The changing role of the.pharmacist This course describes the practice of pharmaceutical care is the new role for the pharmacist. This course is designed

PHARMACEUTICAL CARE PRACTICE

The changing role of the .pharmacist This course describes the practice of

pharmaceutical care is the new role for the

pharmacist. This course is designed to teach students

the essence of what they will do the rest of

their careers – to provide patient care Although students may choose to apply

their pharmacy education in a number of

areas, they will require an understanding of

the rational decision making process for the

use of drug therapy

Dispensing pharmacy Pharmaceutical Care

Product business Bring the product

to consumer Decisions focus on

the business Inventory

generates revenue

Available service supports products

Service (people) business

Bring the practitioner to patient

Decisions focus on the patient

Patient care generates revenue

Available products support service

One is not better than the other, but they require different skills, knowledge, personnel, equipment, time, and resources.

Dispensing pharmacy Pharmaceutical Care

Success measured as # of Rx

Space to display and sell

Records kept for legal purposes

Visits determined by refill supply

Business passive via prescriptions

Success measured as patient outcomes

Space organized to meet patient needs

Documentation to provide quality care

Visits determined by patient risk/benefit

Practice grows via patient recruitment

Direct patient care The patient makes the final decision as to if

and how he/she will take medications every

day

The pharmaceutical care practitioner has a

brief period of time to influence (positively)

how the patient uses medications

The practitioner is expected to follow-up with

the patient to determine if their care plan had a

positive, negative, or no impact.

SELF CARE

Practitioner Practitioner

AssessmentCare Plan

Follow-upEvaluation

Direct patient care

Patient

Pharmaceutical Care in Health Care Primary

FocusKnowledge

Base

Responsibility in the drug use process

Medical Care

Diagnosisand

Treatment of the patient’s

disease

Pathophysiology Prescribing

Nursing Care

Giving care to the whole

patient during the cure or treatment

Biological, psychological,

social, or spiritual human

responses

Drug administration

PharmaceuticalCare

Identifying and meeting a patient’s

drug-related needs

Pharmacotherapy

Identification, prevention,

and resolution of drug therapy

problems

Pharmaceutical care PC is a professional practice that has evolved

from many years of research and development.

PC is designed to complement existing patient

care practices to make drug therapy more

effective and safe.

This practitioner is not intended to replace the

physician, the dispensing pharmacist, or any

other health care practitioner.

Pharmaceutical care Definition:

Pharmaceutical care is a patient-

centered practice in which the

practitioner assumes responsibility

for a patient's drug-related needs

and is held accountable for this

commitment.

Pharmaceutical care It is taking responsibility for ensuring that all of

a patient’s medications are appropriately

indicated, effective, as safe as possible, and

that the patient is able and willing to take them

as intended.

This is accomplished by assessing all the

patient’s drug-related needs in order to identify

if any drug therapy problems exist.

Pharmaceutical care Pharmacists accept responsibility for optimizing

all of a patient's drug therapy, regardless of the

source (prescription, nonprescription, alternative,

or traditional medicines), to achieve better

patient outcomes and to improve the quality of

each patient's life.

With the patient's cooperation and in

coordination with the patient's other health care

providers.

Why do we need PC An increase in the complexity of drug

therapy;

An increase in self-care through

alternative and complementary

medicine;

A high level of drug-related morbidity

and mortality which results in significant

human and financial costs.

Why do we need PC Multiple practitioners writing prescriptions

for a single patient, often without

coordination and communication;

The large number of medications and

overwhelming amount of drug information

presently available to patients;

Patients playing a more active role in the

selection and use of medications;

Pharmaceutical care as a generalist practice

The PC practitioner assesses all of a

patient's medications, medical conditions,

and outcome parameters, not just those

chosen by disease state, drug action, or

quantity of medications consumed

PC is applicable in all patient care practice

settings including ambulatory, long-term

care, hospital, and clinic settings

Pharmacits's responsibility

Assure that the goals of therapy are

achieved by

developing a care plan for each medical

condition

by conducting follow-up evaluations at

appropriate times.

preventing drug therapy problems

whenever possible

Pharmaceutical care The key components of this

description include the PRACTITIONER this individual must posses EXPERT

KNOWLEDGE in the area of PHARMACOTHERAPY

Must apply this knowledge to the benefit of a patient by meeting that patient’s drug-related needs, which BENEFITS the PATIENT.

