Basma Y. Kentab MSc.

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

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 ACCP, Pharmacotherapy 1992;12(4):

 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

 Increase physician availability  Increase number of 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

 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

 Specialty Medicine Clinics ◦ Anticoagulation ◦ Diabetes ◦ Hypertension  Pediatrics ◦ General pediatrics ◦ Asthma or allergy  Home Health Care

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

 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)

 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

 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

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

 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

 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

 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

 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!!

 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 ACCP, Pharmacotherapy 1992;12(4):

 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 ACCP, Pharmacotherapy 1992;12(4):

 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. ACCP, Pharmacotherapy 1992;12(4):

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.

4. Insufficient time and inadequate resources and reimbursement 5. Changing the public’s perception 6. Lack of direct physician contact

 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?

 Tremendous opportunity for growth  Dedicated time for direct patient care and follow-up  Taking the lead in care  Opportunity to try new ideas!