Medication Care Plan Development and Patient Follow-Up

The care plan and the follow-up evaluation are the action and accountability phases of the pharmaceutical care process. After assessment identifies drug therapy problems, the pharmacist works with the patient and prescriber to set goals, agree interventions, and schedule follow-up to determine whether those goals were met.

Definition

A medication care plan is an organised, goal-oriented set of agreed interventions developed with the patient to resolve and prevent drug therapy problems and to achieve defined goals of therapy; the follow-up evaluation is the scheduled reassessment that determines actual outcomes, judges progress against goals, and revises the plan accordingly.

Scope

This topic covers how a medication care plan is structured around goals of therapy and interventions for each medical condition, the negotiation of the plan with the patient and other clinicians, and the follow-up evaluation that closes the loop by measuring outcomes and revising the plan. It is a process-oriented reference entry and does not give individualised treatment advice.

Core questions

• How is a care plan organised around goals of therapy?
• What does negotiating a plan with the patient and prescriber involve?
• Why is the scheduled follow-up evaluation essential to accountability?
• How are outcomes judged and the plan revised over time?

Key concepts

• Goals of therapy
• Interventions to resolve and prevent problems
• Shared decision-making with patient and prescriber
• Follow-up evaluation and outcome status
• Continuity and iterative revision
• Barriers to self-management and adherence

Key theories

Goal-oriented care planning

Cipolle, Strand, and Morley structure the care plan around explicit goals of therapy for each condition, with interventions chosen to resolve drug therapy problems, achieve goals, and prevent new problems.

Follow-up as the accountability step

The model treats the scheduled follow-up evaluation as the phase where actual outcomes are measured against goals, making the pharmacist's accountability for medication outcomes operational rather than rhetorical.

Mechanisms

For each medical condition, the pharmacist and patient set measurable goals of therapy and select interventions — which may include changes proposed to the prescriber, adherence support, monitoring, or education. The plan specifies when the patient will be re-evaluated. At follow-up, the pharmacist measures or estimates actual outcomes, compares them with the goals to assign an outcome status, checks for new drug therapy problems, and revises the plan. The cycle of assessment, planning, and follow-up then repeats, giving the process its continuity.

Clinical relevance

Care planning and follow-up are what turn an assessment into sustained management and let the effect of medication interventions be observed over time. This entry describes the process and the evidence around it; it is a reference orientation, not individualised diagnostic or treatment guidance.

Epidemiology

Programmes built on structured planning and follow-up, such as the Minnesota medication therapy management experience, reported clinical and economic outcomes (Isetts et al., 2008), and a randomised trial of comprehensive pharmacist intervention with follow-up in older patients showed effects on healthcare utilisation (Gillespie et al., 2009). Facility-level data associate clinical pharmacy services with lower hospital mortality (Bond & Raehl, 2007). Patient-level barriers to self-management, especially in multimorbidity, shape what plans can realistically achieve (Bayliss et al., 2007).

History

Care planning and follow-up were defined as explicit phases of practice in the pharmaceutical care model of the 1990s and were detailed in the Cipolle, Strand, and Morley text. As medication therapy management became a reimbursable service in some systems, the documented care plan and scheduled follow-up acquired administrative as well as clinical significance, and outcome studies began to use them as the basis for evaluating service effectiveness.

Debates

How strong and generalisable is the evidence that pharmacist care plans improve outcomes?

Observational programmes and some trials report favourable clinical and economic outcomes, but heterogeneity in interventions, settings, and outcome measures makes it difficult to generalise effect sizes, and results are not uniformly positive across studies.

Key figures

• Robert J. Cipolle
• Linda M. Strand
• Peter C. Morley
• Brian J. Isetts

Seminal works

• cipolle-strand-morley-2012
• isetts-2008

Frequently asked questions

What belongs in a pharmaceutical care plan?

For each condition, the plan states the goals of therapy, the interventions agreed with the patient and prescriber to reach them, and a scheduled time for follow-up evaluation.

Why is follow-up considered part of pharmaceutical care rather than optional?

Because the philosophy holds the pharmacist accountable for outcomes, the scheduled follow-up is what measures whether goals were met and lets the plan be revised, closing the care loop.