Principles of Practice for Pharmaceutical Care

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Pharmaceutical Care is a patient-centered, outcomes oriented pharmacy practice that requires the pharmacist to work in concert with the patient and the patient's other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use to assure that drug therapy regimens are safe and effective. The goal of Pharmaceutical Care is to optimize the patient's health-related quality of life, and achieve positive clinical outcomes, within realistic economic expenditures. To achieve this goal, the following must be accomplished:

A. A professional relationship must be established and maintained.

Interaction between the pharmacist and the patient must occur to assure that a relationship based upon caring, trust, open communication, cooperation, and mutual decision making is established and maintained. In this relationship, the pharmacist holds the patient's welfare paramount, maintains an appropriate attitude of caring for the patient's welfare, and uses all his/her professional knowledge and skills on the patient's behalf. In exchange, the patient agrees to supply personal information and preferences, and participate in the therapeutic plan. The pharmacist develops mechanisms to assure the patient has access to pharmaceutical care at all times.

B. Patient-specific medical information must be collected, organized, recorded, and maintained.

Pharmacists must collect and/or generate subjective and objective information regarding the patient's general health and activity status, past medical history, medication history, social history, diet and exercise history, history of present illness, and economic situation (financial and insured status). Sources of information may include, but are not limited to, the patient, medical charts and reports, pharmacist-conducted health/physical assessment, the patient's family or caregiver, insurer, and other healthcare providers including physicians, nurses, mid-level practitioners and other pharmacists. Since this information will form the basis for decisions regarding the development and subsequent modification of the drug therapy plan, it must be timely, accurate, and complete, and it must be organized and recorded to assure that it is readily retrievable and updated as necessary and appropriate. Patient information must be maintained in a confidential manner.

C. Patient-specific medical information must be evaluated and a drug therapy plan developed mutually with the patient.

Based upon a thorough understanding of the patient and his/her condition or disease and its treatment, the pharmacist must, with the patient and with the patient's other healthcare providers as necessary, develop an outcomes-oriented drug therapy plan. The plan may have various components which address each of the patient's diseases or conditions. In designing the plan, the pharmacist must carefully consider the psycho-social aspects of the disease as well as the potential relationship between the cost and/or complexity of therapy and patient adherence. As one of the patient's advocates, the pharmacist assures the coordination of drug therapy with the patient's other healthcare providers and the patient. In addition, the patient must be apprised of (1) various pros and cons (i.e., cost, side effects, different monitoring aspects, etc.) of the options relative to drug therapy and (2) instances where one option may be more beneficial based on the pharmacist's professional judgment. The essential elements of the plan, including the patient's responsibilities, must be carefully and completely explained to the patient. Information should be provided to the patient at a level the patient will understand. The drug therapy plan must be documented in the patient's pharmacy record and communicated to the patient's other healthcare providers as necessary.

D. The pharmacist assures that the patient has all supplies, information and knowledge necessary to carry out the drug therapy plan.

The pharmacist providing Pharmaceutical Care must assume ultimate responsibility for assuring that his/her patient has been able to obtain, and is appropriately using, any drugs and related products or equipment called for in the drug therapy plan. The pharmacist must also assure that the patient has a thorough understanding of the disease and the therapy/medications prescribed in the plan.

E. The pharmacist reviews, monitors, and modifies the therapeutic plan as necessary and appropriate, in concert with the patient and healthcare team.

The pharmacist is responsible for monitoring the patient's progress in achieving the specific outcomes according to strategy developed in the drug therapy plan. The pharmacist coordinates changes in the plan with the patient and the patient's other healthcare providers as necessary and appropriate in order to maintain or enhance the safety and/or effectiveness of drug therapy and to help minimize overall healthcare costs. Patient progress is accurately documented in the pharmacy record and communicated to the patient and to the patient's other healthcare providers as appropriate. The pharmacist shares information with other healthcare providers as the setting for care changes thus helping assure continuity of care as the patient moves between the community setting, the institutional setting, and the long-term care setting.

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Practice Principles
1. Data Collection

1.1 The pharmacist conducts an initial interview with the patient for the purposes of establishing a professional working relationship and initiating the patient's pharmacy record. In some situations (e.g. pediatrics, geriatrics, critical care, language barriers) the opportunity to develop a professional relationship with and collect information directly from the patient may not exist. Under these circumstances, the pharmacist should work directly with the patient's parent, guardian, and/or principal caregiver.

