Patient Care Involves a patient and a qualified practitioner Requires a face-to-face encounter Practitioner takes responsibility for patients

need(s), his/her interventions and the patients outco es Practitioner provides a service that is consistent, co prehensive and standardi!ed Practitioner assess each patients needs, develops a care plan to follo"s-up to evaluated the outco es# eet these needs and

$%R&I'()(*+ Counselin, -ocu entation *eneralist .pecialist Intervie" Practice Care Phar aceutical care Co,nitive service Patient Profile

Phar aceutical Care in /ealth Care

-efinin, Phar aceutical Care Defined as a practice1 in 1997

Phar aceutical care is a patient-centered practice in "hich the practitioner assu es responsibility for a patients dru,-related needs and is held accountable for this co it ent#0 Phar aceutical Care Phar aceutical care is ho" a practitioner applies e1pert phar acotherapeutic kno"led,e in practice to benefit the patient# 2n %1pert Practitioner Assesses needs Finds problems Fixes problems Prevent problems Takes responsibility Follows-up to determine outcomes Is held accountable *eneralist Practitioner 2 practitioner "ho provides continuin,, co prehensive, and coordinated care to a population undifferentiated by ,ender, disease, or or,an syste #

2 erican 3oards of 4a ily Practice and Internal &edicine (234P and 23I&) .$2'-2R- (4 PR2C$IC%

P/I)(.(P/+ (4 PR2C$IC%

2 set of values that ,uides behaviors associated "ith a professional practice

/elps the practitioner deter ine "hat is i portant and ho" to set priorities

Represents "hat 5should6 be done P/I)(.(P/+ (4 PR2C$IC% $his ust be in the ind and the heart of the practitioner before carin, for a patient

.(CI2) '%%$he professions responsibility to society

Rationale for professional status

(bli,ation to apply unique, e1pert kno"led,e

.tandard by "hich a profession is evaluated

.(CI2) '%%&eetin, a social need requires takin, care of patients###

one patient at a time.

C2RI'* -%4I'%2ssess patient need

Provide resources

%valuate patient outco es

$/% $/%R2P%7$IC R%)2$I('./IP Connection bet"een philosophy and patient care

'ecessary to provide care

-eter ines the quality of care that can be delivered

&ost i portant ele ent of practice C/2R2C$%RI.$IC. of the $/%R2P%7$IC R%)2$I('./IP

&utual respect $rust (pen co unication

Cooperation &utual decision akin,

Co ponents of the &edication %1perience $he patients description of the edication e1perience

$he

edication history

$he current

edication record

$he Patients -escription of the &edication %1perience Patient e1pectations and "ants Patient concerns Patients understandin, of dru, therapy Preferences, attitudes, and beliefs Cultural, ethico-reli,ious, ,enetic influences &edication takin, behavior $he &edication /istory I uni!ations

/istory of social dru, use &edication aller,ies 2dverse dru, reactions 2lerts and special needs /istory of relevant edication use

$he Current &edication Record Indication -ru, Product

-osa,e re,i en .tart date Response

Pharmacotherapy Workup $he Phar acotherapy 8orkup is a lo,ical thou,ht process that ,uides the "ork and decisions as the clinician assesses the patients dru,-related needs and identifies dru, therapy proble s#

D !" T#$ AP% P &'($)* $he identification, resolution, and prevention of dru, therapy proble s are the heart and soul of phar aceutical care practice

-R7* $/%R2P+ PR(3)%& C2$%*(RI%. $he dru, therapy is unnecessary because the patient does not have a clinical indication at this ti e# 2dditional dru, therapy is required to treat or prevent a edical condition in the patient#

$he dru, product is not bein, effective at producin, the desired response in the patient# $he dosa,e is too lo" to produce the desired response in the patient# $he dru, is causin, an adverse dru, reaction in the patient# $he dosa,e is too hi,h, resultin, in undesirable effects e1perienced by the patient# $he patient is not able or "illin, to take the dru, therapy as intended#

9# 2ssess the patients dru,-related needs 0# -evelop a care plan :# Co plete a follo"-up evaluation

Practice Results

PRI&2R+ &%$/(- (4 R%.()7$I(' (4 -R7* $/%R2P+ PR(3)%&.

