1. Emtenan AlHarbi, MSc. Clinical Pharmacy Department College of Pharmacy 1 Pharmaceutical Care: Introduction to Concepts & pharmacist role Fall 2011 PHCL 313

2. Objectives 2 At the end of this lecture students should be able to: Understand the need for pharmaceutical care Define pharmaceutical care and its philosophy Describe the requirements for pharmaceutical care Understand the patient care process and therapeutic relationship.

3. Objectives 3 Recognize patient drug related needs Be familiar with the main categories of drug related problems Understand practice standards and ethical considerations

4. 1850-1900 1900-1960 Late 1960’s-1980’s1990- present From products to patients: Evolution of Pharmacy Practice

5. Pharmaceutical Care “The responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life” Helper & Strand 1990

6. Pharmaceutical Care These outcomes are: Curing of a disease Eliminating or reducing of a patient’s symptoms Arresting or slowing of a disease process Preventing a disease or symptoms

7. Philosophy of Pharmaceutical Care 1. Societal need for pharmacists to address drug-related problems 2. A patient-centered approach to meet this need 3. A practice based on “caring” about and for patients 4. A responsibility for finding and responding to the patient’s drug therapy problems. Pharmacists work with and for the patient to optimize the outcomes of medication therapy.

9. The need for Pharmaceutical Care? 9 The high level of drug-related morbidity and mortality resulting in significant human and financial costs. Increased use of self-care Increased complexity of drug therapy Patients playing a more active role in the selection and use of medications Presence of overwhelming amount of drug information accessible by patients Patients seek multiple practitioners

10. Patient-Centered Practice 10 A cornerstone of the philosophy of pharmaceutical care practice Care that places the patient's needs as the focus of the clinician's work Care that maintains the patient as a "holistic" being and does not fragment the patient into disease groups, organ systems, or drug categories

11. Meeting the health care needs of a patient 11 Patient

12. Patients Drug Related Needs 12 1. The medication is appropriate Legitimate clinical indication for each medication. All of the patient's medical conditions that can benefit from drug therapy have been identified. 2. 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.

13. Patients Drug Related Needs 13 3. The medication is safe There are no adverse drug reactions being experienced. There are no signs of toxicity. 4. The patient is compliant The patient is willing and able to take the medications as intended.

14. Patients Drug Related Needs 14 5. Patients have all drug therapies necessary to resolve any untreated indications

15. Unmet patient needs lead to drug related problems (DRPs) Appropriate indication for each medication An effective drug product A safe drug product Be able to use and comply with the drug regimen Need drug therapy for untreated conditions Inappropriate drug, low dose Unnecessary drug therapy Inappropriate compliance the drug regimen ADR or high dose Need additional drug therapy

16. Categories of drug therapy problems INDICATION 1. Unnecessary drug therapy 2. Needs additional drug therapy EFFECTIVENESS 3. Ineffective drug 4. Dosage too low SAFETY 5. Adverse drug reaction 6. Dosage too high CONVENIENCE of Therapy 7. Noncompliance/ nonadherence

17. 17 Requirements to be a Pharmaceutical Care Practitioner

18. Patient Care Knowledge of drug therapy Knowledge of non- drug therapy Knowledge of laboratory & diagnostic testing Communic ation Skills Patient Monitorin g skills Physical Assessment skills Drug informatio n skills Therapeuti c planning skills Knowledge of disease

19. What are the requirements to be a Pharmaceutical Care Practitioner? 19 1. Develop a therapeutic relationship with each patient 2. Understand one’s responsibilities identify and respond to any DRP for every patient. Learn the patient care process 3. Use a systematic approach to make rational drug therapy decisions “Pharmacotherapy Workup “

20. What are the requirements to be a Pharmaceutical Care Practitioner? 20 4. Have an appropriate knowledge base and clinical skills 5. Understanding of practice standards and ethical considerations. 6. Documentation of all care provided

21. Therapeutic Relationship 21 The therapeutic relationship is a partnership or alliance between the practitioner and the patient formed for the purpose of optimizing the patient's medication experience.

22. Why is therapeutic relationship is important? 22 Facilitate retrieval of information Patient as the Primary Source of Information positively influence the patient's decisions Patient as Decision Maker learn from the patient the actual impact of the drug therapy Use patient as Teacher

23. Pharmacotherapy Workup… 23 The logical, structured and rational thought process that guides work and decisions as the clinician: assesses the patient's drug-related needs and identifies drug therapy problems organizes the interventions that need to be made on the patient's behalf establishes appropriate parameters to evaluate at follow-up

24. Focus of Pharmacotherapy Workup… 24 Is the patient's problem caused by drug therapy? Can the patient's problem be treated with drug therapy?

