Community Pharmacy - Overview PDF

COMMUNITY PHARMACY Outline Introduction Issues in community pharmacy practice Organization of a community pharmacy Services of the community pharmacy Other professional services Epilogue 2 1. Introduction A community pharmacy is a premise regis...

COMMUNITY PHARMACY Outline Introduction Issues in community pharmacy practice Organization of a community pharmacy Services of the community pharmacy Other professional services Epilogue 2 1. Introduction A community pharmacy is a premise registered and licensed by an appropriate government agency for the provision of pharmaceutical services to the general public. Community pharmacist is the professional who would be in direct access to the public and whose duties are widely sought after by the public and patients. 3  Introduction Community pharmacies are very frequently the first contact with the health system, due to Ease of access Convenient Extended opening hours Availability of medicines 4  Introduction Considerable proportions of pharmacists work in this sector (FIP, 2006; B/Mariam, 2010) Overall = 57 % Western Pacific/SE Asia = 51% Europe = 71% Pan America = 66 % Africa / Eastern Mediterranean = 66 % Ethiopia = 19 % 5 Table: Number of community pharmacies and their per capita distribution in selected countries * this figure decreases to 25,712 if drug stores and rural drug vendors are included Country Total number of Community community pharmacy per pharmacies inhabitant Australia 4926 3980 England 9872 5000 Estonia 523 2486 Germany 21,400 3900 Japan 49,956 2600 Kenya 611 55647 Peru 10,000 2722 United States 55,400 5380 Ethiopia 290 286,206* 6  2. Issues in community pharmacy practice o Useful additional business courses: management (personnel, supply chain, finance, marketing), entrepreneurship economics Ownership issues: pharmacist vs. non-pharmacist independent/chain 7  Issues in community … Independent Pharmacy: single Opportunities exist to be: an owner and run the pharmacy, an employee working for the owner/manager. a part-time employee interested in staying in touch with community pharmacy practice,  Ethiopia: approx. 250 independent outlets 8  Issues in community … Chain (multiple) pharmacy: 12 to hundreds and up to thousands of pharmacies Are usually for profit/business corporations with opportunities for multiple jobs: distribution, marketing, and operations 9  Issues in community … oChain (multiple) pharmacy: Ethiopian scenario ◦Kenema Pharmacies (under the AA City Administration): > 20 outlets in Addis Ababa ◦Red Cross Pharmacies (under the ERCS): outlets all over the country 10 Issues in community … Globally: Example is Rite Aid in the US ◦3rd largest drug store in the US ◦ranked #100 on Fortune 500 Largest U.S. Corporations in 2011 ◦reported revenue of $26.3 billion in 2009 ◦4703 locations all over the US and 54,600 employees 11  Issues in community … Products sold: human pharmaceuticals (POM, NP/OTC), veterinary pharmaceuticals herbal/alternative medicines, Cosmetics and sanitary products food items and others Ethiopian setting: different types of retail outlets community pharmacies/drug stores/rural drug vendors (http://fmhaca.gov.et/Documents/Retail outlets guideline.doc) 12  3. Organization of a community pharmacy Human resource ◦Pharmacists (chief/manager and others) ◦Pharmacy technicians, ◦Other support staff (cashier, accountant, cleaner, guard). ◦Pharmacist(s) and other staff on duty must wear a name tag or badge indicating his/her name and designation. ◦Ongoing program to ensure staff development 13 Minimum standards for pharmacy premises, facilities and equipment Appearance of pharmacy premises Design and layout: ◦Permit logical flow of work, effective communication and supervision and ensure effective cleaning and maintenance ◦Minimize the risk of errors, cross-contamination and anything else which would have an adverse effect on the quality of products. 14  Minimum standards  All parts of the premises must be maintained in an orderly and tidy condition.  The external appearance of the pharmacy must portray a professional image.  Entrances, dispensing counters and doorways must be accessible to disabled persons. Security in pharmacy premises  Careful consideration must be given to the overall security of the pharmacy.  Control of access to medicine. 15 Minimum standards Safety of pharmacy premises ◦Fire extinguisher ◦Electrical equipment → safe and maintained regularly. 16  Minimum standards Condition of pharmacy premises oThe walls, floors, windows, ceiling, woodwork and all other parts of the premises →clean and good condition. oCountertops, shelves and walls →finished in a smooth, washable and impermeable material. oSite of premises ◦Far from areas or premises that can cause contamination to the products and affect health in general (e.g. public toilets, waste dump site) 17  Minimum standards Construction of pharmacy premises Prevent: ◦floods ◦entry of insects, animals or birds Easily cleaned and disinfected Allows adequate lighting and air movement Ceiling: ◦Type that minimizes effects of high temperatures ◦Adequate height 18  Minimum standards Environment in pharmacy premises Products stored according to recommended conditions Levels of