Ambulatory Care Pharmacy

1. Ambulatory Care Pharmacy Debbie Kwan, BScPhm., MSc. Toronto Western Hospital -University Health Network Faculty of Pharmacy, Nov. 22, 2002

2. Objectives: 1. Describe ambulatory care practice 2. Describe the impact of ambulatory care practices 3. Provide examples of activities provided through ambulatory care services 4. Identify future opportunities and challenges

3. What is Ambulatory Care? “all health-related services for patients who walk to seek their care” Seaton, Ambulatory Care, PSAP Examples: • clinics - general (primary care); specialty (day surgery, chemotherapy) • ER • private offices • community pharmacies

4. Why ambulatory care? • Shift from acute ambulatory care: • decreasing LOS • increased outpatient procedures • goal: decrease health care costs • Continuity of care: • bridging the gaps • secondary prevention clinics • e.g SPACE

5. What does the Pharmacy profession think? ASHP Survey 1999: • “greatest opportunity for pharmacists in the future lie in primary and ambulatory care” • more emphasis on preventive care • curricula change to support this

6. Documented value of ambulatory Pharmacy services • increase physician availability • increase # patient visits • decrease hospitalization rates: Asthma clinic, Pauley et al, 1995 • drug cost savings: Jones et al, 1991 • improve quality of care: • more thorough work-up • address adherence issues: Ulcers: Lee et al, 1999 • better treatment outcomes: • Anticoagulant control, Chiquette et al, 1998 • Hypertension, Erickson et al, 1997 • Diabetes, Coast-Senior et al, 1998 • fewer adverse drug reactions: Miller et al, 1996

7. Ambulatory Care Primary Care Specialty Care • “first contact” • continuity of care • comprehensive care • individualized care • health promotion, disease prevention, early detection • Particular organ system or disease type • health promotion and prevention • specialized training • one point in time

8. Ambulatory Care services at TWH Community & Population Health • Health Living Centre: • Diabetes Education Centre • Community Arthritis Management Program • Chronic Pain Program • Seniors Wellness Clinic Family Health Centre Mental Health Women’s Health Artists Health Centre

9. Healthy Living Centre Goals: 1. Identify health needs and issues 2. Effective use of resources 3. Improve access, integration and coordination of care 4. Increase community knowledge and responsibility for health status 5. Promote improvement in health systems Improve health status of target populations

10. Target Population profile Eglinton Ave. ~ 40,000 • Seniors (65+) - 11.7% (1/3 live alone) • Ethnic diversity - 88% (not British or Cdn) vs. 82% for Toronto: • Portuguese, Chinese, Italian, Jewish, Polish, Vietnamese, East Indian, Filipino, Jamaican • Literacy/Education - lower rates than rest of Toronto Yonge St. Keele St. Lake Ontario

11. Diabetes, Pain, OA, Seniors Clinics:Common elements • Referral: family MD, patient, HCP • Health promotion and prevention • Promote independence and increase knowledge with self-care of health conditions • Not a cure • Multidisciplinary team • Group education • Individual consultation • Interpreters

12. Diabetes, Pain, OA, Seniors Clinics:Common elements Referral Screening/initial assessment Goal setting Individual counselling * Group Education and/or Follow-up

13. Family Health Centre - TWH • Physicians • medical residents • nurse practitioner • RN, RPN • social worker • pharmacists • chiropodist • Support staff: • receptionists • medical records • administrative staff

14. Family Health Centre Pharmacist’s activities: • Drug information • Consultation • Teaching

15. Pharmacist: Roles & Responsibilities • Screening and early detection • dyslipidemia • hypertension • diabetes • osteoporosis • Health promotion and disease prevention • immunization • smoking cessation • general wellness

16. Pharmacist: Roles & Responsibilities • Medication history and assessment • disease specific • efficacy, toxicity, adherence • medication management • herbal products • Pharmacotherapeutic interventions • identification/prevention of drug-related problems • establishing goals and outcomes • initiate • modify • discontinue • monitor drug therapy Pharmacy Care plan

