Chapter 4 - Community, Ambulatory Care, & Home Care Pharmacy Practice

What is an ambulatory pharmacy?

A pharmacy that serves outpatients and supports clinic-based care through convenient access, coordinated communication, and medication management.

What is the definition of “ambulatory”?

The ability to move about and not be bedridden or a patient’s status as an outpatient.

Which came first: ambulatory pharmacies or community pharmacies?

Community pharmacies

What three buildings are ambulatory pharmacies usually next to?

Clinics, hospitals, or medical centers

Why are ambulatory pharmacies usually next to clinics, hospitals, or medical centers?

They serve outpatients, not inpatients, and are conveniently placed accordingly.

Do ambulatory pharmacies primarily serve prescription drugs or OTC drugs?

Prescription drugs

Is there a limited or nonlimited supply of OTC drugs in an ambulatory pharmacy?

Limited

In the early days of America, what was the role of a pharmacist?

The pharmacist would compound medications based off of a physician’s diagnosis, and they could give patients any drug they made.

What is the Food, Drug, and Cosmetics Act?

A federal law that gives the FDA its authority to regulate the safety, labeling, and quality of food, drugs, medical devices, and cosmetics.

What year did the Food, Drug, and Cosmetics Act go into law?

1938

What 2 key things (noted in the book) did the Food, Drug, and Cosmetics Act do for drugs?

(1) Loosely regulated drugs, requiring premarket approval for new drugs based on safety and prohibited false therapeutic claims for drugs. (2) Allowed drugs to be only prescription but didn’t include specifics.

Why was the Food, Drug, and Cosmetics Act created?

The previous law, the Pure Food and Drug Act of 1906, did not require drugs to be tested for safety before marketing, which then led to the sulfanilamide tragedy of 1937.

What was the sulfanilamide tragedy of 1937?

Sulfanilamide, an antibiotic powder, used to be dissolved in diethylene glycol to make it a liquid, which we now know to be a toxic solvent that causes kidney failure.

What is the Durham-Humphrey Amendment?

An amendment to the Food, Drug, and Cosmetics Act that created the legal distinction between prescription drugs (legend drugs) and over the counter (OTC) drugs.

What year was the Durham-Humphrey Amendment created?

1951

What was another name for prescription that came from the Durham-Humphrey Amendment?

Legend

What does a drug being classified as either a prescription or OTC drug depend on?

The drug’s safety and potential for addiction.

Over time, how did the focus of a pharmacist’s role shift?

From making the drug products to repackaging and dispensing them.

During the shift in pharmacist priority, which healthcare worker was the most likely to discuss information over drugs with a patient?

The doctor

What year range did the pharmacist-patient relationship revert back to discussing medication information?

1960-1970

Why did the pharmacist-patient relationship begin to include discussing medication information once more?

Because of increased adverse reactions from overcrossing drugs.

By what year did pharmacists have a more clinical role in patient care?

1980

What is a pharmacist’s role in pharmaceutical care?

To ensure the patient is receiving proper drug therapy.

What are four examples of third-party payers?

Government employers, government programs like Medicaid, health insurance policies from employers, and private insurance.

What is the Omnibus Budget Reconciliation Act (OBRA)?

A series of several large federal laws passed by Congress to adjust federal spending and revenue so they match goals set in the annual Congressional Budget Resolution.

How many significant OBRA laws were there?

8

What five key areas did the OBRA law of 1981 change?

Social Security and disability (OASDI), Medicare, Medicaid and welfare programs, housing and community development, and education, food assistance, and other social programs.

What five key areas did the OBRA law of 1982 change?

Agriculture and food programs, Medicare and Medicaid, Social Security, veterans’ benefits, and federal retirement and employee benefits.

What four key areas did the OBRA law of 1983 change?

Medicare and Medicaid, Social Security, agriculture and food programs, and federal employee and veterans’ benefits.

What five key areas did the OBRA law of 1986 change?

Medicare and Medicaid, Social Security and federal retirement programs, tax provisions, agriculture and food programs, and veterans’ benefits and federal employee programs.

