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Triple Aim Approach

Pharmacy and nurse practitioner resident interprofessional training

To improve patient experience and health outcomes, decrease medical errors and reduce costs, increasing focus is being placed on the provision of patient-centered care. The Institute for Healthcare Improvement developed what is known as the Triple Aim1 approach to optimizing healthcare outcomes. This framework simultaneously addresses each patient's experience of care as well as population outcomes and cost. Traditionally, individual healthcare organizations are not viewed as responsible for meeting all three objectives. However, the Triple Aim approach recommends that each healthcare organization address these three dimensions together.1

A Collaborative Model
Team-based care that is patient centered focuses on improving the quality of care for the patient, improving outcomes for the population and decreasing costs. The Institute of Medicine recommends using a team-based approach to care to maximize resources.2

Nurse practitioners are well suited to lead primary care teams with patients as central team members.3 Criteria have been developed to guide team-based care: effective communication, clear role delineation and mutual trust.2 The same qualities have been identified as important for effective teamwork by providers and pharmacists in the co-management of patient care.

One way to foster coordinated care is through medication co-management by primary care NPs and clinical pharmacists. This model aims to keep the patient at the center of care rather than requiring him or her to reach out to each distinct service. The goal is that patient-focused care will increase communication among providers to improve outcomes for the patient.4

This article describes a collaborative model in which pharmacy residents worked with a nurse practitioner resident to foster interprofessional and coordinated management of high-acuity patients. It serves as a training model for residency programs specializing in team-based care.

Factors that contribute to the development of effective working relationships between providers and pharmacists include relationship initiation (face-to-face meetings), trustworthiness and role specification.4

Description
This article describes collaboration between three pharmacy residents and one doctor of nursing practice resident at the Veterans Affairs Puget Sound Healthcare System in Seattle in 2014. Panel assessment was based on the DNP resident's panel and the pharmacy resident's clinical availability. Patient charts were reviewed independently by the pharmacy and NP. The residents met in clinic before the start of the day to review pharmacy topics related to each patient visit. Over 8 clinic days, 27 patients were collaboratively managed by the pharmacy residents and the NP. Only one pharmacy resident worked with the NP on any given day.

Topics reviewed included the patient's diagnosis list and medication list. Specific attention was paid to drug-drug interactions, medications that needed to be refilled or were expired, allergies and laboratory studies to be drawn to monitor medication use. Available labs were reviewed.

SEE ALSO: Creating a Model for Professional Advancement

The pharmacy resident offered recommendations about medication monitoring and medication changes. Patient education was discussed and educational pamphlets were shared before the patient visits. These included weight loss programs and smoking cessation assistance. The residents discussed changes to patient care and asked questions from an interprofessional perspective, each offering a different lens on medical management. The pharmacy residents offered resources for calculating creatinine clearance, and the NP resident offered practice guidelines on gout and lipid management in clinic. They collaboratively discussed which patients would best be served in pharmacy clinic for hypertension management or medication reconciliation. Patients with high acuity were ideal for co-management by the NP resident and pharmacy resident. By having reviewed the patients in advance, the patients were better served seeing both the NP resident and pharmacy resident during the same day, with smooth handoff and understanding of goals of care.

Patient Case Example
A 58-year-old patient was scheduled to be seen in primary care for an annual visit and management of hypertension and gout. Before the visit, the nurse practitioner resident and pharmacy resident met to review the chart. The patient had not followed the prescribed course of diuretic medication (hydrochlorothiazide) for blood pressure control by using the medication formulary fill ratio. The residents discussed the need to assess gout flare frequency, since hydrochlorothiazide can contribute to hyperurecemia. Both residents reviewed options for changing the patient's blood pressure medication, including the risks and benefits of an angiotensin-converting enzyme inhibitor (ACEI) such as lisinopril, an angiotensin II receptor blocker (ARB) such as losartan, and a calcium-channel blocker (CCB) such as amlodipine.

The pharmacy resident recommended assessing nonsteroidal anti-inflammatory drug (NSAID) use before prescribing lisinopril. Since the last uric acid level had been drawn more than a year earlier, the NP resident addressed the need to add this to labs that day. The patient was not on a prophylactic gout medication. The two residents collaboratively considered medication management with allopurinol. The NP resident noted the need for a chemistry panel to assess renal function and electrolytes on the thiazide medication and for hypertension follow-up.

The patient was initially seen in clinic by the NP. The patient reported that he had experienced three debilitating gout attacks that year. The NP discussed the use of allopurinol and provided education about the medication. Upon questioning about NSAID use, the patient stated that he had been using indomethacin 50 mg three times daily for the last 2 weeks for a gout flare.

