementation (Lever et al. 2008, Wright et al. 2006).

PCMM Model

The PCMM model embraces patient participation throughout the continuum of acute care

and incorporates the elements of self administration. The vision is that all patients will

participate in PCMM within the hospital. The key elements of PCMM include health care team

roles, the patient’s status and medication requirement. In PCMM medication administration can

take one of three pathways; nurse administration, collaborative administration and self

administration.

Initiation

PCMM is initiated when the patient is being admitted into acute care for a period greater

than 24 hours. Key nursing activities that occur during initiation of PCMM are; adjusting the

medication schedule to reflect the patient’s home schedule, completing the patient medication

assessment tool, identifying any chronic medications that the patient can self administer and

determining if the current medication regimen is stable or unstable. The outcome of these

activities is the nurse assigning the patient to the appropriate administration pathway; nurse

administration, collaborative administration, or self administration.

Nurse Administration Pathway

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Complete medication administration will be done by a nurse in the nurse administration

pathway because; the patient oral medication regimen is not stable, the patient is not cognitively

intact, the patient is receiving narcotics, or the patient does not wish to participate in taking their

medications independently. In this pathway the nurse continues to provide education when a new

medication is introduced or the dosing is changed. As well the nurse continues to assess the

patient’s physical and cognitive abilities using the assessment tool.

If the patient was designated to this pathway because the patient does not wish to

participate in taking their medications independently it is important for the health care team to

explore the patient’s belief around the sick role (Manias et al. 2004). This exploration will allow

the nurse to identify points where the patient can participate in their care.

Collaborative Administration Pathway

The requirements for the collaborative administration pathway is that the patient has

been; deemed cognitively intact, is not utilizing narcotics for pain management, and is willing to

participate in medication administration. This pathway encompasses the nurse administering

medications that have not been stabilized and parenteral medications. The nurse would be

responsible for patient assessment, preparation of medication, calculation and verification of

medication dose, patient education, monitoring of effects pertaining to all medications and

documentation of these activities.

The HCA would assist patients that have been scored as cognitively stable either by

delivering the medication to the patient or assisting the patient in ingesting the medication. The

HCA would be responsible in documenting delivery of medications and communication with the

nurse when medications are not ingested.

The collaborative pathway will be the core pathway for patients that do not administer

their medications independently in the community.

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Self Administration Pathway

The self administration pathway would be utilized for patients that are; cognitively intact,

have the physical ability to administer their own medications, are willing to participate and who

manage their medications independently in the community. The pharmacy would support this

pathway by supplying the patient with a day’s worth of medications in a delivery device such as

a dosette or blister pack. A patient medication administration record would be given to the

patient for them to be aware of medication administration time and record their medication

administration.

The nurse would be responsible for; patient assessment, calculation and verification of

medication dose, patient education specific to their medications, monitoring of effects pertaining

to all medications and administration of any parenteral medications. The nurse also monitors the

patient medication self administration and discusses any concerns or issues with the patient and

health care team.

Discharge

The discharge activities related to the PCMM model are only enacted when patients have

limited or no contact with health professionals in the first 72 hours following discharge. On the

day of discharge medication reconciliation, any additional patient education, empting patient’s

storage device of any medication and returning the storage device to the patient for home use are

the tasks completed by a health professional.

The PCMM Models final steps are 48 to 72 hours post discharge. The primary activity

that an acute care nurse or pharmacist would perform is a telephone interview to determine the

patient’s adherence to the medication regimen. Additional medication education may be

provided at this time as well if required. If it is determined that there are difficulties in adherence

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to the medication regimen the patient would be referred to a community health professional for

further follow up.

PCMM Tools

Assessment Tool

The PCMM Assessment Tool (See additional information in file table 1) was adapted from the

Self-Medication Risk Assessment Instrument (Fuller & Watson 2005) and DRUGS (Lam et al.

2006). The PCMM assessment tool uses commonly agreed upon categories to assess cognitive

abilities and physical impairments. New categories included in the PCMM assessment tool are

the patient’s willingness to participate and whether pain control is required. Patients receiving

narcotics for pain control would be viewed as being potentially cognitively impaired and

therefore would revert to the nurse medication administration pathway.

The outcome of the assessment will place the patient in the appropriate pathway: nurse

administration if any criteria is present under this column, collaborative administration if no

nurse pathway criteria is present and at least one criteria in the collaborative column is present,

or self administration if all self administration column criteria are present.

The assessment tool was designed to be easily applied and accommodated the medication

assistant role that a HCA can fulfill in Alberta. The HCA can deliver oral medications to patients

that are unable to retrieve their medications and assist patients who are physically unable to

administer their own medications.

Documentation Records

To support the collaborative administration pathway the typical medication

administration records would need to be modified to include an area for documentation of nurse

administration, patient education, medication delivery and HCA assistance. In addition to

documentation of HCA assistance a communication process would need to be developed to

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notify the nurse if a patient did not receive a medication and the reason why the HCA assistance

was not completed.

A hospital approved patient medication administration record would also need to be

developed to ensure monitoring of patient medication management by the health care team when

the self administration pathway is being utilized. A patient medication administration record

should include areas to document delivery of medication, ingestion of medication and any

incidences where the patients medication regimen was not followed to ensure good

communication among the health care team.

