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CHAPTER # 07 PHARMACEUTICAL CARE PHARMACEUTICAL CARE INTRODUCTION: DEFINITION: Pharmaceutical care is that component of pharmacy practice which entails the direct interaction of pharmacist with the patient for the purpose of caring for that patient’s drug related needs. Or 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. Or "The responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life." EXPLANATION: Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving the elimination or reduction of a patient's symptomatology; arresting or slowing of a disease process; or preventing a disease or symptomatology.It describes specific services activities through which an individual pharmacist cooperates with patients and other health care professionals in designing, implementing & monitoring a therapeutic plan that will produce specific outcomes for the patient. Goal of pharmaceutical care is to optimize the patient’s healthrelated quality of life and achieve positive clinical outcomes, within realistic economic expenditures. This process requires a clinical pharmacist to review a patient's medication with reference to the doctor's diagnoses, laboratory tests and patient's information. The clinical pharmacist must therefore work very closely with the doctor and patient in order to gain a correct understanding of the relevance and impact of the various medications on the patient's pathology. The pharmaceutical care process was originally conceived to be undertaken in a community pharmacy by community pharmacists. This concept was introduced by helper and strand (1990) when they published an article in ASHP. In 1996 the Pharmaceutical Society of NZ began a programme to implement the process throughout New Zealand. While some 500 pharmacists undertook an expensive training, it was found that the basic skill level of most pharmacists was not sufficient to enable them to undertake an in-depth review of the patients' medication. Pharmacists are now required to complete a postgraduate diploma in clinical pharmacy to enable them to practice as a Clinical Pharmacist before being considered competent to work at this level. AN EASY APPROACH TO CLINICAL PHARMACY CHAPTER # 07 PHARMACEUTICAL CARE SCOPE OF PHARMACEUTICAL CARE: i. ii. iii. iv. Pharmaceutical care can be provided in different health care setting such as hospitals, clinics, nursing home etc. Pharmaceutical care can be provided at different stages of patient journey through a clinical setting or health care setting for seeking a medical care. There are some distinguishing features which make it different from traditional pharmacy care and clinical pharmacy practice. Provision of pharmaceutical care may overlap with them but it’s not the same. Some of the features are as follows; a. The primary focus in pharmaceutical care is patient. b. Continuity in the processes and activity. c. Responsibility of delegation of powers related to medication. d. The ultimate goal is to improve the patient quality of life by interventions. Pharmaceutical care is providing by performing the following activities, e.g. a. Taking medication history. b. Identifying different drug related problems. c. Designing a proper pharmaceutical plan. d. Evaluation and monitoring of the outcomes which be positive or negative. PHARMACEUTICAL CARE PLAN: DEFINITION: A plan developed by clinical pharmacist for individual patients which is evaluated and revised according to the changing needs of the patient on continuous basis for the purpose to formulized, optimize and document a specific cores of treatment. Or The individualized comprehensive medication therapy plan develops for an individual patient based on clearly defined therapeutic goals and that revised on continuous basis. EXPLANATION: The pharmaceutical care plan is a written, individualized, comprehensive medication therapy plan based on clearly defined therapeutic goals. The pharmaceutical care plan, which is available to all pharmacists caring for a patient, is updated with each major change in patient status. It is important that the physician be informed about the care plan to ensure common goals. Patients should also be informed about the general content of the care plan as means of gaining their agreement regarding drug therapy. Patient care planning involves systematically assessing a patient's health problems and needs, setting objectives, performing interventions, and evaluating results. Not all patients require a written PCP. Pharmacists must assess their own patients and identify specific areas on which to focus. For example, the pharmacist may want to identify patients with specific diseases (e.g., asthma, hypertension, diabetes mellitus, or hypercholesterolemia). AN EASY APPROACH TO CLINICAL PHARMACY CHAPTER # 07 PHARMACEUTICAL CARE Pharmaceutical care planning is a systematic, comprehensive process with three primary functions: 1. Identify a patient's actual and potential drug-related problems. 2. Resolve the patient's actual drug-related problems. 3. Prevent the patient's potential drug-related problems. STEPS FOR DEVELOPING AND MANAGEMENT OF PHARMACEUTICAL CARE PLAN: The development of a PCP can be summarized as a eight step process involving the SOAP format (Subjective data, Objective data, Assessment, and Plan of care). The process can be described as follows. Step 1. Gathering Information (patient data): Collection of data may also called as development of patient data base. First start with patient demographic data (age, race, sex etc) which is collected. The pharmacist should gather an accurate medication history, including both prescription and nonprescription medications and the reasons the medications were prescribed or taken. The pharmacist will likely have to obtain some information from the physician, such as laboratory test results and hospitalizations. If so, the pharmacist should get written permission from the patient before soliciting this information. Once