1. Clinical Pharmacy II

2. Topic to be covered
Ambulatory care
Home care

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”
What is Ambulatory Care?
“all health-related services for patients who walk to seek their care”
Examples:
clinics - general (primary care); specialty (day surgery, chemotherapy) ER
private offices
community pharmacies

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 Care Specialty 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
Individual counselling *
Group Education
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: How: physician
Health care team
community pharmacy
community agencies
How:
chart
team rounds
telephone

15. Challenges 1. Team dynamics: 2. Marketing your services:
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!