What six key areas did the OBRA law of 1987 change?

Minimum standards of care, resident Bill of Rights, comprehensive care planning, staffing and training requirements, regulation of restraints, and survey and enforcement system.

What four key areas did the OBRA law of 1989 change?

Creation of the Medicare Fee Schedule (MFS), Resource-Based Relative Value Scale (RBRVS), Volume Performance Standards (VPS), and access and utilization monitoring.

What three key areas did the OBRA law of 1990 change?

Prospective Drug Utilization Review (ProDUR), patient counseling requirements, and maintaining patient medication records.

What two key areas did the OBRA law of 1993 change?

Taxes/revenue and healthcare/Medicaid provisions.

What is prospective drug utilization review (ProDUR)?

Reviewing a patient’s medication profile to identify any potential problems with the prescribed drug.

What are three examples of problems you could run into during a ProDUR?

The appropriateness of the drug and dose for the patient, drug interactions, or drug duplications.

Does OBRA require states to come up with standards for patient counseling?

Yes

What are three examples of standards of patient counseling?

When counseling is to be offered, who may make the offer to counsel, and what types of information should be included during counseling.

What are the two main broad categories of pharmacy practice sites?

Inpatient and outpatient

What is an inpatient pharmacy?

A pharmacy within a hospital or institutional facility that provides pharmaceutical care to admitted patients.

What is an outpatient pharmacy?

A pharmacy that serves patients who are not admitted to their facility.

Which category do community and ambulatory care pharmacies fall into: inpatient or outpatient?

Outpatient

Why is an ambulatory care pharmacy not considered an inpatient pharmacy if it is located in a hospital?

Because it does not serve patients who are admitted to the hospital for long-term stay, whereas inpatient pharmacies do serve chronic hospital care.

What are the two categories of community pharmacies?

Independent and chain

What is an independent pharmacy?

A community pharmacy that is privately owned and operated by one or two pharmacists rather than a large corporation.

What is a chain pharmacy?

A community pharmacy that is part of a large, multi-location corporation.

Which came first: independent or chain pharmacies?

Independent pharmacies

When did chain pharmacies come into development?

20th century

Has the number of independent pharmacies increased or decreased over time?

Decreased

Has the number of chain pharmacies increased or decreased over time?

Increased

What is a clinic pharmacy?

An ambulatory care pharmacy that is located in clinics or medical centers to serve the needs of outpatients.

What are the three modes of ownership for a clinic pharmacy?

The facility itself, independent ownership, or a chain pharmacy.

What are three things clinical pharmacies may be more involved in?

Managing drug therapies, dispensing specialty medications, and offering health screening and immunization services.

Are clinical pharmacies usually smaller or larger facilities?

Smaller

What are two things ambulatory pharmacists have the authority to do?

Initiate, adjust, and discontinue medications and order and interpret test results to monitor therapy.

Does an ambulatory pharmacist need to be under the supervision of the physician to do their tasks?

Yes

Do ambulatory care pharmacies dispense medication?

No

Where do ambulatory care pharmacies obtain their medications from?

Community pharmacies

What is a managed care pharmacy?

An ambulatory care pharmacy that combines healthcare financing with the pharmaceutical services to optimize patient healthcare and healthcare costs.

What are managed care pharmacies operated by?

Managed care organizations

What is a managed care organization?

Healthcare plans or companies that coordinate and manage healthcare services for its members with the goal of controlling costs while maintaining or improving quality.

What are six examples of managed care organizations?

HMOs, PPOs, POS, EPOs, Medicaid/Medicare plans, and PBMs

What facility are managed care pharmacies usually located close to?

A medical facility

What does HMO stand for?

Health Maintenance Organization

What is an HMO?

A health plan with a strict provider network, one fixed primary care provider, referrals required from the provider for specialists, and lower costs due to a prepaid, managed care structure.

What does PPO stand for?

Preferred Provider Organization

What is a PPO?

A flexible plan with no referrals from the provider to specialists necessary, no requirement for a primary care provider, and coverage both in‑ and out‑of‑network, but cheaper in‑network.

