Ambulatory Care Services In Hospital Pharmacy

Anas Bahnassi PhD RPh

Lecture Objectives:

Upon completion of this lecture the student should be able to:

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

Define Ambulatory Care

“all health-related services for patients who walk to seek their

care” Seaton, Ambulatory Care, PSAP

Ambulatory Clinics

general (primary care);

specialty (day surgery,

chemotherapy)

Assisted Living Centers

Hospital Outpatient

Departments

Free Standing Pharmacies

No Need for

Overnight Stay

Rationale of Ambulatory Care

• Shift from Hospital Ambulatory care: – Managed Care requiring decreasing long hospital stays.

– Increased outpatient procedures especially for elderly with multiple chronic conditions

– More focus on preventive medicine and patient education

– The Goal is to decrease health care costs

• Continuity of care: – bridging the gaps

– secondary prevention clinics

Value of Ambulatory Pharmacy Services

o Increase physician availability

o Increase # patient visits

o Decrease hospitalization rates: Asthma clinic, Pauley et al, 1995

o Drug cost savings: Jones et al, 1991

o Improve quality of care:

o More thorough work-up

o Address adherence issues: Ulcers: Lee et al, 1999

o Better treatment outcomes:

o Anticoagulant control, Chiquette et al, 1998

o Hypertension, Erickson et al, 1997

o Diabetes, Coast-Senior et al, 1998

o Fewer adverse drug reactions: Miller et al, 1996

Ambulatory Care

Primary Care

First

Contact

Continuity of Care

Comprehensive Care

Individualization

Disease Prevention

Patient Education

Secondary Care

Particular Organ

Disease Prevention

Specialized Training

Pharmacist: Roles & Responsibilities in Ambulatory Care Services

• Screening and early detection

– dyslipidemia

– hypertension

– diabetes

– osteoporosis

• Health promotion and disease prevention

– immunization

– smoking cessation

– general wellness

Pharmacist: Roles & Responsibilities in Ambulatory Care Services

• 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 Pharmaceutical Care Plan

Documentation

Communication

– With Who: • physician

• Health care team

• community pharmacy

• community agencies (e.g. VON)

– How to: • 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

Documented Study on the Impact of Ambulatory Care Services

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 identified during 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

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

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 Standards

Minimum standards for pharmaceutical care services in ambulatory care:

1. Leadership and Practice management

2. Medication therapy and pharmaceutical care

3. Drug distribution and control

4. Facilities, equipment and other resources

http://www.ashp.org

Future Opportunities

• Reimbursement

• Credentialing (value added)

– residency

– Pharm.D.

– fellowship

– specialty certification

Future Opportunities

• 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?

Summary

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!

abahnassi@gmail.com

http://www.linkedin.com/in/abahnassi

attribution – non-commercial – share alike

Anas Bahnassi PhD RPh

Hospital Pharmacy

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