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Primary Health Care & Health
Promotion
College of Pharmacy
Qatar Primary Health Care-2008
"The Foundation for Health and Wellbeing"
The Team Approach in Asthma Management:
A Primary Health Care Model
from Qatar
Nadir Kheir PhD FNZCP MPS
Assistant Professor, Founding Chair Clinical Pharmacy & Practice
College of Pharmacy, Qatar University
College of Pharmacy- NKheir
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! Primary care should be positioned as
part of an overall strategy for health
promotion, disease prevention and
population health.
College of Pharmacy- NKheir
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6.
7.
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Ottawa Charter for Health
Promotion
Primary Health Care Parameters
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The first level of contact with the health system;
Accessible and Affordable;
Participatory (involves community participation);
Empowering (encourages individuals to take more
responsibility for their own health);
Initiating a continuing health care process which
systematically identifies those at-risk and ensures
illness prevention, health promotion, treatment,
and rehabilitation;
Providing service through multi-disciplinary teams;
Based on practical, scientifically sound and socially
acceptable methods, and encourages appropriate
uses of technology.
First International Conference on Health Promotion
Towards a global public health movement
Built on WHO’s “Targets for Health for All”;
Defined health promotion as:
“ the process of enabling people to increase control
over, and to improve, their health”;
! Promoting health is promoting the multidimensional
context of health
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Ottawa Charter for health promotion. First International Conference on Health Promotion 1986, Ottawa-WHO/HPR/HEP/95.1
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Medical
Care
We now know there is:
a need for pharmacists to shift their focus
a need to target outcomes that matters
a need to take responsibility for outcomes
..thereby, a need to provide patientcentered care
Physiotherapy
Care
“The cooperative, responsible provision of drug therapy
for the purpose of achieving definite outcomes that
improve the patient’s quality of life”
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Geriatric
Care
Pharmaceutical Care
Maternal
Care
Medical
Care
Eye Care
Surgical
Care
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Kheir’s Version
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Nursing
Care
Physiotherapy
Care
Dental
Care
The
Patient
xx
Pharmaceutical
Care
The Patient
Nutritional
Care
Hepler & Strand, 1991
Paediatric
Care
Mental
Health Care
Pediatric
Care
Hepler & Strand’s Vision of Pharmaceutical Care:
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Dental
Care
xx
•
•
•
•
Nursing
Care
Mental
Health Care
Geriatric Care
Eye Care
Nutritional
Care
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Maternal
Care
Surgical
Care
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Strand, Morley, Cipolle, 2004
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Medication Management Service:
A Model for Primary Healthcare Services in Qatar
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3.
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A range of patient-centered services that improve
the use of medicines
Patients may be referred to the service by the
following:
The treating doctor;
The pharmacist;
A patient may make self-referral
Any other healthcare provider
Patient Category
Pharmacist’s Role
2. Patients with actual or
potential DRPs
The pharmacist shall follow
structured process to
identify actual or potential
drug-related problems and
shall develop a plan to
eliminate or minimize these
problems and maximize
desired outcomes
Competence Standards For Medicines Management Services, Pharmacy Council of New Zealand, 2005
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Seven categories of patients who may
benefit from the MMS
Patient Category
1. Patients on polypharmacy
College of Pharmacy- NKheir
Pharmacist’s Role
"The pharmacist shall check each
drug for indication, effectiveness,
safety, and compliance.
