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THE CHANGING ROLE OF THE
PHARMACIST
DISPENSING PHARMACY
PHARMACEUTICAL CARE
Product business
Service (people) business
Bring the product to consumer
Bring the practitioner to patient
Decisions focus on the business
Decisions focus on the patient
Inventory generates revenue
Patient care generates revenue
Available service supports products
Available products support service
DISPENSING PHARMACY
PHARMACEUTICAL CARE
Success measured as # of Rx
Success measured as patient outcomes
Space to display and sell
Space organized to meet patient needs
Records kept for legal purposes
Documentation to provide quality care
Visits determined by refill supply
Visits determined by patient risk/benefit
Business passive via prescriptions
Practice grows via patient recruitment
Patient Care
• Involves a patient and a qualified practitioner
• Requires a face-to-face encounter
• Practitioner takes responsibility for patient’s need(s),
his/her interventions and the patient’s outcomes
• Practitioner provides a service that is consistent,
comprehensive and standardized
• Practitioner assess each patient’s needs, develops a care
plan to meet these needs and follows-up to evaluated
the outcomes.
Patient
SELF CARE
DIRECT PATIENT CARE
Patient-centered
Patient
Practitioner
SELF CARE
DIRECT PATIENT CARE
Assessment
Care Plan
Patient
Practitioner
Follow-up
Evaluation
SELF CARE
Practitioner
DIRECT PATIENT CARE—
CONTINUOUS CARE
Patient
Practitioner
SELF CARE
Practitioner
Practitioner
PHARMACEUTICAL CARE PRACTICE
Think like a practitioner - Pharmacotherapy Workup
Act like a practitioner - Standards of Practice
Speak like a practitioner - Practice Vocabulary
HEALTH CARE SYSTEM
Product
$$
Patient Care Services
$$$$$$
Capitalism
Patient Care Practice
Competition
Documentation
Marketing
Technology
Pharmacy
Evaluation
Reimbursement
TERMINOLOGY
Counseling
Documentation
Generalist
Specialist
Interview
Practice
Care
Pharmaceutical care
Cognitive service
Patient Profile
HEALTH CARE SYSTEM
Product
$$
Capitalism
Competition
Pharmacy
Marketing
Technology
Patient Care Services
$$$$$$
Patient Care Practice
Documentation
Pharmacy
Evaluation
Reimbursement
MANAGING DRUG USE
SYSTEM LEVEL
What is best for society?
(Health Care Policy, Regulation, Legislation)
INSTITUTIONAL LEVEL
What is best for an organization, institution, disease
state?
(formulary, DUE, DUR, protocol, disease state management)
PATIENT LEVEL
What is best for a patient?
Pharmaceutical Care
MANAGING DRUG USE
Health Care Policy, Regulation, Legislation
Formulary, DUE, DUR, protocol,
disease state management
Pharmaceutical Care
HEALTH CARE NEEDS OF A PATIENT
Maternal
Care
Medical
Care
Nutritional
Care
Mental Health
Care
Surgical
Care
PHARMACEUTICAL
CARE
SELF
CARE
Geriatric
Care
Dental
Care
Nursing
Care
Chiropractic
Care
Eye
Care
Pediatric
Care
Figure 1-2
Pharmaceutical Care in Health Care
Primary
Focus
Knowledge
Base
Responsibility
in the drug use
process
Medical Care
Diagnosis
and
Treatment of the
patient’s disease
Pathophysiology
Prescribing
Nursing
Care
Giving care to the
whole patient
during the cure
or treatment
Biological,
psychological,
social, or spiritual
human responses
Drug
administration
Pharmaceutical
Care
Identifying and
meeting a
patient’s drugrelated needs
Pharmacotherapy
Identification,
prevention, and
resolution of drug
therapy problems
Patient Care
Process
Patient
Experience
Medication
Responsibilities
Care Plan
Pharmacotherapy
Workup
Today’s wants
and needs
Practitioner
Assessment
Philosophy of Practice
Follow-up
Evaluation
Social Obligation
Responsibilities
Patient-centered approach
Caring
Therapeutic Relationship
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
THE COMPONENTS OF
PHARMACEUTICAL CARE
PRACTICE
Defining Pharmaceutical Care
Defined as a practice1 in 1997
Pharmaceutical care is a patientcentered practice in which the
practitioner assumes responsibility for
a patient’s drug-related needs and is
held accountable for this
commitment.2
1Cipolle,
R.J., Strand, L.M., Morley, P.C. (1998). Pharmaceutical Care Practice. New York: McGraw Hill.
2Cipolle, R.J., Strand, L.M., Morley, P.C. (2004). Pharmaceutical Care Practice: The Clinicians Guide New York:
McGraw Hill.
Pharmaceutical Care
Pharmaceutical care is how a
practitioner applies expert
pharmacotherapeutic knowledge in
practice to benefit the patient.
An Expert Practitioner
• Assesses needs
• Finds problems
• Fixes problems
• Prevent problems
• Takes responsibility
• Follows-up to determine outcomes
• Is held accountable
Generalist Practitioner
A practitioner who provides continuing,
comprehensive, and coordinated care to a
population undifferentiated by gender,
disease, or organ system.
American Boards of Family Practice and Internal Medicine (ABFP and ABIM)
Patient
Complexity
(Need)
STANDARD OF PRACTICE
Specialty
Practice
Standard of Care
Generalist
Practice
Patients
PROFESSIONAL PRACTICE
Is Not...
• the physical practice site
• a degree qualification
• an arbitrary list of practitioner activities
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
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
• Represents what “should” be done
PHILOSOPHY OF PRACTICE
This must be in the mind and the
heart of the practitioner before
caring for a patient
PHILOSOPHY OF PHARMACEUTICAL CARE
WHAT A PRACTITIONER DOES
Meets a social need
Meets patient-specific responsibilities
PHILOSOPHY OF PHARMACEUTICAL CARE
HOW A PRACTITIONER DOES IT
With a patient-centered approach
Using a caring process
SOCIAL NEED
The profession’s responsibility to society
Rationale for professional status
Obligation to apply unique, expert knowledge
Standard by which a profession is evaluated
COSTS OF DRUG THERAPY PROBLEMS
Total U.S. Costs = $177 billion / year
Physician/Urgent Care Visits
$
14 billion
+Added Medications
$
3 billion
+Emergency Room Visits
$
6 billion
+Hospital Visits
$ 121 billion
+Long-term Care Stays
$
33 billion
Ernest FR and Grizzle AJ. Drug-Related Morbidity and Mortality: Updating the Cost-of-Illness Model J. APhA 41: March 2001.
SOCIAL NEED
Meeting a social need requires
taking care of patients...
one patient at a time.
PHARMACIST RESPONSIBILITIES
The identification
of a patient’s drug-related needs
and the commitment to meet these needs.
PHARMACIST RESPONSIBILITIES
To ensure that all of a patient’s drug
therapy is appropriately indicated, the
most effective available, the safest
possible, and the patient is compliant.
The identification, resolution, and
prevention of drug therapy problems.
PATIENT-CENTERED PRACTICE
Patient’s drug-related needs “drive” the practice
The patient remains a whole person,
not fragmented by age or organ systems or
into diseases or drug categories.
CARING DEFINED
Assess patient need
Provide resources
Evaluate patient outcomes
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
THE THERAPEUTIC RELATIONSHIP
Connection between philosophy and patient care
Necessary to provide care
Determines the quality of care that can be
delivered
Most important element of practice
CHARACTERISTICS
of the THERAPEUTIC RELATIONSHIP
Mutual respect
Trust
Open communication
Cooperation
Mutual decision making
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
Components of the Medication Experience
The patient’s description of
the medication experience
The medication history
The current medication record
The Patient’s Description of the
Medication Experience
• Patient expectations and wants
• Patient concerns
• Patient’s understanding of drug therapy
• Preferences, attitudes, and beliefs
• Cultural, ethico-religious, genetic influences
• Medication taking behavior
The Medication History
• Immunizations
• History of social drug use
• Medication allergies
• Adverse drug reactions
• Alerts and special needs
• History of relevant medication use
The Current Medication Record
• Indication
• Drug Product
• Dosage regimen
• Start date
• Response
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
Pharmacotherapy
©
Workup
The Pharmacotherapy Workup is a logical thought
process that guides the work and decisions as the
clinician assesses the patient’s drug-related needs
and identifies drug therapy problems.