The language of practice

General terms such as assessment, care

plan, and follow-up evaluation

Unique terminology drug therapy problem,

medication experience, and drug-related

needs

Synonymous

Practitioner and clinician

Drug therapy and pharmacotherapy

Practitioner requirements to practice

• Philosophy of practice• Therapeutic relationship with patients• An understanding of the patient’s medication

experience• Rational thought process

-pharmacotherapy workup and drug therapy problems• Patient care process• Documentation system• Reimbursement system

Philosophy of practice

A set of values that guides behaviors

associated with a professional practice

Helps the practitioner determine what

is important and how to set priorities

Philosophy of practice

Represents what “should” be done

Describes what is done in the areas of

minimizing drug-related morbidity and

mortality (social obligation) and ensuring

that individual patients are receiving

drug therapies that are appropriately

indicated, effective, safe, and convenient

(patient-specific)

The therapeutic relationship A therapeutic relationship develops when

you take care of a patient.

The therapeutic relationship is different

than a “personal relationship”, or a

“business relationship”.

The stronger and more positive that the

therapeutic relationship is, the more

likely that positive outcomes can occur

Characteristicsof the therapeutic relationship

Mutual respect Trust Open communication Cooperation Mutual decision making

Components of the medication experience

The patient’s description of the medication experience

The medication history

The current medication record

The medication experience The medication experience includes

more technical aspects as well

The patient's current medications

Social drug use, immunizations

Allergies, alerts, and medication history.

It is usually easier to deal with this

aspect of the medication experience

The medication experience the patient's beliefs, perceptions,

understandings, attitudes, and behaviors

about drug therapy.

The factors that will most directly

influence the patient's decisions about

whether to take a medication or not, how

much of the medication to take, and how

to take the medication.

The medication experience Patients come with their own

medication experience.

The more you know about the

patient's medication experience,

the more likely you are to have a

lasting and positive influence on it.

Steps in the patient care process. The practitioner uses a rational

decision-making process called the Pharmacotherapy Workup to:Make an assessment of the patient's drug-

related needs

Identify drug therapy problems,

Develop a care plan

Conduct follow-up evaluations to ensure that all drug therapies are effective and safe.

The Patient's Drug-Related NeedsThe medication is appropriate

There is a clinical indication for each medication All of the patient's medical conditions that can benefit from drug therapy have been identified.

The medication is effective

The most effective drug product is being used.The dosage of the medication is sufficient to achieve the goals of therapy.

The Patient's Drug-Related Needs

The medication is safe

There are no adverse drug reactions being experienced.

There are no signs of toxicity.

The patient is compliant

The patient is willing and able to take the medications as intended.

Indication Drug product Dosage regimen Outcomes

Safety

Drug Therapy ProblemUnnecessary drug therapy

Needs additional drug therapy

Drug Therapy ProblemIneffective drug

Adverse drug reaction

Drug Therapy ProblemDosage too lowDosage too high

Drug Therapy ProblemNoncompliance

Effectiveness

Structure of the Pharmacotherapy Workup

• In order for a practitioner to evaluate the effectiveness and safety of a patient’s drug therapy he must understand all the steps of the steps above.

• Drug therapy problems can occur anywhere in the patient’s drug use process

The pharmacotherapy workup

a structured, rational thought process for making clinical decisions

a systematic thought process to assess the needs of a patient, identify and resolve problems, and prevent problems from occurring

Requires a unique knowledge base and set of clinical skills


Unique knowledge base is focused

on pharmacology,

pharmacotherapy, and

pharmaceutical care practice.

The practitioner identifies, resolves,

and prevents drug therapy

problems.


