Boylan Paul, Joseph Tina, Hale Genevieve, Moreau Cynthia, Seamon Matthew, Jones Renee
Larkin University College of Pharmacy, Miami, Florida, USA.
Consult Pharm. 2018 Mar 1;33(3):152-158. doi: 10.4140/TCP.n.2018.152.
To develop heart failure (HF) and chronic obstructive pulmonary disease (COPD) self-management kits in an accountable care organization (ACO) to facilitate patients' self-care and prevent hospital readmissions.
Pharmacists practice in an outpatient-based ACO. They participate in interprofessional office visits with providers and independently manage maintenance pharmacotherapies.
Pharmacists collaborate with an interprofessional team within the ACO including physicians, nurses, case managers, and paramedics. Two commonly encountered diseases are chronic COPD and HF. Reducing preventable readmissions for these conditions are important quality benchmarks and cost-saving strategies.
Pharmacists were responsible for developing HF and COPD self-management kits containing patient education materials and prescriptions to facilitate self-care. Prior to kit development, pharmacists performed a literature review to determine the presence of previously published findings on these topics.
The interprofessional team continually evaluates the successes and limitations of this initiative. Pharmacists developed training and instructions for ACO allied health professionals in an effort to incorporate the self-management kits in clinical practice.
The initial literature search revealed no studies describing the intervention of interest. Innovative programs designed to help reduce preventable readmissions are lacking in primary care. Implementation of the self-management kits was accepted by interprofessional ACO leadership and is currently being integrated into allied health workflow.
Patients at risk for having an exacerbation of COPD or HF should receive self-management strategies. Prompt therapy prior to exacerbations reduces hospital admissions and readmissions, speeds recovery, and slows disease progression. Pharmacist-facilitated implementation of self-management kits may be developed by interprofessional health care teams.
在负责医疗组织（ACO）中开发心力衰竭（HF）和慢性阻塞性肺疾病（COPD）自我管理工具包，以促进患者自我护理并预防医院再入院。
药剂师在以门诊为基础的ACO中执业。他们参与与医疗服务提供者的跨专业门诊，并独立管理维持性药物治疗。
药剂师与ACO内的跨专业团队合作，该团队包括医生、护士、病例管理员和护理人员。两种常见疾病是慢性COPD和HF。减少这些疾病的可预防再入院是重要的质量基准和成本节约策略。
药剂师负责开发HF和COPD自我管理工具包，其中包含患者教育材料和处方，以促进自我护理。在工具包开发之前，药剂师进行了文献综述，以确定这些主题是否有先前发表的研究结果。
跨专业团队持续评估该举措的成功与局限。药剂师为ACO联合健康专业人员制定了培训和指导，以便将自我管理工具包纳入临床实践。
初步文献检索未发现描述相关干预措施的研究。初级保健中缺乏旨在帮助减少可预防再入院的创新项目。自我管理工具包的实施得到了ACO跨专业领导层的认可，目前正被纳入联合健康工作流程。
有COPD或HF急性加重风险的患者应接受自我管理策略。在急性加重之前进行及时治疗可减少住院和再入院次数，加快康复速度，并减缓疾病进展。跨专业医疗团队可开发由药剂师推动实施的自我管理工具包。
