1. Ambulatory Care Pharmacy Debbie Kwan, BScPhm., MSc. Toronto Western Hospital -University Health Network Faculty of Pharmacy, Nov. 22, 2002

2. Objectives: 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

3. What is Ambulatory Care? “all health-related services for patients who walk to seek their care” Seaton, Ambulatory Care, PSAP Examples: Fclinics - general (primary care); specialty (day surgery, chemotherapy) FER Fprivate offices Fcommunity pharmacies

4. Why ambulatory care? Shift from acute ambulatory care: –decreasing LOS –increased outpatient procedures –goal: decrease health care costs Continuity of care: –bridging the gaps –secondary prevention clinics e.g SPACE

5. What does the Pharmacy profession think? ASHP Survey 1999: –“greatest opportunity for pharmacists in the future lie in primary and ambulatory care” –more emphasis on preventive care –curricula change to support this

6. 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

7. Ambulatory Care Primary CareSpecialty 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

8. Ambulatory Care services at TWH Community & Population Health Family Health Centre Health Living Centre: Diabetes Education Centre Community Arthritis Management Program Chronic Pain Program Seniors Wellness Clinic Women’s Health Mental Health Artists Health Centre

9. Healthy Living Centre Goals: 1. Identify health needs and issues 2. Effective use of resources 3. Improve access, integration and coordination of care 4. Increase community knowledge and responsibility for health status 5. Promote improvement in health systems Improve health status of target populations

10. Target Population profile Seniors (65+) - 11.7% (1/3 live alone) Ethnic diversity - 88% (not British or Cdn) vs. 82% for Toronto: –Portuguese, Chinese, Italian, Jewish, Polish, Vietnamese, East Indian, Filipino, Jamaican Literacy/Education - lower rates than rest of Toronto Eglinton Ave. Keele St. Yonge St. Lake Ontario ~ 40,000

11. Diabetes, Pain, OA, Seniors 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

12. Diabetes, Pain, OA, Seniors Clinics: Common elements Referral Screening/initial assessment Goal setting Group Education and/or Individual counselling * Follow-up

13. Family Health Centre - TWH Physicians medical residents nurse practitioner RN, RPN social worker pharmacists chiropodist Support staff: –receptionists –medical records –administrative staff

14. Family Health Centre Pharmacist’s activities: Drug information Consultation Teaching

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

16. 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

17. Implementation of PCP Documentation Communication –Who: physician Health care team community pharmacy community agencies (e.g. VON) –How: chart team rounds telephone

18. Telephone follow-ups reduce seniors' drug-related problems Patients aided by pharmacist calls By Lynn Haley VANCOUVER – Telephone followup can greatly reduce drug- related problems (DRPs) in geriatric patients, researchers at the Toronto Rehabilitation Institute reported at the recent 17th World Congress of the International Association of Gerontology. The Medical Post, VOLUME 37, NO. 28, August 21, 2001 Kwan, Alibhai, Papastavros, Armesto, Toronto Rehab Institute

19. 10% 4% 27% 22% 17% *20% * new category that emerged during follow-up Additional Drug-related problems identified during Telephone follow-up:

20. 1. Medication education  41.6% 2. Dosing regimen modification  20.0% (e.g. timing, use of compliance aids) 3. Therapeutic recommendation12.9% (resulting in new prescription) 4. Consult Geriatrician 11.8% 5. Refer to community resources  8.0% (e.g. community pharmacy, VON) 6. Earlier clinic follow-up visit 4.9% 101 interventions were carried out 66% of interventions were provided by the pharmacist over the telephone  Intervention type % Total

21. Initiating ambulatory care practices The Pharmaceutical Care Pilot Project: Structure and Function of Drug-Related Problems in the Community Dwelling Elderly Bowles S, Perrier D. Sunnybrook Health Science Centre and Faculty of Pharmacy; Kwan D, Study Co-ordinator Ontario Drug Benefit Program Grant, $18,000 (1993 – 1995) uambulatory geriatric rehab program - frail elderly u260 DRPs (n=39) –additional drug required (30%) –possible adverse drug reaction (25%) –alternative agent more appropriate (20%)

22. Initiating ambulatory care practices Multidisciplinary falls clinic: Medications contribute to falls Role of the pharmacist: –interventions will be patient specific –weighing risk vs. benefit –preventive measures (e.g. osteoporosis) –education of the patient informed choices

23. Initiating ambulatory care practices Community Mental Health and Addiction Program (TWH) mental health crisis team emergency psychiatry assessment unit Portuguese mental health and addiction unit men and women’s withdrawal programs Opportunities: –provision of drug information (staff, clients) –medication identification –linking with community pharmacies –supportive role vs. direct patient care –student experience

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

25. 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

26. ASHP Standards Minimum standards for pharmaceutical care services in ambulatory care: 1.Leadership and Practice management 2.Medication therapy and pharmaceutical care 3.Drug distribution and control 4.Facilities, equipment and other resources Other resources: CSHP, ACCP – specialty practice groups www.ashp.org

27. Future Directions Reimbursement Credentialing (value added) –residency –Pharm.D. –fellowship –specialty certification

28. 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?

29. 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 - primary liaison  Opportunity to try new ideas!