pharmacist in primary and community care 2012
DESCRIPTION
Pharmacist in primary careTRANSCRIPT
Pharmacist in Primary and Community Care
July Lee
Pharmacy Practice
Learning Objectives
1. To understand the various roles of a pharmacist in primary and community care
2. To understand the importance of communication skills in improving patient adherence and reducing medication errors
3. To understand the responsibility of a pharmacist as a drug supplier
4. To understand the opportunity for a pharmacist to be a health promoter and areas for health promotion
5. To understand the role of pharmacist collaborating with other healthcare professionals
6. To understand the various model of partnerships for primary care pharmacists
Pharmacists
Communicator
Drug Supplier
Trainer and Supervisor
Health Promoter
Collaborator
Why is it important for a pharmacist to be a
communicator?
Drugs Don’t Work In Patients Who Don’t
Take Them
Consider the following scenario
A 36-year-old man was prescribed a fentanyl
patch to treat pain resulting from a back injury. He
was not informed that heat could make the patch
unsafe to use.
He fell asleep with a heating pad and died. The
level of fentanyl in his bloodstream was found to
be 100 times the level it should have been.
(Falik 2006)
Pharmacists have become more patient-centered in their provision of pharmaceutical care
Pharmacist can contribute to patient care by
Reducing medication errors
Improving the use of medications by patients through pharmaceutical care
Using effective communication skills is essential in the provision of patient care
COMMUNICATOR
Pharmacist as a
The pharmacist must be able to:
Understand the illness experience of the patient
Perceive each patient’s experience as unique
Foster a more egalitarian relationship with patients
Build a “therapeutic alliance” with patients to meet
mutually understood goals of therapy
Develop self-awareness of personal effects on patients
Mead and Bower (2000)
Providing Patient-Centered Care
Communication process between a pharmacist and their patients serves two primary functions:
Establishes the ongoing relationship between the pharmacist and their patients (formation of a trusting relationship)
Provides the exchange of information necessary to assess the patient’s health conditions, reach decisions on treatment plans, implement the plans, and evaluate the effects of treatment on patient’s quality of life
Importance of Communication
Low self-confidence
Shyness
Dysfunctional internal monologue
Lack of objectivity
Cultural differences
Discomfort in sensitive situations
Negative perceptions about the value of patient interaction
Potential Pharmacist-Related Personal
Barriers
They have unanswered questions regarding their therapy
They have misunderstandings
They experience problems not related to therapy
They ‘monitor’ their own response to treatment
They make their own decisions regarding therapy
AND
They may not reveal this information unless you initiate a dialogue
Perceive each patient’s experience as unique
Reasons to Encourage Patient Sharing of
Experiences
Effective communication skills essential in assuring that patients understand how to take their medicines correctly
Instrumental in assuring patient safety
Research reveal that preventable medication errors still occur at unacceptable rates (Cohen, 1999)
Medication errors not only cause physical harm to patients but also undermine patient confidence in healthcare system
May not trust information by health care providers
Affects patient adherence with prescribed therapy
Medication Safety and Communication Skills
Distractions and noise that interfere with clear transmission and receipt of the message
Heavy accents and language differences
Use of terminology that other health care providers do not understand
Speaking too rapidly for the listener to clearly comprehend
Medications that sound alike when spoken (Zantac vs Zyrtec)
Numbers that sound alike (15 vs 50; 19 vs 90)
Common issues in verbal communication
Fortunately, many errors are discovered during pharmacist-patient counseling interaction and are corrected before patients leave the pharmacy (Ukens, 1997)
For this to occur, patients need to be actively involved in their drug therapy and pharmacist readily available to communicate
Strategies
1. When giving information to patients, allow patients the opportunity to repeat back key information in order to detect possible errors and misunderstandings
2. Difficult drug names should be spelled out for patients when giving verbal instructions
3. Encourage patients to keep a list of all their medications and other critical health information like drug allergies
Potential Strategies
In Malaysia, general practitioners (GPS) and community pharmacists are normally the first point of contact for patients requiring medical assistance
For patients who wishes to self-medicate, there is no shortage of health-related information all of which provides self-care advice
• from the internet, self-help books, tv advertisement, magazine and radio programs, well-meaning friends and relatives
