1. Department of Clinical Pharmacy, College of Pharmacy PSAU
Pharmaceutical Care
Ziyad Almalki, PhD
Department of Clinical Pharmacy, College of Pharmacy PSAU
week1

2. Pharmaceutical care
The Practice of Pharmacy embraces a variety of settings, patient populations, and specialist as well as generalist pharmacists. Central to the practice of pharmacy, however, is the provision of clinical services directly to, and for the benefit of patients.
The pharmaceutical care is defined as “A patient’s centered practice in which the practitioner responsibility is oriented for patient-drug related needs.”
It describes specific activities and services through which an individual pharmacist cooperates with patient and other professionals in designing and monitoring a therapeutic plan that will produce specific therapeutic outcomes to the patient.”
These outcomes are :
Cure of the disease
Elimination or reduction of patient`s symptomology
Arresting or slowing of a disease process
Preventing a disease or symptoms

3. Importance of Pharmaceutical care
As medication errors is growing, so professionals' efforts must be united.
The number, complexity, and potency of prescription and non prescription drug products are increasing.
Pharmaceutical care activities integrate pharmacists into the health – care system.

4. The need of pharmaceutical care comes from ….
The old
“Physicians Prescribe and Pharmacists Dispense” model
is no longer fully appropriate to
reduce drug therapy problems,
ensure safety,
ensure effectiveness and
adherence to drug therapy.

5. What is wrong with the “old model
What is wrong with the “old model? (Physicians Prescribe and Pharmacists Dispense)
Healthcare costs
Medicine related errors are costly in terms of hospitalizations, physician visits, laboratory tests and remedial therapy.
Adverse drug reaction
4%-10% of all hospital in-patients in developed countries.
The 4th-6th leading cause of death in USA
Estimated cost: up to US $ 139 billion a year in the USA
£ 466 million (over $812 million): in the UK
‘’No documented data in Saudi Arabia’’

6. non compliance is A MAJOR ISSUE
What is wrong with the “old model? (conti..) (Physicians Prescribe and Pharmacists Dispense)
More than 50% of all prescriptions are incorrect
50%–90% of medicines purchased are paid for out-of-pocket in developing countries.
non compliance is A MAJOR ISSUE
 >50% of the people involved fail to take them correctly.

7. What is wrong with the “old model. (conti
What is wrong with the “old model? (conti..) (Physicians Prescribe and Pharmacists Dispense)
Up to 90% developed resistance to original first-line antibiotics such as ampicillin and cotrimoxazole for shigellosis,
Up to 70% resistance to penicillin for pneumonia and bacterial meningitis,
Up to 98% resistance to penicillin for gonorrhea, and
Up to 70% resistance to both penicillin and cephalosporin for hospital-acquired S.aureus infections.
‘’ no documented data in Saudi Arabia’’

8. What could be a solution?????
First think!!!!
Did the pharmacist find the problem or did the problem find the pharmacist?
Most problems are discovered only when a pharmacist thinks
“that can’t be right!” or when the computer goes beep, beep, beep!

9. What could be a solution????? (conti..)
This pharmacist embraces a new practice model - pharmacy care or pharmaceutical care model.
Role change
The pharmacy professional needed today is a knowledgeable drug expert and skilled, persuasive communicator and not a pill counter.

10. The pharmacist role has to be changed from…
medicine supply  more inclusive patient care
A pharmacist who is unable or unwilling to adapt to a new role places millions/billions of money at loss.
All what the pharmacist needs are..
1. Knowledge …………....(easy to fix) √
e.g. Expert knowledge of therapeutics, a good understanding of disease process, knowledge of pharmaceutical products, and provision of drug information
2. Skill ……………………..(easy to fix) √
e.g. Drug monitoring skills, Communication skills
3. Attitude ……………….(hard to fix) ??!!

11. Barriers to the Provision of Pharm. Care
Lack of time
Insufficient knowledge & confidence
Conflicting job functions
Poorly designed workflow
Physical layout problems
Lack of institutional or corporate support

12. Strategies to Overcome the Barriers
The 2003 White Paper endorsed by 12 prominent national pharmacy organizations states that
"implementation of pharm. care requires a fundamental change in the way pharmacies operate. Pharmacists must relinquish routine product-handling Rxs to competent technicians & technology.”
Pharmacists who want to be pharm. care providers will need
Support reassurance, mentors, role models & networks of pharmacists who are working toward a common goal of pharm. care.
Pharmacy must create, implement & evaluate a plan for pharm. Care service provision.

13. Basic Elements of Pharmaceutical Care
Patient oriented.
Both acute and chronic problems addressed.
Focus on prevention of drug related problems.
Documented system on patients record need and care.
Offering continuous care in systematic way.
Taking help of other health care providers in integrating the care provided.
Highly accountable and responsible.
Emphasis on optimizing patients health quality of life.

