Ambulatory Care Pharmacy

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Ambulatory Care Pharmacy

• Debbie Kwan, BScPhm., MSc.
• Toronto Western Hospital -University Health
  Network
• Faculty of Pharmacy, Nov. 22, 2002

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Objectives

• 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

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What is Ambulatory Care?

• all health-related services for patients who
  walk to seek their care
• Seaton, Ambulatory Care, PSAP
• Examples
• clinics - general (primary care) specialty (day
  surgery, chemotherapy)
• ER
• private offices
• community pharmacies

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Why ambulatory care?

• Shift from acute ambulatory care
• decreasing LOS
• increased outpatient procedures
• goal decrease health care costs
• Continuity of care
• bridging the gaps
• secondary prevention clinics
• e.g SPACE

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What does the Pharmacy profession think?

• ASHP Survey 1999
• greatest opportunity for pharmacists in the
  future lie in primary and ambulatory care
• more emphasis on preventive care
• curricula change to support this

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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

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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

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Ambulatory Care services at TWH
Community Population Health

• Health Living Centre
• Diabetes Education Centre
• Community Arthritis Management Program
• Chronic Pain Program
• Seniors Wellness Clinic

Family Health Centre
Mental Health
Womens Health
Artists Health Centre
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Healthy Living Centre

• Goals
• 1. Identify health needs and issues
• 2. Effective use of resources
• 3. Improve access, integration and coordination
  of care
• 4. Increase community knowledge and
  responsibility for health status
• 5. Promote improvement in health systems

Improve health status of target populations
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Target Population profile

• Seniors (65) - 11.7 (1/3 live alone)
• Ethnic diversity - 88 (not British or Cdn) vs.
  82 for Toronto
• Portuguese, Chinese, Italian, Jewish, Polish,
  Vietnamese, East Indian, Filipino, Jamaican
• Literacy/Education - lower rates than rest of
  Toronto

Eglinton Ave.
40,000
Yonge St.
Keele St.
Lake Ontario
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Diabetes, Pain, OA, Seniors ClinicsCommon
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

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Diabetes, Pain, OA, Seniors ClinicsCommon
elements
Referral
Screening/initial assessment
Goal setting
Individual counselling
Group Education
and/or
Follow-up
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Family Health Centre - TWH

• Physicians
• medical residents
• nurse practitioner
• RN, RPN
• social worker
• pharmacists
• chiropodist
• Support staff
• receptionists
• medical records
• administrative staff

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Family Health Centre

• Pharmacists activities
• Drug information
• Consultation
• Teaching

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Pharmacist Roles Responsibilities

• Screening and early detection
• dyslipidemia
• hypertension
• diabetes
• osteoporosis
• Health promotion and disease prevention
• immunization
• smoking cessation
• general wellness

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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
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Implementation of PCP

• Documentation
• Communication
• Who
• physician
• Health care team
• community pharmacy
• community agencies (e.g. VON)
• How
• chart
• team rounds
• telephone

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Telephone follow-ups reduce seniors'
drug-related problems Patients aided by
pharmacist calls By Lynn Haley VANCOUVER
Telephone followup can greatly reduce
drug-related problems (DRPs) in geriatric
patients, researchers at the Toronto
Rehabilitation Institute reported at the recent
17th World Congress of the International
Association of Gerontology. The Medical Post,
VOLUME 37, NO. 28, August 21, 2001 Kwan, Alibhai,
Papastavros, Armesto, Toronto Rehab Institute
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Additional Drug-related problems
identifiedduring Telephone follow-up
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10
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20
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new category that emerged during follow-up
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• 101 interventions were carried out
• 66 of interventions were provided by the
  pharmacist over the telephone ?

1. Medication education ?
41.6 2. Dosing regimen modification ?
20.0 (e.g. timing, use of compliance
aids) 3. Therapeutic recommendation 12.9
(resulting in new prescription) 4.
Consult Geriatrician 11.8 5. Refer to
community resources ? 8.0
(e.g. community pharmacy, VON) 6.
Earlier clinic follow-up visit 4.9
Intervention type Total
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Initiating ambulatory care practices

• The Pharmaceutical Care Pilot Project Structure
  and Function of Drug-Related Problems in the
  Community Dwelling Elderly
• Bowles S, Perrier D. Sunnybrook Health Science
  Centre and Faculty of Pharmacy Kwan D, Study
  Co-ordinator
• Ontario Drug Benefit Program Grant, 18,000 (1993
  1995)
• ambulatory geriatric rehab program - frail
  elderly
• 260 DRPs (n39)
• additional drug required (30)
• possible adverse drug reaction (25)
• alternative agent more appropriate (20)

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Initiating ambulatory care practices

• Multidisciplinary falls clinic
• Medications contribute to falls
• Role of the pharmacist
• interventions will be patient specific
• weighing risk vs. benefit
• preventive measures (e.g. osteoporosis)
• education of the patient informed
  choices

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Initiating ambulatory care practices

• Community Mental Health and Addiction Program
  (TWH)
• mental health crisis team
• emergency psychiatry assessment unit
• Portuguese mental health and addiction unit
• men and womens withdrawal programs
• Opportunities
• provision of drug information (staff, clients)
• medication identification
• linking with community pharmacies
• supportive role vs. direct patient care
• student experience

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Challenges

• 1. Team dynamics
• overlapping scopes of practice (health teaching)
• clarify roles and responsibilities
• key messages
• 2. Marketing your services
• education of patients and health care providers,
  re scope of practice
• when to refer

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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 publics perception
• creating a demand for cognitive services

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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
• Other resources
• CSHP, ACCP specialty practice groups

www.ashp.org
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Future Directions

• Reimbursement
• Credentialing (value added)
• residency
• Pharm.D.
• fellowship
• specialty certification

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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- gt control BS -gt impact
  on complications?

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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 - primary liaison
• Opportunity to try new ideas!