heat, light, noise, ventilation, etc., must exert no adverse effects on pharmaceutical stock as well as personnel. Suitable and effective means of heating or cooling, lighting and ventilation. Background music or other broadcasts → distraction 19  Minimum standards Hygiene in pharmacy premises Regular program for cleaning premises Area for washing equipment and other utensils (hot and cold tap water). Toilet facilities must be kept clean and in good order. Hand-washing facilities 20  Minimum standards Premises Dispensaries The size of the dispensary: allow a safe and efficient flow of work and effective communication and supervision configuration of available space and space available elsewhere for storage of stock. Waiting area Comfortable seating must be provided. Appropriate health-related literature must be provided 21  Minimum standards Ethiopian guideline: 25m² minimum for dispensary and waiting area with shortest side not less than 4 m. Kenyan guideline: 7.42(2.72 each) for dispensary and 9.3(3 each) for general business area. South African guideline: a clear working surface area of at least 90 cm by 1 m (1m²) for each pharmacist or other registered pharmacy personnel. 22  Minimum standards Suitability of dispensary The temperature in the dispensing area must be maintained below 25°C. 23  Minimum standards Counseling area The area(s) must ◦Be easily accessible and, where possible, be close to the dispensary. ◦Ensure reasonable privacy to the patient at all times and eliminate background noise as far as possible. ◦Have sufficient space →appropriate counseling and demonstration of the correct and safe use medicines. 24  Minimum standards Three types of areas may be considered for the pharmacy, depending on the: ◦ services offered by the pharmacy and ◦ degree of privacy required. The models are: ◦ semi-private area ◦ separate private area and ◦ consultation area for the provision of screening and monitoring services 25  Minimum standards Semi-private area ◦This area is for the provision of information and/or advice that may occur in an area visible to other patients. ◦In such an area, patient counseling may take place in a professional manner regarding medicine use and other relevant information, ◦Does not provide the privacy required to advise patients on sensitive issues. 26 Counseling area -Semi-private area 27 Counseling area: Semi-private area 28  Minimum standards Separate private area ◦a small private room within the pharmacy, which is in close proximity to the dispensary. ◦the area should be professionally planned, professionally furnished and equipped, ◦allows the pharmacist to counsel patients on: ◦Sensitive, emotional or health care problems and ◦their medicines, and other related issues. 29 Counseling area -Private area 30  Minimum standards Consultation area for the provision of screening and monitoring services ◦an isolated area within which the pharmacist can ◦consult in private with a patient and/or ◦perform certain screening and monitoring services, e.g. cholesterol tests or blood pressure monitoring. 31  Minimum standards Storage areas in pharmacy premises ◦Self-contained and secure ◦Large enough → orderly arrangement and proper stock rotation ◦Separate storage area for stocking veterinary pharmaceuticals ◦Sufficient shelving Ethiopian guideline:16 m² (4m each) minimum for storage with shortest side not less than 3m. 32  Minimum standards Compounding room ◦Must be of suitable size (Ethiopian guideline minimum of 9 m² size and shortest side not less than 2.5 m. ◦Must have a suitable bench, shelves, washing sink ◦Appropriate references ◦Equipments, apparatuses, chemicals and appropriate materials s 33  Minimum standards Office ◦ secretarial and managerial activities with appropriate furniture and equipment ◦ stock recording and other relevant documents (if applicable) ◦ Telephone and other communications technology Staff room ◦ Cloak room ◦ Tea room 34  Minimum standards Other issues Waste disposal → standard operating procedures (SOPs) ◦Suitable and adequate means in written form Dispensing equipment and materials ◦Adequate, suitable dispensing equipment. ◦Maintained clean, in good repair and of suitable material. Common ones include: ◦Tablets and capsules counting tray/apparatuses. 35  Minimum standards Technology: specialized software: manage the stock of pharmaceuticals and other supplies fills and labels each prescription, processes the sales transaction checks for medication errors, for the management of patients with particular disease states such as diabetes Electronic prescribing 36  Minimum standards Reference sources Current editions recommended: ◦Martindale; ◦Drug interactions reference source; ◦a comprehensive textbook on pharmacology/pharmacotherapy; ◦Standard Treatment Guidelines and Essential Drug List for the appropriate level of care. ◦A pediatric dosing reference guide (where applicable); ◦A medical dictionary; 37  Minimum standards ◦the latest copy of the Pharmacy legislation; ◦Code of ethics ◦Good dispensing practice manual; ◦Pharmacopoeia (BP, USP) (where applicable); ◦Electronic access to the required references is also acceptable in some countries. 