PHARMACOTHERAPY CARE PLAN

PATIENT-SPECIFIC INFORMATION

gives basis for recognition of pharmacotherapy problems or indication for pharmacist intervention

DATA COLLECTION

Collect, synthesize & interpret relevant information such as patient’s Demographic data, Pertinent medical information, Patient complaints, signs & symptoms

MEDICATION THERAPY MANAGEMENT (MTM)

* defined as a distinct service or group of **services** that optimize therapeutic outcomes for individual patients
* It encompasses a broad range of *professional activities* and *responsibilities* within the scope of practice of the licensed pharmacist or other qualified health care providers
* the prime duty of a clinical RPh, in collab w/ other healthcare prof
* Pharmaceutical care would start with

to develop a documentation format that meets individual patient’s  needs that can be useful in achieving the  optimum therapeutic outcomes

GOAL OF MTM

PHARMACOTHERAPY

* therapy using pharmaceutical drugs, as distinguished from therapy using surgery, radiation, movement, or other modes
* Also called drug therapy, is a general term for using medication to treat disease

PHARMACEUTICAL CARE

“A practice in which a practitioner takes responsibility for a patient’s drug related needs and holds him or herself accountable for meeting these needs.”

 -  **Linda Strand 1997**

* It uses a process through which a pharmacist cooperates with a patient and other health care professionals **in designing, implementing, and monitoring** a therapeutic plan that will produce specific therapeutic outcomes for the patient

1\. Identifying potential and actual drug-related problems.

2\. Resolving actual drug-related problems.

3\. Preventing potential drug-related problems.

Pharmaceutical care involves 3 major functions:

* Drug monitoring
* Disease monitoring
* Drug therapy
* Disease management/collaborative practice

Pharmacist’s responsibility

Impacts: Choice of meds, Disease prognosis, Drug effects, ADR, C/I,

*What is the impact of clinical pharmacist to the patient’s outcomes and his attending physician?*

1\. Pharmacist-patient relationship

2\. Pharmacist’s workup of drug therapy (**PWDT**)

Essential Components of Pharmaceutical Care

Pharmacist-patient relationship

\- a collaborative effort between pharmacist & patient

* Empathy
* Caring

Pharmacist’s workup of drug therapy (**PWDT**)

Provision of pharmaceutical care is centered around this, although the methods used for this purpose may vary.

1\. **DATA COLLECTION**

2\. **Develop or identify the CORE pharmacotherapy plan**

**3. Identify** ***PRIME*** **Pharmacotherapy Problems**

COMPONENTS OF PWDT (Pharmacist’s workup of drug therapy)

DEMOGRAPHIC DATA

age, sex, race, etc. and other pertinent medical information

PERTINENT MEDICAL INFORMATION

a) Medical history (current & past)

b) Family history

c) Dietary history

d) Medication history (prescription, OTC, allergies)

e) Physical findings (weight, height, B.P)

f) Lab results (serum drug levels, potassium levels, serum creatinine levels relevant to drug therapy)

**C** = condition or patient need

**O** = outcome desired for that condition

**R** = regimen selected to achieve that outcome

**E** = evaluation parameters to assess outcome achievement

CORE pharmacotherapy plan

P = pharmaceutical based problems

R = risks to patient

I = interactions

M = mismatch between medication & condition or patient needs

E = efficacy

***PRIME*** **Pharmacotherapy Problems**

***PRIME*** **Pharmacotherapy**

* This includes pharmacist's intervention.
* The goal is to identify actual or potential problems that could compromise the desired patient outcome

F - FINDINGS

A - ASSESSMENT

R - RESOLUTION

M - MONITORING

a pharmacist equivalent of a physician’s progress note

S - SUBJECTIVE FINDINGS

O - OBJECTIVE  FINDINGS

A - ASSESSMENT

P - PLAN

Traditional documentation primarily by physicians

**FARM** progress note or **SOAP** progress note

it describe or document the interventions needed or provided by pharmacist

clearly state the nature of the drug-related problem(s)

The first step in the construction of a FARM note is to ?

TRUE

 Each problem in the FARM note should be addressed separately and assigned a sequential number to  facilitate identification of pharmacotherapy problem

1\. Unnecessary drug therapy

2\. Needs additional drug therapy

3\. Ineffective drug

4\. Dosage too low

5\. Adverse drug reaction

6\. Dosage too high

7\. Noncompliance

Seven types of medication-related problems have been identified

1\. it presents a framework, applicable in any practice setting, to assure that the pharmacist has considered each possible type of problem.

2\. categorization allows optimal data analysis and retrieval capabilities

2 advantages of FARM

FINDINGS

* Demographic data that may be reported include a patient identifier (e.g., name, initials, or medical record number), age, race (if pertinent), and gender.
* include both subjective and objective findings that indicate a drug-related problem.

