Clinical Pharmacy II

Topic to be covered   Ambulatory care Home care

Objective 1. Describe ambulatory care practice 2. Describe the impact of ambulatory care practices 3. Provide examples of activities provided through ambulatory care services 4. Identify future opportunities and challenges

“all health-related services for patients who walk to seek their care” What is Ambulatory Care? “all health-related services for patients who walk to seek their care” Examples: clinics - general (primary care); specialty (day surgery, chemotherapy) ER private offices community pharmacies  

Why ambulatory care? Shift from acute hospital care ambulatory care The main goal of this shift is to decrease health cost

Because Managed care approach to decrease hospitalization rates and length of stay The number of elderly patients with multiple chronic medical conditions that require longitudinal management is growing Know there is more focus on preventive health and patient education

Documented value of ambulatory Pharmacy services increase physician availability increase # patient visits decrease hospitalization rates: Asthma clinic, Pauley et al, 1995 drug cost savings: Jones et al, 1991 improve quality of care: more thorough work-up address adherence issues: Ulcers: Lee et al, 1999 better treatment outcomes: Anticoagulant control, Chiquette et al, 1998 Hypertension, Erickson et al, 1997 Diabetes, Coast-Senior et al, 1998 fewer adverse drug reactions: Miller et al, 1996

Ambulatory Care Primary Care Specialty Care “first contact” continuity of care comprehensive care individualized care health promotion, disease prevention, early detection Particular organ system or disease type health promotion and prevention specialized training one point in time

Diabetes, Pain, OA, Geriatric Clinics:Common elements Referral: family MD, patient, HCP Health promotion and prevention Promote independence and increase knowledge with self-care of health conditions Not a cure Multidisciplinary team Group education Individual consultation Interpreters

Diabetes, Pain, OA, Geriatric Clinics:Common elements Referral Screening/initial assessment Goal setting Individual counselling * Group Education Follow-up

Pharmacist’s activities: Assists with designing therapeutic regimen Identifying untreated conditions Proccessing narcotic prescripton Assesing nonformulary prescription Designing long-term follow-up and monitoring plans Identifying therapeutic duplication Establish relationships with patients Educate and counsel patients to enhance compliance Teaching pharmacy students

Pharmacist: Roles & Responsibilities Screening and early detection dyslipidemia hypertension diabetes osteoporosis Health promotion and disease prevention immunization smoking cessation general wellness

Pharmacist: Roles & Responsibilities Medication history and assessment disease specific efficacy, toxicity, adherence medication management herbal products Pharmacotherapeutic interventions identification/prevention of drug-related problems establishing goals and outcomes initiate modify discontinue monitor drug therapy Pharmacy Care plan

Implementation of PCP Documentation Communication Who: How: physician Health care team community pharmacy community agencies How: chart team rounds telephone

Challenges 1. Team dynamics: 2. Marketing your services: overlapping scopes of practice clarify roles and responsibilities 2. Marketing your services: education of patients and health care providers, re: scope of practice when to refer

Challenges 3. Delivering patient education effectiveness and impact adult vs. student education group education - interactive vs. didactic multi-cultural aspects varying levels of education handouts 4. Changing the public’s perception creating a demand for cognitive services

ASHP Standards Minimum standards for pharmaceutical care services in ambulatory care: Leadership and Practice management Medication therapy and pharmaceutical care Drug distribution and control Facilities, equipment and other resources

Future directions Measuring quality of care identifying representative markers of care (e.g. BP, lipid levels) Measuring patient satisfaction timeliness, efficiency, communication Impact on long term outcomes e.g. diabetes education- > control BS -> impact on complications?

Ambulatory Care Pharmacy Tremendous opportunity for growth Multidisciplinary team resources available Dedicated time for direct patient care and follow-up Taking the lead in care Opportunity to try new ideas!