Pharmacist's Role in Various Practice Settings

Course Information

Course Title: PHRM6401 Healthcare Delivery
Instructor: Jayoung Han, PhD

Objectives

Define Long-Term Care (LTC) and Home Care
- Types of patients using LTC services
Identify and Explain LTC and Home Care Services
- Available services for patients and their families
Describe the Role of Pharmacists
- Role in LTC facilities and within home care services
Explain Current Behavioral Health Services in the US
Understand the Role of Healthcare Providers
- Caring for individuals with behavioral health problems
Assess the Role for Pharmacists
- As members of behavioral health services teams

Long Term Care (LTC)

Definition

LTC involves health, social, and residential services provided to chronically disabled individuals who have functional or cognitive impairments.
Purpose: Assist individuals who struggle with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs).

ADLs vs. IADLs

ADLs (Activities of Daily Living):
- Basic activities necessary for independent living that are performed daily.
- Examples include:
- Bathing
- Dressing
- Eating
- Toileting
- Transferring (e.g., from bed to chair)
- Grooming
IADLs (Instrumental Activities of Daily Living):
- Important for independent living but not performed daily.
- Examples include:
- Doing laundry
- Using a phone
- Managing finances
- Shopping
- Preparing meals
- Taking medications
- Housework

Who Typically Needs LTC Services?

Patient Categories:
- Patients with terminal illnesses
- Patients without insurance
- Patients with acute diseases
- Pediatric patients

Older Adults

Primary users of LTC services are individuals over the age of 65.
As age increases, the likelihood of developing chronic diseases, disabilities, and dementia also increases.
Notably, 70% of older adults will require LTC at some stage in their life, with approximately 35% spending time in nursing homes.

Patients with Chronic Diseases

Common diagnoses include:
- Dementia
- Parkinson's disease
- Stroke
- Depression
- Hip fractures
- Diabetes

Patients with Rehabilitative Needs

Some patients may require additional recovery time post-hospital discharge before returning home.
Options include:
- Nursing homes
- Rehabilitation centers
Common scenarios include broken bones or major surgeries.

Patients with Terminal Illness

Defined as individuals with poor prognosis, typically thought to be close to death (within 6 months).
They often utilize hospice care focusing on physical, social, and spiritual support.
- Hospice Care:
- Institutional settings.
- Home hospice with palliative (comfort) care.
Hospice services alleviate the burden on informal caregivers and emphasize quality of life rather than curative measures.
- Palliative Care:
- Can be beneficial at any stage of illness, not just near the end of life.

Increasing Need for Facilities

An anticipated rapid increase in older adult population from 2010 to 2030.
Increased life expectancy and diversity will influence LTC services.
Demographic projections by 2050 indicate non-Hispanic whites will comprise only 58% of the elderly population.
Changing roles of women affecting caregiving dynamics.
- 66% of informal caregiving services typically provided by women (wives, daughters, etc.).
- Many women work outside the home.
- 67% of caregivers with children continue their employment while providing care.

Types of Institutional Services

Adult Day Care Services

A community-based program available during normal business hours for adults with functional or cognitive impairments.
Services typically include:
- Therapy
- Health monitoring
- Personal care
- Social activities
- Transportation
- Meals/snacks.

Nursing Facilities

Previously called nursing homes; average stay is about 13.7 months but can vary.
- Short Stay (< 3 months): Extremely ill or requiring short-term rehab.
- Long Stay (> 1 year): Individuals with cognitive or physical impairments.
Pharmacist's role:
- Activities include dispensing or consulting services, performing educational duties, and ensuring compliance with Medicare/Medicaid for reimbursement.
- Skilled nursing facilities must cater to patients requiring clinical and rehabilitation services, not available at all nursing facilities.

Hospice Services

Approach to managing patients with terminal illnesses centered on compassion and comfort.
Eligibility requires physician certification of impending death (within 6 months).
The primary goal is to sustain quality of life rather than to cure the disease.
Services involved include:
- Physician visits
- Home visits by nurses/LPNs
- Home health aide services
- Medical equipment and supplies
- Medications with therapy assessments
- Physical therapy, occupational therapy, and speech therapy
- Dietary counseling.

Home and Community-Based Services

Assisted Living Facilities

Provide a range of supportive and personal services in a residential environment that is less extensive than nursing facilities.
Residents typically have their own rooms or apartments and receive meals, personal care, nursing assistance, and housekeeping.
Pharmacists ensure medication reviews and provide special packaging and education.

Pharmacy Services in LTC

Types of Pharmacy Services

Distribution

Provision of medications in various unit-dose packaging systems.
Involves specialized packaging, alternative dosage forms, delivery systems, and on-site counseling services.