Ex.  Joint pains, headache, n/v, shortness of breath, etc

* Patient-specific information

**Short term goals:**

Elimination of symptoms  , Lowering of BP

Management of acute asthma without requiring hospitalization

ASSESSMENT

* the pharmacist’s evaluation of the current situation (i.e., the nature, extent, type, and clinical significance of the problem)
* The short term & long term goals of the intervention proposed
* any additional information needed to best assess the problem to make recommendation

**Long term goals:**

◦ Prevent recurrence of disease,  Control B.P.

◦ Prevent progression of diabetes

**Resolution (including prevention)**

The intervention plan includes actual or proposed actions by pharmacist or recommendation to other health care professionals. The rationale for choosing a specific intervention should be stated. If pharmacotherapy is recommended, a specific drug, dose, route, schedule, and duration of therapy should be specified.

a. Observation, reassessing, or follow ups:  if no intervention necessary at this time.

* If no action was taken or recommended, the FARM note serves as a record of the event and should constitute part of the patient’s pharmacy chart or database.

b. Counseling or educating the patient or care giver

c. Making recommendations to the prescriber

d. Informing the prescriber

e. Withholding medication or advising against use

Intervention options may include:

**Monitoring to assess the efficacy, safety & outcome of the intervention**

This should include:

* The parameters to be followed (e.g. pain, depressed mood, serum levels)
* The intent of monitoring e.g. efficacy, toxicity, adverse events
* How the parameters will be monitored e.g. interview patients, serum drug

\- Frequency of monitoring—weekly or monthly

\- Duration of monitoring e.g. until resolved, while on antibiotics, then monthly for one year

\- Anticipated or desired finding e.g. no pain, healing of lesion

\- Decision point to alter therapy when or if outcome is not achieved e.g. pain still present after 3 days, mild hypoglycemia more than 2 times a week.

1\. Patient assessment based skills

2\. Education & counseling based skills

3\. Patient Specific Pharmacist Care Plan based skills

4\. Drug Treatment Protocol based skills

5\. Dosage adjustment based skills

6\. Selection of therapeutic alternatives

7\. Prescriptive authority

8\. Preventive services

Clinical skills & pharmacist’s role in Pharmaceutical Care

* Physical assessment
* Barriers to adherence
* Psychosocial issues

**Patient assessment based skills**

* Interview skills
* Communication skills (e.g. empathy, listening, speaking or writing at patient's level of understanding)
* Ability to motivate & inspire
* Develop & implement patient education plan based on an initial education assessment
* Identification & resolution of compliance barriers

**Education & counseling based skills**

* Recognition, prevention & management of drug interactions
* Pharmacology & therapeutics
* Interpretation of lab tests
* Knowledge of community resources, professional referrals
* Communication & support with community medical providers

**Patient Specific Pharmacist Care Plan based skills**

* Develop & maintain (update) protocols
* Follow protocols as clinical pharmacist - clinician
* Monitor, aggregate adherence to the treatment protocols   - e.g. drug utilization, evaluation, especially for managed care or health system facility

**Drug Treatment Protocol based skills**

* Identify patients at high risk for exaggerated or Subtherapeutic response
* Apply pharmacokinetic principles to determine patient specific dosing

**Dosage adjustment based skills**

* use drug information resources effectively
* review and critique drug literature
* construct comparative analyses to support therapeutic decisions

**Selection of therapeutic alternatives**

In designated practice site and positions

**Prescriptive authority**

* Immunizations
* Screenings
* Health and wellness education

**Preventive services**

◦ limited memory capacity

◦ limited mental processing capacity

◦ negative effects of fatigue other stressors

Error is inevitable due to “our” limitations:

1\. Prescribing error

2\. Communicating those instructions

3\. Supply error

4\. Administration error

5\. Lack of user education

**Sources of Error**

PRESCRIBING ERROR

selecting the wrong or inappropriate drug/ dose/ formulation/ duration etc

SUPPLY ERROR

timely; wrong drug, dose, route; expired medicines, labelling

ADMINISTRATION ERROR

timing; wrong route; wrong rate/technique

LACK OF USER EDUCATION

actions to take

1\. Inappropriate selection of medication

2\. Inappropriate formulation of medication

3\. Inappropriate administration of drug therapy

4\. Inappropriate medication-taking behaviour

5\. Inappropriate monitoring of drug therapy

6\. Inappropriate response to drug therapy

Six types of problems which may result in treatment failure:

1\. Does the patient need this drug?

2\. Is this drug the most effective and safe?

3\. Is this dosage the most effective and safe?

4\. If side effects are unavoidable does the patient need additional drug therapy for these side effects?

5\. Will drug administration impair safety or efficacy?

6\. Are there any drug interactions?

7\. Will the patient comply with prescribed regimen?

**Patient Assessment Questions**

* Competent
* Motivated/Enthusiastic
* Teamwork spirit
* Good communication skills
* Responsible
* Problem solver
* Dedicated

Ideal Pharmacist Candidate?