30:725:424:01 IntroPharmCare Class Outline

Professor John L. Colaizzi, Ph.D., R.Ph. Thursday, September 3, 2009

Ability-based Educational Outcomes; Patient-centered Pharmaceutical Care; The concept of Professionalism _______

Review of Ability-Based Educational Outcomes (ABOs) (refer to ABOs listed on the syllabus):

ABO # 1: Why the emphasis on “patient-centered pharmaceutical care” in this course?

-- In pharmacy today there are three practice models:
I. The drug distribution-centered model (up until the 1970s)
a. “Dispensing model” – just focusing on dispensing (distribution of the product (drug)).
b. Reactive role – not proactive, just filling scripts
c. RPh has little accountability or leadership responsibility – pharmacist not concerned about patient, just
following directions.
d. Focus on process that’s safe and effective on providing the medication

II. Clinical pharmacist-centered model (1970s – 80s)

a. No dispensing/provision responsibility
b. Focus exclusively on clinical activities as a member of the Health care team (HCT) – directed attention to
physician for information on patient drug needs
c. Little or no relation between dispensing pharmacist and clinical pharmacist

III. Patient – Centered integrative model (preferred model of today) integrates the top two models
a. RPh accepts responsibility for both I. and II. – will dispense and also serve clinical duties
b. RPh role enhanced by responsible use and supervision of qualified Pharmacy Technicians (PTs)
c. RPh is proactive on behalf of patient with regard to collaborative medication selection and use.

***Terms that are used interchangeably:

--Pharmaceutical care
--Clinical Pharmacy
--Collaborative MTM

ABO# 2: What is the advantage and importance of having an “evidence-based pharmaceutical care plan?”
--Advantage: looks in a comprehensive way at all the patients’ drug therapies. This is to provide the best outcomes of
pharmacotherapy (RxTx). “To optimize the outcomes of drug therapy”.

ABO # 3: Why should pharmacists need to be knowledgeable about medical terminology, in addition to pharmaceutical
terminology?
--Interacting with physicians and nurses and need to have knowledge to some extent of language and terminology they use.

ABO # 4: Differentiate between drug indications and drug contraindications.

--The indication for a drug “the disease conditions for which a drug has been approved by the FDA”
--The term contraindications for a drug “conditions or characteristics of a patient that make the use of the drug unacceptable in that
patient”

ABO #5: Why are the risk factors and symptoms of diseases important facts for pharmacists to learn? With which one of
your current courses does this kind of information correlate?
--To better evaluate a patient’s RxTx needs and design an appropriate drug MTM in collaboration with a physician.

ABO # 6: Illustrate the concept of “harmful Drug-Drug Interactions (DDIs)” by citing at least one specific, significant
example.
--Coumadin/warfarin – this drug is used as an anticoagulant. If patient is taking warfarin with ibuprofen, naproxen, or aspirin (there
are all analgesics), these drugs inhibit platelet aggregation (they also interfere with blood clotting process), careful maintenance is
required because if taken in improper doses, it can cause patient to bleed or hemorrhage.

ABO # 7: Do brand name drugs or generics account for the majority of products dispensed by pharmacists? Are generics
just as good a brand name drugs?
--Generics make the majority of products dispensed by pharmacist. Generics are for the most part, medically equivalent to their brand
name variants.

ABO # 8: “Drug dosage form” –

--Drug dosage form: it’s the overall physical formulation containing an active drug and excipients (ingredients other than the active
drug). Final dosage form is what the patient actually takes.
 Examples of “Routes of Administration:”
~ GI (p.o.) – PO stands for per os (taken by mouth). GI routes an also be by rectum; and also via feeding
tube. The PO route is primarily used for systemic purposes (absorbed by blood stream and used by body). Can be tablets/capsules/oral
liquids/suppositories/enteral administration (feeding tube; into intestine)

Parenteral -- IV, IM, Subcutaneous (SC, SQ) – (para enterum: alongside intestine) via injection. This
route is used only for systemic effects. Many different ways you can give parenteral medications but main are IV (intravenous), IM
(intramuscular), SC,SQ (subcutaneous).

--If drug is given IV, drug MUST BE true solutions otherwise it can kill the patient. Some exceptions are colloidal.
--Parenteral drugs must be sterile, big role of pharmacist to make sure it is sterile

Topical (dermatomucosal) –(surface or dermatomucosal (skin/mucous membranes) –

-- More local than systemic; some dosage forms: ointments, creams, gels, lotions/liquids, eye drops, transdermal patches (systemic
use), sublingual, buccal (along the cheek) [sublingual and buccal are systemic, rapid absorption ], intranasal.