What does POS stand for?

Point-of-Service plan

What is a POS plan?

A plan that requires a primary care provider and referrals from the provider to specialists, but it covers both in- and out-of-network care, but has cheaper in-network care.

What does EPO stand for?

Exclusive Provider Organization

What is an EPO?

A plan that doesn’t require a primary care provider or referrals from the provider to specialists, but has no out-of-network coverage except in cases of emergencies.

What is medicaid?

A joint federal–state health insurance program that provides coverage to low‑income individuals and families.

What is medicare?

A federal health insurance for people 65 and over as well as certain disabled individuals.

What does PBM stand for?

Pharmacy Benefit Manager

What is a PBM?

A middleman that manages prescription drug benefits, negotiates prices, controls formularies, processes claims, and influences drug access and cost.

What is a mail-order pharmacy?

A distinct type of pharmacy that dispenses and ships prescriptions directly to a patient’s address or preferred address via mail.

What are two things mail-order pharmacies specifically do?

Fill large quantities of prescriptions and specialize in maintenance medications.

What are maintenance medications?

Prescription drugs taken on a regular basis to manage long‑term health conditions.

Is the prescription process more manual or automated in a mail-order pharmacy?

Automated

What are five pharmacy technician responsibilities within a mail-order pharmacy?

Prescription order entry, interacting with patients via phone, insurance review, medication filling, the packing and shipping of medications

What are all the 11 pharmacy technician responsibilities in both community and ambulatory care pharmacies?

(1) Communicating with patients, (2) ensuring patient privacy, (3) receiving prescriptions and registering patients, (4) entering prescriptions in a computer, (5) resolving third-party payer issues, (6) filling and labeling pharmaceutical products, (7) compounding prescriptions, (8) collecting payment and offering patient counseling, (9) fulfilling miscellaneous responsibilities, (10) handling restricted-use medications, (11) transferring prescriptions

Do pharmacy technicians spend more or less time interacting with patients in community and ambulatory care pharmacies than other pharmacies?

More

Who does the patient often interact with the most: the pharmacy technician or the pharmacist?

Pharmacy technician

What year was HIPAA passed?

1906

What does HIPAA do?

Provides healthcare providers with specific guidelines regarding how to handle private patient health information.

What does HIPAA require?

HIPAA requires every pharmacy to have a written policy for handling private patient information.

What are two stipulations with the HIPAA required written policy concerning private health information?

(1) The written policy must be given to new patients the first time they have a prescription filled (2) a reasonable attempt must be made to record the patient’s signature to verify their receipt of a copy of the policy

What is the first important thing to do when greeting a patient?

To have some form of identification for the patient.

What are the seven pieces of information you need to obtain if a patient brings a prescription to you for the first time?

(1) Correct spelling of first and last name (2) address and phone number(s) (3) insurance information from patient’s prescription insurance card (4) date of birth (5) drug allergies (6) other prescriptions or OTC medications the patient takes regularly (7) significant health conditions

What are the ways prescriptions can be received?

Directly from the patient on paper or from the prescriber by telephone, fax, or electronically.

What happens if a patient has prescription coverage by a third-party payer once the prescription is entered into the computer system?

A claim will be sent electronically to the third-party payer.

What is a copayment or copay?

The amount of the cost of the prescription that the patient is responsible for paying.

Are copays the same among plans or do they vary?

Vary

Is a low or high copay charged for generic drugs?

Low

Is a low or high copay charged for preferred brand name drugs?

High

Which copay is usually higher: the one for preferred brand name drugs or non-preferred brand name drugs?

Non-preferred

What is a formulary?

A list of drugs and their tiers that a specific third-party payer will cover.

Who are most claims now often handled by?

PBMs

What happens if there is a problem with the claim?

The pharmacy will receive a message that the claim has been rejected.

What are four common rejections that happen with claims?

(1) Missing/invalid patient ID number (2) refilling prescriptions too soon (3) plan limitations exceeded (4) prior authorization required