38  4. Services of The Community Pharmacy The major work of community pharmacists involves supplying medicines to the public…..Dispensing Dispensing refers to the process of preparing drugs and distributing them to their users with provision of an appropriate information. Good dispensing practices ensure that the correct drug is delivered to the right patient, in the required dosage and quantities, with clear instructions, and in package that maintains an acceptable potency and quality of the drug. 39  SERVICES/dispensing The dispensing process involves correct interpretation of the prescription or oral request accurate preparation and labeling of drugs with provision of appropriate information. 40  SERVICES/dispensing Dispensing procedures Step 1. Receive and validate prescription or verbal request Step 2. Understand and interpret prescription Step 3. Prepare items for issue Step 4. Issue drugs to patient with clear instructions and advice Step 5. Recording, documentation and reporting Step 6. Filing 41  SERVICES/Medication information Medication information and advices Medication information and advice is of vital importance in the correct use of medicines It must respect patient autonomy, improve health and enhance the outcome of medical treatment by: ◦ empowering consumers to make informed decisions about their treatments and take responsibility for their own health care; ◦ improving communication between patients and health care providers s 42  SERVICES/Medication information GENERAL CONSIDERATIONS Pharmacists must:  give advice and information to patients on how to use medicines safely and effectively to maximize therapeutic outcomes. Care must be taken to assess the wishes of the prescriber and the information and counseling needs of individual patients. 43  SERVICES/Medication information Supplementary written information must be used (as appropriate). The pharmacist must assess each patient's ability to understand the information. Confidentiality of the patient must be respected. The provision of advice must take place in a suitable environment. 44  SERVICES/Medication Information Counseling may be defined as “a one-to-one interaction between a pharmacist and a patient and/or caregiver. Steps for counseling a patient on a new prescription  Introduce yourself and identify the patient.  Ask patient to talk with you about the medication.  Update the patient medication profile.  Assess the patient's understanding of his/her disease and expected outcomes of therapy.  Assess patient’s knowledge about the newly prescribed drug and the reason it was prescribed.  Assess patient’s knowledge on how to take the medication as well as its potential adverse effects. 45  SERVICES/Medication information  Discuss on any of the above as per the requirements of the patient/care giver.  Discuss any additional required information.  Ask the patient about any unaddressed concerns or questions  Check patient understanding of the information discussed in the counseling session.  Written instructions  Closing the session. 46  SERVICES/Medication information COUNSELING PATIENTS ON THE USE OF REFILL PRESCRIPTIONS A refill counseling session should concentrate on the following three areas: ◦Confirm that the patient has been taking the correct medication and knows the indication for its use. ◦Ask how the patient has been taking the medication. ◦Ask how the medication is working for the patient. 47  SERVICES/compounding GOOD COMPOUNDING PRACTICE (GCP) Definition Compounding is the preparation of a customized prescription medication to meet the individual patient needs in response to a licensed practitioner's prescription. Why Compounding? 48 SERVICES/compounding Problem Solving… ◦Unavailable Strength/Dosage Form/Route of Administration ◦Unavailable Medications (limited use, short shelf life, etc.) ◦Sensitivity to Dyes, Fillers, Preservatives 49 SERVICES/compounding Basic components of GCP ◦Personnel ◦Facilities ◦Equipment ◦Ingredients ◦The compounding process ◦Packaging and labeling ◦Stability and beyond-use date ◦Records and reports 50  SERVICES/compounding PERSONNEL Pharmacists Pharmacy technicians Supportive staff Appropriate education, training, and proficiency. Proper maintenance, cleanliness, and use of all equipment Only medically fit personnel partake in compounding 51  SERVICES/compounding FACILITIES Site Appropriate for the purpose of preparing quality product. Isolated from potential interruptions, sources of contaminants of any type. Located sufficiently away from dispensing and counseling functions and high traffic areas. Service and utilities Water (acceptable quality); electricity; drainage system; Working tables, laboratory chairs and shelves Fire extinguisher; Temperature and humidity control, if necessary Toilet facility; adequate washing facilities Resting/staff room 52  SERVICES/compounding  Compounding room  Walls, floor, ceilings shall be painted, smooth, washable and have no cracks or holes.  The actual working area should be, non-shedding, free of cracks, holes and dust- collecting overhangs.  Adequate space for the orderly placement of equipment, materials and for compounding.  