1. Clinical Pharmacy II Lobna Al Juffali,MSc Fall-2009

2.  Ambulatory care  Home care Topic to be covered

3. Objective 1. Describe ambulatory care practice 2. Describe the impact of ambulatory care practices 3. Provide examples of activities provided through ambulatory care services 4. Identify future opportunities and challenges

4. “all health-related services for patients who walk to seek their care” Seaton, Ambulatory Care, PSAP  Examples: Fclinics - general (primary care); specialty (day surgery, chemotherapy) FER Fprivate offices Fcommunity pharmacies What is Ambulatory Care?

5. Why ambulatory care? Shift from acute hospital care ambulatory care  The main goal of this shift is to decrease health cost

6. Because  Managed care approach to decrease hospitalization rates and length of stay  The number of elderly patients with multiple chronic medical conditions that require longitudinal management is growing  Know there is more focus on preventive health and patient education

7. Documented value of ambulatory Pharmacy services  increase physician availability  increase # patient visits  decrease hospitalization rates: Asthma clinic, Pauley et al, 1995  drug cost savings: Jones et al, 1991  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

8. Ambulatory Care Primary CareSpecialty Care “first contact” continuity of care comprehensive care individualized care health promotion, disease prevention, early detection Particular organ system or disease type health promotion and prevention specialized training one point in time

9. Diabetes, Pain, OA, Geriatric Clinics:Common elements  Referral: family MD, patient, HCP  Health promotion and prevention  Promote independence and increase knowledge with self-care of health conditions  Not a cure  Multidisciplinary team  Group education  Individual consultation  Interpreters

10. Diabetes, Pain, OA, Geriatric Clinics:Common elements Referral Screening/initial assessment Goal setting Group Education Individual counselling * Follow-up

11. Pharmacist’s activities:  Assists with designing therapeutic regimen  Identifying untreated conditions  Proccessing narcotic prescripton  Assesing nonformulary prescription  Designing long-term follow-up and monitoring plans  Identifying therapeutic duplication  Establish relationships with patients  Educate and counsel patients to enhance compliance  Teaching pharmacy students

12. Pharmacist: Roles & Responsibilities  Screening and early detection  dyslipidemia  hypertension  diabetes  osteoporosis  Health promotion and disease prevention  immunization  smoking cessation  general wellness

13. Pharmacist: Roles & Responsibilities  Medication history and assessment  disease specific  efficacy, toxicity, adherence  medication management  herbal products  Pharmacotherapeutic interventions  identification/prevention of drug-related problems  establishing goals and outcomes  initiate  modify  discontinue  monitor drug therapy Pharmacy Care plan

14. Implementation of PCP  Documentation  Communication  Who:  physician  Health care team  community pharmacy  community agencies  How:  chart  team rounds  telephone

15. Challenges  1. Team dynamics:  overlapping scopes of practice  clarify roles and responsibilities  2. Marketing your services:  education of patients and health care providers, re: scope of practice  when to refer

16. Challenges  3. Delivering patient education  effectiveness and impact  adult vs. student education  group education - interactive vs. didactic  multi-cultural aspects  varying levels of education  handouts  4. Changing the public’s perception  creating a demand for cognitive services

17. ASHP Standards  Minimum standards for pharmaceutical care services in ambulatory care:  Leadership and Practice management  Medication therapy and pharmaceutical care  Drug distribution and control  Facilities, equipment and other resources

18. Future directions  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 BS -> impact on complications?

19. Ambulatory Care Pharmacy  Tremendous opportunity for growth  Multidisciplinary team resources available  Dedicated time for direct patient care and follow-up  Taking the lead in care  Opportunity to try new ideas!