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The Rx VBHC Series: SESSION 3 | The FRAMEWORK: The B.S.M.A.R.T. Checklist | A Mental Framework to incorporate MAB into clinical practice consistently and reliably to maximize patient outcomes





The Rx VBHC Series: SESSION 3 | The FRAMEWORK: The B.S.M.A.R.T. Checklist | A Mental Framework to incorporate MAB into clinical practice consistently and reliably to improve patient health outcomes.


In the introduction to the Rx VBHC (Prescription for Value-Based Health Care) Series, we introduced you to the Smith Family and their challenges as well as the challenges that millions of people experience with the current healthcare system.

  • SESSION 1: We introduced you to Dr. Sam, the Director of Pharmacy of a major healthcare delivery system, one of the first leaders to adopt the prescription strategy based on his CEO’s goals, the pharmacy’s hedgehog concept, and the core stakeholder team. 

  • SESSION 2: We focused on the details of the Medication A.R.E.A.S. Bundle (MAB) Prescription Strategy, the Waste in silos . Synergy in Interdependence . Strength in Structures.

  • SESSION 3: Now, we will start focusing on implementing MAB, starting with a mental framework to help Providers and Team Members incorporate MAB into clinical practice and apply it 100% of the time in patients with multiple chronic conditions (MCC) across the continuum of care maximize patient health outcomes.





In healthcare system today, we know more than ever and have more  information to positively impact patients' health outcomes than ever before.  Yet, healthcare providers and organizations often fail to deliver on the promise of all this knowledge. Why is there so often this mismatch between potential and application?

As our knowledge of the health and healthcare increases, so does its complexity. And as complexity go up, so do the opportunities for failure. For example, research shows that about 30% of patients who suffer a stroke receive incomplete or inappropriate care from their providers, as do 45% of patients with asthma, and 60% of patients with pneumonia.

These errors or incomplete care are not from ignorance or ill-intent, but occur because medicine is more sophisticated and specialized and implementing complex treatments and procedures correctly are harder. There exist multiple streams of information to remember and manage. To improve the success of implementing and incorporating complex procedures and treatments into clinical practice, simplify complex and multiple procedures, avoid misapplying knowledge and processes, and to overcome cognitive flaws that cause errors or incomplete care, providers and organizations are implementing checklists. 

To effectively help providers and team members incorporate the Medication A.R.E.A.S. Bundle (MAB) into their clinical practice and to reliably apply it 100% of the time in all patients with multiple chronic conditions across the continuum of care, a mental checklist has been created.  This framework is known as the BSMART Checklist. The components of the BSMART Checklist include the following:

  • Barriers: Identify barriers and assess readiness to change

  • Solutions: Provide solutions to the identified barriers

  • Motivation: Skills to help patients help themselves—short- and long-term

  • A.R.E.A.S. tools: Provide tools to keep patients on track and make it easier for providers to do the right thing

  • Relationships: Develop optimal relationships with patients and the healthcare team members

  • Triage: Refer patients to other resources in the healthcare system and communities for ongoing support and care

The BSMART Checklist can help providers address MAB, from the hospital setting to the provider’s office to other healthcare infrastructures (pharmacy, care management, and others) and in the home setting.




Identifying barriers is the first step in determining what solutions and interventions a patient’s team will use to optimize medication use and health outcomes. The following are some common barriers that prevent patients from receiving appropriate medication use:

  • Adherence Barriers include Patient-related factors, Healthcare team–related factors, Socioeconomic-related factors, Health system–related factors, and Medication therapy–related factors

  • Reconciliation Barriers include Systems factors, Patient-related factors, and Healthcare team–related factors

  • Engagement Barriers which are primarily Patient-related factors

  • Affordability Barriers which usually focus on cost of medications

  • Safe Medication Use Barriers can start at the prescribing stage, to the transcription and preparation stage, to the dispensing/supply of medication stage, administration stage, and monitoring stage

There exist questions that providers can choose from to help better understand a patient’s medication-taking behaviors and determine what barriers their patient may have – these can be found in Chapter 6 of the Medication A.R.E.A.S. Bundle Handbook.



To ensure optimal outcomes, it’s critical to assess whether a patient is ready to accept a condition and utilize the prescribed medications as part of the overall healthcare plan. This is especially necessary to assess in patients who will be taking medications for an extended period of time (for example, patients taking antihypertensive medications). It is critical the provider elicits any and all perceived barriers and obstacles to medication adherence. The word “but”—as in, “I know I have to take my medications, but ...”—should alert the provider that the patient has some ambivalence.

A tool that can be used to assess readiness is the readiness assessment ruler. The readiness ruler, with a scale from 0 to 10, is an efficient tool for measuring how a patient feels about taking a medication for a long period of time. Exploring readiness helps patients uncover and build their motivation to change habits and accept new therapy.




Once the barriers have been identified and patients assessed for readiness, the next step is tailoring the patient’s action plan with interventions related to the identified barriers. For many patients with MCC, more than one barrier is often involved, so the solutions and interventions must be multifaceted and must be addressed at each point along the continuum (hospital → physician’s office→ pharmacy →care management →home) with patient/caregiver involvement.

The solutions must be aligned with identified barriers. For example, addressing financial issues in a patient whose barrier is primarily a religious belief system is meaningless, potentially harmful, and a waste of time. So, it is critical that solutions be aligned with the identified barriers to improve patient outcomes. Also, the Medication A.R.E.A.S. Solutions have some similarities and uniquenesses across the continuum of care, so whenever possible and meaningful, leverage solutions that cut across most or all practice settings. The MAB solutions across the continuum of care can be found in Chapter 6 of the Medication A.R.E.A.S. Bundle Handbook.