"The pharmacist may suggest
reduction of doses or drugs
"The pharmacist shall advice on how
to minimize adverse effects, and on
best timing to take each drug in
relation to other drugs, meal times,
daily activities, etc
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Patient Category
Pharmacist’s Role
3. Patients who require
education to improve their
compliance with drug
therapy
The pharmacist shall work
with the patient to maximize
compliance with drug
therapy through conducting
an interview to gauge the
reasons for poor compliance
and devising plans to
improve compliance and
concordance
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Patient Category
Pharmacist’s Role
Patient Category
Pharmacist’s Role
4. Patients on medicines
which require the use of
devices (asthma inhalers) or
who use devices to monitor
diseases status
(glucometers, peak flow
meters)
The pharmacist shall identify
problems with how the
patient use the drug giving
devices and provide train
the patient on the proper
use of theming to maximize
the benefit of the drugs. For
example, the pharmacist
may check inhaler technique
6. Patients who request the
use of the service to discuss
other drug-related problems
and issues
Patients may request the
use of the service to discuss
other issues associated with
drug therapy or where they
require to speak in private
manner with the pharmacist
about drug therapy
problems
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Patient Category
Pharmacist’s Role
5. Patients on potentially
harmful drugs which require
education and monitoring
(warfarin, steroids,
chemotherapy)
The pharmacist shall
educate the patients on the
use of drug with potential
for serious adverse effects
or for drug-drug or drugfood interactions, and also
those drugs which require
monitoring to avoid harmful
effects
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Patient Category
Pharmacist’s Role
7. Patients referred by their
clinicians
Clinicians may wish to refer
specific patients to the
service when they identify
an issue where the
pharmacist might have
appropriate input
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Asthma: A Model
A model condition for which there is no Cure
Prevalent, and climbing
Needing a Multidimensional team approach
Has defined treatment protocols, and outcomes
Impact on healthcare services & budget
Impact on other outcome measures:
- Productivity
-Schooling
! Severely compromises QoL:
-Restrictions on daily activities & work
-Difficulties in controlling symptoms
-Poor social & psychological functioning
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Source: BMJ, 1996
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What do we know about asthma status and control
worldwide?
! In Australia, 45% of candidates for reliever use are
not taking one
! 30% of candidates for a preventor are not taking one
! In New Zealand, 49% of asthma patients are undertreated
! 71% of children with asthma are under-treated
! However, 80-85% of asthmatics are satisfied with
their asthma control
! Out of these, 40% of children missed > 5 days of
school/yr
! ..and 20% of adults were off work 3-4 days/yr
! ..and 33% had either been in hospital or treated in
A&E
! 20% of asthmatics are using >10 puffs/day of reliever
& think their asthma is well controlled
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Jenkins, C. An update on asthma management. Internal medicine journal. 2003; 33:365-71
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Evidence from Research
It's not all about inhaler technique
! Patients under-use their preventor therapy
! Patients over-use their reliever therapy
! Patient have poor understanding of asthma
! Patients might be on poly-pharmacy
! Patients may have misconceptions about asthma therapy
! Preventative therapy might be under-prescribed
Emmerton L, Shaw J, Kheir N. Asthma management by New Zealand pharmacists: a pharmaceutical care
demonstration project. Journal of Clinical Pharmacy & Therapeutics 2003;28(5):395-402.
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Mehuys E et al. Effectiveness of
pharmacist intervention for
asthma control improvement.
Eur Respir J. 2008; 4:790-9
Community pharmacy-based
programs can significantly
improve therapeutic outcomes in
adult asthma patients
Barbanel D et al. Can a selfmanagement programme
delivered by a community
pharmacist improve asthma
control? A randomised trial.
Pharm World Sci. 2007;
29(3):228-39
A self-management programme
delivered by a community
pharmacist can improve asthma
control in individuals recruited at
a community pharmacy.
Pauley TR et al. Pharmacistmanaged, physician-directed
asthma management program
reduces emergency department
visits. The Annals of
Pharmacotherapy 1995; 29(1):
5-9.
The comprehensive asthma
management program reduced
the number of ED visits for
acute exacerbations of asthma.
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Community Pharmacy Asthma Self-management Program
Final Report December 2005, The University of Sydney,
Faculty of Pharmacy
Key Elements for Optimal Asthma Management
1. Assessment of asthma severity
! Medication adherence scores in the Intervention
Group improved significantly over time (p=0.04),
whilst Control Group scores did not (p=0.64).
! Asthma self-efficacy scores in the Intervention
Group improved significantly over time (p=0.01)
whereas Control Group scores did not (p=0.95).
! Asthma quality of life scores improved significantly
for intervention Group over time (p<0.01).
(Step
1)
2. Achieving best lung function (Step 2)
3. Identifying and avoiding triggers (Step
3)
4. Optimizing medication (Step 4)
5. Developing an action plan (Step 5)
6. Educating and reviewing regularly
Centre for Asthma Monitoring. Health care expenditure and the burden of disease due to asthma in Australia.
