Clinical Pharmacy Part 3

1. Clinical Pharmacy Part 3 Basma Y. Kentab MSc.

2. Ambulatory Care

3. Outline 1. Define ambulatory care 2. Describe the value of ambulatory care practices 3. Explore pharmacy services in some ambulatory care settings 4. Identify standards of practice in ambulatory care 5. Identify future opportunities and challenges

4. Definition Ambulatory care consists of health related services provided to patients who are able to walk to seek their care and who are not confined to an institutional setting ACCP, Pharmacotherapy 1992;12(4):358-364

5. Emergence of Ambulatory Care • Shift from acute hospital care ambulatory care Because: • Incentives to decrease hospitalization rates and length of stay (cost containment) • The number of elderly patients with multiple chronic medical conditions that require longitudinal management is growing • There is more focus in medicine on disease prevention and patient education

6. Documented Value of Ambulatory Pharmacy services • Increase physician availability • Increase number of patient visits • Decrease hospitalization rates: Asthma clinic, Pauley et al, 1995 • Drug cost savings: Jones et al, 1991

7. Documented Value of Ambulatory Pharmacy services • Improve quality of care: • more thorough work-up • address adherence issues: Ulcers:Leeet 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

8. Ambulatory Care Settings • Outpatient Pharmacy Services • Community pharmacy • Hospital outpatient pharmacy • Emergency room pharmacy • Private group practice pharmacy • General Medicine (Primary Care) Clinics • Pharmacy clinics • Family medicine clinics

9. Ambulatory Care Settings • Specialty Medicine Clinics • Anticoagulation • Diabetes • Hypertension • Pediatrics • General pediatrics • Asthma or allergy • Home Health Care

10. Primary Vs. Specialty Care Clinics

11. Pharmacy Services in Primary Care Clinics

12. Primary Care Practice • Primary care is the subset of ambulatory care that provides patients with an initial point of contact with the medical system • Primary care practitioners serve patients who present with wide variety of illnesses • Practitioners assume a coordinating role for a patient’s overall health care needs (e.g. facilitating access to subspecialty)

13. Pharmacy Services in Primary Care Clinics • Pharmacists involved in primary care generally are members of a multidisciplinary team • Pharmacists frequently assist with designing therapeutic regimens and monitoring plans, counseling and education of physicians • Primary care pharmacists also can run pharmacy clinics or pharmacotherapy clinics

14. Pharmacy/Pharmacotherapy Clinics • Pharmacist-managed primary care clinics that rely on pharmacists as an integral part of the healthcare team • Clinical pharmacists work both alone & collaboratively with a specific primary care team to provide comprehensive pharmaceutical services • Pharmacists may utilize protocols or clinical drug use criteria to autonomously initiate, modify, & monitor a patient drug therapy

15. Pharmacy/Pharmacotherapy Clinics • Common conditions managed in pharmacy clinics: • Hypertension • Dyslipidemia • Heart failure • Diabetes • Smoking cessation

16. Pharmacy Services in Family Medicine Clinics

17. Family Medicine • Subspecialty primary care practice • Involves the provision of total care to patients of all ages and their families regardless of their state of health • Considers the patient’s family members and the contribution of family and social dynamics to the expression of disease

18. Pharmacy Services in Family Medicine Vs. Primary Care Clinics • In family medicine practice, pharmacists perform a variety of educational & clinical functions, scholarly activities & administrative duties • The clinical pharmacist may be less likely to serve as an independent primary care provider • But, still works in collaboration with physicians focusing on drug related issues

19. Pharmacy Services in Family Medicine Vs. Primary Care Clinics • A major component of the service is education of patients and healthcare professionals • Pharmacists also participate in clinical research and investigative drug trials • May also be involved in committee work , pharmaceutical representative meetings, medication sample management

20. Pharmacy Services in Outpatient Community Pharmacies

21. Pharmacy Services in Outpatient Community Pharmacies • Have the advantage of representing the most trusted and accessible healthcare practitioner • Requires close collaboration with physicians (access to medical records/lab data) • Useful in providing point-of-care testing and patient education • Exciting practice opportunities in the future!!

22. Standards of Practice • Provide primary or consultative care as a member of the healthcare team • Designing, implementing, monitoring, evaluating, and modifying pharmacotherapy to ensure effective, safe, and economical patient care. • Documenting the care provided in patients’ records • Effectively counsel patients on prescription and nonprescription drug use ACCP, Pharmacotherapy 1992;12(4):358-364

23. Standards of Practice • Evaluate studies published in the literature • Develop a quality assurance program to measure the quality of care provided by the pharmacy service • Conduct continuing education lectures, grand rounds, and other educational interventions to physicians and other health care professionals ACCP, Pharmacotherapy 1992;12(4):358-364

24. Standards of Practice • Provide a teaching environment to educate and train pharmacy students • Provide individualized health promotion and disease prevention, including administration of immunizations where this is legally and organizationally authorized. ACCP, Pharmacotherapy 1992;12(4):358-364

25. Challenges to Ambulatory Care • Absence of a formal structure & communication network between the pharmacist & other health professionals • Team dynamics (attitudinal barriers) • overlapping scopes of practice • clarify roles and responsibilities • Marketing the service: • Educating patients and health care providers, regarding scope of practice, when to refer patients……etc.

26. Challenges to Ambulatory Care • Insufficient time and inadequate resources and reimbursement • Changing the public’s perception • Lack of direct physician contact

27. 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 blood sugar impact on complications?

28. Ambulatory Care Pharmacy • Tremendous opportunity for growth • Dedicated time for direct patient care and follow-up • Taking the lead in care • Opportunity to try new ideas!