I&P2C$ (4 P/2R&2C%7$IC2) C2R% PR2C$IC% Resolution of dru, therapy proble s "ith Physicians initiate ne" dru, therapy chan,e dru, dosa,e re,i ens chan,e dru, product discontinue dru, therapy laboratory other +han,e in +linical *tatus at Follow-up $valuation --./ Patients and 012-34 )edical +onditions +linical &utcomes 3-5 o6 the medical conditions re7uirin, dru, therapy2 which were not already stable at the time o6 the 6irst pharmaceutical care encounter2 improved 89.5: or remained the same8045: throu,h the provision o6 pharmaceutical care; onitorin, initiated 9< ; 9< ; 9=; >; :9 ; 0: ;

Identi6yin, Dru, 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 patients drug therapy regimens.

7nique set of proble s

-e arcate professional responsibilities

Central to your activities and practice Dru, Therapy Problems .tatin, the dru, therapy proble ? Dru, Therapy Problems Dru, Therapy Problems Dru, Therapy Problems

Purposes@ $o seek help fro a collea,ue

&ost frequent

ethod you "ill use to co

unicate "ith collea,ues

/o" your perfor ance "ill be Aud,ed

8hat infor ation do you presentB (student vs# practitioner)

(rder of infor ation presented

$er inolo,y used

The Patient +are Process The three ma<or steps in the patient care process are the assess ent leadin, to dru, therapy proble identification, care plan develop ent, and follo"-up evaluation; Assessment The purpose o6 the assessment is three 6old; 4irstly, to understand the patient "ell enou,h to and for hi /her# ake rational dru, therapy decisions "ith

.econdly, to deter ine if the patients dru, therapy is appropriate, effective and safe, and to deter ine your patients co pliance "ith his/her edication re,i ens#

$hirdly, the purpose is to identify dru, therapy proble s# 2..%..&%'$ -%CI.I('.

2..%..&%'$ .ettin,

Co fortableCunhurried

PrivateCperson to person

ProfessionalCclean, or,ani!ed P/2R&2CI.$. 2..%..&%'$ P/2R&2CI.$. 2..%..&%'$ +our role is to facilitate the patients presentation, usually by askin, a fe" open-ended questions, providin, encoura,e ent, and to listen carefully# P/2R&2CI.$. 2..%..&%'$ Introduce yourself

5I "ould like to talk "ith you today in order to ,ather so e infor ation about your edications and deter ine ho" "e can best or 5I "ould like to talk "ith you today in order to ,ather so e infor ation about your edications so "e can ake certain all eet your needs#6

that you ,et the results you "ant fro of your edications#6

2..%..&%'$ Patient description (de o,raphics, back,round) Reason for the encounter (8hat your patient "ants) 5chief co plaint6 &edication e1perience Patients description of the &edication history Current (ther edication record edical history edication e1perience

Revie" of syste s

2..%..&%'$ R%2.(' 4(R $/% %'C(7'$%R 5chief co plaint6

P/2R&2CI.$. 2..%..&%'$ 5I a ,lad you ca e in today# $ell e "hy you are here to see e#6

58hat can you tell

e about that proble B6

5/o" "ould you describe the proble 2..%..&%'$ 58hat see s to helpB6

that concerns you the

ostB6

5/o" have you tried to treat it in the pastB6 5-escribe "hat it feels like#6 58hat "as the pain like for youB6 5$ell e "hat else you noticed#6

58hen does it occurB6

2..%..&%'$ 5/o" "ell has this edication "orked for youB6

58hat kind of treat ent do you think "ould "ork best for youB6 5/o" lon, have you had itB6 5/o" often does it occurB6 58hen did it startB6 58hat did it look likeB6 58hat do you 58hat ean by DtiredB6

akes it "orseB6

2..%..&%'$ Patient 3ack,round

8ho is this personB -escribe "hat a typical day is like# P/2R&2CI.$. 2..%..&%'$ 4a ily 3ack,round

5/as anyone in your fa ily also had thisB6

5Is anyone else at ho e also illB6 2..%..&%'$ &%-IC2$I(' %EP%RI%'C% LISTEN

LISTEN, LISTEN 2..%..&%'$ &edication %1perience Know what to isten for... /o" your patient akes decisions about edication use