A logical thought process that guides work and decisions as the clinician assesses the patient's drug-related needs and identifies drug therapy problems

It organizes the interventions that need to be made on the patient's behalf.

It establishes appropriate parameters to evaluate at follow-up.


consists of an ordered series of decisions

that allow the practitioner to determine

whether drug therapy problems exist in any

category:

indication, effectiveness, safety, or

compliance

The Pharmacotherapy Workup can be

applied to help all types of patients, with all

types of diseases, with any type of drug

therapy


asking a standard series of questions,

constantly generating a set of hypotheses,

continuously searching for cues that reject

or accept these hypotheses,

Eliciting more information,

Integrating all of this with existing

knowledge to decide on the best

pharmacotherapy for the patient

PW: the questions

Are Always Generated as a Response

to Two Basic Questions

Is the patient's problem caused by drug therapy?

Can the patient's problem be treated with drug

therapy?

The pharmacist’s approach is that drug

therapy is the cause of or cure for the

problem

The patient care process

Establish a therapeutic relationship

What does my patient want and

need?

What am I going to do

for my patient?

How will we know if it is working?

Continuous Follow-up

ASSESSMENT CARE PLAN EVALUATION


all highly dependent upon each other.

completion of all steps is necessary The process is continuous and

occurs over multiple patient visits Each step of the process depends

on the previous step having been completed well


Assessment

the patient,

his/her medical problems,

drug therapies

→ leading to drug therapy problem

identification


The initial assessment, drug therapy

problem identification, and care

planning occur at the first encounter

with each patient

Follow-up evaluations and additional

adjustments to drug therapy occur at

subsequent patient encounters.


The Pharmacotherapy Workup

describes all the work that you do

mentally while the patient care

process describes the work that

you do physically.

Activities and Responsibilities in the Patient Care Process

Assessment Meet the patient Establish the therapeutic relationship

Elicit relevant information from the patient

Determine who your patient is as an individual by learning about the reason for the encounter, the patient's demographics, medication experience, and other clinical information

Make rational drug therapy decisions using the Pharmacotherapy Workup

Determine whether the patient's drug-related needs are being met (indication, effectiveness, safety, compliance), identify drug therapy problems

Activities and Responsibilities in the Patient Care ProcessCare plan Establish goals of therapy Negotiate and agree upon endpoints and

timeframe for pharmacotherapies with the patient

Select appropriate interventions for:

resolution of drug therapy problems

achievement of goals of therapy

prevention of drug therapy problems.

Consider therapeutic alternatives

Select patient-specific pharmacotherapy

Consider nondrug interventions

Educate patient

Schedule a follow-up evaluation Establish a schedule that is clinically appropriate and convenient for the patient

Activities and Responsibilities in the Patient Care Process

Follow-up evaluation

Elicit clinical and/or lab evidence of actual patient outcomes and compare them to the goals of therapy to determine the effectiveness of drug therapy

Evaluate effectiveness of pharmacotherapy

Elicit clinical and/or lab evidence of adverse effects to determine safety of drug therapy

Evaluate safety of pharmacotherapy

Determine patient compliance

Document clinical status and any changes in pharmacotherapy that are required

Make a judgment as to the clinical status of the patient's condition being managed with drug therapy

Assess patient for any new drug therapy problems

Identify any new drug therapy problems and their cause

Schedule the next follow-up evaluation

Provide continuous care

AssessmentThe purpose is

(1) To understand the patient well enough to

make rational drug therapy decisions with

and for him/her

(2) To determine if the patient's drug therapy is

appropriate, effective, and safe, and to

determine if the patient is compliant with

his/her medications

(3) To identify drug therapy problems

AssessmentThe information required

patient data (demographic information,

medication experience)

disease data (current medical conditions,

medical history, nutritional status, review of

systems)

drug data (current medications, past

medication use, social drug use,

immunizations, allergies, and alerts).

Assessment

The two major activities that occur

during the assessment are:

Eliciting information from the patient

Making clinical decisions about the

patient's medications and meeting

his/her drug-related needs or drug

therapy problems.

