Clinical Pharmacy (PSMA)

Clinical Pharmacy

• A practice in which the pharmacist utilizes his professional judgment in the application of pharmaceutical sciences to foster the safe and appropriate use of drugs, in or by patients, while working with members of the health care team (Francke 1969)

• Goal: Educate the patient on how to properly use their medications

General Clinical Pharmacist Functions

• Providing drug information to physicians and other health professionals

• Medication history taking by conducting interviews regarding medication reviews and reconciliation

• Medication profile preparation

• Drug therapy monitoring

• Disease screening

• Monitor and maintain care for patients, especially with chronic diseases

• Participate in the management of Emergency Medical Care (EMC), especially in drug use review and patient audits

Patient Counseling

• Provision of oral or written information about drugs and other health related information to a patient or his or her representative during the dispensing process or stay in hospital

• reduces the chances of medication errors and motivates patient to adhere to the medication regimen

• Stop talking

• Get rid of distractions

• React to the ideas, NOT to the person

• Read non verbal messages

• Listen to how something is said

• Provide feedback to clarify any message

Attending and active listening skills examples

• Build the trust and respect among patients

• Enable the patient and pharmacist to release their emotions and reduce tension

• Create a safe environment that is conducive to collaboration and problem solving

Purposes of active listening examples

• Reflecting

• Paraphrasing

• Focusing

• Empathy

Empathic Responding skills

Reflecting

• concentrating on the emotional meaning

Paraphrasing

• conveying the essence of what was said

Focusing

• getting back to the topic of conversation

Empathy

• ability to project oneself into the personality of another person

Patient Care Process

• A systematic, cyclical process, and comprehensive method that is employed basically to identify, solve, and prevent drug therapy problem

• Collect

• Assess

• Plan

• Implement

• Follow-up: Monitor and Evaluate

What is the process of Patient Care Process

1. Problem identification

2. Problem prioritization

3. Selection of the patient specific drug and nondrug interventions

4. Development of integrated monitoring plan

Steps in therapeutic planning

Therapeutic planning

• Facilitates the selection of appropriate drug and nondrug interventions for specific patient problems

• Provides a framework for monitoring a patient’s response to the drug and nondrug interventions

• It incorporates a well thought out alternative regimens

Problem identification

• Step 1: Obtain patient data

• Step 2: Group related data

• Step 3: Determine each problem

• Step 4: Assess each problem

Step 1: Obtain Patient Data

• History of the patient

• Physical examination findings

• Results of laboratory and diagnostic tests

• Medication history, including herbal and alternative medications

• Relevant data resources: Data from the current patient chart and past chart, data obtained from patient interview or interviews with relatives or significant others

• Subjective Data

• Objective Data

two types of Subdivision of Data

Subjective Data

• these are describable but cannot be precisely measured or quantified (e.g., thirst, confusion, blood-tinged sputum, decreased apetite, chills) ; symptoms

Objective Data

• data that can be precisely measure or quantified (e.g., diarrhea, weight, vital signs, pH, hematocrit, total protein, peak expiratory flow rate, RBC count) ; signs

Step 2: Group Related Data

• It only takes one piece of data to to identify a patient problem

• Evaluate the list of objective and subjective data for possible relationships among the data

• This step requires comprehensive knowledge of the signs and symptoms of disease and pharmacotherapy

Step 3: Determine Each Problem

• Evaluate each group of related and subjective data items to determine the specific patient problem or issue, that should be available to the pharmacist, such as the past and current

• medical problems, past surgeries, cases of non-adherence, cases of drug abuse, and patient’s allergies to drugs

• The problem is not always the specific diagnosis but may be a preliminary identification of the issue pending acquisition of additional data (e.g., acute diarrhea, not shigellosis)

Step 4: Assess Each Problem

1. Acuity (acute or chronic)

2. Severity (mild, moderate, and severe)

3. Symptom level (symptomatic or asymptomatic)

4. Treatment status ( treated or untreated)

5. Degree of control (controlled and uncontrolled)

6. Classification (staging of disease)

Acuity

(acute or chronic)

Severity

(mild, moderate, and severe)

Symptom level

(symptomatic or asymptomatic)

Treatment status

(treated or untreated)

Degree of control

(controlled and uncontrolled)

Classification

(staging of disease)

Problem Prioritization

• Step 1: Identify the active problems

• Step 2: Identify the inactive problems

• Step 3: Rank the problems

Step 1: Identify the Active Problems

• Health professionals interacts with patients in ambulatory setting

• Are problems that require some kind of drug or nondrug intervention to resolve or manage the problem

• includes pneumonia, asthma, CHF, dyslipidemia, osteoporosis, and DM

Step 2: Identify the Inactive Problems

• Problems that do not require any kind of drug or nondrug intervention and are of historical interest only

• includes a history of an appendectomy at age 12, a history of pneumonia 2 years ago, and history of smoking two packs of cigarettes per day until quitting 10 years ago

Step 3: Rank of Problems

• Rank order the active patient problems

• One approach is to identify the problem that needs the most immediate attention and then rank the remaining active problems in order of need for intervention. The number one problem is the problem that if left untreated will cause the most harm to the patient in the shortest amount of time

