Clinical Pharmacy Part 3

Basma Y. Kentab MSc.

Ambulatory Care

1. Define ambulatory care

2. Describe the value of ambulatory care practices

3. Explore pharmacy services in some ambulatory care settings

4. Identify standards of practice in ambulatory care

5. Identify future opportunities and challenges

Outline

Ambulatory care consists of health related services provided to patients who are able to

walk to seek their care and who are not confined to an institutional setting

Definition

ACCP, Pharmacotherapy 1992;12(4):358-364

Shift from acute hospital care ambulatory care

Because:

◦ Incentives to decrease hospitalization rates and length of stay (cost containment)

◦The number of elderly patients with multiple chronic medical conditions that require longitudinal management is growing

◦There is more focus in medicine on disease prevention and patient education

Emergence of Ambulatory Care

Increase physician availability

Increase number of patient visits

Decrease hospitalization rates: Asthma clinic, Pauley et al, 1995

Drug cost savings: Jones et al, 1991

Documented Value of Ambulatory Pharmacy services

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

Documented Value of Ambulatory Pharmacy services

Outpatient Pharmacy Services◦Community pharmacy◦Hospital outpatient pharmacy◦Emergency room pharmacy◦Private group practice pharmacy

General Medicine (Primary Care) Clinics◦Pharmacy clinics◦ Family medicine clinics

Ambulatory Care Settings

Specialty Medicine Clinics◦Anticoagulation◦Diabetes◦Hypertension

Pediatrics◦General pediatrics◦Asthma or allergy

Home Health Care

Ambulatory Care Settings

Primary Vs. Specialty Care Clinics

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

- One point in time

- Specialized training

- Health promotion and disease prevention

Pharmacy Services in Primary Care Clinics

Primary care is the subset of ambulatory care that provides patients with an initial point of contact with the medical system

Primary care practitioners serve patients who present with wide variety of illnesses

Practitioners assume a coordinating role for a patient’s overall health care needs (e.g. facilitating access to subspecialty)

Primary Care Practice

Pharmacists involved in primary care generally are members of a multidisciplinary team

Pharmacists frequently assist with designing therapeutic regimens and monitoring plans, counseling and education of physicians

Primary care pharmacists also can run pharmacy clinics or pharmacotherapy clinics

Pharmacy Services in Primary Care Clinics

Pharmacist-managed primary care clinics that rely on pharmacists as an integral part of the healthcare team

Clinical pharmacists work both alone & collaboratively with a specific primary care team to provide comprehensive pharmaceutical services

Pharmacists may utilize protocols or clinical drug use criteria to autonomously initiate, modify, & monitor a patient drug therapy

Pharmacy/Pharmacotherapy Clinics

Common conditions managed in pharmacy clinics:◦Hypertension◦Dyslipidemia◦Heart failure◦Diabetes◦Smoking cessation

Pharmacy/Pharmacotherapy Clinics

Pharmacy Services in Family Medicine Clinics

Subspecialty primary care practice

Involves the provision of total care to patients of all ages and their families regardless of their state of health

Considers the patient’s family members and the contribution of family and social dynamics to the expression of disease

Family Medicine

In family medicine practice, pharmacists perform a variety of educational & clinical functions, scholarly activities & administrative duties

The clinical pharmacist may be less likely to serve as an independent primary care provider

But, still works in collaboration with physicians focusing on drug related issues

Pharmacy Services in Family Medicine Vs. Primary Care Clinics

A major component of the service is education of patients and healthcare professionals

Pharmacists also participate in clinical research and investigative drug trials

May also be involved in committee work , pharmaceutical representative meetings, medication sample management

Pharmacy Services in Family Medicine Vs. Primary Care Clinics

Pharmacy Services in Outpatient Community

Pharmacies

Have the advantage of representing the most trusted and accessible healthcare practitioner

Requires close collaboration with physicians (access to medical records/lab data)

Useful in providing point-of-care testing and patient education

Exciting practice opportunities in the future!!

Pharmacy Services in Outpatient Community Pharmacies

Provide primary or consultative care as a member of the healthcare team

Designing, implementing, monitoring, evaluating, and modifying pharmacotherapy to ensure effective, safe, and economical patient care.

Documenting the care provided in patients’ records

Effectively counsel patients on prescription and nonprescription drug use

Standards of Practice

ACCP, Pharmacotherapy 1992;12(4):358-364

Evaluate studies published in the literature

Develop a quality assurance program to measure the quality of care provided by the pharmacy service

Conduct continuing education lectures, grand rounds, and other educational interventions to physicians and other health care professionals

Standards of Practice

ACCP, Pharmacotherapy 1992;12(4):358-364

Provide a teaching environment to educate and train pharmacy students

Provide individualized health promotion and disease prevention, including administration of immunizations where this is legally and organizationally authorized.

Standards of Practice

ACCP, Pharmacotherapy 1992;12(4):358-364

1. Absence of a formal structure & communication network between the pharmacist & other health professionals

2. Team dynamics (attitudinal barriers)◦overlapping scopes of practice ◦ clarify roles and responsibilities

3. Marketing the service:◦Educating patients and health care providers, regarding

scope of practice, when to refer patients……etc.

Challenges to Ambulatory Care

4. Insufficient time and inadequate resources and reimbursement

5. Changing the public’s perception

6. Lack of direct physician contact

Challenges to Ambulatory Care

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 blood sugar impact

on complications?

Future Directions

Tremendous opportunity for growth

Dedicated time for direct patient care and follow-up

Taking the lead in care

Opportunity to try new ideas!

Ambulatory Care Pharmacy