this information is compiled, the preparation of a PCP can begin. Step 2. Identifying Problems: A drug related problem is an event of circumstances, which involving in drug therapy that actually or potentially interferes with the desired health outcome. It can also be defined as any underisrable events, experienced by a patient which involves or suspect to involves drug therapy and that interfares with achieving the desired goals of therapy. Different catogries of drug related problems are given below, these are; a. Untreated condition(s) b. Drug(s) without medication(s). c. Improper drug (drug product) selection. d. Subtherapeutic dosage. e. Excessive dosage: In this condition dose should be adjusted. f. Adverse drug reactions g. Non-compliance h. Drug interactions. Step 3. Setting of outcomes goals: Outcome goals must be established for each drug-related problem so that the pharmaceutical care planning process can be effective. Outcome goals should be definite, realistic and, if possible, measurable. Most outcome goals relate are: 1. Approach to normal physiology (i.e., normalize blood pressure). 2. Slow down progression of disease (i.e., slow progression of cancer). 3. Alleviate symptoms (i.e., optimize pain control). AN EASY APPROACH TO CLINICAL PHARMACY CHAPTER # 07 4. 5. 6. 7. PHARMACEUTICAL CARE Prevent adverse effects. Control medication costs. Educate the patient about his or her medication. Normalization of labortary data. Step 4. Designing a pharmacotherapeutic regimen: Pharmacotherapeutic regimens should be selected on the basis of; Effecetiveness Safety Economic/cost effectiveness Availability Patient convenience Individualized Patient education and counselling. Designing a pharmacotherapeutic regimen is done by the following way. 1. Therapeutic regimens: a. Existing therapy: For example, a pharmacist is asked to wiork with a patient for whom one or more agents are already prescribed for the disease process or problem. Evaluate and revise the current regimen if appropriate. b. Initial therapy: A pharmacist is asked to work with a patient whose condition was newly diagnosed or is asked to develop an initial treatment plan. Then the pharmacist should list the therapeutic options (drug and regimen) most likely to achieve the desired end points. Then select the best suited therapeutic option for the patient well being. 2. Goal setting and behavior regimens: The patient is an essential partner for setting and achieving intermediate and short term goals and the behaviour changes necessary to achieve those goals. To construct effective behaviour regimens, the pharmacist practitioner must incorporate the following concepts; a. Identify the type of goal being set, such as the following; Start a new positive action, e.g. start an execise program. Increase the frequency or intensity of a positive action e.g. overdose Stope or decrease the frequency or intensity of a destructive action. e.g. Stope smoking. Continue the action that is perfect. e.g. continue to exercise 30 min a day. b. State the behaviour goal in terms that are clear, specific and reasonable. Set time limits. e.g. over the next 3 weeks. Target a specific action. e.g. i will walk. Set a measure and frequency. e.g. six blocks, three days a week. Divide a big task into several small ones, making each change small relative to the current patient behavior. Step 5. Designing a monitoring Plan: Pharmacist will design a proper monitoring plan, to evaluate the progress towards the pharmacotherapeutic objectives. It may be in the form of some labortary values or some sign and AN EASY APPROACH TO CLINICAL PHARMACY CHAPTER # 07 PHARMACEUTICAL CARE symptoms monitoring and frequency of monitoring will also be define in the plan. e.g. LFTs, INR value, B.P, improved in the pain relief will be monitor after every 12 hour etc. Step 6. Implementation of pharmacotherapeutic regimen with corrosponding monitoring plan: In order to implement the pharmacotherapeutic and monitoring plan, the pharmacist will order the medication therapy according to the regimen prescribed and lab test, the signs and symptoms of the patient will be check from time to time and the patient will be counsel about the medication or some side effects which may occure with the prescribed medications. Step 7. Monitoring the Outcomes: Outcomes that will be used to evaluate the success of the PCP treatment plan must be meaningful, measurable, and manageable. Outcomes are specific, measurable indicators for the goals of treatment. Thus, they should be identified in the planning process. The possible outcomes may either be positive or negative or neutral. In case of the negative or neutral outcomes, the pharmaceutical care plan should be review and if possible the plan should be re-design by some possible interventions according to the need of the individual patient. Step 8. Documentation: Documentation help to improve the quality of care. It is used for the purpose of justification of services. It is also used for legal as well as research purpose. Documentation should include these components, these are; 1. Patient data such as name, medical record number, location, date of hospital admission (if applicable). age, sex, height, weight, known medication or other allergies, and medication history. 2. Name of pharmacist(s) responsible for developing and implementing the PCP. 3. Patient problem(s) listed Individually in order of potential pharmacotherapeutic impact (highest to lowest priority). Subjective and objective data that lead to identification of a specific problem and potential drug-related problems should also be included. 