The traditional medical system inbuilt around the doctor and leaves out many other important members such as pharmacists and nurses. This in fact creates problems for the patient since the process of obtaining drugs via the pharmacist becomes often long and cumbersome. A collaborative medication management system is a planned team-approach involving health care professionals such as a physician, pharmacist, nurses, etc. Thus a common ground for these health care professionals to interact efficiently and have their roles defined and ultimately address the issues that remain unresolved by a conventional system. The goal is to provide a health care system that works to provide optimum care and attention to the patient with the medication outcomes. Many models have been tested wherein the process of prescribing to the patient is enhanced (Medication Therapy Management, Home Medication Review). All these models bare in common the collaborative roles as well as individualized roles of health care professionals towards the patient.

In order to develop an efficient model we must first understand the needs and gaps of knowledge in the patient. With newer drug regiments and with the complexities involved with them medication management has become increasingly complicated and confusing to the patient. This is seen most prominently with chronic illnesses, where the patient is required to adhere to the prescription and constant follow ups are required. Non compliance may lead to poor outcome and patient may try to resolve his health related symptoms by self medication which poses a threat to the patient if not counseled properly. Poly pharmacy is a phenomenon commonly seen in chronic illnesses, multiple regiments lead to excessive drug usage which is counter productive.

Impetus for framework
The involvement of large variety of specialists may complicate the issue of health provision. Some of the issues like over focus on the specialist area of health may lead to ignoring the comprehensive picture of health care for a patient. This is a pressing issue since the number of players involved causes a number of problems. There is a greater possibly of turf conflicts, interaction with all of them becomes complex from a patients point of view, some of these members may not be present under the same roof. Many players define their own role and patients also express their willingness to participate in the view that they share. In order to avoid conflicts arising from clashing roles the playing field had to be leveled in terms of roles they play while keeping responsibilities intact. The role of the pharmacist within the team based collaborative care system had to be isolated as a unique set of contributions which help in the overall beneficial outcome of the patient. Thus it was important to set apart activities such as patient counseling prescribing and extensive drug knowledge as unique to the pharmacist, and using this successfully in the collaborative system.

Components of team based collaborative module
The ultimate health outcome lies within the patient. This fact refers to compliance/adherence to medication. Thus certain factors seem to lie outside the sphere of the health care providers. The existing frame work was identified and various components were analyzed in order to address the two issues and to help in the development of the new system Viz., drug use process, medication use process and pharmaceutical care.

In drug use process, the activities such as perception of a need of drug, selection of specific drug, administration and effect of drug are looked into. Medication use process analyses the process from the view of medication errors .It includes activities such as prescribing, transcribing, dispensing, administration, career assistance. In pharmaceutical care-assessment, care plan and periodical follow-up of the patients will be assessed for expected outcomes. This frame work does not include all the key players and is instead focused on medication errors and drug product which should be taken care by the pharmacist alone. Hence it is evident that their roles in this system are not adequately defined. Limiting a process to medication errors ignores factors such as effectiveness and patient preferences which may lead to non compliance. Certain factors such as patient care are not addressed effectively since it is also a part of the process whereas it should be maintained throughout the period of treatment.

The third issue was that the patient’s role needed to be more explicitly detailed and understood. The patient is the ultimate deciding factor for the outcome of the therapy. It all comes down to the compliance of the patient to the regimen. This can be addressed collaboratively with the help of pharmacist and adequate counseling and keeping track of follow ups.