1.2 The interview is organized, professional, and meets the patient's need for confidentiality and privacy. Adequate time is devoted to assure that questions and answers can be fully developed without either party feeling uncomfortable or hurried. The interview is used to systematically collect patient-specific subjective information and to initiate a pharmacy record which includes information and data regarding the patient's general health and activity status, past medical history, medication history, social history (including economic situation), family history, and history of present illness. The record should also include information regarding the patient's thoughts or feelings and perceptions of his/her condition or disease.

1.3 The pharmacist uses health/physical assessment techniques (blood-pressure monitoring, etc.) appropriately and as necessary to acquire necessary patient-specific objective information.

1.4 The pharmacist uses appropriate secondary sources to supplement the information obtained through the initial patient interview and health/physical assessment. Sources may include, but are not limited to, the patient's medical record or medical reports, the patient's family, and the patient's other healthcare providers.

1.5 The pharmacist creates a pharmacy record for the patient and accurately records the information collected. The pharmacist assures that the patient's record is appropriately organized, kept current, and accurately reflects all pharmacist-patient encounters. The confidentiality of the information in the record is carefully guarded and appropriate systems are in place to assure security. Patient-identifiable information contained in the record is provided to others only upon the authorization of the patient or as required by law.

2. Information Evaluation

2.1 The pharmacist evaluates the subjective and objective information collected from the patient and other sources then forms conclusions regarding: (1) opportunities to improve and/or assure the safety, effectiveness, and/or economy of current or planned drug therapy; (2) opportunities to minimize current or potential future drug or health-related problems; and (3) the timing of any necessary future pharmacist consultation.

2.2 The pharmacist records the conclusions of the evaluation in the medical and/or pharmacy record.

2.3 The pharmacist discusses the conclusions with the patient, as necessary and appropriate, and assures an appropriate understanding of the nature of the condition or illness and what might be expected with respect to its management.

3. Formulating a Plan

3.1 The pharmacist, in concert with other healthcare providers, identifies, evaluates and then chooses the most appropriate action(s) to: (1) improve and/or assure the safety, effectiveness, and/or cost-effectiveness of current or planned drug therapy; and/or, (2) minimize current or potential future health-related problems.

3.2 The pharmacist formulates plans to effect the desired outcome. The plans may include, but are not limited to, work with the patient as well as with other health providers to develop a patient-specific drug therapy protocol or to modify prescribed drug therapy, develop and/or implement drug therapy monitoring mechanisms, recommend nutritional or dietary modifications, add non-prescription medications or non-drug treatments, refer the patient to an appropriate source of care, or institute an existing drug therapy protocol.

3.3 For each problem identified, the pharmacist actively considers the patient's needs and determines the desirable and mutually agreed upon outcome and incorporates these into the plan. The plan may include specific disease state and drug therapy endpoints and monitoring endpoints.

3.4 The pharmacist reviews the plan and desirable outcomes with the patient and with the patient's other healthcare provider(s) as appropriate.

3.5 The pharmacist documents the plan and desirable outcomes in the patient's medical and/or pharmacy record.

4. Implementing the Plan

4.1 The pharmacist and the patient take the steps necessary to implement the plan. These steps may include, but are not limited to, contacting other health providers to clarify or modify prescriptions, initiating drug therapy, educating the patient and/or caregiver(s), coordinating the acquisition of medications and/or related supplies, which might include helping the patient overcome financial barriers or lifestyle barriers that might otherwise interfere with the therapy plan, or coordinating appointments with other healthcare providers to whom the patient is being referred.

4.2 The pharmacist works with the patient to maximize patient understanding and involvement in the therapy plan, assures that arrangements for drug therapy monitoring (e.g. laboratory evaluation, blood pressure monitoring, home blood glucose testing, etc.) are made and understood by the patient, and that the patient receives and knows how to properly use all necessary medications and related equipment. Explanations are tailored to the patient's level of comprehension and teaching and adherence aids are employed as indicated.

4.3 The pharmacist assures that appropriate mechanisms are in place to ensure that the proper medications, equipment, and supplies are received by the patient in a timely fashion.

4.4 The pharmacist documents in the medical and/or pharmacy record the steps taken to implement the plan including the appropriate baseline monitoring parameters, and any barriers which will need to be overcome.