14. Basic Elements of Pharmaceutical Care (conti.)
Emphasis on patient`s health education and health promotion.
Three major functions
1-Identifying potential and actual drug-related problems.
2-Pesolving actual drug-related problems and
3-Preventing potential drug-related problems.

15. Pharmaceutical Care - Benefits
Decrease medication misadventures
Increase patient compliance to therapy
Empowers patients to take in-charge of their own health and treatment
Decrease healthcare cost and demand
Decrease morbidity of mortality
Increase patients’ quality of life

16. Department of Clinical Pharmacy, College of Pharmacy PSAU
Pharmaceutical Care
Ziyad Almalki, PhD
Department of Clinical Pharmacy, College of Pharmacy PSAU
week2

17. Steps in the Pharmaceutical Care Process (Patient Care Process)
A- Assessment
Meet patient
Establish relationship, determine individual needs & medication experience (beliefs & practices)
Gather information
What information is needed, best sources
Analyze
Are drug therapy needs being met?
Is the patients problem being caused by drug therapy
Can the patient’s problems be treated with drug therapy
Indication, effectiveness, safety & compliance

18. Steps in the Pharmaceutical Care Process (Patient Care Process) (conti
Assess needs and Identify drug problems.
Medical Vs drug therapy problems
Medical problems
A disease state ; A change in physiology that (potentially) results in clinical evidence of damage to an organ system. E.g. HTN, HF, DM, etc.
Drug therapy problems
A patient problem that is either caused by a drug or may be treated/prevented by a drug

19. Steps in the Pharmaceutical Care Process (Patient Care Process) (conti
B- Care Plan
Establish goals including time frame to achieve
Base on medical literature, corroborated with patient
– Select interventions / alternative therapies to resolve any drug- therapy problems
• May include pharmacotherapy, lifestyle modifications…
– Schedule follow-up & evaluation
C- Follow-up
– Collect subjective & objective data related to achievement of outcomes (efficacy & safety) including compliance
– Assess / compare data to goals set with patient
– Document assessment and updated care plan
– Schedule follow-up & evaluations

20. Patient Care Process - Assessment
Purposes
Understand patient’s condition well (to make rational drug therapy decision).
To determine the patient-drug related needs (appropriate, effective, safe, compliant).
Identify DRP.
Activities done during assessment
Meet the patient. (establish a therapeutic relationship).
Eliciting information from the patients (patients, disease and drug data).

21. Patient Care Process - Assessment
Information needed to give good assessment
Patient’s data
socio-demographics (age, gender, … )
Other data [height, weight, Lean Body Weight (use for calculating pharmacokinetic parameters and dosage recommendations), smoking, alcohol/drug abuse history,..]
Can this patient's history affect drug absorption, distribution, metabolism or elimination, or can it contribute to the patient's medical problems?
Disease data
Current and past medical history
Have the present medical problems been treated with drugs previously? What was the outcome? Is there anything in the history to suggest a contraindication to drug therapy or anything that would affect the drug's action or effectiveness?
Family history, social history
Dietary history
Laboratory or other test results. (e.g. K level, serum creatinine level)

22. Patient Care Process - Assessment
Information needed to give good assessment
Drug data
current medication
What medications, routes of administration, doses and duration of treatment are presently being taken? Have the medications produced the desired therapeutic outcomes? Can these medications be contributing to some or all of the present medical problems? What organ systems (functions) are these medications affecting? Is there a history of success or failure with past drug therapy? Have past drugs adversely affected an organ system or function?
This type of information may be obtained not only from the chart, but also from the patient interviews.

23. Patient Care Process - Assessment
Information needed to give good assessment
Drug data
previous medications
Immunization
What is the immunization history?
Allergy
Have any allergic reactions occurred in the past? What is the nature and significance of past allergic reactions? Do potential allergies exist (drug, food, etc)? Is there evidence that the patient could not tolerate a medication in the past?
Medication experience
Has the patient experienced side effects from any drugs before? If so, what drugs and what reactions? What was the treatment, if any? What was the outcome?
The summation of all the events a patient has in his lifetime that involves drug therapy.

24. Patient Care Process - Assessment
Information needed to give good assessment
Drug data
Compliance History
Do past therapeutic failures suggest a lack of adherence to drug regimens? What social history, living conditions and/or physical limitations might affect patient compliance? How reliable is the source of information? Is the patient responsible for his/her own drug taking. If not, who is? What is the patient's understanding of the instructions for taking the medication?

25. Patient-drug related needs
Medication is appropriate.
Medication is effective.
Medication is safe.
Patient is compliant.

26. Drug-Related Needs of Patients
Patients need every medication they are taking to have an appropriate indication.
If a drug does not have an appropriate indication, the drug therapy problem “unnecessary drug therapy” will be identified.
Patients need their drug therapy to be effective
When a patient’s need for medication to be effective is not met, two possible drug therapy problems can arise. They are “wrong drug” and “dosage too low”.
Patients need their drug therapy to be safe
Not meeting a need for medication safety can result in the drug therapy problems of “dosage too high” or “adverse drug reaction.”
Patients need to be able to comply with drug therapy and other aspects of their care plans
Not meeting a need for medication safety can result in the drug therapy problem of “noncompliance” results.