4. Date on which a patient problem is identified. Many diseases remain chronic throughout the patient's life. Problems such as urinary tract infection or upper respiratory tract infection usually resolve in 10 to 14 days. Methods of documentations: Different methods are used to describe and document the interventions intended or provided by the pharmacist. Some healthcare facilities may specify one format over the other format. Pharmacist need to become proficient in each. a) Format of a FARM note: The description & documentation of interventions intended or provided by pharmacist. FARM stands for; F = Findings: The patient specific information that Gives the basis for recognition of pharmacotherapy problems or indication for pharmacist intervention. Within the FARM format, findings include subjective and objective information about the patient. A = assessment: The pharmacist’s evaluation of the findings, including statements of, AN EASY APPROACH TO CLINICAL PHARMACY CHAPTER # 07 PHARMACEUTICAL CARE i. Any additional information needed to best assess the problem to make recommendation. ii. The severity, priority or urgency of the problem. iii. The short term & long term goals of the intervention proposed. Short term goals: Examples are; a. Elimination of symptoms b. Lowering of BP c. Management of acute asthma without requiring hospitalization Long term goals: Examples are; a. Prevent recurrence of disease. b. Control B.P. c. Prevent progression of diabetes R = resolution: The plan includes actual or proposed actions by the pharmacist or recommendations to other healthcare professionals. The retionale for choosing a specific intervention should be stated. It including prevention, observing & reassessing, counseling or educating the patients & care givers, informing the prescriber, making recommendation to prescriber and withholding medication or advising against use. M = monitoring: The parameters and timing of follow upmonitoring, to assess the efficacy, safety & outcome of the intervention. This portion of FARM note should include the following; i. The parameter to be followed. e.g. pain, depressed mood, serum potassium level. ii. The intent of monitoring. e.g. efficacy, toxicity, adverse event. iii. How the parameter will be monitored. e.g. patient interview, serum drug level, physical examination. iv. Frequency of monitoring . e.g. weekly, monthly. v. Duration of monitoring. e.g. until resolved, while on antibiotic. vi. Anticipated or desired finding. e.g. no pain, euglycemia, healing of lesion. vii. Decision point to alter therapy when or if outcome is not achieved. E.g. pain still present after 3 days. b) Format of a SOAP note: The SOAP format is the one used most often by medical practitioners; however, when used within the pharmaceutical care context, the content of the sections must be revised to match the pharmacist’s legal scope of practice. S = Subjective: The patient specific subjective information that gives a basis for, or leads to, the recognition of a pharmacotherapy problem or indication for pharmacist intervention. Within the SOAP format, patient findings are delineated into subjective and objective data. AN EASY APPROACH TO CLINICAL PHARMACY CHAPTER # 07 PHARMACEUTICAL CARE i. Subjective data are open to individual interpretation. Examples of subjective findings include the patient’s statement of complaint ( the chief complaint; C.C) and duration or severity of symptoms. ii. Sometimes, the data to be noted are not clearly delineated as subjective or objective or there may be prepoderance of one type of data. In these instances, the subjective and objective data may be combined as a single section, labeled S/O findings. O = Objective: The patient specific objective information that gives a basis for or leads to the recognition ofa pharmacotherapy problem or indication for pharmacist intervention. Objective data are easily duplicated or quantified. e.g. laboratory data, weight, height, blood pressure and pulse. A = Assessment: In the medical model, the assesment states the physician’s working diagnosis and/or possible explanations for the patient’s medical problems. It is a brief, complete description of a problem. In the pharmaceutical care model, however, diagnosis is not normally within the pharmacist’s scope of practice. Instead the assessment section includes the pharmacist’s evaluation of the subjective and objective findings in a manner similar to the description of the assessment in the FARM format. P = Plan: It is a detailed description of further workup, treatment, education, monitoring and follow-up relative to assessment. In the medical model, the plan states the physician’s intended drug regimens, surgical procedures and/or diagnostic tests. In the pharmaceutical care model, pharmacists may not have the authority tointiate or alter drug therapy regimens or order laboratory tests. Laboratory or prescriptive authority may be granted on a state by state basis, under collaborative protocol with specific physician(s) or within a specific healthcare facility or system. Actions included within the plan section should be identified as tecommended actions when appropriate. In the pharmaceutical care model, the plan is usually expanded to describe information included in the monitoring and follow-up section of the FARM note. PHARMACEUTICAL CARE PLAN SUMMARY: In summary, the general steps involved in creating a pharmaceutical care plan are: 1. 2. 3. 4. 5. Create comprehensive patient database. Assess for actual and potential drug-related problems. Establish therapeutic goals. Specify monitoring parameters with end points and frequency. Document the patient's progress towards therapeutic goals. The care plan function in Kinetics is basically just a skeleton that you can expand on because plans will differ depending on the practice setting in which the program is being used. Acute care, homecare and long term care all have different monitoring parameters and schedules. The default care plan for a drug can be changed on the Edit drug model function which is accessed via the drop down menu tree or by the keyboard shortcut Ctl+E. The care plan field is free form text entry, you can enter anything you like in this field. ***************************************************************************** AN EASY APPROACH TO CLINICAL PHARMACY