Description of frame work
Three main components were identified and the frame work was subsequently built upon
A) Medication prescribing
B) Medication dispensing
C) Medication taking
D) Supporting staff











Figure 1: Outline of collaborative care centre

Introduction of these components is advantageous since it includes the roles of the key players and defines the roles adequately. The patient is also considered explicitly in the medication taking aspect. As mentioned earlier the ultimate outcome of the regiment is in the hand of the patient and hence he plays a central role and in integral part of the team based conceptual frame work for collaborative medication management. All the players are involved and their cross communication is possible without turf conflicts and thus a dynamic concept is formed which can take on any situation due to its flexibility

Medication taking
It is estimated that anywhere between 20% to 70% of patients do not follow the prescription. This is most common in patients suffering from chronic illness. Non compliance are of many types some intentional and some non intentional. The intentional non- compliance posses the biggest threat to therapy. In order to tackle this problem the root cause of non compliance has to be known and then worked upon with adequate counseling by the pharmacist. Many patients engaged in self regulation of their regiment which posses a major issue if the health care providers are not consulted. several points are to be considered by the patient or their caregiver in order to achieve maximum outcome.(a)To understand their illness and thus being able to make proper decisions.(b)making informed choices about their medication.(c)Taking their medication at a timely basis as prescribed and counseled(d)Being able to evaluate their status of illness and being able to identify complications(e) To effectively tackle such complications or adverse reactions(f)accessing the medications or navigating systems to facilitate access.

Medication prescribing
This is the second component is the medication prescribing practice. Research has shown that there are 1%-2% cases of hospitalization due to prescribing error. Errors are mainly related to improper dose or poor selection of medication or some times over prescription also occur. The following points are to be considered by the physician
(a) correct diagnosis
(b) decides if therapy needs to be continued
(c) selection of proper medication
(d)proper dose selection
(e) writes prescription
(f) evaluation and monitoring

With large number of drugs and options it is essential that the physician be competent and make correct choices when it comes prescribing drugs and diagnosis. In the collaborative setting such errors are minimized since the in house pharmacist is involved and authenticates the prescription before it reaches the patient. Patient preference and proper doses are taken into account since both pharmacist and physician have proper interaction with the patient. In traditional system where there is no in house pharmacist this becomes complex and many times erroneous prescriptions go unnoticed.

Medication dispensing
Medication dispensing is one of the main roles of the pharmacist. Apart from this the pharmacist also engages in patient counseling which plays a major role since noncompliance can be reduced by proper counseling and imparting appropriate knowledge regarding the pharmacotherapy. Medication errors can be reduced when the pharmacist considers the patient preference of medication and can dispense an equivalent medication which would better suit the patient. Validating the prescription written by the physician is also important since any discrepancies can be eliminated by interacting with the physician. Interaction is made more convenient in the team based collaborative care approach since they are present under the same roof.

Supportive staff
It is necessary to have the help of supportive members of health care profession in order to achieve a whole some system, a sphere in essence which comprises not only of physicians and pharmacists but also players such as nurse, dietician, addiction councilor and so on, with the patient in the middle.













Figure 2: The circles of care

It is through their support that optimum care can be achieved.

For e.g.-a resident nurse can administer a drug without delay and hence can cope with emergencies. An addiction councilor can give proper advice to patients on narcotics. A dietician can give proper instructions on diet intake; this is of special concern for people suffering from diabetes or hyperlipidemia.

The process of being properly diagnosed then receiving proper drugs with proper counseling and other peripheral care can be done in one visit under one roof.
Their role in the team based collaborative care setting can be well defined.

Case example
A patient 'Mr X' was referred to the physician in the collaborative care center. The patient was suffering from diabetes mellitus who complained of raised blood glucose levels and on inspecting the prescription it was found out that he was already on two oral hypoglycemic.

The physician was compelled to switch him on insulin. The prescription was examined then by the pharmacist and the patient was counseled. It was discovered that the patient was forgetting to take his medication that resulted in raised blood sugar level and did not maintain proper diet.

 As the pharmacists responsibility a medication calendar was made for the patient aiding him in compliance. He was also referred to the dietician. Over a period of time and regular follow ups it was seen that with proper adherence and diet control the blood sugar level had gone down without the need of insulin.

The physician was consulted regarding this and required changes in his prescription were made.

Thus through the proper collaboration between medication taking, medication dispensing, medication prescribing and supportive staff the patient benefited from the regiment.