Discussion

Benefits

By utilizing the PCMM model medication administration will be transparent throughout

the health care team, involve and empower the patient, and improve patient and staff satisfaction.

PCMM will promote a patient centered environment which has been shown to improve recovery

and decrease readmission rates (Murray 2011). By giving patients the responsibility of managing

their own medications when they are deemed capable promotes the idea of wellness and

minimizes the sick role that some patients perform when in acute care setting (Manias et al.

2004).

PCMM also promotes collaborative care among the health care team and patient. For

PCMM to be effective nurses, HCA, pharmacists, pharmacy technicians and physicians will need

to consult, strategize and formulate a plan of medication management working in partnership

with the patient. By collaborating health care professionals will increase their understanding of

each other’s roles, scopes of practice and exchange interprofessional knowledge within their

health care team (Orchard, et al. 2005).

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For PCMM to be effective an increased focus on patient medication education is

necessary. Patient education may be provided by a variety of different health professionals but it

results in the patient and health care team gaining and sharing knowledge (Murray, 2011).

PCMM promotion of patient education will also result in meeting Accreditation Canada’s

standards (2013).

By involving the patient throughout their acute care hospital stay the patient will be more

informed of medication management and their specific medication regimen. Patients will take on

at least partial responsibility for their medications while in acute care and therefore be better

equipped to manage their medication regimen post discharge.

By creating and utilizing PCMM as a hospital wide process patients can expect to be

involved in medication management including administering their own medications when

appropriate (Wright et al, 2011). Tools that support safe storage and appropriate documentation

will be readily available to patients and the health care team. The goal is that patients will move

through the PCMM pathways with ease.

The medication administration record will need to be modified to ensure all members of

the collaborative health care team, including the patient, have an appropriate place to document

their role in medication management. Areas that are suggested for inclusion in a medication

administration record supportive of PCMM include; administration (nurse), education (nurse,

pharmacist) delivery (nurse, HCA, pharmacy technician) and ingestion (nurse, HCA, patient). By

developing the advanced medication administration record communication throughout the health

care team, which includes the patient, should improve from current practice.

Challenges

The major challenges arise during implementation of the PCMM model. The PCMM

model requires changes to the traditional roles played by the health care team and the patient in

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relation to medication management. One of PCMM objectives is to utilize all members of the

health care team to their full scope of practice or ability. For existing roles to change discussions

between the professional nursing colleges and institutions regarding the role of the HCA in

medication management need to be undertaken. Professional nursing colleges need to review and

update their definitions of medication administration and focus on the cognitive aspects of

medication administration that are the responsibility of the nurse, allowing others, the patient or

HCA, to assume responsibility for the psychomotor tasks of delivery and ingestion.

For the PCMM model to be implemented effectively specific members of the health care

team will need to be designated to ensure that the storage of patient specific medications is

secure and accurate. This role may be designated to or split between pharmacy services and the

patient care unit. Secure medication storage for self administered or assisted medication

pathways need to meet Accreditation Canada(2013) standards. As well, they need to be easily

accessible to the health care team and when necessary the patient. If a specific consumable

device, such as a dosette, is used in the process then budgeting for the device will need to be

included in the PCMM implementation plan.

Implications for nursing

PCMM is a model that nurses can embrace which supports the movement toward patient

centered care. By dividing some of the traditional roles of the nurse among the health care team

the patient will benefit from the nurses advanced knowledge and training. The lower risk roles

of delivery and ingestions of oral medications can be assigned to HCA or the patient when

appropriate. Nurses will be able to focus more of their time on the advanced cognitive functions

of assessment, preparation of medications, patient education and monitoring of effects. The

PCMM model provides the patient with the greatest opportunity to participate in their medication

management and be involved in their acute care experience. This will raise their satisfaction

15

level as they are actively involved in their treatment and become more attuned to their health

care needs.

Conclusion

The PCMM model is a patient centered approach to medication management in acute

care. PCMM has expanded on the principles of self administration that have been discussed in

the literature for over 40 years. To overcome the traditional model of medication administration

PCMM involves the patient in their medication administration through the continuum of care

during a hospitalization.

The goal of PCMM is to ensure the medication management is transparent to the

healthcare team and patient throughout the hospital stay. Patients are empowered as they are part

of a collaborative team focussed on their healthcare needs. Health care roles are redefined to

utilize all staff to their full scope of practice. Nurses will be better able focus on the cognitive

tasks of medication administration: assessment, preparation, monitoring and education. The

psychomotor tasks of oral medication delivery and ingestion become the responsibility of the

HCA or patient when appropriate.

Additional tools need to be implemented to ensure successful transformation to the

PCMM model. For PCMM to be successful a medication administration patient assessment

needs to be completed and updated on a continual basis to ensure the patient is moving through

the PCMM model appropriately. In the self administration pathway, a bedside storage device and

medication delivery process will need to be developed to ensure that medication security is

maintained. Incorporation of an advanced medication administration record is required to ensure

the appropriate member of the health care team, including the patient, can document their role in

medication administration.

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PCMM is expected to allow members of the health care team to focus more on their

higher level competencies while engaging the patient in their own medication regimen. This will

increase the satisfaction of health care team members and patients and will enable better patient

outcomes.

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