The Pharmacotherapy Workup also organizes the
interventions that need to be made on the patient’s behalf.
The Pharmacotherapy Workup establishes
appropriate parameters to evaluate at follow-up
DRUG-RELATED NEEDS:
During a pharmaceutical care encounter, the patient, the patient’s medical
conditions, and all of his/her drug therapies are assessed to determine if the
following drug-related needs are being met:
The medication is appropriately indicated
There is a clinical indication for each medication being taken.
All the medication that is needed to treat each of the
patient’s medical conditions is being taken.
The medication is effective
The most effective product is being used.
The dose of the medication is achieving the intended goals
of therapy.
The medication is safe
There are no adverse reactions being experienced.
There are no signs of toxicity.
The patient is compliant
The patient is able and willing to take the medications that
have been determined to be appropriate, effective, and safe
for the patient.
Effectiveness
Indication
Drug product
Dosage regimen
Outcomes
Safety
Figure 6-5
Drug Therapy Problem
Drug Therapy Problem
Unnecessary drug therapy
Needs additional drug therapy
Dosage too low
Dosage too high
Indication
Drug product
Dosage regimen
Effectiveness
Outcomes
Drug Therapy Problem
Drug Therapy Problem
Ineffective drug
Adverse drug reaction
Noncompliance
Safety
Figure 7-1
DRUG THERAPY PROBLEMS
The identification, resolution, and
prevention of drug therapy problems are
the heart and soul of pharmaceutical
care practice
PATIENT EXPRESSION
OF NEEDS
TRANSLATION TO
DRUG-RELATED NEEDS
Understanding
Indication
Expectations
Effectiveness
Concerns
Safety
Behavior
Compliance
RELATIONSHIP of DRUG-RELATED NEEDS and
DRUG THERAPY PROBLEMS
Patient’s
Expression
Drug-related
Needs
Drug Therapy
Problems
Understanding
Indication
Unnecessary Drug Therapy
Needs Additional Drug Therapy
Expectations
Effectiveness
Ineffective Drug
Dosage Too Low
Concerns
Safety
Adverse Drug Reaction
Dosage Too High
Behavior
Compliance
Noncompliance
DRUG THERAPY PROBLEM CATEGORIES
1. The drug therapy is unnecessary because the patient does not
2.
3.
4.
5.
6.
7.
have a clinical indication at this time.
Additional drug therapy is required to treat or prevent a
medical condition in the patient.
The drug product is not being effective at producing the desired
response in the patient.
The dosage is too low to produce the desired response in the
patient.
The drug is causing an adverse drug reaction in the patient.
The dosage is too high, resulting in undesirable effects
experienced by the patient.
The patient is not able or willing to take the drug therapy as
intended.
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
WHAT IS THE PATIENT CARE PROCESS?
A guide for the practitioner
A standard for the practice
A comprehensive and consistent description of
the practitioner’s work
WHAT IS THE PATIENT CARE PROCESS?
A method that allows the practitioner to make
rational (well-reasoned, scientific) decisions.
An application of the problem-solving process
PHARMACEUTICAL CARE PATIENT
CARE PROCESS
1. Assess the patient’s drug-related needs
2. Develop a care plan
3. Complete a follow-up evaluation
THE PATIENT CARE PROCESS
ESTABLISH A THERAPEUTIC RELATIONSHIP
ASSESSMENT
CARE PLAN
EVALUATION
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
ASSESSMENT
A systematic review of the patient’s drug-related
needs
Performed by the pharmacist with the patient to
ensure that all drug therapy is indicated,
effective, safe, patient is compliant,
and to identify drug therapy problems
CARE PLAN
A structure for working together with a person who
may have different understandings, expectations,
concerns, and a different value system.
Agree on goals of therapy
Select interventions to achieve goals of therapy
EVALUATION
Scheduled follow-up intervals during which
the pharmacist...
Evaluates current status and progress in meeting
therapeutic goals
Documents actual patient outcomes
Determines whether new problems have developed
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
NO DOCUMENTATION
MEANS YOU DID NOT
DO IT!!
REASONS TO DOCUMENT
1.
2.
3.
4.
5.
6.
Provide quality patient care
Manage the practice
Liability issues
Evaluate performance
Justify professional role
Reimbursement
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
REIMBURSEMENT and/or
WORKLOAD MEASUREMENT
A Resource-based Relative Value Scale includes 5
levels of patient need and complexity.
The level of reimbursement is determined as a function of
number of medical conditions
number of drug therapy problems
number of active medications
RESOURCE-BASED RELATIVE VALUE SYSTEM
(RBRVS)
Level 1
(0.4)
Level 2
(1.0)
Level 3
(1.8)
Level 4
(2.5)
Level 5
(3.0)
Medical
Conditions
1
1
2
3
>4
Drug
Therapy
Problems
0
1
2
3
>4
Medications
0-1
1-2
3-4
5-8
$
$$
$$$
$$$$
Amount
>9
$$$$$
Practice Results
MOST FREQUENT INDICATIONS FOR DRUG THERAPY
(N = 26,238 Patient Encounters)
1.
2.
3.
4.
5.
HYPERTENSION
HYPERLIPIDEMIA
DIABETES
OSTEOPORSIS
VITAMIN/DIETARY SUPPLEMENT
6.
7.
8.
9.
10.
ALLERGIC RHINITIS
ESOPHAGITIS
DEPRESSION
MENOPAUSAL SYMPTOMS
ARTHRITIS PAIN
These 10 conditions represent
50% of all indications for drug therapy
DRUG THERAPY PROBLEMS (DTP)
(N =26,238 Patient Encounters)
Percent
Indication
Effectiveness
Safety
Compliance
Unnecessary Drug Therapy
6%
Needs Additional Drug Therapy
28 %
Ineffective Drug
8%
Dosage Too Low
20 %
Adverse Drug Reaction
14 %
Dosage Too High
34%
28%
19%
5%
Noncompliance
19 %
Total
100%
19%
Table 7-6
PRIMARY METHOD OF RESOLUTION
OF DRUG THERAPY PROBLEMS
Protocol
Physician
(19%)
Carrier
Patient
(79%)
IMPACT OF PHARMACEUTICAL CARE PRACTICE
Resolution of drug therapy problems with Physicians
initiate new drug therapy
31 %
change drug dosage regimens
23 %
change drug product
15 %
discontinue drug therapy
15 %
laboratory monitoring initiated
10%
other
6%
Change in Clinical Status at Follow-up Evaluation
4492 Patients and 10,485 Medical Conditions
Condition Declined
(16 %)
Condition Improved
or
Remained the Same
(84 %)
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.
