Pharmaceutical Care Plan

Key Concepts of pharm. care plan 1. A care plan is developed for each of the patient's medical conditions being managed with pharmacotherapy. 2. A goal of therapy is the desired response or endpoint that you and your patient want to achieve from pharmacotherapy. 3. The key to a successful care plan is clear, measurable goals of therapy which include a parameter, desired value(s), and a timeframe for achieving them.

4. The care plan includes interventions to resolve the drug therapy problems, interventions to achieve goals of therapy, and any necessary interventions to prevent drug therapy problems. 5. Pharmacotherapy interventions include initiating new drug therapy, discontinuing drug therapy, or changing the product and/or dosage regimen.

6. Additional interventions to achieve the goals of therapy can include patient education, medication compliance reminders/devices, referrals to other health care providers, or monitoring equipment to measure outcome parameters.

7. The last activity in the care plan is scheduling a follow-up evaluation with the patient to determine the outcomes of pharmacotherapy at a clinically appropriate time. 8. Documentation of the care plan establishes the relationships between the goals of therapy, and interventions designed to achieve the goals.

purpose of the care plan The purpose of the care plan is to determine how to manage patient medical conditions or illness successfully. It includes all the work that is necessary to accomplish this.

Development of Goals of Therapy (Identify goals of therapy for each patient) 1. Goals of therapy are established for each indication for drug therapy. 2. Desired goals of therapy are described in terms of the observable or measurable clinical and/or laboratory parameters to be used to evaluate effectiveness and safety of drug therapy. 3. Goals of therapy are mutually negotiated with the patient and health care providers when appropriate. 4. Goals of therapy are realistic in relation to the patient's present and potential capabilities. 5. Goals of therapy include a timeframe for achievement.

The care plan allows you to work with patient, who may have different expectations or understanding of his or her medication. It serves as a negotiated agreement. It includes several individuals such as patients, family members, physicians, and pharmacists.

In pharmaceutical care, care plans are organized by indications for drug therapy. Patients often have multiple medical conditions. Some conditions are acute and many are chronic requiring long-term treatment.

Multiple drug therapies for the same indication are grouped together with the same care plan.

The major questions you must consider to construct a successful care plan are: 1. What goals of therapy are you and your patient trying to achieve with pharmacotherapy? 2. What are you going to do, or how are you going to intervene, to resolve any drug therapy problems identified during the assessment? 3. What interventions (drug therapies, devices, patient education) are you going to provide to ensure that your patient achieves the desired goals of therapy? 4. When are you going to follow-up with your patient to determine the actual outcomes of drug therapies and other interventions?

Establishing Goals of Therapy They are necessary in order to produce and document positive outcomes. You and the patient must agree upon clear and concise goals of therapy. It is essential to ensure that a patient will maximally benefit from drug therapies.

The goals of drug therapy are to: 1. Cure a disease 2. Reduce or eliminate signs and/or symptoms 3. Slow or halt the progression of a disease 4. Prevent a disease 5. Normalize laboratory values 6. Assist in the diagnostic process

Goals of therapy have a specific structure and always include: 1. Clinical parameters (signs and symptoms) and/or lab values which are observable, measureable, and realistic; 2. Desired value or observable change in the parameters; 3. Specific timeframe in which the goal is to be met.

Example For a patient who suffers from allergic rhinitis and presents with nasal congestion, runny nose, and eye itching, but no cough or loss of taste, the patient-specific goals of therapy might include the relief of the patient's complaints of nasal congestion, runny nose, and eye itching in a timeframe of 48 hours.

What would you like to achieve with your medications? Eliciting goals of therapy and obtaining agreement with the patient can be facilitated with the following discussion questions. What would you like to achieve with your medications? What are your goals for this therapy? How do you feel about trying to achieve . . . with a new drug therapy?

Interventions The Practitioner Develops a Care Plan that Includes Interventions to: Resolve Drug Therapy Problems, Achieve Goals of Therapy, and Prevent Drug Therapy Problems.

Measurement Criteria 1. Each intervention is individualized to the patient's conditions, drug related needs, and drug therapy problems. 2. All appropriate therapeutic alternatives to resolve drug therapy problems are considered, and the best are selected.

3. The plan is developed in collaboration with the patient, his/her family and/or care-givers, and health care providers, when appropriate. 4. All interventions are documented. 5. The plan provides for continuity of care by including a schedule for continuous follow-up evaluation.

Interventions to Resolve Drug Therapy Problems It is given highest priority They interfere with patients. If your patient is not realizing the full effectiveness form her prescribed antihistamine to manage seasonal allergic rhinitis because the dose is too low, the dosage regime must be increased before there is any realistic hope of achieving a positive outcome.

Similarly, if your patient is experiencing dose-related side effects from her antihistamine, the dosage regimen must be modified in order for her to receive appropriately indicated drug therapy that is both effective and safe.