(Step 6) Australian
Canberra: AIHW; 2005.
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The Asthma Support Center
QP Pharmacy- Doha Healthcare Centre
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The Multidisciplinary Approach in Asthma
Management:
The Asthma Clinic and Support Centre
QP-MS
Philosophy of Practice:
!
An important element of optimal asthma management is
for people with asthma to practice productive selfmanagement behaviors.
Critical Elements
!
Adopting a patient-centered approach to the problems
patients were encountering with their asthma;
!
Applying a structured, stepwise cognitive-behavioral
model of asthma self-management; patient education;
support; and feedback to facilitate the acquisition of lifelong asthma self-management skills.
Nurse:
Doctor:
Diagnose
Prescribe
Monitor
Referral
Pharmacist:
Patient education
Care planning
Monitoring
Documenting
Referral
1: Kheir N. Proposal for an asthma care centre in Ras Abu Aboud Clinic, QP Pharmacy,
CPDP preserntation, RAA Clinic, 2007.
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Appointments
Patient education
Follow-up
Documenting
Referral
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Why to refer to a Pharmacist?
Aim:
1. To develop a Pharmacy-based referral
Asthma Support service in which the
pharmacist takes proactive, patientcentered, outcome-oriented role in asthma
management.
2. To work collaboratively with the patient,
the physician and the nurse to provide
comprehensive asthma care
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! A new healthcare team (patient + carers as
one team)
! Limited doctor-patient interaction time
! Pharmacotherapy (education, monitoring,
safety) is principal role of the Pharmacist
! Integral part in the move of Pharmacy from
robotic dispensing and inventory control to
patient care and accountability for outcomes
! We use our training, experience and interest
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… and also, if relevant:
Who to refer?
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2.
3.
4.
5.
6.
Patients newly diagnosed with asthma and for
whom initial therapy was prescribed
Returning patients with poorly controlled
asthma after being examined by the physician
Patients with apparent poor compliance with
asthma medication
Patients with suspected poor inhaler technique
Patients who need asthma education (selfreferred)
Asthma patients on multiple drugs
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! Checks the entire drug & medical history:
#
#
#
#
#
#
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Comorbidities
Drug doses
Potential interactions
Adverse effects
Need for the drug,
etc
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Medication
history
What does the Pharmacist Do?
Demographic, Medical,
Medicines, Behavioural,
Social
Plans and institutes education on asthma
Teaches inhaler technique
Assesses compliance
Develops individualized asthma action plan
Teaches the use of symptom diaries and
Peak Flow Meter
! Makes recommendations to the doctor
! Monitors progress
! Documents intervention and undertake
small-scale research
!
!
!
!
!
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Assessment of
therapy
Identification of drugrelated problems
Follow up
Goals of therapy met?
DRP resolved?
Ongoing monitoring
Primary-secondary
care continuum
Report send to GP &
Feedback from GP
Medication
Review
Clinic
Bringing everything
together
Documentation
Care Plan
Establish Goals of
Therapy
Patient
education
Verbal and written
counselling
Followup appt booked
Electronic records
Audit DRP
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Foundation
Other models to follow
• Cooperation: team-work and mutual
respect
• Treating the patient as partner
• Assuming and accepting responsibility
• Shift of focus
• Target: Improving Outcomes
• Ability and desire to follow-up
! Diabetes care centre
! Dislipidaemia care centre
! Other services?
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! Asthma is a chronic condition that
compromises the patient’s QoL and that
has heavy financial cost
! Pharmacists can work in a multi-disciplinary
team to improve asthma outcomes
! To provide effective service, the pharmacist
needs specialized training in medication
management services and Pharmaceutical
Care
! Implementing this model would prove costeffective, and would pave the way for
extension to other services
! Intensive and directed asthma
counseling
! Developing and publicizing Asthma
Action Plans
! Conducting asthma management
workshops for pharmacists
! Providing training on Pharmaceutical
Care principles
! Agree on documentation plans
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Summary
Asthma Care
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