THE PHARMACOTHERAPY
WORKUP AND DRUG THERAPY
PROBLEMS
Pharmacotherapy Workup
Medication Experience
Pharmacotherapy Workup
Medication Experience
Drug Therapy Decisions
Medication-related review of systems
cardiovascular
renal
hematology
musculo-skeletal
pulmonary
Pharmacotherapy Workup
Patient’s description of the medication experience
Indication
Drug product
Dosage regimen
Current medication record
Medication history
Patient Demographics
Medication-related review of systems
Outcomes
Indication
Drug product
Dosage regimen
Outcomes
Indication
Indication
Indication
Drug product
Drug product
Drug product
Dosage regimen
Dosage regimen
Dosage regimen
Outcomes
Outcomes
Outcomes
Basic Structure of the Pharmacotherapy Workup
Indication
Drug product
Dosage regimen
Outcomes
Figure 6-4
Indication
Drug product
Dosage regimen
Outcomes
Drug Therapy Problems
Drug Therapy Problem
Drug Therapy Problem
Dosage too low
Dosage too high
Unnecessary drug therapy
Needs additional drug therapy
Indication
Drug product
Dosage regimen
Outcomes
Drug Therapy Problem
Drug Therapy Problem
Ineffective drug
Adverse drug reaction
Noncompliance
Figure 7-1
Basic Structure of the Pharmacotherapy Workup
Indication
Drug product
Dosage regimen
Outcomes
Effectiveness
Indication
Drug product
Dosage regimen
Outcomes
Effectiveness
Indication
Drug product
Dosage regimen
Outcomes
Safety
Figure 6-5
Labs
Goals of Therapy
Indication
Drug product
Dosage regimen
Clinical
Effectiveness
Outcomes
Signs & Symptoms
Abnormal Laboratory Values
Goals of Therapy
Indication
Drug product
Dosage regimen
Labs
Clinical
Effectiveness
Outcomes
Figure 6-6
Signs & Symptoms
Abnormal Laboratory Values
Goals of Therapy
Indication
Drug product
Adverse Drug Reaction
Dosage regimen
Toxicity
Labs
Clinical
Effectiveness
Outcomes
Safety
Labs
Clinical
Abnormal Laboratory Values
Goals of Therapy
Indication
Drug product
Toxicity
Clinical
Effectiveness
Outcomes
Safety
Labs
Clinical
Negative Outcomes
Adverse Drug Reaction
Dosage regimen
Labs
Positive Outcomes
Signs & Symptoms
Figure 6-7
The questions, hypotheses, and cues generated by the
Pharmacotherapy Workup are in response to two basic
questions:
Is the patient’s problem caused by drug therapy?
Can the patient’s problem be treated with drug therapy?
Identifying Drug Therapy Problems
Drug therapy problems are undesirable events
or risks that the patient experiences that
inhibit or delay him/her from achieving the
desired goals of therapy.
They are identified during the assessment
process, so they can be resolved through
individualized changes in the patient’s drug
therapy regimens.
DRUG THERAPY PROBLEMS
Unique set of problems
Demarcate professional responsibilities
Central to your activities and practice
Drug Therapy Problems
Stating the drug therapy problem…
Problem
Drug Therapy
Relationship
Drug Therapy Problems
The problem can take the form of a
medical complaint, sign, symptom,
diagnosis, disease, illness, impairment,
disability, abnormal laboratory value, or
syndrome.
Drug Therapy Problems
The drug therapy (products and/or dosage
regimen) involved
Drug Therapy Problems
The relationship that exists (or is suspected
to exist) between the undesirable patient
event and drug therapy
This relationship can
-be the consequence of drug therapy
-require the addition or modification of drug
therapy
Drug Therapy Problem
Description of the Drug Therapy Problem
Unnecessary Drug
Therapy
The drug therapy is unnecessary because the
patient does not have a clinical indication at this
time
Needs Additional Drug
Therapy
Additional drug therapy is required to treat or
prevent a medical condition
Ineffective Drug
The drug product is not being effective at
producing the desired response
Dosage too low
The dosage is too low to produce the desired
response
Adverse Drug Reaction
The drug is causing an adverse reaction
Dosage too high
The dosage is too high, resulting in undesirable
effects
Non-compliance
The patient is not taking the drug regimen
appropriately
101
INDICATION
1. UNNECESSARY DRUG THERAPY
No medical indication
Duplicate therapy
Non-drug therapy more appropriate
Treating avoidable adverse reaction
Addictive / recreational drug use
INDICATION
2. NEEDS ADDITIONAL DRUG THERAPY
Untreated condition requires initiation of
drug therapy
Preventive therapy is required
Synergistic or potentiating therapy required
EFFECTIVENESS
3. INEFFECTIVE DRUG
More effective medication available
Condition refractory to drug
Dosage form inappropriate
Drug not effective for condition
EFFECTIVENESS
4. DOSAGE TOO LOW
Dose too low
Frequency inappropriate
Drug interaction
Duration inappropriate
SAFETY
5. ADVERSE DRUG REACTION
Undesirable reaction
Unsafe drug for patient
Drug interaction
Dosage increased or decreased too fast
Allergic reaction
SAFETY
6. DOSAGE TOO HIGH
Dose is too high
Frequency inappropriate
Duration inappropriate
Drug interaction
Administered too rapidly
COMPLIANCE
7. NONCOMPLIANCE
Patient does not understand instructions
Patient prefers not to take the medication
Patient forget to take medication
Drug product is too expensive for the patient
Cannot swallow or self-administer appropriately
Drug product not available
Noncompliance
Noncompliance is defined as the patient’s
inability or unwillingness to take a drug regimen
that the practitioner has clinical judged to be
appropriately indicated, adequately efficacious,
and able to produce the desired outcomes
without any harmful effects
MAKING A PHARMACEUTICAL CARE
PATIENT CASE PRESENTATION
CASE PRESENTATION
Purposes:
1. To seek help from a colleague
2. Most frequent method you will use to
communicate with colleagues
3. How your performance will be judged
CASE PRESENTATION
What information do you present?
(student vs. practitioner)
Order of information presented
Terminology used
PHARMACEUTICAL CARE
PATIENT CASE PRESENTATION FORMAT
I. Pharmacist's Assessment of the Patient's
Drug-related Needs
A. Brief description of the patient
B. Reason for the pharmacist-patient
encounter
C. Patient background
D. Medication experience
E. Medication history
F. Current medication record
G Past medical history
H. Review of systems
I. Identification & description of drug
therapy problems
J. Summary of the assessment
II. The Care Plan
A.
B.
C.
D.
E.
Goals of therapy
Resolve any drug therapy problems
Interventions to meet goals of therapy
Prevent new drug therapy problems
Schedule for follow-up
III. Follow-up Evaluation
A. Evaluate actual patient outcomes
B. Evidence of effectiveness
C. Evidence of safety
D. Evaluate patient for new drug therapy
problems
Assessment
Brief description of the patient (age, gender, appearance)
Primary reason for the patient encounter or visit
Additional patient background/demographics
The medication experience as reported by the patient (wants, expectations, concerns,
understanding, preferences, attitudes, beliefs that determine the patient’s medication taking
behavior)
Comprehensive Medication History (allergies, alerts, social drug use, immunization status)
Current Medication Record: description of all medical conditions being managed with
pharmacotherapy with the following associations made:
Indication—Drug product—Dosage regimen—Result to date
Relevant Past Medical History: outcomes of past medication use
Review of Systems
Identification of Drug Therapy Problems: Description of the drug therapy problem,
medications involved, and causal relationships
Prioritization if multiple drug therapy problems
Summary of the Assessment
Table 13-1
Care Plan
Goals of therapy
Clinical and laboratory parameters used to define the goal of therapy. Observable,
measurable value and timeline for each.
How you plan to resolve the patient’s drug therapy problems
Therapeutic alternative approaches considered
Rationale for your product and dosage selections
How you plan to achieve goals of therapy
Non-pharmacologic interventions
Prevention of drug therapy problems
Schedule for follow-up plan
Table 13-1
Follow-up Evaluation
Clinical and laboratory evidence of effectiveness of drug therapies to manage each condition
Clinical and/or laboratory evidence of safety of every drug regimen
Evidence of compliance
Evaluation of outcome status
Changes required in drug therapies
Schedule for future evaluation
Summary of Case
Table 13-1
PHARMACEUTICAL CARE PRACTICE:
PATIENT-CENTERED CASE PRESENTATION FORMAT
I.
Assessment of the Patient's
Drug-related Needs
II. The Care Plan
A. Brief description of the patient
B. Reason for the pharmacist-patient
encounter
A. Establish Goals of therapy
D. Medication experience
F. Current medication record
E. Schedule for follow-up
J. Determine if there are drug
therapy problems present
III. Follow-up Evaluation
THE PATIENT CARE PROCESS –
ASSESSMENT
The Patient Care Process
The three major steps in the patient care
process are the assessment leading to drug
therapy problem identification, care plan
development, and follow-up evaluation.
These steps are all highly dependent upon
each other. The completion of all steps is
necessary to have a positive impact on your
patient’s medication experience. The process
is continuous and occurs over multiple patient
visits.