The NP consulted the pharmacy resident to discuss medication selection for hypertension and gout for this patient. The concern was about NSAID use coupled with an ACEI. The pharmacy resident highlighted the importance of avoiding concurrent use of these medications. Points specifically addressed were the importance of improved hypertension control and monitoring of renal function on each medication.

The residents discussed the risk-benefit profile of lisinopril as a medication selection for this patient. The nurse practitioner resident selected an ARB, losartan 25 mg, as an alternative medication for renal protection. The pharmacy resident pointed out that losartan was not on the patient's formulary and reviewed the benefits of a calcium channel blocker, which requires less monitoring. To seek perspective on the pros and cons of each medication class for this patient, the pharmacy resident consulted her supervisor, who recommended lisinopril 10 mg daily, with instructions to avoid long-term NSAID use. The experienced pharmacist also advised that short-term indomethacin use during a gout flare would be acceptable with this patient's normal renal function in conjunction with lisinopril.

The NP resident then met with the patient to describe the collaborative discussion and the risks and benefits of each approach. The NP resident provided medication education to the patient, including reasons to change from hydrochlorothiazide and evidence supporting the use of lisinopril. The NP explained the importance of avoiding of NSAIDS except for short-term indomethacin use and the option of allopurinol to prevent frequent gout attacks.

The NP resident ordered a uric acid and chemistry panel at 2 weeks after initiation of the lisinopril. The NP resident asked the patient to schedule an appointment for medication reconciliation and education with the pharmacy resident. The patient was able to ask questions about medication selection and lead the choice of treatment from an informed position. The NP resident coordinated care for the patient by ensuring an appointment was set.

Interprofessional exchanges between providers and patients often occur routinely in any clinical setting. Placing focus on this type of learning is critical for training programs. Working together to select a drug that meets the specific characteristics of a patient provides the opportunity for real-time learning and collaboration. In a training setting, experiences such as these open up critical questions about medication interactions, safety and monitoring. This type of collaboration fosters trust between professions, enhances experience for advanced learners and offers team-based, patient-centered care.

Interprofessional Training
While each resident comes from a different background with distinct expertise and training, co-management of patients in a training setting is ideal for learning to optimize patient care. It also offers opportunities for residents to share knowledge in an open learning environment. The pharmacy residents shared clinical resources and online tools for calculating creatinine clearance. One pharmacy resident demonstrated how to adjust the calculation for obese patients. Another pharmacy resident offered medications to avoid in elderly patients by highlighting the Beer's list recommendations. The nurse practitioner resident discussed changes to recent lipid guidelines, and after discussing the case with another provider in clinic, offered recommendations based on practice standards and updated guidelines. The NP resident investigated a question about uric acid levels, and a discussion was initiated by referencing resources and pairing recommendations with patient-specific characteristics.

Collaborative learning through interprofessional co-management of patient care is ideal because questions are live, real and productive. By working together, residents from distinct professional backgrounds are able to better understand each other's expertise and gain clarity on how to leverage those skills in practice. Finally, after the intentional pairing exercise was complete, residents were familiar and comfortable with each other, which offered easy opportunity to ask questions ad hoc during a clinic day through email, instant message or paging. This familiarity and trust-building are principal predictors of interprofessional collaboration.5

Critical to Health Outcomes
In a healthcare system that is increasingly complex and short on primary care providers, collaboration among professions is critical. A focus on team-based care should begin during professional education so that providers and pharmacists understand each other's roles and gain appreciation for each other's expertise.

Complex patients with chronic illnesses require more attention to medication management and education. Often, patient education needs to be provided in more than one way. Co-managed care involving a provider and pharmacist may improve patient understanding and retention. Team-based care enhances communication among all members of the team - including the patient. Relationships among providers of different professions create learning opportunities that are unique and useful. Each brings distinct perspectives and background to the care provided.

References
1. Brooks K. The IHI Triple Aim. http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx

2. Wynia MK, et al. Challenges at the intersection of team-based and patient-centered health care: Insights from an IOM working group. JAMA. 2012;308(13):1327-1328.

3. Nurse Practitioners and the Future of Primary Care. http://dhhs.ne.gov/publichealth/licensure/documents/FutureOfPrimaryCare.pdf

4. Schnur ES, et al. PCMHs, ACOs, and medication management: Lessons learned from early research partnerships. J Managed Care Pharm. 2014;20(2):201-2015.

5. Snyder ME, et al. Exploring successful community pharmacist-physician collaborative working relationships using mixed methods. Res Social Admin Pharm. 2010;6(4):307-323.

Adeline Wakeman is a primary care nurse practitioner at ALEPH in Missoula, Mont.

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