28. Identifying DTP…
These problems are identified during the assessment process, so that they can be resolved through individualized changes in the patient's drug therapy regimens.
The synthesis and application of this knowledge occurs in a logical, systematic manner using the Pharmacotherapy Workup.

29. The Pharmacotherapy Workup
The Pharmacotherapy Workup is a rational decision- making process used in pharmaceutical care practice to identify, resolve, and prevent drug therapy problems, establish goals of therapy, select interventions and evaluate outcomes.
Components of pharmacotherapy workup
Data collection
Develop and identify CORE pharmacotherapy plan
C = Condition or potential need.
O = Outcomes desired for the condition.
R = Regimen to achieve the desired outcomes.
E = Evaluation parameter to assess outcome achievement.

30. The Pharmacotherapy Workup
Components pharmacotherapy workup
C. Identify the PRIME pharmacotherapy problems:
P = Pharmaceutical based problems.
R = Risks to patient e.g. adverse effects.
I = Interactions: Drug – drug, drug - disease, drug - food interactions.
M = Mismatch between medications and condition or patient needs.
E = Efficacy issues: too much of the correct drug, too little of the correct drug, wrong drug, device, intervention or regime prescribed.
D. Documentation

31. Drug Therapy Problem
A drug therapy problem is any undesirable event experienced by a patient which involves, or is suspected to involve, drug therapy, and that interferes with achieving the desired goals of therapy.

32. Components of a Drug Therapy Problem
An undesirable event or risk of an event experienced by the patient.
e.g. Medical complaint, illness, impairment, disability, abnormal laboratory value, or syndrome.
The drug therapy (products and/or dosage regimen) involved.
The relationship (exists or is suspected to exist) b/n the undesirable patient event and drug therapy.
the consequence of drug therapy, suggesting a direct association or even a cause and effect relationship, or
to require the addition or modification of drug therapy for its resolution or prevention.

33. Drug Therapy Problem sources
No valid medical indication
The drug therapy is unnecessary because the patient does not have a clinical indication at this time.
Duplication of therapy
Additional drug therapy is required to treat or prevent a medical condition in the patient.
Nondrug therapy more appropriate
The drug product is not being effective at producing the desired response in the patient.
The dosage is too low to produce the desired response in the patient.
The drug is causing an adverse reaction in the patient.
The dosage is too high, resulting in undesirable effects experienced by the patient.
Addiction/recreational use.
The patient is not able or willing to take the drug therapy as intended.

34. Discovering Drug Therapy Problems requires more than chart review
Example
KT, a 67-year-old man admitted with a probable thrombotic stroke. The patient was on warfarin 1 mg tablet for atrial fibrillation, esomeprazole 20 mg for gastric reflux, and an albuterol inhaler for occasional mild asthma.
In talking with the patient, the pharmacist found that KT was not taking his warfarin because he runs out. His stroke and hospitalization are a direct result of the drug therapy problem of noncompliance.
The pharmacist uncover the drug therapy problem by discussing with the patient
The pharmacist would not be able to get this if he only relies on the patient chart.

35. Patient Care Process - Care plan development
Definition
Organization of all the work agreed upon by the practitioner, other health care providers and by the patient to achieve the goal of therapy (Intervention).
Collaboration with patient (first) and with other health care provider (if needed).

36. Patient Care Process - Care plan development
Steps of care plan
Resolve DRP if occur.
Optimize patient medication experience (needs to change the drug therapy, provides patients instruction, counseling and education)
Prevent DRP from occurring (for patients at risk).
Schedule for follow up (to determine the outcome of therapy).

37. Patient Care Process - Care plan development
Goal of therapy
Is the positive outcome that should be achieved.
The future desired endpoint.
To be measured, it needs
- Parameter.
- Value.
- Time frame.

38. Patient Care Process - Follow up evaluation
This step is where the clinical experience, new knowledge and learning are gained.
Purpose
To determine the actual outcome of drug therapy.
To compare the results with the intended goal.
To determine the appropriateness, efficacy and safety of the medications.
To evaluate the patient’s compliance.
To establish the current status of the patient.

39. Patient Care Process - Follow up evaluation
Activities Performed in follow up
Observe or measure the positive results that the patient experienced from drug therapy (Effectiveness)
Observe or measure the undesirable effect that the patient experienced from drug therapy (Safety)
Determine the actual dosage of medications the patient has taken that produce the results observed (Compliance)
Make a clinical judgment of the status of patient’s condition being managed by drug therapy (Outcome)
Reassess the patient to determine if he develops a new DRP.

40. Patient Care Process - Follow up evaluation
Both safety and efficacy need compliance to medications to be positive once measured.
The patient’s outcome
Resolved.
Stable.
Improved.
Partially improved.
Unimproved.
Worsen.
Failed.