Consulting

Pharmacists who are part of a distribution pharmacy, LTC facility networks, or as independent consultants:
- Conduct medication regimen reviews.
- Monitor treatment outcomes.
- Identify and resolve medication interactions.
- Select cost-effective medications and educate healthcare providers.

Medication Regimen Review (MRR)

Also known as drug regimen review (DRR).
A component of quality assurance programs for Medicare patients in skilled nursing facilities.
The inclusion of pharmacists in LTC is increasing, leading to improved medication-related services.
Encourages systematic approaches to identifying drug therapy problems.
- Can be prospective, concurrent, or retrospective.

Home Care

Definition

Home care refers to healthcare services provided in a patient's home intended to restore and maintain optimal well-being in a familiar environment.
Initiation occurs when a patient cannot manage self-care due to illness.

Home Healthcare Services

Comprises a range of products and services, primarily provided through:
- Home health services
- Home infusion therapy
- Home medical equipment
Growth factors include:
- Aging population
- Increasing prevalence of chronic diseases
- Technological advances
- Consumer preferences and rising healthcare costs.

Home Health Services

Generally linked with nursing care from home health agencies.
Providers coordinate care with other healthcare professionals and caregivers.
- Examples:
- Speech therapy for stroke recovery.
- Physical therapy for postoperative recovery.

Home Infusion Therapy

Involves parenteral administration of drugs, solutions, and nutrition at patients' homes.
Previously required hospitalization due to complexity.
The most common use is anti-infective therapy and pain management.
Clinical protocols have been developed to ensure safe at-home administration.

Roles of the Pharmacist in Home Care

Develop Care Plans

Responsibilities include selecting therapy, monitoring lab results, and ensuring positive therapeutic outcomes.
Aim to minimize the possibility of drug-related problems through detailed intervention strategies.

Compounding

Home care challenges include unique compounding issues such as drug/solution stability, packaging, infusion devices, and delivery schedules.
Compliance with USP regulations (aseptic technique) is necessary for home infusion companies.

Monitoring Therapy

Critical for effective patient management.
- Establish monitoring parameters (e.g., serum drug levels, blood chemistries).
- Coordination of tests and communication of results.

Communication

Essential for effective healthcare team collaboration.
Poor communication can lead to adverse events, potentially resulting in hospitalizations.

Drug Information

Pharmacists must have access to comprehensive information resources.
Responsible for assessing safe home administration of medications, stability and compatibility information, and potential complications.

Behavioral Health

Overview

Mental disorders account for an estimated 14% of the global disease burden.
Behavioral health problems are characterized as chronic diseases requiring long-term management and can adversely affect work productivity.
Consequences of unchecked behavioral health include social isolation and diminished quality of life.

Examples of Behavioral Health Disorders

Mood Disorders:
- Depression
- Bipolar disorder
Eating Disorders:
- Anorexia
- Bulimia
- Binge eating
Anxiety Disorders:
- Anxiety
- Panic disorders
- Phobias
Personality Disorders:
- Antisocial
- Borderline personality disorder
Psychotic Disorders:
- Schizophrenia
Others:
- ADHD
- Alcoholism
- PTSD

Legislative Context

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA)

Aims to eliminate less favorable limitations on mental health benefits by group health plans.
Requires parity between mental health/substance use disorder benefits and medical/surgical benefits.
Prohibits separate cost-sharing requirements for behavioral health benefits compared to medical/surgical benefits.

The Patient Protection and Affordable Care Act (PPACA)

Signed into law in 2010; expanded access to healthcare services.
Mandated insurance coverage for citizens and legal residents.
Emphasized the provision of rehabilitative services to support individuals with behavioral health problems.
Introduced comprehensive health insurance reforms including preventative services for Medicare populations and Medicaid expansion for low-income Americans.

Role of the Pharmacist in Behavioral Health

Role of the Community Pharmacist

Medication adherence presents a major challenge for patients with chronic behavioral health issues, with studies showing patients only take 50% of prescribed doses.
Community pharmacists can enhance patient counseling and support, critical due to the potential for adverse consequences associated with medication nonadherence.
- Misinterpreting nonadherence as treatment inefficacy can lead to:
- Excessive doses
- Increased nonadherence
- Side effects

Role of the Clinical Pharmacist

Integral member of the mental health treatment team.
Clinical psychiatric pharmacists are involved in:
- Medication management
- Laboratory monitoring
- Authorizing and monitoring refills
- Interacting with other team members
- Billing for services

Team Structure

Collaborative healthcare team may include:
- Psychiatrist
- Clinical or psychiatric nurse specialist
- Social worker
- Psychologist
- Care manager
- Pharmacist

Conclusion

The notes provided are a comprehensive overview encapsulating the essential roles and responsibilities of pharmacists in long-term care, home care, and behavioral health services.
These roles underline the importance of pharmacists within multidisciplinary teams and the healthcare system in enhancing patient outcomes.