Indication for -ru, $herapy and *oals of $herapy

.i,ns and sy pto s fro

the ti e the patient felt "ell throu,h the present

)et your patient talk? use open-ended questions Co ponents of the &edication %1perience $he patients description of the edication e1perience

$he

edication history

$he current

edication record

2..%..&%'$ -istin,uish bet"een dru, aller,ies and adverse dru, reactions

-escribe the nature of the event, the ti in, "ith respect to the offendin, dru,, and the consequences of the episode# 2dverse -ru, Reaction 'e,ative or undesirable effect that occurs at co only used dosa,e re,i ens#

$ype 2Ckno"n, but undesirable phar acolo,y of the dru, $ype 3Cidiosyncratic reactions unrelated to phar acolo,y or dosa,e 2..%..&%'$ Childhood i uni!ation record

2dult i

uni!ation record

2..%..&%'$ 52re you, or have you ever been a s okerB6

5-escribe your atte pts to cut do"n or quit#6

5Is this so ethin, you "ould find difficult to ,ive upB6 P/2R&2CI.$. 2..%..&%'$ %nsures you have the story strai,ht /elps clarify a bi,uities 7seful to transition to the ne1t part of your assess ent /elps keep the assess ent on track

2..%..&%'$

8hat

edications is your patient currently takin, (or supposed to be takin,)B

&ake the connections bet"een### Current &edication Record

Include all re,ularly used dru,s includin,@ oral contraceptives vita ins F inerals

cou,h F cold preparations la1atives aspirin, aceta inophen, ibuprofen natural and herbal preparations 2..%..&%'$ C7RR%'$ &%-IC2$I(' R%C(R-

5/o" is that bein, treatedB6

5/o" "ell are you satisfied "ith that therapyB6

58hat positive results have you had fro

this

edicationB6

58hat chan,es "ould you like to see in your dru, therapyB6

P/2R&2CI.$. 2..%..&%'$ .erious illnesses requirin, dru, therapy /ospitali!ations .ur,ical procedures 2ccidents and inAuries Pre,nancies and deliveries P/2R&2CI.$. 2..%..&%'$ &edication /istory

3e precise -o not over-interpret uni portant data

Re e ber, your patient is here for todays proble #

4ocus on past treat ent successes or failures for si ilar disorders# P/2R&2CI.$. 2..%..&%'$ &edication /istory 5(G, I think I understand "hats been happenin, over the past fe" "eeks# /o" about your health in the past6

5/o" has your health been in the pastB6

5$ell

e about any serious illnesses or

edical proble s you have had in the past#6

2..%..&%'$ .u ari!e

%nsures you have the story strai,ht /elps clarify a bi,uities 7seful to transition to the ne1t part of your assess ent /elps keep the assess ent on track

P/2R&2CI.$. 2..%..&%'$

-iscover other or additional co plaints, questions, or concerns (side effects)

It is not al"ays necessary to ask detailed questions about every possible sy pto 7se ,eneral questions@ P/2R&2CI.$. 2..%..&%'$ P/2R&2CI.$. 2..%..&%'$ .u ari!e for every or,an syste

%nsures you have the story strai,ht

P/2R&2CI.$. 2..%..&%'$ &ake certain your patient is co fortable )isten (nly collect infor ation you need to assess dru,-related needs and identify dru, therapy proble s# 4ocus on the patients pri ary proble s or concerns .u ari!e

Dru, Therapy Problems

$he patients proble $he dru, therapy involved $he relationship (cause and effect)

+are Plan $he purpose of the care plan is to or,ani!e all of the "ork a,reed upon by the practitioner and the patient to achieve the ,oals of therapy#

$his requires interventions to resolve dru, therapy proble s, to opti i!e the patients edication e1perience and prevent ne" dru, therapy proble s fro developin,#

2ny difficulty you have in developin, a care plan, eans you issed so ethin,

in your assess ent# "oals o6 Therapy Curin, a disease 2ddress si,ns and/or sy pto s .lo" pro,ression of a disease Prevent a disease 'or ali!e laboratory values 2ssist in the dia,nostic process "oals o6 Therapy +urin, a disease

Address si,ns and=or symptoms *low pro,ression o6 a disease Prevent a disease >ormali?e laboratory values Assist in the dia,nostic process