25. Patient Care Process Initiate relationship with the patient or caregiver Gather patient information(subjective and objective) Assess information(patient assessment) Develop patient care plan Complete the intervention Implement follow-up

26. Patient Care Process 26 describes the interaction between the patient and the practitioner Involves 3 steps: AssessmentCare Plan DevelopmentFollow-Up Evaluation Continuous

27. 27 Pharmacotherapy Workup is the cognitive work occurring in the mind of the practitioner while caring for the patient. The mental part of pharmaceutical care Patient Care Process is what the patient experiences when he/she receives pharmaceutical care. The physical work of pharmaceutical care

28. Documentation 28 critical and essential step “if you didn’t document it, you didn’t do it.” Systematic documentation styles, different format: SOAP (subjective, objective, assessment, plan), Places importance on intervention most common, universally recognized TITRS (title, introduction, text, recommendation, signature) an assessment approach FARM (findings, assessment, recommendations, management) places importance on monitoring.

29. information that is given by the patient, family members, significant others, or care- givers. 29 Summarizes pharmacist critical thinking and analysis of the patient needs and DRP Document actions that were or need to be taken to resolve any problems that have been identified. Sufficient detail needs to be included without being too lengthy,. Include FU and Monitoring

30. Why Documentation is Important? 30 Provides a permanent record of patient information Provides evidence of patient care activities by the pharmacist Communicates essential information to other pharmacists and healthcare professionals Serves as a legal record of patient care that was provided

31. Oath of Pharmacists 31 I will consider the welfare of humanity and relief of human suffering my primary concerns King Saud University Pharmacy Code of Ethics/oath of pharmacist Adopted by the membership of the American Pharmacists Association October 27, 1994.

32. Beneficence 32 Doing what is best for the patient Involves decisions related to medical indications Base decision on risk-benefit assessment Negotiate with the patient the decision Example: A patient with asthma and diabetes needs a course of steroids for worsening asthma, but the steroids will make diabetes control more difficult.

33. Nonmaleficence 33 Do no harm linked to the principle of beneficence Benefit: risk assessment Any risk >>> potential harm Example: Forcing a treatment on a patient, regardless of any justification

34. Veracity الصدق 34 Telling the truth about during all aspects of patient care Basis of therapeutic relationship Pharmacists should demonstrate sensitivity and thoughtful communication skills. Example: Withholding information about treatment Being vague, or mumble information

35. Justice العدل 35 Relates to fair, equitable, and appropriate treatment in the light of what is due or owed to persons Example: Discrimination because of political status, religion, gender, financial status..etc Deciding if a drug to be added/deleted from the formulary

36. Fidelity الاخلاص 36 relates "to the concept of faithfulness and the practice of keeping promises” Example: upholding the profession's code of ethics

37. Autonomy الحكم الذاتي 37 Autonomy: patient having the freedom to make choices for him or herself conditions: Patient clearly informed about care plan Cognitively competent Example: Surgery vs. pharmacotherapy

38. Autonomy 38 Paternalism overriding or ignoring preferences of patients to benefit them or enhance their welfare. It represents the judgment that beneficence takes priority over autonomy Paternalism is not an option unless in certain circumstances: patient is incompetent, child

39. Confidentiality 39 The act to protect patient medical and personal information Example: disclose personal health-related information about your patient with one of your friends or family members who is not a health care provider and who is not involved in the care of that patient. Designing a consultation room with opaque glass

40. Caring for others is a privilege that is reserved for those individuals who are uniquely well prepared and who adhere to standards for professional behavior.. 40

41. Standards of Professional Performance for Pharmaceutical Care Practitioners 41 Pharmaceutical Care practitioner is accountable to maintain his professional practice through Self regulation Self evaluation

42. Standards of Professional Performance for Pharmaceutical Care Practitioners 42 Quality of care Ethics Collegiality Collaboration Education Research Resource Allocation

43. Standard I: Quality of Care 43 The practitioner evaluates his/her own practice in relation to professional practice standards and relevant statutes and regulations

44. Standard II: Ethics 44 The practitioner's decisions and actions on behalf of patients are determined in an ethical manner

45. Standard III: Collegiality 45 The pharmaceutical care practitioner contributes to the professional development of peers, colleagues, and others.

46. Standard IV: Collaboration 46 The practitioner collaborates with the patient, significant others, and health care providers in providing patient care.

47. Standard V: Education 47 The practitioner acquires and maintains current knowledge in pharmacology, pharmacotherapy, and pharmaceutical care practice.

48. Standard VI: Research 48 The practitioner routinely uses research findings in practice and contributes to research findings when appropriate.

49. Standard VII: Resource Allocation 49 The practitioner considers factors related to effectiveness, safety, and cost in planning and delivering patient care.