Ambulatory Care Pharmacy

Debbie Kwan, BScPhm., MSc.

Toronto Western Hospital -University Health Network

Faculty of Pharmacy, Nov. 22, 2002

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

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)ERprivate officescommunity pharmacies

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

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

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

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

Ambulatory Care services at TWH

Community & Population Health

Family Health Centre

Health Living Centre:

• Diabetes Education Centre

• Community Arthritis Management Program

• Chronic Pain Program

• Seniors Wellness Clinic

Women’s Health

Mental Health

Artists Health Centre

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

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.

Keele St.Yonge St.

Lake Ontario

~ 40,000

Diabetes, Pain, OA, Seniors 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

Diabetes, Pain, OA, Seniors Clinics:Common elements

Referral

Screening/initial assessment

Goal setting

Group Education

and/orIndividual counselling *

Follow-up

Family Health Centre - TWH• Physicians• medical residents• nurse practitioner• RN, RPN• social worker• pharmacists• chiropodist

• Support staff:– receptionists– medical records– administrative staff

Family Health Centre

Pharmacist’s activities:

• Drug information

• Consultation

• Teaching

Pharmacist: Roles & Responsibilities

• Screening and early detection– dyslipidemia– hypertension– diabetes– osteoporosis

• Health promotion and disease prevention– immunization– smoking cessation– general wellness

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

Implementation of PCP

DocumentationCommunication

– Who:• physician• Health care team• community pharmacy• community agencies (e.g. VON)

– How:• chart • team rounds• telephone

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

Non-adherence

Adverse reaction

Pt unclear about med.regimen

Inappropriatedosing/administration

Additional drug req'd

Unclear indication

10% 4% 27%

22%

17%

*20%

* new category that emerged during follow-up

Additional Drug-related problems identifiedduring Telephone follow-up:

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%

•101 interventions were carried out

• 66% of interventions were provided by the pharmacist over the telephone

Intervention type % Total

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 (n=39)

– additional drug required (30%)– possible adverse drug reaction (25%)– alternative agent more appropriate (20%)

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

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 women’s withdrawal programs

Opportunities:– provision of drug information (staff, clients)– medication identification– linking with community pharmacies– supportive role vs. direct patient care– student experience

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

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

ASHP StandardsMinimum standards for pharmaceutical care

services in ambulatory care:

1. Leadership and Practice management2. Medication therapy and pharmaceutical care3. Drug distribution and control4. Facilities, equipment and other resources

Other resources:CSHP, ACCP – specialty practice groups

www.ashp.org

Future Directions

• Reimbursement

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

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?

Ambulatory Care Pharmacy

Tremendous opportunity for growthMultidisciplinary team resources

availableDedicated time for direct patient care

and follow-upTaking the lead in care - primary liaisonOpportunity to try new ideas!