Assessment

Involves:

discussing the patient's medication

experience.

The sum of all the events in a patient's

life that involve medication use.

Identifying drug therapy problems undesirable events or risks experienced by

the patient that involve or are suspected to

involve drug therapy and that inhibit or

delay him/her from achieving the desired

goals of therapy.

These problems are identified during the

assessment process, so that they can be

resolved through individualized changes in

the patient's drug therapy regimens.

Identifying drug therapy problems

The Process Used to Identify Whether a

Patient has a Drug Therapy Problem

requires a

Continuous Assessment of 4 Logical

Questions

1. Does the patient have an indication for

each of his/her drug therapies, and is each

of the patient's indications being treated

with drug therapy?

Identifying drug therapy problems

2. Are these drug therapies effective for

his/her medical condition?

3. Are the drug therapies as safe as

possible?

4. Is the patient able and willing to

comply with the drug therapies as

instructed?

CategorizationFirst step

Categories of Drug Therapy ProblemsDescription of the Problem Drug Therapy Problem

The drug therapy is unnecessary because the patient does not have a clinical indication at this time.

Unnecessary drug therapy

Additional drug therapy is required to treat or prevent a medical condition.


The drug product is not effective at producing the desired response.

Ineffective drug

The dosage is too low to produce the desired response.

Dosage too low

The drug is causing an adverse reaction.

Adverse drug reaction

The dosage is too high resulting in undesirable effects.

Dosage too high

The patient is not able or willing to take the drug regimen appropriately.

Noncompliance

IdentificationSecond Step

Identifying drug therapy

Identify the cause for each drug therapy

problem.

When multiple drug therapy problems exist, they

need to be prioritized

The order of priority is based on the patient's

views regarding which one is causing the most

concern, and the preferences he/she has toward

addressing the problem

Identifying drug therapy

Final outcome:

the description and prioritization of the

drug therapy problem(s) to be resolved

through specific interventions in the

care plan.

Care plan development

The purpose

To organize all of the work agreed

upon by the practitioner and the

patient to achieve the goals of

therapy.


The requirments

Interventions to resolve drug

therapy problems

Interventions to meet these goals

Interventions to prevent new drug

therapy problems from developing.


Constructing care plans is done in

collaboration with the patient and other

health care practitioners providing care to

the patient.

Care plans are organized by medical

condition

A separate care plan is constructed for each

condition or illness


Involves three steps:

1. Establishing goals of therapy

2. Selecting appropriate

individualized interventions

3. Scheduling the next follow-up

evaluation.

Establish goals of therapy

Goals consist of a parameter, a value, and a timeframe.

Goals guide all subsequent decisions, actions, interventions, and patient education.

Establish goals of therapy

Goals Must be explicitly statedconsistent with the patient's

preferences and desiresclinically soundobservable or measurable in a stated

timeframe.understood and agreed upon by

practitioner and patient.

Interventions

They are designed to:

Resolve drug therapy problems

Achieve the stated goals of therapy

Prevent new drug therapy problems

from developing

InterventionsThey are designed to:

Resolve drug therapy problems

takes precedence within the care plan

because goals of therapy cannot be achieved

until patient's drug therapy problems are

resolved

Achieve the stated goals of therapy

Prevent new drug therapy problems from

developing

InterventionsThey are designed to: Resolve drug therapy problems

Achieve the stated goals of therapyinclude changes in drug therapy regimens and

individualized patient instructions. E.g patient education or instructions as to the

optimal use of medications, related technology, and/or diet and exercise to increase the probability of success with the medication regimen.

prevent new drug therapy problems from developing

InterventionsThey are designed to: Resolve drug therapy problems Achieve the stated goals of therapy Prevent new drug therapy problems

from developingespecially important for patients who

have a higher than normal probability of developing a drug therapy problem due to some identified risk factor(s).

Follow-up evaluation schedule the follow-up evaluation to

determine the outcomes of drug therapy. If there are multiple care plans, the

schedules for the follow-up evaluations must be coordinated

During the follow-up evaluation,The results of care plan actions are judged as

to their positive or negative impact on the patient.