Assessment
The purpose of the assessment is three fold.
Firstly, to understand the patient well enough to
make rational drug therapy decisions with and for
him/her.
Secondly, to determine if the patient’s drug therapy
is appropriate, effective and safe, and to determine
your patient’s compliance with his/her medication
regimens.
Thirdly, the purpose is to identify drug therapy
problems.
ASSESSMENT DECISIONS
PATIENT
Drug-related needs
being met?
Drug therapy problems
present?
ASSESSMENT
Begin Here
Determine what your patient Wants
(Expectations and Goals)
Determine what your patient does Not Want
(Concerns)
ASSESSMENT
Indication
Understanding
“Why do I need to take this medication?”
Effectiveness
Expectations
“What can this medication do for me?”
Safety
Concerns
“What can this medication do to me?”
ASSESSMENT
Primary sources of information:
Patient
Family
Caregivers
Texts
Literature
Pages 294-295
ASSESSMENT
Other sources of information:
Prescribers
Medication profiles
Medical chart
Laboratory test results
ASSESSMENT
Setting
Comfortable—unhurried
Private—person to person
Professional—clean, organized
PHARMACIST’S ASSESSMENT
Taking notes...
Workup
PHARMACIST’S ASSESSMENT
Your role is to facilitate the patient’s
presentation, usually by asking a few
open-ended questions, providing
encouragement, and to listen carefully.
PHARMACIST’S ASSESSMENT
How to Start
Introduce yourself
“I would like to talk with you today in order
to gather some information about your
medications and determine how we can
best meet your needs.”
or
“I would like to talk with you today in
order to gather some information about
your medications so we can make certain
that you get the results you want from all
of your medications.”
ASSESSMENT
• Patient description
(demographics, background)
• Reason for the encounter
(What your patient wants)
“chief complaint”
• Medication experience
– Patient’s description of the
medication experience
– Medication history
– Current medication record
• Other medical history
• Review of systems
ASSESSMENT
Demographics
Used to personalize and individualize
interpretations of the patient’s drug-related
needs and
drug therapy instructions
ASSESSMENT
REASON FOR THE ENCOUNTER
“chief complaint”
“What can I do for you today?”
“How can I help you today?”
“Tell me how you have been feeling
since the last time we talked.”
PHARMACIST’S ASSESSMENT
“I am glad you came in today. Tell me why
you are here to see me.”
“What can you tell me about that problem?”
“How would you describe the problem that
concerns you the most?”
ASSESSMENT
What, When, Where, Who, Why and How…
“What seems to help?”
“How have you tried to treat it in the past?”
“Describe what it feels like.”
“What was the pain like for you?”
“Tell me what else you noticed.”
“When does it occur?”
ASSESSMENT
“How well has this medication worked for you?”
“What kind of treatment do you think would
work best for you?”
“How long have you had it?”
“How often does it occur?”
“When did it start?”
“What did it look like?”
“What do you mean by ‘tired?’”
“What makes it worse?”
ASSESSMENT
Patient Background
Who is this person?
Describe what a typical day is like.
Can you tell me a little about yourself?
Describe your family?
What type of work do you do?
PHARMACIST’S ASSESSMENT
Family Background
“Has anyone in your family also had this?”
“Is anyone else at home also ill?”
ASSESSMENT
MEDICATION EXPERIENCE
LISTEN
LISTEN, LISTEN
Know what to listen for...
ASSESSMENT
Medication Experience
Know what to listen for...
How your patient makes decisions about medication use
Indication for Drug Therapy and Goals of Therapy
Signs and symptoms from the time the patient felt well
through the present
Let your patient talk… use open-ended questions
Components of the Medication Experience
The patient’s description of the medication
experience
The medication history
The current medication record
ASSESSMENT
Allergies and Alerts
• Distinguish between drug allergies and
adverse drug reactions
• Describe the nature of the event, the timing
with respect to the offending drug, and the
consequences of the episode.
“What happened when you took the drug?”
Adverse Drug Reaction
Negative or undesirable effect that occurs at
commonly used dosage regimens.
Type A—known, but undesirable pharmacology
of the drug
Type B—idiosyncratic reactions unrelated to
pharmacology or dosage
Page 111
ASSESSMENT
Immunization History
Childhood immunization record
Adult immunization record
Childhood
Immunizations*
Birth
Dose
1
Hepatitis B
1
2
4
6
12
15
18
24
4-6
11-12
13-18
mo
mos
mos
mos
mos
mos
mos
mos
yrs
yrs
yrs
Dose 2
Dose 3
Diphtheria, Tetanus, Pertussis
1
2
3
Haemonphilus influenzae Type b
1
2
3
Polio-inactivated
1
2
Measles, Mumps, Rubella
4
4
3
4
1
2
Varicella (chicken pox)
Pneumococcal
1
2
3
4
Hepatitis A(children in high risk
regions)
Influenza (Children >6 with asthma,
diabetes, HIV, sickle cell, cardiac
disease)
*see http:///www.cdc.gov/nip for more information
Hepatitis A Series
Yearly
Appendix C
Adult
Immunizations*
19-49 Years
Tetanus, Diphtheria
(Td)
1 booster every ten
years
Influenza
1 dose annually for
persons with medical
or occupational
indications or
household contacts of
persons with
indications
1 annual dose
1 annual dose
Pneumococcal
(polysaccharide)
1 dose for persons
with medical or other
indications. (1 dose
revaccination for
immunosuppressive
conditions)
1 dose for person
with medical or
other indications.
(1 dose
revaccination for
immunosuppressive
conditions)
1 dose for
unvaccinated
persons
1 dose
revaccination
50-64 Years
65 Years & Older
1 booster every ten 1 booster every ten
years
years
*see http:///www.cdc.gov/nip for more information
Appendix C
ASSESSMENT
Smoking, alcohol, and drugs of abuse
“Are you, or have you ever been a smoker?”
“Describe your attempts to cut down or quit.”
“Is this something you would find difficult to
give up?”
PHARMACIST’S ASSESSMENT
Summarize
• Ensures you have the story straight
• Helps clarify ambiguities
• Useful to transition to the next part
of your assessment
• Helps keep the assessment on track
ASSESSMENT
Current Medication Record
What medications is your patient currently
taking (or supposed to be taking)?
Make the connections between...
Indication -- product -- dosage regimen -- patient response
Current Medication Record
Include all regularly used drugs including:
oral contraceptives
vitamins & minerals
cough & cold preparations
laxatives
aspirin, acetaminophen, ibuprofen
natural and herbal preparations
ASSESSMENT
CURRENT MEDICATION RECORD
“How is that being treated?”
“How well are you satisfied with that therapy?”
“What positive results have you had from this medication?”
“What changes would you like to see in your drug therapy?”
PHARMACIST’S ASSESSMENT
Medication History
Serious illnesses requiring drug therapy
Hospitalizations
Surgical procedures
Accidents and injuries
Pregnancies and deliveries
PHARMACIST’S ASSESSMENT
Medication History
Be precise
Do not over-interpret unimportant data
Remember, your patient is here for today’s problem.
Focus on past treatment successes or failures for
similar disorders.
PHARMACIST’S ASSESSMENT
Medication History
“OK, I think I understand what’s been
happening over the past few weeks. How
about your health in the past”
“How has your health been in the past?”
“Tell me about any serious illnesses or medical
problems you have had in the past.”
ASSESSMENT
Summarize
• Ensures you have the story straight
• Helps clarify ambiguities
• Useful to transition to the next part
of your assessment
• Helps keep the assessment on track
PHARMACIST’S ASSESSMENT
Review of Systems
Discover other or additional complaints, questions, or concerns
(side effects)
It is not always necessary to ask detailed questions
about every possible symptom for every organ system
Use general questions:
“Are you having any trouble with your vision?”
“Have you ever had any stomach or bowel problems?”
PHARMACIST’S ASSESSMENT
Review of Systems
EENT
Cardiovascular
Pulmonary
Gastrointestinal
Skin
Endocrine Systems
GU/Reproductive
Urinary
Hematopoietic symptoms
Musculoskeletal
Neuropsychiatric
Infectious Disease
Table 6-8, pages 150-151
PHARMACIST’S ASSESSMENT
Summarize
• Ensures you have the story straight
“Now let me determine if we both see things the
same way.”
