2. 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

3. 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.

4. 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

5. 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 impac t.

6. SELF CARE Practitioner Assessment Care Plan Follow-up Evaluation Direct patient care Patient

7. Pharmaceutical Care in Health Care PrimaryFocusKnowledgeBase Responsibility in the drug use process Medical Care Diagnosisand Treatment of the patient’s disease PathophysiologyPrescribing NursingCare 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

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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;

14. 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

15. 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

16. 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.

17. 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

18. 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

19. 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

20. 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)

21. 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

22. C haracteristics of the t herapeutic r elationship  Mutual respect  Trust  Open communication  Cooperation  Mutual decision making

23. Components of the medication experience  The patient’s description of the medication experience  The medication history  The current medication record

24. 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

25. 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.

26. 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.

27. 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.

28. The Patient's Drug-Related Needs The 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.

29. 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.

30. IndicationDrug productDosage regimenOutcomes Safety Drug Therapy Problem Unnecessary drug therapy Needs additional drug therapy Drug Therapy Problem Ineffective drug Adverse drug reaction Drug Therapy Problem Dosage too low Dosage too high Drug Therapy Problem Noncompliance 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

31. The Patient's Drug-Related Needs  We have 2 scenarios

32. Scenario 1 1-All of the criteria are met; The patient's drug-related needs are also being met No drug therapy problems exist. the pharmacist’s responsibility is to ensure that the goals of therapy for each medical condition continue to be achieved.

33. Scenario 2. 2- Criteria are not met a drug therapy problem exists. pharmacits's responsibility to resolve drug therapy problems with and for the patient

34. 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

35. The pharmacotherapy workup  Unique knowledge base is focused on pharmacology, pharmacotherapy, and pharmaceutical care practice.  The practitioner identifies, resolves, and prevents drug therapy problems.

36. The pharmacotherapy workup  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.

37. The pharmacotherapy workup  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

38. The pharmacotherapy workup  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

39. 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

40. A method that allows the practitioner to make rational (well-reasoned, scientific) decisions. An application of the problem-solving process W hat is the p atient c are p rocess?

41. 1. Assess the patient’s drug-related needs 2. Develop a care plan 3. Complete a follow-up evaluation P harmaceutical c are p atient c are p rocess

42. 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 ASSESSMENTCARE PLANEVALUATION

43. The patient care process  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

44. The patient care process  Assessment the patient, his/her medical problems, drug therapies → leading to drug therapy problem identification

45. The patient care process  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.

46. The patient care process  The Pharmacotherapy Workup describes all the work that you do mentally while the patient care process describes the work that you do physically.

47. Activities and Responsibilities in the Patient Care Process

50. Assessment The 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

51. Assessment The 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).

52. 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.

53. Assessment Involves: discussing the patient's medication experience. The sum of all the events in a patient's life that involve medication use.

54. 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.

55. 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?

56. 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?

57. First step

58. Categories of Drug Therapy Problems Description of the ProblemDrug 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. Needs additional drug therapy 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

59. Second Step

60. 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

61. 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.

62. 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.

63. Care plan development The requirments  Interventions to resolve drug therapy problems  Interventions to meet these goals  Interventions to prevent new drug therapy problems from developing.

64. Care plan development  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

65. Care plan development Involves three steps: 1. Establishing goals of therapy 2. Selecting appropriate individualized interventions 3. Scheduling the next follow-up evaluation.

66. Establish goals of therapy  Goals consist of a parameter, a value, and a timeframe.  Goals guide all subsequent decisions, actions, interventions, and patient education.

67. Establish goals of therapy  Goals Must be explicitly stated consistent with the patient's preferences and desires clinically sound observable or measurable in a stated timeframe. understood and agreed upon by practitioner and patient.

68. Interventions They are designed to:  Resolve drug therapy problems  Achieve the stated goals of therapy  Prevent new drug therapy problems from developing

69. Interventions They 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

70. Interventions They are designed to:  Resolve drug therapy problems  Achieve the stated goals of therapy include 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

71. Interventions They are designed to:  Resolve drug therapy problems  Achieve the stated goals of therapy  Prevent new drug therapy problems from developing especially important for patients who have a higher than normal probability of developing a drug therapy problem due to some identified risk factor(s).

72. 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..

73. Follow-up evaluation 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.

74. Follow-up evaluation 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).

75. Follow-up evaluation 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.

76. Follow-up evaluation 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.

77. Follow-up evaluation 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.

78. 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.

79. Follow-up evaluation Clinical 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.

80. 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.

81. Documentation in practice  Comprehensive documentation is required and includes patient's clinical information drug therapy problems a comprehensive medication record goals of therapy evidence of effectiveness and safety of pharmacotherapies at every follow-up visit

82. Reasons to document 1. Provide quality patient care 2.Manage the practice 3. Liability issues 4. Evaluate performance 5. Justify professional role 6. Reimbursement NO DOCUMENTATION MEANS YOU DID NOT DO IT!!

83. 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

84. Practice Results

85. 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.

86. Frequency of patients by age.

87. Frequency of patients by number of medical conditions

88. 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.

89. 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.

90. 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.

91. 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.

92. Key Points  P harmaceutical care practice saves patients and the health care system a significant amount of money and produces a positive savings to cost ratio

93. M OST F REQUENT I NDICATIONS FOR D RUG T HERAPY (N = 26,238 Patient Encounters) 1. HYPERTENSION 2. HYPERLIPIDEMIA 3. DIABETES 4. OSTEOPORSIS 5. VITAMIN/DIETARY SUPPLEMENT These 10 conditions represent 50% of all indications for drug therapy 6. ALLERGIC RHINITIS 7. ESOPHAGITIS 8. DEPRESSION 9. MENOPAUSAL SYMPTOMS 10. ARTHRITIS PAIN

94. 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% Table 7-6

95. Drug therapy problems by category.

98. PRIMARY METHOD OF RESOLUTION OF DRUG THERAPY PROBLEMS Patient (79%) Physician (19%) Protocol Carrier

99. Table 2-24 Interventions Made to Resolve Drug Therapy Problems Patients < 65 yearsPatients 65 year % of interventions% of intervention Required patient intervention only Initiate new drug therapy358451 Change drug product5881 Change dosage regimen293352 Discontinue drug therapy129138 Initiate laboratory test monitoring 126204 Education beyond OBRA330430 Provided medication reminder device 4354 Removed patient barrier126131 Other20959 Total1672 (77.6%)1905 (81.7%) Required protocol/carrier intervention Initiate new drug therapy40 Change drug product61 Change dosage regimen40 Discontinue drug therapy14 Other81 Total23 (1.1%)6 (0.2%)

100. I MPACT OF PHARMACEUTICAL CARE PRACTICE Resolution of drug therapy problems with Physicians initiate new drug therapy 31 % change drug dosage regimens23 % change drug product15 % discontinue drug therapy 15 % laboratory monitoring initiated10% other 6%

101. Change in Clinical Status at Follow-up Evaluation 4492 Patients and 10,485 Medical Conditions Condition Improved or Remained the Same (84 %) Condition Declined (16 %)

102. 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.

103. The purpose of this course is to teach you how to become pharmaceutical care practitioners