Interventions might include: 1. Initiating new drug therapy, 2. Changing the drug product, 3. Altering the dose and/or the dosing interval, or 4. Discontinuing drug therapy

How do you feel about making these adjustments in your medications? It is important to include the patient at each step in your decision making process. The following questions can facilitate this discussion: How do you feel about making these adjustments in your medications? Is this a change that you think you can manage in your daily use of this medication? What do you think would be the best way to improve your therapy?

Interventions to Achieve Goals of Therapy Establish with your patient effectively and efficiently all drug related needs. The interventions you select are grounded in patient preferences, selected according to patient needs, and limited by patient tolerance.

Interventions to achieve the goals of therapy can include 1. Drug regimen(s) the patient should receive, 2. Changes in drug therapy that are required, 3. Patient-specific education or information, 4. Referrals to specialists, 5. Instructions on how to properly use prescription drug products, Nonprescription drug products, and How to use other remedies, products, and devices.

Interventions to Prevent Problems Each pharmaceutical care plan must address the need to prevent the development of new drug therapy problems. In clinical practice design drug therapies and patient education to avoid preventable side effects or risks known to be associated with certain drug therapies or diseases.

Examples include initiating antihypertensive therapy with a minimal dosage to prevent orthostatic hypotension or warning patients about drowsiness associated with some antihistamine products. Practitioners also routinely recommend that patients take certain medications with food to avoid stomach upset.

These types of interventions are due to the pharmacological or chemical properties of the drug and/or the disease but are not unique to the patient. These would be considered standard or routine instructions and would be provided for all patients taking those medications.

Therapeutic Alternatives There is seldom only one best Intervention. Decide what interventions you will select to resolve drug therapy problem Decide what interventions you will select to achieve the goals of therapy. Decide what other interventions in order to prevent the development of drug therapy problems. Notice that for each set of clinical decisions you are making you must consider all of the reasonable alternatives available.

Learning tip During the learning phase, it is useful to always identify at least three different therapeutic alternatives for every drug therapy decision you make with your patients. This helps you to learn about drugs that you may not otherwise encounter, and it helps you to learn to investigate, compare, and contrast the evidence supporting efficacy and safety of drug products used for similar indications. When you make recommendations to prescribers for changes in your patient's drug therapy, you will want to provide two alternatives that you consider acceptable. Always indicate which of the two is preferred and why.

Discussing options with your patient can be facilitated with the following questions. What is your preference given these approaches for treating your illness There are several medications available to treat your illness, which would you prefer? Which therapy do you feel will work best for you?

Cost Considerations Cost considerations should become important only after you have generated therapeutic alternatives based on effectiveness and safety. Any drug therapy that is ineffective for a patient or results in toxicity is too expensive.

Too often, if the differences between the clinical efficacies and/or safety of various drug therapy alternatives have not been well documented, they are considered to be the same. This results in choosing the less expensive of the alternatives.

Note Considering drug product costs before efficacy and safety considerations is not rational and can often be harmful and wasteful. Cost is an important management issue, but effectiveness and safety always take precedence

After you have considered the evidence of efficacy and safety, then convenience and cost considerations can be applied. The least expensive drug therapy is the one that is effective and does not cause the patient harm.

Schedule and Plan for Follow-Up Evaluations The Practitioner Develops a Schedule to Follow-Up and Evaluate the Effectiveness of Drug Therapies and Assess Any Adverse Events Experienced by the Patient.

Measurement Criteria 1. The clinical and laboratory parameters to evaluate effectiveness are established, and a timeframe for collecting the relevant information is selected. 2. The clinical and laboratory parameters that reflect the safety of the patient's medications are selected, and a timeframe for collecting the relevant information is determined. 3. A schedule for the follow-up evaluation is established with the patient. 4. The plan for follow-up evaluation is documented.

The plan for the follow-up evaluation addresses three basic questions: 1. When should the follow-up evaluation be scheduled? 2. How will you determine if positive outcomes have occurred? 3. How will you determine if negative outcomes have occurred?

Documenting the Care Plan The care plan document lists the indication and includes a brief summary of the signs and symptoms. Goals of therapy must be a prominent part of every care plan. One of the most valued additions that a pharmaceutical care practitioner makes to the patient's health records is explicitly stated goals of therapy.

The care plan needs to be complete and should follow the structure of drug product(s) and dosage instructions including dose, route, frequency, and duration. Any special dosing instructions that will help the patient maximally benefit from the drug therapy should be included in the care plan

If the drug therapy is a change from earlier regimens, it should be noted and dated in the care plan. Multiple drug therapies for the same condition are contained in the same care plan. Any changes in drug products, dosage regimens, or instructions should be recorded so that the patient's care plan is continuously current and includes all forms of pharmacotherapy the patient is receiving.

Other interventions to support the specific pharmacotherapy should also be recorded. These often include health advice, exercise, dietary changes, or instructions on the proper use of medication administration devices or drug monitoring devices.

The care plan should include the schedule for the next follow-up evaluation including effectiveness and safety parameters to be evaluated.

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