PHARMACIST’S ASSESSMENT
• Make certain your patient is
•
•
•
•
comfortable
Listen
Only collect information you need
to assess drug-related needs and
identify drug therapy problems.
Focus on the patient’s primary
problems or concerns
Summarize
Patient
Drug-related Needs
Drug Therapy
Problems
Drug Therapy Problems
Stated as:
The patient’s problem
The drug therapy involved
The relationship (cause and effect)
Drug Therapy Problem
Description of the Drug Therapy Problem
Unnecessary Drug
Therapy
The drug therapy is unnecessary because the
patient does not have a clinical indication at this
time
Needs Additional Drug
Therapy
Additional drug therapy is required to treat or
prevent a medical condition
Ineffective Drug
The drug product is not being effective at
producing the desired response
Dosage too low
The dosage is too low to produce the desired
response
Adverse Drug Reaction
The drug is causing an adverse reaction
Dosage too high
The dosage is too high, resulting in undesirable
effects
Non-compliance
The patient is not taking the drug regimen
appropriately
160
THE PATIENT CARE PROCESS –
THE CARE PLAN
Care Plan
The purpose of the care plan is to organize
all of the work agreed upon by the
practitioner and the patient to achieve the
goals of therapy.
This requires interventions to resolve drug
therapy problems, to optimize the patient’s
medication experience and prevent new
drug therapy problems from developing.
CARE PLAN
ASSESSMENT
CARE PLAN
Any difficulty you have in developing a
care plan, means you missed something
in your assessment.
Goals of Therapy
• Curing a disease
• Address signs and/or symptoms
• Slow progression of a disease
• Prevent a disease
• Normalize laboratory values
• Assist in the diagnostic process
Goals of Therapy
• Curing a disease
•
•
•
•
•
Strepococcal pnuemonia
Address signs and/or symptoms Osteoarthritis
Slow progression of a disease Diabetes mellitus
Prevent a disease Osteoporosis
Normalize laboratory values Hypokalemia
Assist in the diagnostic process MRI anxiety
Goals of Therapy
What you are trying to
accomplish with
pharmacotherapy
Parameters
How long it will
take
Time Frame
Improvements in clinical signs
and symptoms (observed values)
When to expect evidence
of improvement
Changes in laboratory test results
as evidence of improvements
(measured values)
Time required to achieve
full therapeutic response
Fig 8-1
PATIENT CARE PROCESS
ESTABLISH A THERAPEUTIC RELATIONSHIP
Assessment
Care Plan
Evaluation
Signs and
Symptoms
Goals of
Therapy
Outcomes
Continuous Follow-up
Fig 9-2
Goals of Therapy
Goals of therapy have a specific structure:
1. clinical parameter signs, symptoms and/or
laboratory values which are observable,
measurable, and realistic.
2. A desired value or observable change in the
parameter
3. A specific timeframe in which the goal is to be
met
Table 8-4
CARE PLAN
GOALS OF THERAPY
...involves the patient
What are your patient’s goals?
Discuss with your patient how certain you are that
the drug therapy will be effective at achieving the
goals of therapy.
Tell your patient when to expect to see the benefit
from drug therapy.
CARE PLAN
INTERVENTIONS
Initiate new drug therapy
Increase dosages
Decrease dosage
Discontinue drug therapy
Referrals
Provide instructions for optimal use of medications
CARE PLAN
Schedule for the next follow-up evaluation
When do you plan to see your patient again to
determine the effectiveness and safety of your
interventions?
CARE PLAN
Let’s go over the plan.
Let’s take things one at a time.
What do you think about this plan?
Do you foresee any difficulties with this plan?
When would be a good time during the day for you
to remember to take this medication?
CARE PLAN
What else do you need to know in order to
manage things until our next visit?
Have we accomplished what you wanted for
this visit?
Do you have any questions?
Is there anything else you would like me
to explain now?
THE PATIENT CARE PROCESS –
FOLLOW-UP EVALUATION
Follow-up Evaluation
The purpose of the follow-up evaluation is
to determine the actual outcomes of drug
therapy for the patient, compare these
results with the intended goals of therapy,
and determine the effectiveness and safety
of pharmacotherapy and the current status
of the patient.
FOLLOW-UP EVALUATION
Review your documentation ahead of time
Make a personal connection
Let your patient tell the story
“How have you been?”
“What’s happened since our last visit?”
“Let’s go over how well your new medications
are working for you.”
EVALUATION
Look for and document:
GOOD
(achieving goals of therapy most often
improvement in the medical condition)
BAD
(side effects, adverse drug reaction,
or toxicity resulting from drug therapies)
NEW
(new problems, noncompliance, new
medical conditions requiring drug therapy)
EVALUATION—EFFECTIVENESS
Evidence:
Clinical signs and/or symptoms
(improvements in the presentation of the disease or illness)
Laboratory test results
(improvements in the indicators of the disease or illness)
EVALUATION—EFFECTIVENESS
“What improvements have you noticed?”
“How well did things go with taking these
medications?”
“As you recall, our goal was to…
…how well do you think your
medications are working for you?”
EVALUATION—SAFETY
Evidence:
Clinical signs and/or symptoms
(Undesirable effects of drug therapy)
Laboratory test results
(Indicators of harmful effects of drug therapy)
EVALUATION—SAFETY
“Tell me, do you think your medications have caused
you any difficulties?”
“Have you experienced any undesirable
effects that you think might be caused by
your medication?”
“Do you have any concerns about continuing
this medication?”
EVALUATION—COMPLIANCE
“How much of your medication were you able to
take?”
“How many do you take at a time?”
“When do you take them?”
“What kind of reminders do you find helpful?”
EVALUATION—COMPLIANCE
“ About how often would you say you
remembered to take you medications”
“Under what circumstances do you tend to
forget to take your medications?”
PATIENT CARE PROCESS
ESTABLISH A THERAPEUTIC RELATIONSHIP
Assessment
Care Plan
Evaluation
Signs and
Symptoms
Goals of
Therapy
Outcomes
Continuous Follow-up
Figure 9-2
OUTCOME EVALUATIONS
Resolved
Goals achieved, therapy completed
Stable
Goals achieved, continue therapy
Improved
Progress being made, continue therapy
Partial ImprovementProgress made, minor adjustments required
Unimproved
No progress yet, continue therapy
Worsened
Decline in health, adjust therapy
Failure
Goals not achieved, initiate new therapy
Expired
Patient died while receiving therapy
Table 9-4
EVALUATION—NEW PROBLEMS
“Have you noticed any new problems that
you would like to discuss?”
PHARMACEUTICAL CARE PROCESS
ESTABLISH A THERAPEUTIC RELATIONSHIP
ASSESSMENT
CARE PLAN
EVALUATION
Ensure all drug therapy is
indicated, effective, safe
and patient can and will
comply with instructions
Resolve drug therapy
problems
Record actual patient
outcomes
Achieve goals of therapy
Identify drug therapy
problems
Prevent drug therapy
problems
Evaluate status as progress
in meeting therapeutic goals
Reassess for new problems
Continuous Follow-up
Figure 9-4
EVALUATION—NEW PATIENTS
“If you know of anyone of your friends or
family members that might benefit from
my services, have them come in and see me”
PRACTICE MANAGEMENT SYSTEM
Completely separate from dispensing
Different expectations
Different priorities
Different personnel required
Different rewards
Different resources required
Management
Pharmacist
Patient
Patient
Pharmacist
Management
PRACTICE MANAGEMENT SYSTEM
• Define the service-mission of the organization
• Obtain necessary resources
• Create and implement an evaluation system
• Utilize a patient-based reimbursement system
DEFINE THE MISSION
• To meet the Drug-related needs of our
patients in a compassionate, caring, and
professional manner.
• To ensure that all of our patients’ drug therapy
is appropriately indicated, effective, safe, and
convenient.
