One of ACCP’s most successful and productive areas of interprofessional outreach to help advance and position clinical pharmacists in the evolving health care delivery system has been our participation in and work with the Institute of Medicine’s Best Practices Innovation Collaborative (BPIC), a working subgroup of the IOM Roundtable on Value & Science-Driven Health Care. The charge to the collaborative has been to identify and disseminate information from both the practice and research communities that advances the practice of patient-centered and team-based care for patients with multiple and/or complex chronic medical conditions. Among the key areas of interest, inevitably, has been the unequal quality of the pharmacotherapeutic care experienced by such patients and the need to promote systems of care that ensure safer and more effective medication therapy outcomes in this population.
Although ACCP’s engagement with the collaborative began before the completion and release of the College’s strategic plan and advocacy platform in 2011, this forum has provided a unique and receptive environment in which to engage nationally known health care leaders from the practice, policy, payment, and research communities during the past 2½ years. Both in formal presentations and informal interactions, we have used the opportunity to educate about and advocate for inclusion of the clinical pharmacist as a credible and essential clinician in the delivery of contemporary health care. As the only pharmacist practitioner organization at the table, we are well positioned to describe and promote a clinically focused and patient-centered practice that aligns with the goals and objectives of other participants within the collaborative who share the commitment to an improved and patient-centered health care delivery system.
Several reports from the roundtable’s deliberations have been published during the past 2 years (www.nationalacademies.org), and its work, together with that of the BPIC, will continue into 2012 and beyond.
Most recently, the IOM took the novel step of commissioning a series of concise “discussion papers,” written by selected participants of the roundtable, that are designed to summarize information around key issues that have been the subject of group discussion. The first of these discussion papers, titled “Patient-Clinician Communication: Basic Principles and Expectations,” was recently released and is now available on the ACCP Web page at http://www.accp.com/docs/positions/misc/IOMPatientClinicianDiscussionPaper.pdf. The paper presents a framework for use by clinicians and patients to promote improved communication that facilitates the shared decision-making essential to the provision of patient-centered care.
The core principles outlined in the discussion paper include the following:
1. Mutual respect
• Each patient (or agent) and clinician engaged as full decision-making partners
Communication should seek to enhance health care decision-making through the exchange of information and by supporting the development of a partnership relationship—whenever possible—based on trust and focused on the whole patient. This includes considering psychosocial needs, identifying and playing to the patient’s strengths, and building on experience to meet immediate need and anticipate future concerns.
• Respect for the special insights that each brings to solving the problem at hand
Information exchange should be characterized by listening, inquiry, and facilitation that are active as well as respectful on the part of both the patient and the clinician. Information should include patients’ ideas, preferences, and values; the living and economic contexts that may affect patients’ health or decision-making; the basis and evidence for alternatives and recommendations; and the uncertainties related to the proposed course of action.
2. Harmonized goals
• Common understanding of and agreement on the care plan
A full understanding—to the extent practicable—of care options and the associated risks, benefits, and costs, as well as patient preferences and expectations, should lead to an explicit determination of the shared agenda and goals. Factors should include health, lifestyle, and economic preferences and should accommodate language or cultural differences and low health literacy.
3. A supportive environment
• A nurturing and secure services environment
The success of the care plan depends on the attention paid in the service setting to patient culture, skills, convenience, information, costs, and implementation of the care decision.
• A nurturing and secure decision climate
The comfort and ability of the patient and clinician to speak openly is paramount to a discussion of potentially sensitive issues inherent to many health decisions.
4. Appropriate decision partners
• Clinicians, or clinician teams, with skills appropriate to patient circumstances
With increasingly complex problems and time often a factor for any individual clinician, it is important to ensure that the patient has access to clinicians with skills appropriate to a particular encounter; that, as indicated, alternative clinician opinions are embraced; and that provisions are made for the communication needed among all relevant clinicians.
• Assurance of competence and understanding by patient or agent of the patient
Understanding by both patient and clinician is crucial to arriving at the most appropriate decision. Understanding of patient options is important: how specific they are to circumstances; the associated risks, benefits, and costs; and the needed follow-up. If indicated, an appropriate family member or similar designee should be identified to act as the patient’s agent in the care process.
5. The right information
• Best-available information at hand; choices and trade-offs thoroughly discussed
The starting point for shared decision-making should be the sharing of all necessary information. When working collaboratively to create an appropriate care plan, clinicians should provide evidence regarding risks, benefits, value, and costs of alternative options. All options should be discussed to bring out patient preferences, goals, and concerns and to explicitly consider the impact of various options on these issues.
• Presentation by patient of relevant perceptions, symptoms, personal practices
The clinician’s appreciation and understanding of patient circumstances depend on accurate sharing by the patient of perceptions, symptoms, life events, and personal practices that may have a bearing on the condition and its management.
6. Transparency and full disclosure
• Candid and explicit acknowledgment to patient of limits in science and system
A basic element of the care process is comprehensiveness and candor with respect to the limits of the evidence, delivery system constraints, and costs to the patient that may affect the range of options or the effectiveness of their delivery.
• Patient openness to clinician on all relevant circumstances, preferences, medical history
Only by understanding the patient’s situation can the most appropriate care be identified. Patient and family or agent openness in sharing all relevant health and economic circumstances, preferences, and medical history ensures that decisions will be made with complete understanding of the situation at hand.
7. Continuous learning
• Effective approach established for regular feedback on progress
Identifying and implementing a system of feedback between patients and clinicians on status, progress, and challenges are integral to developing a learning relationship that is flexible and can adapt to changing needs and situations.
• Established periodicity for course assessment and alteration as necessary
Early specification of treatment strategy, expectations, and course correction points is important for ongoing assessment of care efficacy and for alerting both clinician and patient to the possible need for care strategy changes.
These guiding principles provide a framework for all clinicians involved in direct patient care and emphasize the full engagement of the patient as a partner in the care process. This level of communication requires a substantial commitment from the clinician and, consequently, demands both the necessary time and organizational culture and environment to achieve the objectives outlined. For the clinical pharmacist, this will require an assessment of the level of practice setting support, as well as a commitment to the consistent patient care practice that is required to achieve this degree of communication.
The second discussion paper in the series, planned for release in the summer of 2012, will focus on the nature and core elements of team-based practices that promote the full participation of all appropriate clinicians in the patient care process (see principle 4 above on “appropriate decision partners”). ACCP staff will serve on the group of six coauthors on this paper, drawing on the experience of the College and its members as we strive to define the essential characteristics of high-performing interprofessional teams in the delivery of care that truly reflects “best practices.” We are pleased to have been invited to participate in this effort and look forward to sharing the product with ACCP members when it is complete.
As we reflect back on a very busy year of health care reform implementation, organizational advocacy, and outreach activities, we believe that ACCP’s members and clinical pharmacists across the nation are being increasingly recognized for their significant contributions to improved patient care in many health care settings. We have much work left to be done on many fronts, but the future is bright, and the environment is right, to effectively develop, position, and advance clinical pharmacists to contribute in major ways to the improved health of the patients we serve.
From the staff of the Washington office of ACCP, our best wishes to you and yours for the upcoming holiday season and a successful 2012.