• Patient specific factors

• External factors

Two factors to be considered in Selection of Patient-Specific Drug and Nondrug Interventions

Selection of Patient-Specific Drug and Nondrug Interventions

• This step requires the willingness and commitment of the patient

• Step 1 : Determine short term and long term goals of therapy

• Step 2 : Create a list of options

• Step 3 : Eliminate options based on patient specific and external factors

• Step 4 : Select appropriate drug and nondrug interventions

• Step 5 : Identify alternative interventions

Step 1: Determine Short-Term and Long-Term Goals of Therapy

• All drug and nondrug interventions should be in the context of the specific short-term and long-term goals of therapy, which may or many not be the same depending on the specific patient problem

Step 2: Create a List of Options

• Identify all classes of drugs and possible therapeutic approaches for each problem ; do not eliminate any option at this stage of planning

• As the member of the health care team with the most knowledge of pharmacotherapy, it is the pharmacist’s responsibility to identify all possible drug therapy options. This step becomes easier and more time efficient with practice and experience

Step 3: Eliminate Options Based on Patient Specific and External Factors

• Once all therapeutic options are identified, eliminate options based on:

1. The comparative effectiveness of the drugs

2. The suitability of the drug for the patient given the other patient medical conditions and drug therapies

3. The ability of the patien to adhere to the proposed regimen

4. Other factors such as the effectiveness of previous treatment regimens and cost

Step 4: Select the Appropriate Drug and Nondrug Interventions

• Determine the best drug and nondrug regimen, including each specific drug to be used, dosage, route, duration, and rationale (must be specific based on current evidences) for the selection of each drug and nondrug component of the regimen

Step 5: Identify Alternative Inteventions

• An important part of the planning process is anticipation of potential problems witn the prescribed and/or recommended drug and nondrug interventions

  • A well thought-out plan always include an alternative medication regimens

Develop a Monitoring Plan

• Step 1: Determine specific monitoring parameters

  • Select specific target outcomes

  • Select monitoring intervals for each parameter

• Step 2 : Integrate the monitoring plan

• Step 3 : Obtain data

• Step 4 : Assess the response to therapy

Communication skills

Skill/ability to communicate clearly and effectively with patients, significant others (SO/relative or family), physicians, nurses, pharmacists, and other health care team

Patient Counseling

It is the provision of verbal or written information about drugs and other health related information by a pharmacist to a patient representative of the patient

Patient Care Process

This is a systematic and comprehensive method that is employed to identify, solve, and prevent drug therapy problems

Documentation

• required to record pertinent facts, findings, and observation, about a patient’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes

• derived from patient care process

Documentation

• To document and plan patient immediate treatment

• Collect the data that may be useful for research and education

Components of Documentation

• A complete and legible record;

• Documentation for each encounter with a rationale for the encounter, physical findings, prior test results, assessment, clinical impression/ diagnosis and plan for care;

• Identified health risk factors, and an easily inferred rationale for ordering diagnostic tests or ancillary services; and

• The patient’s progress, response to and changes in treatment, and revision of the original diagnosis/assessment

Pharmaceutical Care

• Responsible provision of drug therapy for the purpose of achieving definite outcomes that improves a patient’s quality of life (Hepler and Strand 1990)

• A patient centered practice in which the practitioner assumes responsibility for a patient’s drug related needs and is held accountable for this commitment (Cipolle 1998)

Hepler and Strand 1990

“Responsible provision of drug therapy for the purpose of achieving definite outcomes that improves a patient’s quality of life” - this definition is by?

Cipolle 1998

“A patient centered practice in which the practitioner assumes responsibility for a patient’s drug related needs and is held accountable for this commitment” - this definition is by?

• C - cure of the disease

• E - elimination or reduction of symptoms

• A - arrest or slow down disease progression

• P - prevention of disease and symptoms

What are the Expected outcomes for Pharmaceutical Care

Pharmaceutical Care Plan

• Assessment: a review of the medical conditions and symptoms to determine the need for drug therapy

• Plan: a decision of an appropriate drug therapy based on the assessment of the patient

• Monitoring: a review of the outcomes of drug therapy (goals and endpoints) to determine if the patient is obtaining the desired outcomes

Assessment

• a review of the medical conditions and symptoms to determine the need for drug therapy

Plan

• a decision of an appropriate drug therapy based on the assessment of the patient

Monitoring

• a review of the outcomes of drug therapy (goals and endpoints) to determine if the patient is obtaining the desired outcomes

Medication Therapy Management

• A distinct service or group of services that optimize therapeutic outcomes for individual patients

• Patient centered assessment and evaluation of the patient’s full medication regimen and not only individual medications

Medication Therapy Management

1. Optimize medication use

2. Improve collaboration

3. Enhance communication

4. Empower the patients

• Medication Therapy Review (MTR)

• Personal Medication Record (PMR)

• Medication-related Action Plan (MAP)

• Intervention and/or referral

• Documentation and follow-up

What are the Core Elements of an MTM Service

Medication Therapy Review (MTR)