• To identify, resolve, and prevent any drug
therapy problems that interfere with these
goals.
NECESSARY RESOURCES
• Personnel
• Physical resources
• Documentation—data
• Educational
• Financial
DEVELOP AN EVALUATION SYSTEM
• Measure quality of patient care provided
• Measure efficiency/effectiveness of the
practice
DOCUMENTATION OF
EVALUATION=
PATIENT CARE
REASONS TO DOCUMENT
1.
2.
3.
4.
5.
6.
Provide quality patient care
Manage the practice
Liability issues
Evaluate performance
Justify professional role
Reimbursement
DOCUMENTATION: PATIENT CARE
Patient demographics
Drug-related needs
Drug therapy problems
Care plans
Outcomes
Connections
patients—indications—drug therapies—outcomes
NO DOCUMENTATION
MEANS YOU DID NOT
DO IT!!
REIMBURSEMENT and/or
WORKLOAD MEASUREMENT
1. Separate product from service
2. Establish patient as source of payment
3. Obtain payment for all aspects of care
REIMBURSEMENT and/or
WORKLOAD MEASUREMENT
4.
All drug therapy problems should be
included
5.
Select an approach consistent with other
health care providers
6.
Identifies pharmacist doing the work
APPROACHES TO REIMBURSEMENT
•
•
•
Fee-for-service
Capitation
Resource-based relative value system
FEE-FOR-SERVICE APPROACH
• Practitioner generates costs
• Fees vary with practitioner
• No limits on costs to the system
• Not acceptable to most payers
CAPITATION APPROACH
• Must know costs involved
• Must know impact of the service
• Must know risk involved
RESOURCE-BASED RELATIVE VALUE
SYSTEM (RBRVS)
• Payment based on level of patient need
• Pharmacist paid for all work
• Same system as other providers
REIMBURSEMENT and/or
WORKLOAD MEASUREMENT
A Resource-based Relative Value Scale includes 5
levels of patient need and complexity.
The level of reimbursement is determined as a function of
number of medical conditions
number of drug therapy problems
number of medications involved
RESOURCE-BASED RELATIVE VALUE SYSTEM
(RBRVS)
Level 1
(0.4)
Level 2
(1.0)
Level 3
(1.8)
Level 4
(2.5)
Level 5
(3.0)
Medical
Conditions
1
1
2
3
>4
Drug
Therapy
Problems
0
1
2
3
>4
Medications
0-1
1-2
3-4
5-8
>9
$
$$
$$$
$$$$
Amount
$$$$$
RESOURCE-BASED RELATIVE VALUE
SYSTEM (RBRVS)
For a patient who has three(3) active medical
conditions and has one(1) drug therapy
problem involving four(4) medications…
…the resource-based relative value scale
would assign this workload to a “level 2”
RESOURCE-BASED RELATIVE VALUE SYSTEM
(RBRVS)
Level 1
(0.4)
Medical
Conditions
Level 2
(1.0)
Level 3
(1.8)
Level 4
(2.5)
Level 5
(3.0)
1
1
2
3
>4
Drug
Therapy
Problems
0
1
2
3
>4
Medications
0-1
1-2
3-4
5-8
>9
$
$$
$$$
$$$$
Amount
$$$$$
RESOURCE-BASED RELATIVE VALUE SYSTEM
(RBRVS)
Level 1 (0.4) Level 2 (1.0) Level 3 (1.8) Level 4 (2.5) Level 5 (3.0)
99201
99202
99203
99204
99205
Work-up of
Drug-related
Needs
0-1 Drugs
1-2 Drugs
3-4 Drugs
5-8 Drugs
>9 Drugs
Pharmacist’s
Assessment
No Drug
Therapy
Problems
1 Drug
Therapy
Problems
2 Drug
Therapy
Problems
3 Drug
Therapy
Problems
>4 Drug
Therapy
Problems
Care Plan &
Evaluation
1
Medical
Condition
1
Medical
Conditions
2-3
Medical
Conditions
3
Medical
Conditions
>4
Medical
Conditions
$
$$
$$$
$$$$
$$$$$
Amount
Pharmaceutical Care Reimbursement Grid©: Resource-based Relative Value Scale
Key
Components
Assessment of
Drug-related
Needs
Identification
Drug Therapy
Problems
Care Planning &
Follow-up
Evaluation
Amount
Level #1a
(0.4)b
99201c
Level #2
(1.0)
99202
Level #3
(1.8)
99203
Level #4
(2.5)
99204
Level #5
(3.0)
99205
Problem-focused
Expanded
Problem
Detailed
Expanded
Detailed
Comprehensive
0-1 Medication
1-2 Medications
3-4 Medications
5-8 Medications
≥9 Medications
Problem-focused
Expanded
Problem d
Detailed
Expanded
Detailed d
Comprehensive
0 Drug Therapy
Problems
1 Drug Therapy
Problem
2 Drug Therapy
Problems
3 Drug Therapy
Problems
≥4 Drug Therapy
Problems
Straightforward
Straightforward
Low Complexity
Moderate
Complexity
High
Complexity
1 Medical
Condition
1 Medical
Condition
2 Medical
Conditions
3 Medical
Conditions
≥4 Medical
Conditions
$ 34.00
$ 85.00
$ 153.00
$ 212.50
$ 250.00
Service level.
Resource-based relative value unit.
c An example of a current procedural terminology (CPT) billing code for payment level calculation.
d Additional patient information required.
a
b
Table 14-1
REIMBURSEMENT FOR
PHARMACEUTICAL CARE
Private pay (cash)
Third party (insurance)
Government (reimbursement)
REIMBURSEMENT FOR
PHARMACEUTICAL CARE
In the beginning, this is a private pay
health care service, just like...
• Chiropractic care
• Home health care
• Eye care
• Dental care
GOALS OF A PATIENT CARE PRACTICE
1. Provide direct patient care by accepting the
responsibility for drug therapy (practice)
2. Generate evidence that you have an impact on
patient outcomes (database)
3. Collaborate with others in the health care
system ($$, physicians, industry, managers)
BUILDING A PRACTICE
Established Practice Phase
N=1000-2500
Number
Of
Patients Learning Phase
Growth Phase
N=250-500
N=50
1-2 months
6-12 months
Time
18-36 months
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
Document all care provided
Acquire an appropriate pharmacotherapeutic
knowledge base
Develop clinical skills
Understand practice standards and ethical
considerations
PHARMACEUTICAL CARE PRACTICE
“We work directly with patients to get the
results they want from their
medications.”
R.J. Cipolle
Clinical & Economic Impact of
Pharmaceutical Care Practice
Clinical & Economic Impact of
Pharmaceutical Care Practice
A database of 20, 761 patients who received
pharmaceutical care during 59,361 patient encounters has
been established over the past ten years.
A sample of 5,480 patients were selected and evaluated
from this population, and their results are described here.
•Younger patients, those less than 65 years old (n=3,064)
•Older patients, those 65 years and older (n=2,072)
Number of Patients by Ages
(n= 5136 patients)
600
# of Patients
500
 patients < 65 years old (n=3064)
 patients > 65 years old (n=2072)
400
300
200
100
0
0-5
6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-64 65-70 71-75 76-80 81-85 86-90 91-95
96100
Age in Years
Figure 2-1
Frequency of Patients by
Number of Medical Conditions
50
45
% of Patients
40
N=5136 patients
35
Average = 4 medical conditions / patient
30
25
20
15
10
5
0
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19
# of Medical Conditions
from Figure 2-2
MOST FREQUENT INDICATIONS FOR DRUG THERAPY
(N = 26,238 Patient Encounters)
1.
2.
3.
4.
5.
HYPERTENSION
HYPERLIPIDEMIA
DIABETES
OSTEOPORSIS
VITAMIN SUPPLEMENT
6.
7.
8.
9.
10.
