Intervention: pediatric medication therapy management steps
toxicity, taste aversion
DISEASE, PML, ADVERSE EFFECTS, ASTHMA, PCP
Following baseline patient and caregiver assessments, patients randomized to the intervention will take part in a PharmD visit for application of the pMTM intervention, occurring in person or via telehealth within 3 days prior to the planned PCP clinical visit. The pMTM intervention will be applied during a 30- to 45-min visit in which the PharmD will work collaborative with the caregiver to complete 3 major activities (Table Components of comprehensive pMTM InterventionFirst, the PharmD will perform with the patient and caregiver a comprehensive medication review (CMR) of the patient’s current personal medication list (PML). CMR is a systematic process of collecting patient-specific data and assessing for potential medication-related problems. Subsequent clinical decisions are reliant on accuracy of available data; therefore, the first step of CMR is to conduct a thorough medication history using all available resources, updating the patient’s PML where necessary, and documenting that such activities have occurred. The PharmD will gather a list of active medications (including prescriptions, over-the-counter medications, dietary supplements, and complementary medicines), determine and confirm active disease states, and identify providers involved in the prescribing and management of current medication therapy. Next, the PharmD will review each disease therapy with the caregiver and patient, if appropriate, to determine current goals of therapy. Caregiver understanding of goals of therapy is important to their ability to provide confident care to CMC. Education related to mismatch of therapy goals and known medication effects may be addressed at this time. Additionally, the PharmD will determine if any barriers may be affecting adherence. Barriers to adherence in CMC often include taste aversion, difficult or confusing administration techniques, burdensome dosing schedule, or medication cost, among others. Such barriers may be addressed in subsequent steps of the pMTM intervention. Following review of therapy goals and adherence, the PharmD will evaluate any available laboratory data and discuss ongoing clinical symptoms to determine current medication effectiveness or lack thereof. The PML will be appraised for potential therapeutic duplication and therapies for which resolution of symptoms may render ongoing treatment unnecessary. Common examples of duplication of therapy within this population include use of multiple NSAID agents or acetaminophen-containing products or use of multiple medications within the same therapeutic class (e.g., clonidine and guanfacine). Such duplication may cause potentiation of adverse effects or contribute to excessive medication costs without conferring additional therapeutic benefit. As the final component of CMR, the PharmD will review current patient symptoms to identify those which may be attributable to medication use or toxicity, which may result in recommendations for alternative therapy or deprescribing. Gaps in therapy for guideline-directed care of various disease states (e.g., asthma) may also be identified at this stage.The second essential element of the pMTM intervention involves optimization of the medication regimen to address those concerns or opportunities identified within the preceding CMR. With the caregiver, a list of all ongoing concerns will be prioritized according to goals of therapy. Considerations related to safety, patient quality of life, and caregiver or family quality of life will be measured during this process and communicated within subsequent recommendations for medication optimization. Next, the PharmD will formulate a plan for recommended medication-related changes, including potential dose or frequency adjustment, discontinuation of therapy, or initiation of alternate medications to manage untreated or ongoing disease symptoms. Recommendations will be classified according to type (Table Types of interventions recommended within pMTM interventionAs the final component of the pMTM intervention, after the clinical visit, the PharmD will create a written, patient-centered, and caregiver-friendly MAP using a template populated from the EHR. This MAP will describe a prioritized list of specific action items resulting from the interactive pMTM consultation, which empowers the caregiver to be personally involved in the administration of the proposed optimization(s). The document was developed from the CMS standardized format to allow for tracking of patient progress, clarification of intended patient response, and documentation of the perceived clinical effects of all changes [