ABO # 9: Are there more than one form of the IV route of drug administration?
--Yes. IV push – injection is pushed into vein, or rapid IV injection. Only good for relatively small volumes 10-15 ml. More common
way is IV infusion – flexible plastic bag suitable for large volumes of solution going through catheter into the vein of arm;
administered over an extended period of time. Via infusion, rate of delivery must be carefully regulated.

ABO # 10: How many potential pharmacotherapy problems are there?

--Seven. A major clinical role for the pharmacist is to be able to identify and resolve/prevent these problems.

ABO # 11: Are “therapeutic alternatives” the same thing as “generic equivalents?”
--No. Generic equivalents involve the same drug molecule but a different brand. A therapeutic alternative is a different drug molecule,
but has similar medicinal properties.

ABO # 12: The meaning and difference in the terms “Prescription” and “medication order:”
--Prescription is a term used primarily in community pharmacy situations: anything that is not in a hospital where you have in-
patients. In hospitals these orders for drugs are called medication orders. Both are issued via an authorized prescriber. Traditionally
both are hard-copy, they’re increasingly becoming electronic today.

ABO # 13: Why not reserve all of the regulatory issues in pharmacy for the Pharmacy Law and Bioethics course in the P-3
year?
--There are so many laws and regulations that affect all areas of pharmacy and it’s too much to just leave for the law and ethics
courses. Another reason is that you need some knowledge of these laws and ethical responsibilities to function properly in IPEs. And
also, if you’re working part time you have to know some of these laws/ethics.

ABO # 14: Do all pharmacy practitioners perform some aspects of Drug Utilization Review (DUR) on a daily basis?
--Yes. It’s one of the very basic functions of pharmacy practitioners.
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ABO # 15: Name one debate or controversial or political issue that is being faced by the profession of pharmacy today
(perhaps one that is particularly relevant to students in pharmacy school). Are there others?
--Reimbursement for MTM.
--Expansion in number of pharmacy schools. Floods market with pharmacists, makes career options tight
--If pharmD should be only degree for pharmacists

ABO # 16: Why is advocacy important and necessary for the profession of pharmacy? Is advocacy a role solely for our
professional associations?
--Political advocacy is needed because nurses are gaining prescribing authority faster than pharmacists.
--In all 50 states, pharmacists can now immunize. (NJ was one of last to do this).

ABO #17: Differentiating “Practitioner” and “Non-Practitioner” career options for pharmacists:
--Practitioner: refers to any employment situation where pharmacist is involved in a patient-care setting.
--Non-practitioner: working in industry or research or FDA, etc. Do not work in patient-care setting. (Technically do not have to be
licensed)

The basic definition of Pharmaceutical Care:

--The responsible and competent provision of RxTx to achieve definite outcomes that improve the QoL for specific patients. Primary
emphasis of pharmaceutical care is on a personal professional relationship between the pharmacist and the patient. Ideally, it should be
delivered in a collaborate manner.

Differentiating the terms “Pharmaceutical Care” and “Clinical Pharmacy:” Pharmaceutical care related to practice site.
--One of the aspects of clinical pharmacy is that it was largely practiced solely in hospitals. Pharmaceutical care and MTM can be
practiced irrespective of setting. Also differs from clinical pharmacy because clinical pharmacy primarily emphasizes
pharmacist/physician relation. MTM and pharm care is between pharmacist/patient.

The role that practitioner pharmacists have in delivering pharmaceutical care is apparent; the role of non-practitioner
pharmacists is less apparent, but they too have a role…….
--Non-practitioner pharmacists are patient focused but in a population aspect as opposed to a 1 on 1 aspect.

The Joint Commission of Pharmacy Practitioners (JCPP) has adopted a supportive and visionary consensus statement on
pharmaceutical care:
● Optimal medication therapy outcomes…. –Pharmaceutical care involves optimum medication therapy outcomes

● Medication Therapy Management ( “MTM”) ….. MTM can be viewed as a comprehensive framework for all
drug-focused patient care service components of the practice of pharmacy. It is driven by the concept of pharmaceutical care.
--Three steps involved in delivering MTM.
I. To design a medication treatment plan
II. To select and initiate medication therapy, also includes maintenance (changing and improving medication therapy)
III. Provide verbal and written education to the patient about the use of their drugs (Patient counseling).
Not solely limited to pharmacists. Nurses are fighting for it, and physicians can do it.

● Similarities & differences among pharmacist-provided patient counseling, disease management, and MTM:
-- I. Counseling is an essential step and should be continued with new prescriptions and refills. Occasionally should check to
see it drugs are working as intended. It should be done in a private area.
II. Disease management – part of MTM
III. MTM – A comprehensive approach to serve drug therapy needs of a patient. Managing multiple medications

The organizations that make up the JCPP (and their basic purposes):
● APhA (American Pharmacists Association) – oldest pharmacy association. Approaches pharmacy generally

● ASHP (American Society of Health-System Pharmacists) – hospital pharmacists specifically

● NCPA (National Community Pharmacists Association) – independent pharmacies

● ASCP (American Society of Consultant Pharmacists). – deal with long term care/ nursing home pharmacists

● AMCP (Academy of Managed Care Pharmacists) – PBMs (Pharmacy Benefit managers) – work for companies like
Medco.