Cleaning on regular schedules and according to SOPs  Restricted access  All unrelated activities are prohibited in the room 53  SERVICES/compounding EQUIPMENT Appropriate design, adequate size, and suitably located to facilitate operations. Non-interacting, non-additive and non-absorbing. SOPs should be followed for storage, inspection, calibration, use, maintenance and cleaning of the equipments. 54  SERVICES/compounding INGREDIENTS  Stored according to the manufacturers’ directions or the specifications on official monographs  Should meet official compendial requirements  Strength, quantity and expiry date of each ingredient, and any sign indicating stability problem should be checked prior to compounding.  When commercial drug products are used, the effect of excipients in the product on the stability and bioavailability of the preparation should be considered. 55  SERVICES/compounding THE COMPOUNDING PROCESS  Validate the prescription  Check that the ingredients are available in desired quality and quantity  Perform calculations  Sign and date the prescription  Identify the equipment needed  Wear the proper clothing and wash hands.  Clean the compounding area and the equipment  Only one prescription is compounded at a time  Assemble all the necessary materials/ ingredients for compounding 56  SERVICES/compounding SOPs shall be followed for the following operations: Weighing/measuring Mixing of ingredients Labeling the preparation Entering information in the compounding log Cleaning (room, equipment, containers) Final check before the preparation is being dispensed Calculated yield vs. the actual yield Physical characteristics Quality tests, when appropriate The beyond-use date Label Documentation 57  SERVICES/compounding PACKAGING AND LABELING Standard type of packaging material to maintain the stability of the product Patient-friendly package Containers and closures cleaned according to SOPs The label on bulk preparations: Name, strength and quantity of the product Date of preparation Batch number/control number Storage condition Name and address of the compounding institution 58  SERVICES/compounding The label on compounded preparations for individual patient:  Name and address of the patient  Name, strength and total quantity of the preparation  Control number/batch number of the prod  Beyond-use date  Directions for use  Storage condition  Special precautions  Name and address of the pharmacy 59  SERVICES/compounding STABILITY AND BEYOND-USE DATE Compounded drug preparations are used immediately or stored for a very limited time. Stability evaluation and expiration dating are different from manufactured drug products Beyond-use date/ ‘discard after date’ is used, instead of the expiration date 60  SERVICES/compounding The beyond-use date is defined as that date after which a dispensed product should no longer be used by a patient. All the available stability information should be consulted and a conservative estimate be made for the product Source of information: expiry date of similar commercial products manufacturer’s literature contacting the manufacturer published stability studies compiled source of stability data books 61  SERVICES/compounding  In the absence of stability information, the following general guideline can be used: Solids and non-aqueous liquids prepared from commercially available dosage forms - 25% of the remaining expiration date of the commercial product, or 6 months, whichever is earlier Solids and non-aqueous liquids prepared from bulk ingredients - up to 6 months Water-containing formulations (prepared from ingredients in solid form) - up to 14 days All other formulations - up to 30 days or the intended duration of therapy, whichever is earlier. 62  SERVICES/compounding RECORDS AND REPORTS Content of compounding records for products: ◦ Bulk preparations ◦ Compounded preparations for individual patients 63 SERVICES/Record keeping Record keeping Must be both accurate and up-to-date. ◦Compounding record ◦Prescription Registration ◦Patient medication records ◦Stock records ◦Health-screening related ◦Others 64  SERVICES/Record keeping Compounding record The compounding information is recorded on the compounding log/compounding sheet Content of compounding records for products prepared on individual prescription: Date of preparation. Control number Source, batch number and expiration date of all components Complete formula, methodology and equipment used. Quantity prepared Container used 65  SERVICES/Record keeping ◦Beyond-use date ◦Signature or initials of pharmacist or supportive person performing the compounding function Recording of the compounding prescription ◦Patient identifiers ◦Diagnosis or ICD code number ◦Description of the preparation ◦Control number ◦Signature or initials of the dispenser 66  SERVICES/Record keeping Other Records related to compounding ◦ Records related to receipt, stock and distribution of ingredients and finished products ◦ Equipment maintenance records ◦ Quality control tests, checks and procedures; certificate of analysis of ingredients ◦ Records related to cleaning and sanitation of the compounding facility, equipment and containers 67  SERVICES/Record keeping Patient medication records  Patient medication records must be developed, preferably using computer technology.  Patient medication records must respect the patient's privacy.  