ALLERGIC RHINITIS
ESOPHAGITIS
DEPRESSION
MENOPAUSAL SYMPTOMS
ARTHRITIS PAIN
These 10 conditions represent
50% of all indications for drug therapy
Frequency of Patients by
Number of Drug Therapies
25
% of Patients
20
N=5136 patients
15
Average = 6 drug therapies / patient
10
5
0
0
2
4
6
8
10
12
14
16
# of Drug Therapies
18
20
22
24
26
28
from Figure 2-3
DRUG THERAPY PROBLEMS (DTP)
(N =26,238 Patient Encounters)
Percent of DTP
Indication
Unnecessary Drug Therapy
Needs Additional Drug Therapy
Effectiveness
Safety
28 %
Ineffective Drug
8%
Dosage Too Low
20 %
Adverse Drug Reaction
14 %
Dosage Too High
Compliance
6%
34%
28%
19%
5%
Noncompliance
19 %
Total
100%
19%
from Table 2-11
Drug Therapy Problems
(N=3995 drug therapy problems identified and resolved in 5136 patients at their first encounter)
50
% of Drug Therapy Problems
40
30
20
10
0
Unnecessary
Needs
Additional
Ineffective
Dosge too low
Adverse
reaction
Category of Drug Therapy Problems
Dosage too
high
Noncompliance
from Figure 2-4
PRIMARY METHOD OF RESOLUTION
OF DRUG THERAPY PROBLEMS
Protocol
Physician
(19 %)
Carrier
Patient
(79 %)
IMPACT OF PHARMACEUTICAL CARE PRACTICE
Resolution of drug therapy problems with Physicians
initiate new drug therapy
change drug dosage regimens
change drug product
discontinue drug therapy
laboratory monitoring initiated
other
31 %
23 %
15 %
15 %
10 %
6%
Workload Based on Patient Complexity*
Resource-based Relative Value Scale
100
90
80
70
% of Patient
Encounters
60
48%
50
32%
40
30
12%
20
5%
3%
Level 4
Level 5
10
0
Level 1
Level 2
Level 3
*All documented pharmaceutical care encounters (n=26,238) from sample patients (n=5,136) described in chapter 2
Figure 14-1
Pharmaceutical Care Services
Positive Impact
Individual Patients
Better Clinical Outcomes
Populations of Patients
Health Care Savings
Comparison of Goals met at
Follow-up within the Same Patient
Patients
(n=4,492)
OUTCOMES
Goals of therapy at
first encounter
Goals of therapy at
most recent
encounter
Goals
met
13,595
72.5%
16,980
90.6%
Goals
not met
5,156
27.5%
1,771
9.4%
Clinical Outcomes
• 5136 patients
• 4492 patients in whom there were at least
two evaluations of the same medical
condition being managed with drug therapy.
• 18,919 total medical conditions managed
with drug therapy were evaluated on at least
two occasions. (average = 4.2/patient)
Clinical Outcomes
• 8434 conditions were STABLE at both the
first (earliest) evaluation and at the most
recent evaluation
Therefore, the status of
• 10,485 medical conditions could possibly
have changed through the provision of
pharmaceutical care
in these cases….
Clinical Outcomes
• 7564 (69 %) IMPROVED with
pharmaceutical care
• 1581 (15%) remained the SAME,
and the status of
• 1699 (16 %) DECLINED.
Clinical Outcomes
Therefore, 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.
Change in Clinical Status at Follow-up Evaluation
4492 Patients and 10,485 Medical Conditions
Condition Declined
(16 %)
Condition Improved
or
Remained the Same
(84 %)
Drug Costs and Savings
Medication Interventions
Totals
Interventions
n=2,355
Increased medications used as prevention,
treatment and/or improved compliance
Average
Total increased medication costs/90 days =
$122,634
$52.07
per occurrence
Interventions
n=1,317
Decreased medication use to reduce toxicity,
adverse reactions, and/or eliminate
unnecessary therapies
Average
Total decreased medication costs/90 days =
$145,719
$110.64
per occurrence
from Table 2-28
Health Care Savings
5,136 patients
26,238 encounters
Health Care Savings*
# of events
$ Savings
Clinic outpatient visit avoided
1997
$ 529,205
Specialty office visit avoided
170
$ 51,680
Employee work days saved
112
$ 26,544
Laboratory service avoided
341
$ 8,184
Urgent care visit avoided
51
$ 4,182
Home health care visit avoided
16
$ 4,336
Long term care admission avoided
6
$ 336,000
Emergency department visit avoided
148
$ 66,896
Hospital admission avoided
31
$ 498,821
2882
$ 1,525,848
Total
from Table 2-29
Health Care Savings
These savings represent an average of $297
per patient receiving pharmaceutical care.
In the younger group the average savings
was $258, while in the older patients, an
average of $355 in health care expenses
were able to be avoided.
Health Care Benefits
These practice-based data
demonstrate that pharmaceutical care
practice can improve patient clinical
outcomes and avoid unnecessary
health care expenditures.
Patient Care
Process
Patient
Experience
Medication
Responsibilities
Care Plan
Pharmacotherapy
Workup
Today’s wants
and needs
Practitioner
Assessment
Philosophy of Practice
Follow-up
Evaluation
Social Obligation
Responsibilities
Patient-centered approach
Caring
Therapeutic Relationship
DEMOGRAPHICS
CONTACT
INFORMATION
Pharmacotherapy Workup©
NOTES
ASSESSMENT
Name
Address
Telephone (h)
City
State
(w)
(cell)
Pharmacy Name
Clinic Name
(tel)
(tel)
Postal Code
e-mail
Age
Date of Birth
Gender: M/F
Weight
Height
Lean Body Weight
Pregnancy status: Y/N
Breast Feeding: Y/N
Due Date
Occupation
Living Arrangements/Family
Health Insurance (coverage issues):
REASON
FOR THE ENCOUNTER
What is the patient’s general attitude toward taking medication?
Needs attention
in care plan
Y
What does the patient want/expect from his/her drug therapy?
Needs attention
in care plan
MEDICATION EXPERIENCE
Y
What concerns does the patient have with his/her medications?
N
Needs attention
in care plan
Y
Describe the patient’s medication taking behavior
N
Needs attention
in care plan
Y
Are there cultural, religious, or ethical issues that influence the patient’s
willingness to take medications?
N
Needs attention
in care plan
Y
To what extent does the patient understand his/her medications?
N
N
Needs attention
in care plan
Y
N
DEMOGRAPHICS
CONTACT
INFORMATION
Pharmacotherapy Workup©
NOTES
ASSESSMENT
Name
Address
Telephone (h)
City
State
(w)
(cell)
Pharmacy Name
Clinic Name
(tel)
(tel)
Postal Code
e-mail
Age
Date of Birth
Gender: M/F
Weight
Height
Lean Body Weight
Pregnancy status: Y/N
Breast Feeding: Y/N
Due Date
Occupation
Living Arrangements/Family
Health Insurance (coverage issues):
REASON
FOR THE ENCOUNTER
What is the patient’s general attitude toward taking medication?
Needs attention
in care plan
Y
What does the patient want/expect from his/her drug therapy?
Needs attention
in care plan
MEDICATION EXPERIENCE
Y
What concerns does the patient have with his/her medications?
N
Needs attention
in care plan
Y
Describe the patient’s medication taking behavior
N
Needs attention
in care plan
Y
Are there cultural, religious, or ethical issues that influence the patient’s
willingness to take medications?
N
Needs attention
in care plan
Y
To what extent does the patient understand his/her medications?
