I have read many things about medicines optimisation that complicates it and adds unnecessary dimensions.
Medicines optimisation is goal setting and goal delivery. That is it – nothing more.
For appropriate goal setting we must have knowledge of the disease / condition and an understanding of motivational interview or joint goal setting techniques. We should explore the patient’s understanding and experience of the disease / condition. Through this we can understand which symptom or which complication most worries the individual patient or most interrupts their life and progress to goal setting. The goal must be specific, measurable, achievable, results orientated and time specific, targeting only the goal that is important to the individual patient. Pharmacists have been working SMART for years so this is not a foreign concept, but pay attention to the word achievable.
What is perhaps more difficult is keeping the patient goal at the centre, but paying attention to and understanding what might be clinical, system and service goals. In an ideal world all goals would be identical, but the patient goal must be our focus.
We need to create and deliver a care package that delivers the patient goal. Although the care package usually contains a medicine, we need to think about elements of self care and support that would help to deliver the goal. On occaisions additional targeted compliance support will be neccessary, but these are usually easier when the patient is committed to the treatment.
Please remember that some goals are time dependent and will need to be reviewed. Conditions change and when a treatment helps one symptom another one may appear. Patients may improve their lifestyle and the risk of a complication reduces such that the patient may not consider the absolute risk worth continuing with the treatment. So review and goal checking or goal development is essential.
When we follow up and discuss medicines with patients we should support a change to goal orientated language. Patients should feel able to connect a medicine with a goal. For example Ramiplril could be described as an ACE inhibitor or a blood pressure tablet, but we should support the link between reducing and controlling the blood pressure to reducing the chance of a stroke or heart attack. This is particularly important with medicines such as tricyclics antidepressants which might be used to reduce symptoms of pain
Formulary and critical appraisal
If we are practising medicines optimisation we need something different from a formulary and the critical appraisal. Rather than looking for medicines that have a population effect, we are looking for medicines which have a specific beneficial effect and a valued place in a pathway. More options for goal targeted treatments, rather than less.
So medicines optimisation is simple, putting it into practice is the task.