• A systematic process of collecting patient specific information, assessing medication therapies to identify medication related problems, developing a prioritized list of medication related problems, and creating a plan to resolve them

• Goal: Make the patient more knowledgeable about their drugs

Personal Medication Record (PMR)

• A comprehensive record of the patient’s medications (prescription and non-prescription medications, herbal products, and other dietary supplements) 

• Either electronic or written

• It is important that the pharmacist provides the PMR with appropriate level of literacy and easily understood by the patient

Medication-related Action Plan (MAP)

• patient centric document containing a list of actions for the patient to use in tracking progress for self management

Documentation and Follow-up

• MTM services are documented in a consistent manner, and a follow up MTM visit is scheduled based on the patient’s medication related needs, or the patient is transitioned from one care setting to another

• Documentation is an essential element of the MTM service model. The pharmacist documents services andintervention(s) performed in a manner appropriate for evaluating patient progress and sufficient for billing purposes

Patient demographics

• Basic information: address, phone, email, gender, age, ethnicity, education status, patient’s special needs, health plan benefit/insurance coverage

Subjective observations

• Pertinent patient reported information: previous medical history, family history, social history, chief complaints, allergies, previous adverse drug reactions

Objective observations

• Laboratory results, vital signs, diagnostic signs, physical exam results, review of systems

Assessment

• Problem list, assessment of medication related problems

Plan

• A care plan is the healthcare professional’s course of action for helping a patient achieve specific health goals

Education

• Goal setting and instruction provided to the patient with verification of understanding

Collaboration

• Communication with other healthcare professionals: recommendations, referrals, and correspondence with other professionals (cover letter, SOAP note)

PMR

• A record of all medications, including prescription and nonprescription medications, herbal products, and other dietary supplements

MAP

• Patient centric document containing a list of actions to use in tracking progress for self management

Follow-up

• Transition plan or scheduling of next follow up visit

Billing

• Amount of time spent on patient care, level of complexity, amount charged

MTM flowchart

Collaborative medication therapy management

Pharmaceutical Care

including pharmaceutical care plan process

(PRIME and FARM/SOAP) is a systematic method for recording

the pharmacist’s examination of patient pharmacotherapy and

subsequent modification of medication related problems

Soap note

• Highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health professional

S - Subjective

(e.g., CC of the patient ; records of present illness)

O - Objective

(e.g., results of lab tests)

A - Assessment

the analysis or conclusion on the patient current status or behavior

P - Plan

action taken in response to assessment

Farm note

• an alternative approach to documenting drug related problems and plan which is a pharmacist equivalent of a physician progress note in a systematized approach

• It actually includes provisions for identification and assessment of actual or potential medication related problems, description of a therapeutic plan and appropriate follow up monitoring of problems

F - Findings

patient specific information

A - Assessment

evaluation of findings (e.g) severity duration

R - Resolution

(including prevention) rationale for the intervention should be mentioned

M - Monitoring

(and follow up) assess efficacy, safety and outcome of the intervention

Assessment

• It contains pharmacist evaluation of the present situation

• It should delineate the thought process that led to the conclusion on problem whether it did or did not exist and active intervention either was or was not necessary

• The severity or urgency of the problem should be indicated by stating whether the interventions should be made immediately or within one day, one week or longer

• Therapeutic endpoint or outcome stated may be short term goals or long term goals

Resolution

• It highlights the actions proposed to resolve drug related problem based upon preceding analysis

• Common recommendations include non-pharmacologic therapy like dietary modifications or assisting devices

• Rationale for selecting a particular therapy should be clearly depicted. Alternative therapy in case of emergency switching of of drugs must be enlightened

• Patient counseling provided must be elaborated

(PRIME)

P

Pharmaceutical based problems

(PRIME)

R

Risks to the patient

(PRIME)

I

Interactions

(PRIME)

M

Mismatch between medication and condition or patient needs

(PRIME)

E

Efficacy issues

Medication Therapy Review

• A systematic process of collecting patient specific information, assessing medication therapies to identify medication related problems, developing a prioritized list of medication related problems, and creating a plan to resolve them

Personal Medication Record

• A comprehensive record of the patient’s medications (prescription and non prescription medications, herbal products, and other dietary supplements)

Soap note

• A highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health professional

Anemia

• It is a condition characterized by a decrease in hemoglobin or RBC mass which results to decreased oxygen carrying capacity of the blood

• It may decrease due to blood loss, increased destruction of RBCs or decreased production of RBCs

Hemoglobin

is a protein within RBC that carries oxygen from the lungs to body tissues

• Hemoglobinopathies

• Thalassemias

• Enzyme abnormalities of the glycolytic pathways

• Defects of the RBC cytoskeleton

• Congenital dyserythropoietic anemia

• Rh null disease

• Hereditary xerocytosis

• Abetalipoproteinemia

• Fanconi anemia

Genetic Etiology of anemia

Thalassemias

inherited and a blood disorder related to the body’s inability to produce hemoglobin

Rh null disease or Rh null syndrome

lack of Rh antigens present in RBC