The vast number of competing non-prescription products makes selection difficult
Drug Supplier
Pharmacist as a
Pharmacists play a crucial role in assisting patients who are seeking self-care products
Pharmacists have the expertise to screen patient health information and apply their knowledge and training to select products according to individual health care needs
• In Malaysia, pharmacists are legally allowed to dispense ‘NP’ and ‘Group C’ medications without a prescription
Access to a pharmacist for assistance should be readily available for patients who request it
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In the community pharmacy, the duties of the manager depends on the size and requirement of the pharmacy and professional organisation
At the store level, the pharmacy manager is in charge of the
Staff
Clinical services
Inventory management
Recruitment
Training and development
General business management
Trainer /Supervisor (Manager)
Pharmacist as a
In training and development, community pharmacists are involved in training or supervising student pharmacists or pharmacists undergoing their pupillage training
Community pharmacists are also involved in training pharmacy staff in the following areas:
• Product knowledge for common minor ailments
• Training the pharmacy staff to act as a filter for information and referring customers to the pharmacist where the customer requires further advice on medications, treatments or medical conditions
• Training the pharmacy staff to refer the sale of Group C medicines (Pharmacist Only Medicines), Group B medicines (Prescription Only Medicines) and customers with health conditions to the pharmacist for further advice
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Pharmacist as a
Why should health promotion be part of pharmacist’s roles?
Health Promoter
Trustable and well-recognised as health consultant
• Easy accessible
• Beliefs to hold most of the latest knowledge about medication
• Patient confidentiality
Pharmacist as primary care provider
• Consulted more than 200,000 customers in practice
• Opportunity to deliver information
Pharmacist as drug expert & health care product expert • Good knowledge about disease- drug relationship, correct use of
product • Wide knowledge about disease prevention & promotion of good
health
Pharmacist as ‘good’ communicator
• Well trained in communication skills - allows open discussion and acceptance of information
Roles of Pharmacist in Health Promotion
Health screening and information
Disease prevention
Product information
Risk reduction information
Referral to other health professionals
Drug Abuse/Misuse (OTC/Medicine/Dangerous drugs)
Areas of Health Promotion Disease /Risk Prevention
• Smoking cessation
• Alcohol use
• Healthy lifestyle
Prevention of drug misuse including OTC misuse
Sexual Health
Prevention of Pregnancy
Harm/Risk reduction
• Methadone supervision
• Needle exchange scheme
Are customers willing to discuss health topics with the pharmacist?
Users experience of advice and services in the pharmacy setting
23% came into the pharmacy to ask for advice
>3/4 were satisfied with the advice and has learned from it • Nearly all of them - would use pharmacy again as source of
advice on health matters
2/3 respondents - like to talk to the pharmacist in private; only 5% had such facilities
41% of 224 respondents - most important to consider when using a pharmacy on contraception and safer sex issues is the availability of quiet area
17.6% of 336 users reported being embarrassed to speak about head lice.
How do public perceive the pharmacists’ role in giving health advice?
Of 592 community pharmacy service user, the preferred source of advice for ‘staying healthy’ was the GP for 77% and the pharmacist 8%.
15% claimed had ever sought such advice
90% had noticed information leaflets of health topics, 30% had taken one or more than one and read
Case 1: Osteoporosis Study Objectives
To investigate the effectiveness of an osteoporosis
screening and awareness programme by pharmacist in
community setting
Method
Level of awareness were tested pre & post screening and
educational interventions
Result
26% increase in awareness about steps to prevent or delay
fractures post-intervention
Law AV, Shapiron K. Impact of a community pharmacist-directed clinic in improving screening
andawareness of osteoporosis. 2004 Journal of Evaluation in Clinical Practice ,11, 3, :247-255
Case 2: Cholesterol Reduction
Study Objectives To assess the effect of a multidisciplinary program on attempts to lower total cholesterol levels
Method
Cholesterol reduction in two arms - standard medical care vs interventions e.g. diet, behavioural, pharmacological with close interaction between physician and pharmacist
Result Lower cholesterol with combined program that include physician and pharmacist interaction
Bogden PE, Koontz L, Williamson P, Abbott RD, The physician and pharmacist team : an effective approach to cholesterol reduction. JGIM, 1997, 12 : 158-164
How can pharmacists promote health or educate patient?