N
N
Needs attention
in care plan
Y
N
Birth
CHILDHOOD IMMUNIZATIONS*
Hepatitis B
1
mo
Dose 1
2
mos
4
mos
6
mos
Dose 2
Diphtheria, Tetanus,
Pertussis
Haemonphilus influenzae
Type b
Polio-inactivated
12
mos
15
mos
18
mos
4-6
yrs
11-12
yrs
13-18
yrs
Dose 3
1
2
3
1
2
3
1
2
Measles, Mumps, Rubella
4
4
3
4
1
2
Varicella (chicken pox)
Pneumococcal
1
2
3
4
Hepatitis A(children in
high risk regions)
Hepatitis A Series
Influenza (Children >6
with asthma, diabetes,
HIV, sickle cell, cardiac
disease)
□ Current
Yearly
on all childhood immunizations
19-49 YEARS
ADULT IMMUNIZATIONS*
24
mos
Tetanus, Diphtheria (Td)
1 dose annually for persons
with medical or
occupational indications or
household contacts of
persons with indications
1 dose for persons with
medical or other
indications. (1 dose
revaccination for
immunosuppressive
conditions)
Influenza
Pneumococcal
(polysaccharide)
□ Current
1 booster every ten years
50-64 YEARS
65 YEARS & OLDER
1 booster every ten
years
1 booster every ten
years
1 annual dose
1 annual dose
1 dose for person with
medical or other
indications. (1 dose
revaccination for
immunosuppressive
conditions)
1 dose for unvaccinated
persons
1 dose revaccination
on all adult immunizations
SOCIAL DRUG USE
*see http:///www.cdc.gov/nip for more information
Substance
Tobacco
□ No tobacco
use
Caffeine
□ No caffeine
use
History of Use
□
□
□
□
□
□
□
□
0-1 packs per day
>1 packs per day
previous history of smoking
attempts to quit
< 2 cups per day
2-6 cups per day
> 6 cups per day
history of caffeine dependence
Substance
Alcohol
□ No alcohol
use
Other
recreational
drug use
History of Use
□
□
□
□
< 2 drinks per week
2-6 drinks per week
> 6 drinks per week
history of alcohol dependence
ALLERGIES & ALERTS
Medication Allergies (drug, timing, reaction—rash, shock, asthma, nausea, anemia)
Adverse reactions to drugs in the past
Other Alerts/Health Aids/Special Needs (sight, hearing, mobility, literacy, disability)
DRUG PRODUCT
PAST DRUG THERAPIES
CURRENT MEDICAL CONDITIONS AND MEDICATIONS
INDICATION
INDICATION
PAST MEDICAL HISTORY
DRUG THERAPY
(RELEVANT
DOSAGE REGIMEN
dose, route, frequency
START
DATE
RESPONSE
RESPONSE
effectiveness/safety
DATE
ILLNESSES, HOSPITALIZATIONS, SURGICAL PROCEDURES, INJURIES, PREGNANCIES , DELIVERIES)
MEDICAL CONDITION
AND
DRUG THERAPY INVOLVED
INDICATION
Unnecessary Drug Therapy
__No medical indication
__Duplicate therapy
__Nondrug therapy indicated
__Treating avoidable ADR
__Addictive/recreational
Needs Additional Drug Therapy
__Untreated condition
__Preventive/prophylactic
__Synergistic/potentiating
MEDICAL CONDITION
AND
DRUG THERAPY INVOLVED
EFFECTIVENESS
Needs Different Drug Product
DRUG THERAPY PROBLEMS
__More effective drug available
__Condition refractory to drug
__Dosage form inappropriate
__Not effective for condition
Dosage Too Low
__Wrong dose
__Frequency inappropriate
__Drug interaction
__Duration inappropriate
MEDICAL CONDITION
AND
DRUG THERAPY INVOLVED
SAFETY
Adverse Drug Reaction
__Undesirable effect
__Unsafe drug for patient
__Drug interaction
__Dosage administered or changed too rapidly
__Allergic reaction
__Contraindications present
Dosage Too High
__Wrong Dose
__Frequency inappropriate
__Duration inappropriate
__Drug interaction
__Incorrect administration
MEDICAL CONDITION
AND
DRUG THERAPY INVOLVED
COMPLIANCE
Noncompliance
__Directions not understood
__Patient prefers not to take
__Patient forgets to take
__Drug product too expensive
__Cannot swallow/administer
__Drug product not available
y/n
General
Systems
EENT
REVIEW OF SYSTEMS
Cardiovascular
y/n
Poor appetite
Weight change
Pain
Headache
Dizziness (vertigo)
Change in vision
Loss of hearing
Ringing in the ears
(tinnitus)
Bloody nose
(epistaxis)
Allergic rhinitis
Glaucoma
Bloody sputum
(hemoptysis)
Chest pain
Hyperlipidemia
Hypertension
Myocardial
Infarction
Orthostatic
hypotension
Pulmonary
Asthma
Shortness of breath
Wheezing
Gastrointestinal
Heartburn
Abdominal pain
Nausea
Vomiting
Diarrhea
Constipation
Skin
Eczema/Psoriasis
Itching (pruritis)
Rash
Endocrine
Systems
Diabetes
Hypothyroidism
Menopausal
Symptoms
Cirrhosis
Hepatitis
Hepatic
Nutrition/Fluid/
Electrolytes
Dehydration
Edema
Potassium deficiency
GU/Reproductive
Kidney/Urinary
Hematopoietic
Symptoms
Musculoskeletal
Neuropsychiatric
Infectious
Disease
Dysmenorrhea/
menstrual bleeding
Incontinence
Impotence
Decreased sexual
drive
Vaginal discharge or
itching
Hot flashes
Urinary frequency
Bloody urine
(hematuria)
Renal dysfunction
Excessive bruising
Bleeding
Anemia
Back pain
Arthritis pain
(osteo/rheumatoid)
Tendonitis
Painful muscles
Numb, tingling
sensation in
extremities
(parasthesia)
Tremor
Loss of balance
Depression
Suicidal
Anxiety, nervousness
Inability to
concentrate
Seizure
Stroke/TIA
Memory loss
HIV/AIDS
Malaria
Syphilis
Gonorrhea
Herpes
Chlamydia
Tuberculosis
Pharmacotherapy Workup ©
Care Plan
Notes
Indication_____________________________________
(Description and history of the present illness or medical condition including previous approaches to treatment and responses)
Goals of Therapy (improvement or normalization of signs/symptoms/laboratory tests or reduction of risk)
1.
2.
Drug Therapy Problems to be resolved
□ None at this time
Therapeutic Alternatives (to resolve the drug therapy problem)
1.
2.
Pharmacotherapy Plan (Includes current drug therapies and changes)
Medications
Dosage Instructions
(drug products)
(dose, route, frequency, duration)
Other interventions to optimize drug therapy
Schedule for Next Follow-up Evaluation:
Notes Changes
Pharmacotherapy Workup©
EVALUATION
NOTES
Medical Condition:__________________________________
Pretreatment
Baseline (Date)
Outcome Parameter
First Follow-up
(Date)
Second Follow-up
(Date)
EFFECTIVENESS
Sign/symptom
Sign/symptom
Lab value
Lab value
Sign/symptoms
SAFETY
Signs/symptoms
Lab value
Lab value
Other
STATUS
STATUS
Initial: goals being established, initiate new therapy
Resolved: goals achieved, therapy completed
Stable: goals achieved, continue same therapy
Improved: adequate progress made continue same therapy
Partial Improvement: progress being made, adjustments in
therapy required
Unimproved: no progress yet, continue same therapy
Worsened: decline in health, adjust therapy
Failure: goals not achieved, discontinue current therapy and
replace with different therapy
New Drug Therapy Problems Identified
Date Schedule for next follow-up evaluation
Signature
○ none at this time
○ documented
Comments
Date
○ none at this time
○ documented
Pharmacotherapy Workup©
EVALUATION
NOTES
Medical Condition:__________________________________
Pretreatment
Baseline (Date)
Outcome Parameter
First Follow-up
(Date)
Second Follow-up
(Date)
EFFECTIVENESS
Sign/symptom
Sign/symptom
Lab value
Lab value
Sign/symptoms
SAFETY
Signs/symptoms
Lab value
Lab value
Other
STATUS
STATUS
Initial: goals being established, initiate new therapy
Resolved: goals achieved, therapy completed
Stable: goals achieved, continue same therapy
Improved: adequate progress made continue same therapy
Partial Improvement: progress being made, adjustments in
therapy required
Unimproved: no progress yet, continue same therapy
Worsened: decline in health, adjust therapy
Failure: goals not achieved, discontinue current therapy and
replace with different therapy
New Drug Therapy Problems Identified
Date Schedule for next follow-up evaluation
Signature
○ none at this time
○ documented
Comments
Date
○ none at this time
○ documented