"oals o6 Therapy "oals o6 therapy have a speci6ic structure@

clinical parameter si,ns, sy pto s and/or laboratory values "hich are observable, easurable, and realistic# 2 desired value or observable chan,e in the para eter 2 specific timeframe in "hich the ,oal is to be C2R% P)2' *(2). (4 $/%R2P+ ###involves the patient 8hat are your patients ,oalsB et

)ets ,o over the plan# )ets take thin,s one at a ti e#

8hat do you think about this planB

-o you foresee any difficulties "ith this planB

8hen "ould be a ,ood ti e durin, the day for you to re e ber to take this

edicationB

8hat else do you need to kno" in order to ana,e thin,s until our ne1t visitB

/ave "e acco plished "hat you "anted for this visitB

Follow-up $valuation $he purpose of the follo"-up evaluation is to deter ine the actual outco es of dru, therapy for the patient, co pare these results "ith the intended ,oals of therapy, and deter ine the effectiveness and safety of phar acotherapy and the current status of the patient# 4())(8-7P %H2)72$I(' Revie" your docu entation ahead of ti e &ake a personal connection )et your patient tell the story

)ook for and docu ent@ *(((achievin, ,oals of therapy i prove ent in the edical condition) ost often

32-

(side effects, adverse dru, reaction, or to1icity resultin, fro dru, therapies)

'%8 (ne" proble s, nonco pliance, ne" edical conditions requirin, dru, therapy)

%H2)72$I('C%44%C$IH%'%.. %vidence@ Clinical si,ns and/or sy pto s (i prove ents in the presentation of the disease or illness)

)aboratory test results (i prove ents in the indicators of the disease or illness)

%H2)72$I('C%44%C$IH%'%.. 58hat i prove ents have you noticedB6 5/o" "ell did thin,s ,o "ith takin, these edicationsB6

52s you recall, our ,oal "as to? %H2)72$I('C.24%$+ %vidence@ Clinical si,ns and/or sy pto s (7ndesirable effects of dru, therapy)

)aboratory test results (Indicators of har ful effects of dru, therapy)

%H2)72$I('C.24%$+ 5$ell e, do you think your edications have caused

you any difficultiesB6

5/ave you e1perienced any undesirable effects that you think your edicationB6 i,ht be caused by

5-o you have any concerns about continuin, this edicationB6

%H2)72$I('CC(&P)I2'C% 5/o" 5/o" uch of your edication "ere you able to takeB6

any do you take at a ti eB6

58hen do you take the B6

58hat kind of re inders do you find helpfulB6

%H2)72$I('CC(&P)I2'C% 5 2bout ho" often "ould you say you re e bered to take you edications6

57nder "hat circu stances do you tend to for,et to take your edicationsB6

%H2)72$I('C'%8 PR(3)%&. 5/ave you noticed any ne" proble s that you "ould like to discussB6

%H2)72$I('C'%8 P2$I%'$. 5If you kno" of anyone of your friends or fa ily e bers that i,ht benefit fro co e in and see e6

y services, have the

PR2C$IC% &2'2*%&%'$ .+.$%& !omp ete y separate from dispensin"

-ifferent e1pectations -ifferent priorities -ifferent personnel required -ifferent re"ards -ifferent resources required

&ana,e ent

Phar acist

Patient

Patient

Phar acist

&ana,e ent PR2C$IC% &2'2*%&%'$ .+.$%& -efine the service- ission of the or,ani!ation

(btain necessary resources

Create and i ple ent an evaluation syste

7tili!e a patient-based rei burse ent syste -%4I'% $/% &I..I(' $o eet the -ru,-related needs of our patients in a co passionate, carin,, and professional anner# $o ensure that all of our patients dru, therapy is appropriately indicated, effective, safe, and convenient# $o identify, resolve, and prevent any dru, therapy proble s that interfere "ith these ,oals#

'%C%..2R+ R%.(7RC%. Personnel Physical resources -ocu entationCdata %ducational 4inancial

-%H%)(P 2' %H2)72$I(' .+.$%& &easure quality of patient care provided

&easure efficiency/effectiveness of the practice

-(C7&%'$2$I('@ P2$I%'$ C2R% Patient de o,raphics -ru,-related needs -ru, therapy proble s Care plans (utco es !onnections patients#indications#dr$" therapies#o$tcomes

4%%-4(R-.%RHIC% 2PPR(2C/ Practitioner ,enerates costs 4ees vary "ith practitioner 'o li its on costs to the syste 'ot acceptable to ost payers

4or a patient "ho has three(:) active edical conditions and has one(9) dru, therapy proble involvin, four(I) edications?