1. Plan your session • Especially if tit is a new session
• Identify the aims, how to introduce and develop the session, how will you involve in audiences
2. Work from the Known to the Unknown • Building new information or facts on what is already known
• Not to waste time for facts that is already known but is sometimes necessary if you have audiences with varies degree of knowledge
• So, spend time to find out what people know : information should be tailored to needs
3. Aim for Maximum Involvement (relevance to learners) • People learn best when they are involved in it rather than to work
under direction
• Ask yourself - “Is what you teach what my clients want to learn?”
4. Devise learning activities • Should be tailored to groups
• Should encourage participation
5. Varying teaching and learning methods
• It is important to look from the learner’s point of view
6. Identify realistic goals and objectives • Teaching more does not necessary mean they learn more
• Teaching should have a clear aims and objectives - deliver important facts
7. Organise your materials
8. Evaluation, Feedback and Assessment
Common Types of Learning Activities
Types of Activity Example
Diary Records Analysing and discussing about
diary records for asthma or
tobacco or alcohol consumption
Identify own thoughts, feelings or
behaviour in different scenarios
Discussion of feelings when
smoking in front of non-smokers
Practical skills development Leaflets, videos of using nicotine
patch or gum
Identifying barriers Identify and generate list of
barriers to smoking cessation
Learning Methods Involving Clients
Client Involvement Materials and Methods
Listen Lectures, audiotapes
Read Books, leaflets, handouts, posters, flipcharts
Visual aid Photographs, charts, material from magazines
Look and listen Film, videotapes, demonstrations
Listen and talk Q+A session, discussions, informal conversation, debate
Read, listen and talk Case studies, discussions based on study questions or handouts
Read, listen and talk and actively participate
Drama, role-play, games, simulations, practicing
skills
Read and actively participate
Programmed learning, computer assisted learning
Make and use Models, charts , drawing
Important points in health education & promotion
1. Get your facts right
2. Say the important points first • Patients are more likely to remember what was said at the
beginning of session, so give the most important advice and instruction first, whenever possible.
3. Give specific and precise advice
• “You should do a 30 minutes brisk walk 3 times a week” rather
than “You should exercise more”
4. Ensure advice is relevant and realistic
5. Get feedback from patients or clients
Primary care pharmacist normally work as part of a interdisciplinary team that provides services to patient
An interdisciplinary team would normally consist of
Doctors, Pharmacists, Nurses
Dietician, Psychologist
Community pharmacists may have interaction with physician and nurses in the community but it normally occurs through telephone conversation
• Time spent collaborating with other professionals would depend on the level of management held by the pharmacist
Collaborator
Pharmacist as a
Model of Partnership in Primary Care
Model of Partnerships in Primary Care
Monte SV, “Clinical and economic impact of a diabetes clinical pharmacy service program in a university and primary care–based collaboration model.”
J Am Pharm Assoc. 2009;49:200-208.
SETTING: Regional primary care group in Buffalo, New York. CONCLUSION: In this CPS model, there were initial and sustained reductions in the primary diabetes endpoints and a high rate of improvement for accompanying metabolic parameters. Concurrent with clinical improvements, total direct medical costs were reduced despite an increase in antidiabetic medication and total medication costs.
Model of Partnerships in Primary Care
Nkanash NT et al, “Clinical outcomes of patients with diabetes mellitus receiving medication management by pharmacists in an urban private physician practice.” Am J Health-Syst Pharm. 2008; 65:145-9. SETTING: Johns Hopkins Community Physicians Maryland; pharmacy clinic located within the physician’s practice. CONCLUSION: Integrating a pharmacist into a private physician practice significantly improved patients’ glycaemic control and maintained patients’ weight and the number of patients at blood pressure goal. Clinic adherence with ADA recommendations was sustained.
Model of Partnerships in Primary Care
Zerumsky K et al, “Pharmacist Detection of Peripheral Arterial Disease Through the Use of a Handheld Doppler.”