The following information must be captured in a patient medication record: the full name of the patient; the address and telephone number of the patient; the patient's date of birth; 68  SERVICES/Record keeping ◦the patient's sex; ◦Current weight of the patient; ◦the name of the prescriber and date of consultation; ◦any known allergies of the patient; ◦idiosyncrasies or negative reactions of the patient towards medicine; ◦family history; ◦the presence of other factors, e.g. smoking, drinking, etc. ◦chronic conditions, disease states or other relevant conditions of the patient; 69  Patient medication record date prepared:________________ name:______________________sex: ______ date of birth: _____________ weight______ pharmacist name: _____________________________ phone: __________________ primary physician name: ______________________ phone: ____________________ adrs (if known):_______________________________________________________ medication allergies (if known):___________________________________________ medical conditions (if any): ______________________________________________ social history: smoking : ______________alcohol drinking : ____________________ caffeinated beverages : ____________________others: :_______________________ family medical history:___________________________________________________ list of medications (including non-prescription and herbal products): ____________________________________________________________________________________________ MEDICATION DOSE DIREC-TIONS PURPOSE FOR PRESC-RIBER START STOP REMARKS NAME USE DATE DATE 70  SERVICES/Record keeping Patient medication records must: be readily retrievable by manual or electronic means; enable the pharmacist to identify medicine dispensed previously and known disease conditions; and enable the pharmacist to determine the impact of medicine dispensed previously and known disease conditions upon the newly submitted prescription or other medicine sold or supplied to the patient. The pharmacist must ensure a system is in place to guarantee the confidentiality of data relating to individual patients. 71  SERVICES/sops Standard operating procedures (SOPs)  A SOP is a written document that specifies what should be done, when, where and by whom. help to assure the quality of the service help to ensure that good practice is achieved consistently enable pharmacists to delegate more readily and may possibly free the pharmacist’s time for other activities help to avoid confusion over who does what and clarify roles within the pharmacy provide advice and guidance to locums and part-time staff provide useful training tools for new members of staff provide a contribution to the audit process. 72 SERVICES/sops The main part of the document includes: ◦stapes of the process – describe how the task is to be carried out step by step ◦responsibility – who is responsible for carrying out each stage of the process ◦other useful information – is there any other information that could usefully be included in the procedure? Does the SOP incorporate mechanisms for audit? 73  SERVICES/public health Public health is part of the community pharmacist’s roles:  Disease prevention  Health promotion Promoting healthy lifestyles consists of two separate areas:  prescription-linked intervention  involvement in public health campaigns. Prescription-linked intervention involves offering opportunistic advice on public health topics to patients that present a prescription. 74  SERVICES/public health Promotion of healthy lifestyles will include offering advice in the following areas: ◦Sexually transmitted diseases (STDs) and HIV/AIDS ◦Infectious diseases such as malaria, URTIs and diarrheal diseases ◦Family Planning and child care ◦Antimicrobial resistance (AMR) ◦Cardio Vascular Diseases, Cancer, Diabetes and other No- communicable disease ◦Health issues: Smoking Cessation, Alcohol intake, nutrition advice and increased physical activity, etc. ◦Other conditions 75  SERVICES/public health The verbal advice should be backed up by written information such as leaflets and posters can be used in the waiting area Advice given will be recorded on the patient’s pharmacy record which allows: ◦follow up of progress of individual patients, ◦follow up the consultation with further advice, and ◦facilitate audit of this service. 76  SERVICES/responding to symptoms Responding to symptoms: is an important role that Community Pharmacists should play a great role. It is assessing the patients symptoms and providing appropriate interventions(if minor dispensing OTC drugs and if not referral to physicians) Advice on appropriate OTC medicines for symptomatic relief in the case of self-limiting minor illnesses and common complaints. Members of the public sometimes expect all OTC medicines to be completely safe for them to take. 77  SERVICES/responding… The patient's need to ask for a particular OTC medicine/self-medication may arise due to several factors: Influence of advertisements or the media. Recommendations by friends or relatives. Prior use for similar conditions. Inability to go to a physician for various reasons such as Cost factor. Lack of time. Unavailability of a doctor. The feeling that their condition is simple enough to be treated with OTC medicines. 