.


The purpose

To determine the actual outcomes of drug

therapy for the patient

Compare these results with the intended goals of

therapy

Determine the effectiveness and safety of

pharmacotherapy,

Evaluate patient compliance

Establish the current status of the patient.


The specific activities performed

Observe or measure positive from drug

therapies (effectiveness).

Observe or measure any undesirable effects

that were caused by a drug therapy (safety).

Determine the actual dosage of medication the

patient is taking that is producing the results

observed (compliance).


The specific activities performed

Make a clinical judgement of the status of

the patient's medical condition or illness

being managed with drug therapy

(outcomes).

Reassess the patient to determine if

he/she developed any new drug therapy

problems.


Data to evaluate effectiveness

Improvement or reduction of the signs

or symptoms of the patient's medical

condition or illness.

the extent to which abnormal

laboratory test results have returned to

within the desired or normal range.


Data to evaluate the safety

Evaluation of unintended

pharmacological effects (side

effects) of the patient's drug therapy.

if lab tests have become dangerously

abnormal due to drug therapy.

Follow-up evaluation It is important to determine patient

compliance at each follow-up

evaluation, Because both effectiveness

and safety are evaluated based upon

the drug dosages that the patient has

actually taken.

Follow-up evaluationClinical judgment about the outcomes At each evaluation the status might be resolved,

stable, improved, partially improved, unimproved, worsened, or failed.

Each term contains two items of important information: The patient's present condition What was done to the drug therapy in response to the

patient's condition.

This clinical judgment is recorded and compared to the status at each evaluation to determine if drug therapies are helping the patient meet the desired goals.

Documentation in practice As pharmacotherapy and medical

services become more complex, creating an effective record of all decisions made concerning the patient's drug therapies and the outcomes of those decisions is essential.

Documentation in practice Comprehensive documentation is

required and includes patient's clinical informationdrug therapy problemsa comprehensive medication recordgoals of therapyevidence of effectiveness and safety of

pharmacotherapies at every follow-up visit

Reasons to document

1. Provide quality patient care2. Manage the practice3. Liability issues4. Evaluate performance5. Justify professional role6. Reimbursement

NO DOCUMENTATION MEANS YOU DID NOT DO IT!!

Requirements for the pharmaceutical care practitioner Understand your responsibilities. Develop a therapeutic relationship with each patient. Apply the Pharmacotherapy Workup to make rational

drug therapy decisions. Learn the patient care process. Acquire an appropriate pharmacotherapeutic

knowledge base. Develop clinical skills. Understand practice standards and ethical

considerations. Document all care provided

Practice Results

Key Points A database of 20,761 patients who received

pharmaceutical care during 59,361 patient

encounters has been established over the past

10 years.

A sample of 5136 was selected and evaluated.

patients <65 years (n = 3064), had an average

of 3 medical conditions with an average of 5

drug therapies.

Frequency of patients by age.

Frequency of patients by number of medical conditions

Key Points Patients >65 years (n = 2072), had an average

of 5 medical conditions being treated with 7

medications.

34% of the younger patients had a drug therapy

problem, while 54% of the older patients had ≥

1 drug therapy problems identified by the

clinician at the first pharmaceutical care visit.

Key Points

The most common drug therapy

problem, in both groups, was the

need for additional drug therapy,

followed by dosages too low and then

patient compliance problems.

Key Points

The decisions made by

pharmaceutical care practitioners

have been found to be clinically

credible based on the evaluations and

comments of peer-reviewed panels.

Key Points

Pharmaceutical care practitioners

resolve almost 80% of drug therapy

problems directly with the patient.

Practitioners were able to produce

positive patient outcomes in 90% of

patients, regardless of the patient's age,

medical conditions, or type of drug

therapy problem.

