Transcript Ambulatory Care Pharmacy

Ambulatory Care Pharmacy
Debbie Kwan, BScPhm., MSc.
Toronto Western Hospital -University Health Network
Faculty of Pharmacy, Nov. 22, 2002
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
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
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
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
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
Ambulatory Care
Primary Care
• “first contact”
•continuity of care
•comprehensive care
•individualized care
•health promotion,
disease prevention,
early detection
Specialty Care
•Particular organ
system or disease
type
•health promotion and
prevention
•specialized training
•one point in time
Ambulatory Care services at TWH
Community & Population Health
Health Living Centre:
Family
Health
Centre
• Diabetes Education Centre
• Community Arthritis
Management Program
• Chronic Pain Program
• Seniors Wellness Clinic
Mental
Health
Women’s
Health
Artists Health
Centre
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
Target Population profile
Eglinton Ave.
Keele St.
~ 40,000
Yonge
St.
Lake Ontario
• 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
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
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Multidisciplinary team
Group education
Individual consultation
Interpreters
Diabetes, Pain, OA, Seniors Clinics:
Common elements
Referral
Screening/initial
assessment
Goal setting
Group
Education
and/or
Follow-up
Individual
counselling *
Family Health Centre - TWH
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•
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Physicians
medical residents
nurse practitioner
RN, RPN
social worker
pharmacists
chiropodist
• Support staff:
– receptionists
– medical records
– administrative staff
Family Health Centre
Pharmacist’s activities:
• Drug information
• Consultation
• Teaching
Pharmacist: Roles & Responsibilities
• Screening and early detection
– dyslipidemia
– hypertension
– diabetes
– osteoporosis
• Health promotion and disease prevention
– immunization
– smoking cessation
– general wellness
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
Pharmacy Care
plan
– discontinue
– monitor drug therapy
Implementation of PCP
 Documentation
 Communication
– Who:
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physician
Health care team
community pharmacy
community agencies (e.g. VON)
– How:
• chart
• team rounds
• telephone
Telephone follow-ups reduce seniors' drug-related
problems
Patients aided by pharmacist calls
By Lynn Haley
VANCOUVER – Telephone followup can greatly reduce drugrelated 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
Additional Drug-related problems identified
during Telephone follow-up:
10%
4%
Non-adherence
27%
Adverse reaction
17%
Pt unclear about med.
regimen
Inappropriate
dosing/administration
Additional drug req'd
*20%
22%
* new category that emerged during follow-up
Unclear indication
•101 interventions were carried out
• 66% of interventions were provided by the
pharmacist over the telephone 
Intervention type
% Total
1. Medication education 
41.6%
2. Dosing regimen modification 
(e.g. timing, use of compliance aids)
20.0%
3. Therapeutic recommendation
(resulting in new prescription)
12.9%
4. Consult Geriatrician
11.8%
5. Refer to community resources 
(e.g. community pharmacy, VON)
8.0%
6. Earlier clinic follow-up visit
4.9%
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%)
Initiating ambulatory care
practices
Multidisciplinary falls clinic:
• Medications contribute to falls
• Role of the pharmacist:
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interventions will be patient specific
weighing risk vs. benefit
preventive measures (e.g. osteoporosis)
education of the patient
informed choices
Initiating ambulatory care
practices
Community Mental Health and Addiction Program
(TWH)
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mental health crisis team
emergency psychiatry assessment unit
Portuguese mental health and addiction unit
men and women’s withdrawal programs
Opportunities:
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provision of drug information (staff, clients)
medication identification
linking with community pharmacies
supportive role vs. direct patient care
student experience
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
Challenges
3. Delivering patient education
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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
ASHP Standards
Minimum standards for pharmaceutical care
services in ambulatory care:
1.
2.
3.
4.
Leadership and Practice management
Medication therapy and pharmaceutical care
Drug distribution and control
Facilities, equipment and other resources
www.ashp.org
Other resources:
CSHP, ACCP – specialty practice groups
Future Directions
• Reimbursement
• Credentialing (value added)
– residency
– Pharm.D.
– fellowship
– specialty certification
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?
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!