Table 3.

Example of patient work: home-based management of heart failure medications.

Patient work – Work in which the patient (and/or family caregiver) is the primary agent, with minimal active healthcare professional involvement. Example: Patient managing heart failure medications at home with the help of a spouse.

Agent(s): Patient, patient’s spouse.a Co-agent(s): Physicians, nurses, pharmacists, clergy, other family members (e.g., son visiting his mother).

Work system factors. Person(s) factors include the age, cognitive function, and attitudes of the patient and spouse toward medications. Task factors include the number of medications, the complexity of the medication regimen, and the real or perceived side effects of medications. Tool/technology factors include the presence and design of a pillbox system, the clarity of written notes and instructions, and access to telehealth and telemonitoring systems that connect patients to remote healthcare professionals. Organization factors include whether the patient or spouse works during the day, the affordability of medications, and the social influence imposed on the patient to adhere to the medication regimen. Internal environment factors might include lighting, clutter, and noise in the area where medications are managed. External environment factors include the financial, motivational, and spiritual support offered by the patient’s local community. These factors interact to shape the performance of medication management.

Process. The process of home-based medication management could be decomposed into tasks such as learning the medication regimen, procuring and refilling medications, planning doses, adjusting the regimen, preparing to take the medication (e.g., obtaining water, meal), taking the medication, documenting medication taking, and communicating about the medication to healthcare professionals. Performance of each may be shaped by unique configurations of work system factors.

Outcomes. From a clinical perspective, the main outcomes may be accurate and timely (i.e., adherent) medication taking (proximal) and resultant health or disease control (distal). Whether the patient is readmitted for heart failure exacerbation affects hospital (organizational) outcomes, both proximal (e.g., patient census) and distal (e.g., penalties for exceeding average national heart failure readmission rates). For the patient and spouse, the outcomes may be clinical, functional, or personal, including feeling better or being symptom-free (proximal), hiking with friends, living to a certain age (distal), and satisfaction with specific clinical encounters (proximal) and with their course of care (distal). Other outcomes may include financial ones, including continuing to work and avoiding hospitalization.

^aNote that the work may become collaborative if, for example, a home health nurse or case manager is assigned to assist with medications. Additionally, co-agents may become agents when their roles becomes more direct, as when the patient’s son moves home to help his mother, which may include preparing and reminding her about medications.