R%I&37R.%&%'$ 4(R P/2R&2C%7$IC2) C2R% Private pay (cash) $hird party (insurance) *overn ent (rei burse ent) R%I&37R.%&%'$ 4(R P/2R&2C%7$IC2) C2R% Chiropractic care /o e health care %ye care -ental care

9# Provide direct patient care by acceptin, the responsibility for dru, therapy (practice)

0#

*enerate evidence that you have an i pact on patient outco es (database)

:#

Collaborate "ith others in the health care syste ana,ers)

(JJ, physicians, industry,

e7uirements 6or the Pharmaceutical +are Practitioner !nderstand your responsibilities Develop a therapeutic relationship with each patient Apply the Pharmacotherapy Workup to make rational dru, therapy decisions (earn the patient care process Document all care provided Ac7uire an appropriate pharmacotherapeutic knowled,e base Develop clinical skills !nderstand practice standards and ethical considerations

%&e wor' direct y with patients to "et the res$ ts they want from their medications.(

Clinical F %cono ic I pact of Phar aceutical Care Practice Clinical F %cono ic I pact of Phar aceutical Care Practice A database o6 /12 A90 patients who received pharmaceutical care durin, 4.2B90 patient encounters has been established over the past ten years;

A sample o6 42-31 patients were selected and evaluated 6rom this population2 and their results are described here;

%oun,er patients2 those less than 94 years old 8nCB219-: &lder patients2 those 94 years and older 8nC/21A/:

>umber o6 Patients by A,es 8nC 40B9 patients: Fre7uency o6 Patients by >umber o6 )edical +onditions

Fre7uency o6 Patients by >umber o6 Dru, Therapies

Dru, Therapy Problems PRI&2R+ &%$/(- (4 R%.()7$I(' (4 -R7* $/%R2P+ PR(3)%&. I&P2C$ (4 P/2R&2C%7$IC2) C2R% PR2C$IC% Resolution of dru, therapy proble s "ith Physicians

initiate ne" dru, therapy chan,e dru, dosa,e re,i ens chan,e dru, product discontinue dru, therapy laboratory other 8orkload 3ased on Patient Co ple1ityK esource-based elative Dalue *cale onitorin, initiated 9< ;

:9 ; 0: ;

9< ; 9= ; >;

+omparison o6 "oals met at Follow-up within the *ame Patient +linical &utcomes 40B9 patients

--./ patients in whom there were at least two evaluations o6 the same medical condition bein, mana,ed with dru, therapy;

032.0. total medical conditions mana,ed with dru, therapy were evaluated on at least two occasions; 8avera,e C -;/=patient: +linical &utcomes 3-B- conditions were *TA'($ at both the 6irst 8earliest: evaluation and at the most recent evaluation

There6ore2 the status o6

012-34 medical conditions could possibly have chan,ed throu,h the provision o6 pharmaceutical care in these casesE; +linical &utcomes A49- 89. 5: I)P &D$D with 0430 8045: remained the *A)$2 and the status o6 09.. 809 5: D$+(I>$D; pharmaceutical care

+linical &utcomes There6ore2 3-5 o6 the medical conditions re7uirin, dru, therapy2 which were not already stable at the time o6 the 6irst pharmaceutical care encounter2 improved 89.5: or remained the same8045: throu,h the provision o6 pharmaceutical care;

+han,e in +linical *tatus at Follow-up $valuation --./ Patients and 012-34 )edical +onditions Dru, +osts and *avin,s #ealth +are *avin,s #ealth +are *avin,s These savin,s represent an avera,e o6 F/.A per patient receivin, pharmaceutical care;

In the youn,er ,roup the avera,e savin,s was F/432 while in the older patients2 an avera,e o6 FB44 in health care expenses were able to be avoided;

#ealth +are 'ene6its These practice-based data demonstrate that pharmaceutical care practice can improve patient clinical outcomes and avoid unnecessary health care expenditures;