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ACCP Report - June 2017

Highlights from the CMM Effectiveness and Implementation Grant: A Report from the CMM Study Team


Each quarter, the ACCP Report features a column written by the comprehensive medication management (CMM) study team that provides ACCP members with highlights and learnings from the CMM Effectiveness and Implementation Grant study. The previous reports for January, March, June, and September 2016 and March 2017 can be found in archived ACCP Reports.

This column updates the progress made by the CMM study team and concludes with Research Insights, which highlights a particular aspect of the team’s work with the goal of sharing the key learnings emerging from the team’s efforts.

Study Updates

Revisit the study team’s aims here.

In the installment for this quarter, the CMM study team focuses on work that is producing tangible tools and resources to assist clinical pharmacists in implementing CMM services. In addition to the progress highlighted in this update, the team’s work continues to extend across many different facets of understanding, implementing, and justifying CMM services in primary care settings. Areas of active research not highlighted here include:

  • measuring CMM’s impact on clinical quality measures, health care costs, and the return on investment that can be realized from CMM (aim 4 of the CMM study);
  • applying a defined process of “improvement cycles” to the installation and growth of CMM services;
  • detailing CMM’s influence on medical provider “well-being” in primary care settings; and
  • devising strategies to deploy resources that accelerate CMM’s implementation.
  • In the past quarter, the CMM study team also convened the CMM study’s Steering Committee and Payer and Policy Advisory Board, both of which are composed of national leaders and researchers in CMM, primary care, implementation science, and health care policy and payment. The team shared progress and insights from the study and received input on the study’s strategic direction and dissemination of its findings. The team is pleased to report that both of these groups continue to be enthusiastic about the study’s design and its emerging findings.

    The CMM study team is also pleased to report that a paper based on the study’s design has been included in a special theme issue on implementation science in Research in Social and Administrative Pharmacy. The paper, titled “The Active Implementation Frameworks: A Roadmap for Advancing Implementation of Comprehensive Medication Management in Primary Care,” describes the novel application of five “active implementation frameworks” as defined by the National Implementation Research Network to facilitate CMM implementation and improvement in primary care practices.

    Research Insights: Developing Resources to Support CMM Implementation for the Study and Beyond

    Aims 2 and 3 of the CMM study focus on determining the best practices for CMM design and delivery in primary care as well as determining the structural and system-level elements needed to support CMM. The study team has focused on the three primary CMM components—philosophy of practice, patient care process, and structural and system-level elements (i.e., CMM practice management system)—that allow the CMM service to be integrated and managed within a primary care practice. Previous work has described these as the components of a patient-centered practice.1

    CMM Philosophy of Practice: The first component of a professional practice, a philosophy of practice, is a set of professional values that guide a practitioner’s actions and behaviors and help develop trust in the care delivered. When pharmacists dedicate themselves to CMM, they are committing to core tenets that define the practice’s philosophy, which in turn ensures consistency across the discipline of practitioners. Having a clear understanding of what guides the practice helps the practitioner communicate the meaning and rationale for clinical pharmacists providing CMM more articulately and effectively with patients and the care team.

    To explore the concept of philosophy of practice as connected to the work of practitioners providing CMM, the CMM study team developed, piloted, and administered a philosophy of practice exercise to all pharmacists participating in the study. Data collection is now complete, and analysis is under way. This work will establish the proposed “core tenets” of a philosophy of practice for clinical pharmacists providing CMM. A self-assessment resource that guides clinical pharmacists in linking a philosophy of practice to their CMM service delivery activities is also under way.

    CMM Patient Care Process: The second component of a professional practice, the essential functions of the CMM patient care process and the steps necessary to make CMM operational, must be articulated and defined. Moreover, this “common language” must be established to ensure the service is delivered consistently and with fidelity. Having applied a rigorous methodology to develop a CMM common language document for the patient care process, the CMM study team has now finalized the document and is preparing for its release and widespread dissemination beyond the study’s sites (discussed in the September 2016 ACCP Report).

    Measuring fidelity (the extent to which an intervention is delivered as intended) is a critical element of the CMM study. Fidelity is frequently overlooked in clinical research and often poorly described if carried out, making it difficult for clinicians and researchers to interpret the actual impact of an intervention on study results and to compare findings across studies. Moreover, understanding an intervention’s impact is challenging if the extent to which the intervention was carried out consistently is unknown. This issue was recently highlighted in the 2014 “Final Report: Medication Therapy Management Interventions in Outpatient Settings” by the Agency for Healthcare Research and Quality.2 In this systematic review, inconsistent nomenclature and poorly described interventions within the studies reviewed made it difficult for the researchers to draw meaningful conclusions from their review.

    Assessing fidelity is key to the CMM study for two reasons. First, the study will use fidelity assessment results to objectively determine the service provided by enrolled practitioners, thus creating a clear link between the intervention and the results of the study’s clinical and economic outcomes evaluation. Second, because no “system” of fidelity assessment tools for CMM currently exists in the literature, the study will contribute to the research and practice communities. To measure fidelity, the study will assess:

    • adherence to the CMM patient care process as defined in the CMM common language;
    • the contextual factors necessary to effectively carry out CMM (e.g., appropriate training, partnerships with teams); and
    • the quality of the care delivery process (e.g., patient engagement in the care process, provider collaboration).
    • The CMM study team will initially assess fidelity through a CMM self-assessment tool that reflects the CMM common language (see more details in the March 2017 ACCP Report) and evaluates pharmacists’ clinical documentation. A rubric developed to assess adherence to the CMM patient care process according to a review of pharmacists’ clinical documentation is currently being piloted and tested for inter-rater reliability. Ultimately, these resources will consist of many elements of a fidelity assessment system produced by this study and made available to the practice community.

      CMM Practice Management System: The third component of a professional practice is the structures and system-level elements that support the clinical service, allowing it to be delivered consistently, effectively, efficiently, and in a sustainable manner. This is the “practice management system” for CMM, yet little research has been completed previously to define and measure these structures in a practice. However, a multiphase qualitative research strategy is now complete, which has produced a set of themes and strategies for a comprehensive practice management system for CMM. Moreover, these findings now serve as the basis for developing a practice management assessment tool that will assist practitioners in understanding the practice management components of CMM and produce an assessment that helps a practice prioritize specific areas for development or improvement.

      The CMM study team is grateful for the contributions by study-site pharmacists to the development of field-tested resources that will provide structure and support to practitioners seeking to implement and expand CMM services. With their assistance, this study team is producing a suite of tools that will help practitioners adopt a clear and identifiable philosophy of practice, use a consistent and validated process of care, and establish the components of a practice management system that allows consistent, effective, and efficient delivery of CMM services in primary care medical practices.

      On behalf of the investigators and study team, we hope these highlights are informative. Please feel free to reach out to Mary Roth McClurg at mroth@unc.edu or Todd Sorensen at soren042@umn.edu at any time with questions.

      References

      1. Cipolle RJ, Strand L, Morley P. Pharmaceutical Care Practice: The Patient-Centered Approach to Medication Management, 3rd ed. New York: McGraw-Hill, 2012.
      2. Viswanathan M, Kahwati LC, Golin CE, et al. Medication Therapy Management Interventions in Outpatient Settings. Comparative Effectiveness Review No. 138. (Prepared by the RTI International–University of North Carolina at Chapel Hill Evidence-Based Practice Center under Contract No. 290-2012-00008-I.) AHRQ Publication No. 14(15)-EHC037-EF. Rockville, MD: Agency for Healthcare Research and Quality, November 2014. Available at http://www.effectivehealthcare.ahrq.gov.