4.5 The pharmacist communicates the elements of the plan to the patient and/or the patient's other healthcare provider(s). The pharmacist shares information with other healthcare providers as the setting for care changes, in order to help maintain continuity of care as the patient moves between the ambulatory, inpatient or long-term care environment.

5. Monitoring and Modifying the Plan/Assuring Positive Outcomes

5.1 The pharmacist regularly reviews subjective and objective monitoring parameters in order to determine if satisfactory progress is being made toward achieving desired outcomes as outlined in the drug therapy plan.

5.2 The pharmacist and patient determine if the original plan should continue to be followed or if modifications are needed. If changes are necessary, the pharmacist works with the patient/caregiver and his/her other healthcare providers to modify and implement the revised plan as described in "Formulating the Plan" and "Implementing the Plans" above.

5.3 The pharmacist reviews ongoing progress in achieving desired outcomes with the patient and provides a report to the patient's other healthcare providers as appropriate. As progress towards outcomes is achieved, the pharmacist should provide positive reinforcement.

5.4 A mechanism is established for follow-up with patients. The pharmacist uses appropriate professional judgement in determining the need to notify the patient's other healthcare providers of the patient's level of adherence with the plan.

5.5 The pharmacist updates the patient's medical and/or pharmacy record with information concerning patient progress, noting the subjective and objective information which has been considered, his/her assessment of the patient's current progress, the patient's assessment of his/her current progress, and any modifications that are being made to the plan. Communications with other healthcare providers should also be noted.

Prepared by the APhA Pharmaceutical Care Guidelines Advisory Committee, approved by the APhA Board of Trustees, August 1995.
 

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Appendix

Pharmaceutical care is a process of drug therapy management that requires a change in the orientation of traditional professional attitudes and re-engineering of the traditional pharmacy environment. Certain elements of structure must be in place to provide quality pharmaceutical care. Some of these elements are: (1) knowledge, skill, and function of personnel, (2) systems for data collection, documentation, and transfer of information, (3) efficient work flow processes, (4) references, resources and equipment, (5) communication skills, and (6) commitment to quality improvement and assessment procedures.

Knowledge, skill, and function of personnel

The implementation of pharmaceutical care is supported by knowledge and skills in the area of patient assessment, clinical information, communication, adult teaching and learning principles and psychosocial aspects of care. To use these skills, responsibilities must be reassessed, and assigned to appropriate personnel, including pharmacists, technicians, automation, and technology. A mechanism of certifying and credentialling will support the implementation of pharmaceutical care.

Systems for data collection and documentation

The implementation of pharmaceutical care is supported by data collection and documentation systems that accommodate patient care communications (e.g. patient contact notes, medical/medication history), interprofessional communications (e.g. physician communication, pharmacist to pharmacist communication), quality assurance (e.g. patient outcomes assessment, patient care protocols), and research (e.g. data for pharmacoepidemiology, etc.). Documentation systems are vital for reimbursement considerations.

Efficient work flow processes

The implementation of pharmaceutical care is supported by incorporating patient care into the activities of the pharmacist and other personnel.

References, resources, and equipment

The implementation of pharmaceutical care is supported by tools which facilitate patient care, including equipment to assess medication therapy adherence and effectiveness, clinical resource materials, and patient education materials. Tools may include computer software support, drug utilization evaluation (DUE) programs, disease management protocols, etc.

Communication Skills

The implementation of pharmaceutical care is supported by patient-centered communication. Within this communication, the patient plays a key role in the overall management of the therapy plan.

Quality Assessment/Improvement Programs

The implementation and practice of pharmaceutical care is supported and improved by measuring, assessing, and improving pharmaceutical care activities utilizing the conceptual framework of continuous quality improvement.

This document will not cover each and every situation; that was not the intent of the Advisory Committee. This is a dynamic document and is intended to be revised as the profession adapts to its new role. It is hoped that pharmacists will use these principles, adapting them to their own situation and environments, to establish and implement pharmaceutical care.

(1)Although "drug therapy" typically refers to intended, beneficial effects of pharmacologic drugs, in this document, "drug therapy" refers to the intended, beneficial use of drugs -- whether diagnostic or therapeutic -- and thus includes diagnostic radiopharmaceuticals, X-ray contrast media, etc. in addition to pharmacologic drugs. Similarly, "drug therapy plan" includes the outcomes oriented plan for diagnostic drug use in addition to pharmacologic drug use.

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