Pharmacotherapy 2005;25(6):797–802.
SETTING: Primary care and consultative outpatient clinic.
CONCLUSION: This pharmacist-initiated screening program increased recognition of peripheral arterial disease in previously unscreened patients. A pharmacist can play a role in a clinic where patients at highest risk are seen. This finding can further assist pharmacists in developing a role in the primary care clinic setting. The clinical pharmacist at the Benedum Geriatric Center, University of Pittsburgh, continues to screen patients without documented peripheral arterial disease. As a result of this research, the Benedum Geriatric Center will establish a program for a pharmacist to evaluate patients for peripheral arterial disease and assist in controlling other cardiovascular risk factors.
Model of Partnerships in Primary Care
Carter BL et al, “A Cluster Randomized Trial to Evaluate Physician/Pharmacist Collaboration to Improve Blood Pressure Control” J Clin Hypertens. 2008;10:260–271. SETTING: Two family medicine clinics at a major teaching hospital in the mid-western United States. CONCLUSION: An intervention involving physician/pharmacist collaboration that focused on optimizing and intensifying medications was associated with significant reductions in BP and improvements in BP control. This study was the first to include 24- hour BP monitoring to objectively confirm clinic pressures. [cont]
Model of Partnerships in Primary Care
Carter BL et al, “A Cluster Randomized Trial to Evaluate Physician/Pharmacist Collaboration to Improve Blood Pressure Control” CONCLUSION: [cont] These improvements were correlated with increased intensity of medication use, which suggests that the model had an effect to overcome suboptimal medication regimens. The intervention also improved medication adherence in the small number of patients with poor adherence without increasing adverse effects. This study suggests that for clinics or health systems that have clinical pharmacists, their reallocation to provide more direct patient management may significantly improve BP control.
Model of Partnerships in Primary Care
Devine EB et al, “Strategies to optimize medication use in the physician group practice: The role of the clinical pharmacist.”
J Am Pharm Assoc 2009;49:181–191. SETTING: Community-based, multispecialty, physician group practice located in the north Puget Sound area between 2003 and 2007. CONCLUSION: In 2006–2007, 71% of our hypertensive patients received generic agents compared with a network average for receiving generic agents of 43%, while the proportion of patients with controlled blood pressure increased from 45% to 60%. We saved $450,000 in inpatient costs for deep venous thrombosis. Clinical pharmacists employed in a physician group practice can optimize medication use, improve care, and reduce costs.
Model of Partnerships in Primary Care
Hunt JS et al, “A Randomized Controlled Trial of Team-Based Care: Impact of Physician-Pharmacist Collaboration on Uncontrolled Hypertension.” J Gen Intern Med 23(12):1966–72. SETIING: Providence Primary Care Research Network-Providence Physician Division, Beaverton, OR, USA. CONCLUSION: Patients randomized to collaborative primary care-pharmacist hypertension management achieved significantly better blood pressure control compared to usual care with no difference in quality of life or satisfaction.
Model of Partnerships in Primary Care
Isetts BJ et al, “Clinical and Economic Outcomes of medication therapy management services: the Minnesota experience.”
J Am Pharm Assoc January 2009. SETTING: Six ambulatory clinics in Minnesota.
CONCLUSION: Patients receiving face-to-face MTM services provided by a pharmacist in collaboration with prescribers experienced improved clinical outcomes and lower total health expenditures. Clinical outcomes of MTM services have chronic care improvement and value-based purchasing implications, and economic outcomes support inclusion of MTM services in health plan design.
Model of Partnerships in Primary Care
Michael EE et al, “Evaluation of 4 Years of Clinical Pharmacist Anticoagulation Case Management in a Rural, Private Physician Office.” J Am Pharm Assoc. 2003; 43:630–6. SETTING: Rural, private physician office in Mt. Vernon, Iowa. CONCLUSION: A clinical pharmacist can provide anticoagulation case management services safely and effectively in a private physician office, and the service is highly valued by both patients and providers. We believe case management is an optimal method for systematically monitoring outpatient anticoagulation therapies and is preferable to usual medical care.
Thank You