● ACA (American College of Apothecaries) – Pharmacists who work in specialty pharmacies. Compounding pharmacies.

What is the role or position of these related national organizations? Why are they not members of the JCPP?
-- membership of these organizations do not relate specifically to those who are pharmacy practitioners.

● NACDS (National Association of Chain Drug Stores) --

● PhRMA (Pharmaceutical Research and Manufacturers Association)

● PCMA (Pharmaceutical Care Management Association)

Summary: Three principal responsibilities of pharmacy practitioners based on JCPP’s vision of the profession……
 Rational selection and use of medicines. Pharmacists should be more proactively involved in selecting medicines that patients
should use
 Assessment of outcomes of drug therapy
 Disease prevention – promotion of wellness
 Design and oversight of safe, accurate, and efficient medication distribution systems. (Implies pharmacist himself doesn’t
distribute medication but supervises and takes responsibility of his/her technicians)
Challenges that must continuously be overcome to provide pharmacists with sufficient authority and flexibility to manage
medication therapy for patients……..(including access to the patient’s medical and/or medication record)……..
 Have to have corporate or management commitment (pharmacists are no longer self-employed; they work for chains. The
corporation also has to be committed to the goal of MTM).
 Pharmacist must be devoted and committed to MTM. (Some older pharmacists don’t engage in counseling or MTM and
blame the corporate structure///lazy?)
 Have to have sufficient knowledge and skill. (pharmD degree ensures this)
 More autonomy is needed. The prescriptive authority that nurse practitioners have been more successful in obtaining…
having prescriptive authority will give pharmacists responsibility in prescribing but also CHANGING medications. This
would be done collaboratively with a physician
 Alter public perception of what pharmacists do. In the past it seemed like pharmacists didn’t communicate with patients and
this image has carried on.

The concept of professionalism in health care:

● expanded sense of professionalism….why it’s more important now in pharmacy? [emphasis now on drug and
patient]
-- The patient centered focus of pharmacy today makes professionalism a more important concept that should be learned.

● “Professionalization” is a term that refers to “the development of professionalism,” which needs to begin in the P-
1 year. The key influential parties in the process of professionalization are:
-- Believed that it is needed to begin in the P1 year and the two principle parties involved are: i. exemplary pharmacist practitioners
(especially those you do rotations with) ii. Pharmacist educators

Characteristics that collectively differentiate a profession from a regular occupation:

1. knowledge and skills ….

2. Service orientation and a commitment to integrity, compassion, altruism……

3. Code of ethics…..

4. Licensure and/or certification…..

5. Recognized settings……and a commitment to the “institutions” in which pharmacists work. Must also be dually
licensed with the state as well to protect public health.

6. Utility….. –Continually strive to show what we do is useful

The most desirable traits of respected professionals:

1. Knowledge, skills, lifelong learning (continuous improvement with an aspiration to excellence).
--
2. Social contract (covenantal [you take serious concern on drug usefulness for patient] commitment to the patient)

3. Pride in the profession, accountability, leadership, advocacy

4. Working in partnership with members of the wider health care team.

Challenges to professionalism:
● Inconsistent messages…. –bad preceptors for example.

● Commercialization, competition, business demands inherent in all areas of the health professions…..
--

● Managed care, third party reimbursement, PBMs (Pharmacy Benefit Managers)…..

--economic realities that are with us today are here to stay. The impetus of managed care is to reduce costs, although most don’t
believe this.

~ Reimbursement for distributive/transactional services rather than payment for MTM, patient education, patient
counseling….

--Based on how many prescriptions filled. (especially retail). However no money is compensated for MTM
Relationship between pharmaceutical care and the dispensing function……… --technicians do the dispensing to allow
pharmacists to have more involvement in clinically oriented activities. Pharmacist however still holds responsibility for what techs do

Medication errors and the Institute of Medicine’s 2000 report “To err is human.” – related to inadequate oversight of pharmacist
or bad systems in dispensing functions
--Goal is to minimize meditational errors

Drug Therapy Plan – strategic and comprehensive plan to optimize RxTx in a specific patient. Involves patient education and
counseling.

Patient education/counseling subsequent to the development of the Drug Therapy Plan – responsibility can’t fall completely on
patient and physician. Patient has to be responsible as well.

Documentation of the Drug Therapy Plan – records need to be kept of patient consultation. If we eventually want to be reimbursed
for MTM, then documentation is required for proof

Patient monitoring and follow-up – assessment must be done.