For people to be motivated to change and maintain the change, they must have a strong sense of purpose and meaning that will motivate their decision to change.

Healthcare providers must help their patients recognize their personal reasons and desires for wanting to get better. A deep personal motivator can be used to encourage patients to take medications consistently, change their diets, and exercise. The motivator can be linked to specific health goals—for example, to help a diabetic man get his HbA1c to under 7 so he can stay healthier and work for a longer period of time. Whatever health goal is set, the patient is more likely to follow through on the necessary health behaviors that will make the goal a reality if it’s linked to strong personal motivators.

Linking the importance of getting better to the identified  motivators should be done in a warm, nonjudgmental style of interaction. This can be accomplished through motivational interviewing (MI), a technique used to understand patient challenges, help patients come to terms with the challenges and changes occurring in their lives, help them link the new behaviors with a strong personal motivator, and use “change talk” techniques to get patients on the right track towards improving their health outcomes.

Since the main goal of motivational interviewing is increasing intrinsic motivation for change (“I will change because I want to”), helping the patient become aware of the discrepancies between current behaviors and highly cherished personal motivators, values, and goals is critical. There are many courses and articles that can be found on the Internet that teaches providers and team members the motivational interviewing techniques needed to help patients improve their intrinsic motivation to change.

The Marathon Runner Versus the Sprinter: Think of running a 26.2-mile marathon but without the following: spectators to cheer you on, water or drinks along the way to keep you hydrated, and other participants running alongside you. With none of these supportive infrastructures, do you believe you would complete the 26.2 miles successfully? While some people can, many cannot. Many marathon runners have attributed a part of their success to the motivation of other runners, the support along the way, and spectators cheering them on. Now, imagine yourself as a sprinter, running a 100-meter dash that lasts a few seconds. Would you need as much support as someone running a grueling marathon over the course of several hours?

A patient given a seven-day course of antibiotics is similar to a sprinter. He or she does not always need motivators to take medication over a short period of time. However, a patient who is on medication for a chronic condition is more like a marathon runner. Because outcomes aren’t always felt or visible, and the medication must be taken for a long period of time, this type of patient will need motivation and support to keep going. There are a number of tools and resources that can help motivate and keep patients on track with their medication regimens (see chapter 6 for a partial list).

Feedback: Also, to keep this motivation alive, there must be ongoing feedback. Feedback should be congratulatory when the patients are on track, or empathetic when the patients have problems that prevent them from achieving their goals. Therefore, at each visit, the provider should review the health goals, link goals to something important to the patient, provide tools and resources when appropriate, and provide feedback along the way. This will give patients the support needed to continue striving toward their goals and to succeed.



A.R.E.A.S. Tools

There are many tools and resources to help keep patients on track once they start taking their medications. These include apps, reminder tools, memory tools, safety resources, written information, and many others. See chapter 6 of the MAB Handbook for the list.




In a study published in JAMA Internal Medicine in 2012, patients who felt their doctors listened to them and involved them in decisions gained their trust quicker, which contributed to patients following their doctor’s orders more often and taking their drugs as prescribed. “By supporting doctors in developing meaningful relationships with their patients, we could help patients take better care of themselves,” said the lead author Dr. Neda Ratanawongsa, an assistant professor at the University of California San Francisco Department of Medicine.

A positive patient-provider relationship is one of the strongest predictors of whether patients will take their medications as prescribed. Studies show that patients who have good relationships with their healthcare providers and do not feel judged by them will be more honest about their medication use. These patients will be more likely to tell their provider of issues and barriers that prevent them from using their medications appropriately. When a patient tells a provider of any medication barrier, the provider can do the following:

  • Explore readiness to change through motivational interviewing techniques.

  • Engage patients in setting goals related to their medication use and overall health. Involve family members or caregivers whenever possible.

  • Explain the purpose of the medication, how it works, its benefits, and what results or side effects to expect. This will help patients anticipate what to expect from their medications, which can be empowering.

  • Let your patients know you believe in them and their abilities to take their medications as prescribed.

  • Encourage questions from patients.



Once the provider has identified barriers and applied various solutions to improve a patient’s appropriate medication use, he or she may need to coordinate the patient’s medication therapy management plan with broader healthcare management services. This will help ensure that the patient receives continuous support. Patients will be linked to specific services based on their needs. These services can provide additional support through more in-depth screening for any medication A.R.E.A.S. issues and barriers, explore readiness to change, encourage goal setting, and provide more in-depth education. Many healthcare organizations have some or all of these services to enhance the patient- provider relationship: clinical pharmacy services, care/case management, behavioral and social  medicine, health education classes, community programs, and other resources.


The BSMART Checklist is an example of a framework that can help providers systematically and consistently implement MAB across practice settings successfully. It does this by remembering to identify barriers, tailor solutions to the barriers, motivate patients at every point of contact, provide A.R.E.A.S. tools to help patients stay on track, build positive relationships with patients, and triage/leverage the larger healthcare system and communities to optimize MCC patients’ health outcomes, reduce total healthcare costs, and improve organizational performance.


In Session 4 of this 10-Part Series, we will discuss in detail how to make MAB REAL by:

  • PART 1: Implementing Effective Efficiencies . Creating an Economic Engine . Building Collaborative Pharmacist Care Delivery Models

  • PART 2: Executing MAB effectively in moderate and high-risk populations with MCC – African American Population with Diabetes


More information about the MAB Rx Strategy can be found at:


My hope and goal is to provide you with a prescription strategy that will make a difference in the lives of patients with multiple chronic conditions – the most frequent and expensive users of healthcare, contribute to making healthcare value a reality for all, and give you a competitive advantage in this new era of value-based healthcare!

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