Key Points

Pharmaceutical care practice saves

patients and the health care system a

significant amount of money and

produces a positive savings to cost

ratio

MOST FREQUENT INDICATIONS FOR DRUG

THERAPY(N = 26,238 Patient Encounters)

1. HYPERTENSION2. HYPERLIPIDEMIA3. DIABETES4. OSTEOPORSIS 5. VITAMIN/DIETARY SUPPLEMENT

These 10 conditions represent 50% of all indications for drug therapy

6. ALLERGIC RHINITIS7. ESOPHAGITIS8. DEPRESSION9. MENOPAUSAL SYMPTOMS10. ARTHRITIS PAIN

DRUG THERAPY PROBLEMS (DTP) (N =26,238 Patient Encounters)

Unnecessary Drug Therapy 6 %

Needs Additional Drug Therapy 28 %

Ineffective Drug 8%

Dosage Too Low 20 %

Adverse Drug Reaction 14 %

Dosage Too High 5 %

Noncompliance 19 %

Total 100%

Percent

Indication

Effectiveness

Safety

Compliance

34%

28%

19%

19%

Table 7-6

Drug therapy problems by category.

Table 2-13 Type of Drug Therapy Problem—Needs Additional

Drug Therapy

Cause of the problem Patients < 65 yrs olda

Patients 65 yrs oldb

Medical condition requires the initiation of drug therapy

235 (40.1%) 225 (34.9%)

Preventive drug therapy is required to reduce the risk of developing a new condition

228 (38.9%) 274 (42.6%)

Medical condition requires additional drug therapy to attain synergistic or additive effects

123 (21.0%) 145 (22.5%)

Table 2-19 Most Common Drug Therapy Problems and

Associated Medical Conditions

Patients < 65 yrs old Patients 65 yrs old

Diabetes Needs additional drug therapy

Arthritis Needs additional drug therapy

Depression Needs additional drug therapy

Arthritis Dosage too low

Asthma Needs additional drug therapy

Hypertension Needs additional drug therapy

Asthma Dosage too low Anxiety Needs additional drug therapy

Menopausal symptoms


Hyperlipidemia Needs additional drug therapy

Hypertension Needs additional drug therapy

Hypertension Dosage too low

Allergic rhinitis Needs additional drug therapy

Arthritis Adverse drug reaction

Diabetes Dosage too low Arthritis Noncompliance

Hyperlipidemia Needs additional drug therapy

Ischemic heart disease


Allergic rhinitis Dosage too low Diabetes Dosage too low

PRIMARY METHOD OF RESOLUTIONOF DRUG THERAPY PROBLEMS

Patient(79%)

Physician(19%)

Protocol Carrier

Table 2-24 Interventions Made to Resolve Drug Therapy Problems

Patients < 65 years Patients 65 year

% of interventions %of interventionRequired patient intervention only

Initiate new drug therapy 358 451Change drug product 58 81

Change dosage regimen 293 352Discontinue drug therapy 129 138

Initiate laboratory test monitoring

126 204

Education beyond OBRA 330 430Provided medication reminder

device43 54

Removed patient barrier 126 131Other 209 59Total 1672 (77.6%) 1905( 81.7%)

Required protocol/carrier interventionInitiate new drug therapy 4 0

Change drug product 6 1Change dosage regimen 4 0Discontinue drug therapy 1 4

Other 8 1Total 23 (1.1%) 6( 0.2%)

IMPACT OF PHARMACEUTICAL CARE

PRACTICE Resolution of drug therapy problems with

Physiciansinitiate new drug therapy

31 %change drug dosage regimens 23 %change drug product

15 % discontinue drug therapy

15 %laboratory monitoring initiated10% other 6%

Change in Clinical Status at Follow-up Evaluation4492 Patients and 10,485 Medical Conditions

Condition Improvedor

Remained the Same(84 %)

Condition Declined(16 %)

Clinical Outcomes

84% of the medical conditions requiring drug therapy, which were not already stable at the

time of the first pharmaceutical care encounter, improved

(69%) or remained the same(15%) through the

provision of pharmaceutical care.

Documents

The changing role of the.pharmacist This course describes the practice of pharmaceutical care is the new role for the pharmacist. This course is designed