T3 - PPCP Last Steps Flashcards
What is PPCP?
A systematic, consistent process for delivering patient-centered care in any setting
What is plan?
The plan should be patient-centered.
The plan should be individualized.
The plan should be collaborative.
What question should we ask when developing a patient-centered plan?
Whatare the goals of therapy?
What are you going to do to resolve anyDRPs?
What interventions are you going to provide?
When are you going to follow-up to determine the actual outcomes?
What are some problem solving approaches?
- Trial and error
- Step by step
- Self explanation
- Brainstorming
- Analogies
- Root cause analysis
What questions should ask to set patient-centered goals?
What would you like to achieve with your medications?
What are your goals for this therapy?
How do you feel about trying to achieve…with a new drug therapy?
What are SMART Goals?
Specific
Measurable
Achievable
Realistic
Time specific
How should we resolve DRPs and optimize therapy?
Prioritize the problem list
Establish short and long term goals to optimize therapy
Consider the clinical goals set by the provider
Consider the patient’s preference
What are examples of intervention?
Patient education
Adherence reminders
Referrals
Initiating new therapy
Discontinuing therapy
Increasing or decreasing dosage
Changing the product
What are the outcomes of therapy?
- Efficacy
- Safety
- Adherenvce
What are examples of efficacy outcomes?
HgA1c
BP
Mobility
What are examples of safety outcomes?
Side effects
Drug interactions
Inappropriate use
What are examples of adherence outcomes?
Refills
Medication schedule
Affordability
What questions do we ask when scheduling a followup?
When should the follow-up evaluation occur?
How will you determine if positive outcomes have occurred? (effectiveness)
How will you determine if negative outcomes have occurred? (safety)
Are any referrals needed?
Perform medication reconciliation to support continuity of care. (adherence)
What does documentation entail?
Each medical condition being managed should have a separate care plan.
Each care plan is documented separately.
What should each plan include?
Indication
Summary of signs/symptoms
Goals of therapy
Medications and dosage instructions
Non-pharmacologic interventions
Dates for follow up
What is implement according to PPCP?
Put the plan into action.
Collaborate with the patient.
Collaborate with other healthcare professionals.
What should we document?
All communications
What is implementing entail?
Address medication and health related problems and engage in preventative care strategies (i.e. immunizations).
Initiate, modify, discontinue, or administer medication therapy as authorized.
Provide education and self-management training.
Contribute to coordination of care (referrals, transitions of care).
Schedule follow-up care as needed.
What is SBAR
Situation, Background, Assessment, Recommendation
What is situation?
Identify the patient/reason for initial communication.
What is background?
Provide relevant history or data needed to evaluate the situation.
What is assessment?
Provide your assessment and any identified problem(s).
What is recommendation?
Describe the action needed and recommend specific solutions.
What is SOAP?
Subjective, objective, assessment, plan
What is subjective?
Information provided by patient
What is objective
Info observed or measured
What is assessment?
Review of each problem, therapeutic goals/endpoints, appropriateness of drug therapy
What is plan?
Treatment/monitoring plan for each problem that is consistent with the assessment
What questions are involved with follow up?
- How are things going
- Is the plan effective
- What changes do we need to make?
What is monitor and evaluate?
Medication appropriateness, effectiveness, and safety
Patient adherence
Outcomes of care
How do we monitor patient adherence?
Use available health data, biometric test results, and patient feedback.
How do we monitor outcomes of care?
How do these compare with the goals of therapy?
What do we monitor for clinical outcomes?
- Collect new data
- Assess DRPs and health status
- Clinical measures
- Humanistic measures
- Economic measures
What is evaluate?
Document patient outcomes (actual vs. expected)
Identify new problems
Revise care plan as needed and document revisions
Provide positive feedback/strategies
Continue with ongoing monitoring/evaluation until all goals are achieved.