78  SERVICES/responding… Skills required may be:  Communication skills  Clinical skills  Knowledge of current OTC medication  Directing/referral What the pharmacist can do:  Enquire whether the patient knows the correct use of the medicine.  Get into a conversation so that you can ask the patient to tell you the symptoms for which he/she wants the particular OTC medicine. 79  SERVICES/responding…  Enquire whether the client is taking any other medicines.  Enquire whether the client suffers from any other illness/conditions.  Assist the patient in selecting an OTC medicine suitable to his symptoms and also check that it is not contraindicated for the illness/condition of the patient, and is not likely to interact with other medicines being consumed. Inform the patient  How to take.  How much to take (maximum permissible daily dose).  When to take; for how long to take. 80  SERVICES/responding…  Any adverse drug reactions observed.  Any side effects likely to occur.  Any precautions to be taken.  To see a physician if the condition does not improve in a few days or if it worsens. Further reading Blenkinsopp A, Paxton P, Blenkinsopp J (2009). Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition, Blackwell Publishing Ltd. Oxford. 81  Other professional services Emergency hormonal contraceptives (‘morning-after-pill’).  Emergency contraception (EC) refers to contraceptive methods that may be used in the first few days after unprotected sexual intercourse, to prevent unwanted pregnancy.  It potentially reduces unintended pregnancy and (unsafe) abortion rates.  Pharmacies are ideally placed to provide this service and increase access to the service.  Effectiveness of ECs (within 72 hrs to 120hrs)  C/I: Confirmed pregnancy  Counseling  Appropriate use of EC  Effective, ongoing contraceptive use 82  Other professional services Health screening and Monitoring:  Body weight and height;  Blood pressure;  Blood glucose;  Pregnancy;  Cholesterol;  Peak flow test;  HIV Requirements: facilities and training Appropriate public health education and counseling 83  Other professional services First aid provision  Emergency treatment of wounds; bone fractures; burns; bleeding; foreign objects in nose, ear, eye and respiratory system; severe diarrhea; high fever; poisoning and snake bite; etc. Adverse drug reaction detection and reporting (Pharmacovigilance) Report suspected adverse drug reactions (ADRs) to the regulatory body (e.g. Food, Medicines and Healthcare Administration and Control Authority, FMHACA) For new drugs that have received market authorization in the last 2 years) for which any suspected ADRs should be reported All other drugs, for which only serious suspected ADRs should be reported. 84  Other professional services Nutrition advice (diabetes, hypertension, pregnancy, etc.) Site for training of pharmacy students Drug information services  General public  Healthcare providers Immunization services  travel,  childhood,  tetanus, etc. 85  Other professional services Smoking cessation services Pharmacies are recognized as being well placed to offer a smoking-cessation service as they are readily accessed by the public and have a resident healthcare professional. Pharmacists are involved routinely in brief interventions as part of the essential service promoting healthy lifestyles. 86  Other professional services Initial and follow up consultations ◦Nicotine replacement therapy (NRT) ◦NRT delivers nicotine in a clean form and helps smokers to overcome withdrawal symptoms such as irritability and craving while avoiding the many harmful chemicals in tobacco and the carbon monoxide that cause serious damage. ◦There are many different forms of NRT available including patches, gum, sublingual tablets, lozenges, inhalators and nasal spray.s 87  Other professional services  Medication therapy management (MTM) Medication Therapy Management (MTM) officially recognized by the US Congress in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA 2003). Requirements for MTM Programs are “designed” to “optimize therapeutic outcomes through improved medication use” and “reduce the risk of adverse events, including adverse drug reactions.” Objectives are to increase patient adherence, prevent drug complications, and enhance patient understanding of their medication therapy. 88  Other professional services ◦An MTM program established for targeted beneficiaries such as those ◦who have multiple chronic disease states (number and type determined by the plan sponsor), ◦are taking multiple drugs (number determined by the plan sponsor), and ◦are likely to incur high annual costs. 89  Other professional services  Core elements for MTM services  Medication therapy review,  Personal medication record,  Medication-related action plan  Intervention and/or referral, and  Documentation and follow-up Assignment: Discuss in detail about the 5 core elements for MTM services? 90  6. Epilogue High proportion of pharmacists work in community pharmacy practice which has a huge potential in terms of:  serving the health needs of the population and  practice area for pharmacists There is a need to attain and maintain standards of human resources, premises, facilities and services. 91