17. Implementation of PCP • Documentation • Communication • Who: • physician • Health care team • community pharmacy • community agencies (e.g. VON) • How: • chart • team rounds • telephone

18. Telephone follow-ups reduce seniors' drug-related problems Patients aided by pharmacist calls By Lynn Haley VANCOUVER – Telephone followup can greatly reduce drug-related problems (DRPs) in geriatric patients, researchers at the Toronto Rehabilitation Institute reported at the recent 17th World Congress of the International Association of Gerontology. The Medical Post, VOLUME 37, NO. 28, August 21, 2001 Kwan, Alibhai, Papastavros, Armesto, Toronto Rehab Institute

19. Additional Drug-related problems identifiedduring Telephone follow-up: 4% 10% 27% 17% *20% 22% * new category that emerged during follow-up

20. 101 interventions were carried out • 66% of interventions were provided by the pharmacist over the telephone  1. Medication education  41.6% 2. Dosing regimen modification  20.0% (e.g. timing, use of compliance aids) 3. Therapeutic recommendation 12.9% (resulting in new prescription) 4. Consult Geriatrician 11.8% 5. Refer to community resources  8.0% (e.g. community pharmacy, VON) 6. Earlier clinic follow-up visit 4.9% Intervention type % Total

21. Initiating ambulatory care practices The Pharmaceutical Care Pilot Project: Structure and Function of Drug-Related Problems in the Community Dwelling Elderly Bowles S, Perrier D. Sunnybrook Health Science Centre and Faculty of Pharmacy; Kwan D, Study Co-ordinator Ontario Drug Benefit Program Grant, $18,000 (1993 – 1995) • ambulatory geriatric rehab program - frail elderly • 260 DRPs (n=39) • additional drug required (30%) • possible adverse drug reaction (25%) • alternative agent more appropriate (20%)

22. Initiating ambulatory care practices Multidisciplinary falls clinic: • Medications contribute to falls • Role of the pharmacist: • interventions will be patient specific • weighing risk vs. benefit • preventive measures (e.g. osteoporosis) • education of the patient informed choices

23. Initiating ambulatory care practices Community Mental Health and Addiction Program (TWH) • mental health crisis team • emergency psychiatry assessment unit • Portuguese mental health and addiction unit • men and women’s withdrawal programs Opportunities: • provision of drug information (staff, clients) • medication identification • linking with community pharmacies • supportive role vs. direct patient care • student experience

24. Challenges 1. Team dynamics: • overlapping scopes of practice (health teaching) • clarify roles and responsibilities • key messages 2. Marketing your services: • education of patients and health care providers, re: scope of practice • when to refer

25. Challenges 3. Delivering patient education • effectiveness and impact • adult vs. student education • group education - interactive vs. didactic • multi-cultural aspects • varying levels of education • handouts 4. Changing the public’s perception • creating a demand for cognitive services

26. ASHP Standards Minimum standards for pharmaceutical care services in ambulatory care: • Leadership and Practice management • Medication therapy and pharmaceutical care • Drug distribution and control • Facilities, equipment and other resources Other resources: CSHP, ACCP – specialty practice groups www.ashp.org

27. Future Directions • Reimbursement • Credentialing (value added) • residency • Pharm.D. • fellowship • specialty certification

28. Future directions • Measuring quality of care • identifying representative markers of care (e.g. BP, lipid levels) • Measuring patient satisfaction • timeliness, efficiency, communication • Impact on long term outcomes • e.g. diabetes education- > control BS -> impact on complications?

29. Ambulatory Care Pharmacy • Tremendous opportunity for growth • Multidisciplinary team resources available • Dedicated time for direct patient care and follow-up • Taking the lead in care - primary liaison • Opportunity to try new ideas!