Patient Care Process Clinical Thinking - ACPHS PDF

Patient Care Process Clinical Thinking Jacqueline Cleary, PharmD, BCACP Associate Professor Pharmacy Practice [email protected] OB210D Objectives  List and explain the components of the JCPP Pharmacists’ Patient Care Process  Identify examples of compon...

Patient Care Process Clinical Thinking Jacqueline Cleary, PharmD, BCACP Associate Professor Pharmacy Practice [email protected] OB210D Objectives  List and explain the components of the JCPP Pharmacists’ Patient Care Process  Identify examples of components of the JCPP Pharmacists’ Patient Care Process  Understand the role of clinical thinking in pharmaceutical care Pre Knowledge Check #1  Which of the following pharmacists MUST employ the patient care process: a) CVS pharmacist counseling a patient on a new BP medication b) Anticoagulation pharmacist calling a patient about a lab result c) Albany medical center pharmacist on ICU rounds d) ALL OF THE ABOVE Pre Knowledge Check #2  Pharmacists are ONLY responsible for the management of a patient’s medications? a) True b) False Patient Care  WHO  WHEN  WHAT  WHY  WHERE Joint Commission of Pharmacy Practitioners (JCPP)  “patients achieve optimal health and medication outcomes with pharmacists as essential and accountable providers within patient-centered, team-based healthcare” Pharmacist’s Patient Care Process Pharmacists’ Patient Care Process: Collect  Chief complaint (CC)  Current medication list  History of Present Illness (HPI)  Prescription and  Past Medical History (PMH) nonprescription medications  Personal and Social History  Herbals and other dietary (SH) supplements  Family History (FH)  Med history  Lab results/physical exam  Lifestyle habits, preferences & findings (review of systems- beliefs, health and functional ROS) goals, and socioeconomic factors  Health Maintenance and  Patient centered factors that immunizations affect care Pharmacists’ Patient Care Process: Collect  What is relevant?  Professionalism  Interview proficiency  Interpersonal and communication skills  Social determinants of health and their influence on Self-Care (more on this later) Pharmacists’ Patient Care Process: Assess  Assess each medication for:  Appropriateness, effectiveness, safety, and patient adherence, dose, tolerability  Assess the patient’s:  Health & functional status, risk factors, health data, cultural factors, health literacy, and access to medications and other needs  Assess for preventative care and need for other healthcare services  Immunizations Pharmacists’ Patient Care Process: Assess  TYPICALLY WHEN YOU DETERMINE IF THEY ARE A CANDIDATE FOR SELF CARE… Pharmacists’ Patient Care Process: Plan  Develop an individualized patient-centered care plan in collaboration with the patient and other healthcare professionals  Must be evidence-based and cost-effective  Address medication-related problems and optimize therapy  Set patient-specific goals of therapy  Engage patient through education, empowerment and self-management  Include follow-up Pharmacists’ Patient Care Process: Plan  Could be pharmacologic or non pharmacologic  Could be a referral to another healthcare professional  Could be a recommendation until they can be seen by an additional healthcare professional  Engage the patient! Unique Plan Example  Recommend for self-care UNTIL a primary care provider can be consulted:  NOT urgent  Immediate medical attention not needed  Example: 4 year old Gus presents today with his mom with moderate signs of dehydration. After your assessment you have concerns given, however you recommend both an oral rehydration solution to use while they wait for their appointment that is later today. Pharmacists’ Patient CareINProcess: TE Implement RP R  …execution of the developed plan OF ES SI  Address the identified problems including administration of ON vaccines AL IS  Initiate, modify, discontinue or administer medication therapy as M authorized  Opportunity to work within a collaborative practice agreement  Provide education and self-management training to patient  Coordinate care if needed (i.e. referral to another health care professional)  Schedule follow-up as needed to achieve goals of therapy Implementation Tools  COMMUNICATION IS KEY  Need patient engagement here  Teach-back method  Open ended questions Pharmacists’ Patient Care Process: Follow-up  Bring it full circle!  Monitor and evaluate the effectiveness of the care plan  Continuously monitor labs and patient feedback for:  Medication appropriateness, effectiveness, safety and patient adherence  Clinical end points that contribute to the patients’ overall health  Outcomes of care  Progress toward or achievement of therapy goals Knowledge Check #3  Which of the following is NOT an important assessment step when assessing a patient? a) Adherence b) Immunizations c) Scheduled patient follow-up d) Preventative Health Screenings Knowledge Check #4  Which of the following information is important to collect when interviewing a patient? a) Medical History b) Medications c) Allergies d) ALL OF THE ABOVE Pharmacist’s Patient Care Process Patient Centered Care  “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.” – Institute of Medicine  Collaborate  Communicate  Document (more on this later) Patient Centered Care  How would this process differ for a child?  For a pregnant or lactating patient?  For a geriatric patient? Introduction to the Patient Case Get familiar with it… Patient Case (ALPHABET SOUP)  Example:  R.R. is a 55 yo M. PMH: diabetes (DM), hypertension (HTN), peripheral neuropathy, anxiety and insomnia  SH: smoking (-), alcohol (occasionally)  FH (family history): mother- alive with diabetes; father- deceased (MI- 2008)  Allergies: penicillin's (rash)  Immunizations: UTD (up to date)  Medications: metformin 1000mg PO BID, lisinopril 20mg PO daily, gabapentin 900mg PO TID, trazodone 100mg PO QHS, furosemide 20mg PO daily  Labs:…. Patient Case  Example:  CC (chief complaint): patient presents today because his provider told him to take OTC aspirin and he wants to know which one to take Patient Case  Treatment of a chief complaint  Disease state management  Provider question  Patient counseling  Drug-information question  Etc.  YOU HAVE TO EXTRACT INFORMATION Difference between patient case presented in self care vs. other places? Standardized IPS template Patient Case Example #1  T.C. is a 33 year old male who comes to your counter complaining of an ear ache Collect  What questions do you want to ask T.C.?  He has not tried anything yet  He has no allergies  He has no significant past medical history  He does not take any medications regularly  He is up to date on his immunizations  He states he recently spent the weekend in Lake George and thinks he has water trapped in his ear  No labs are available to you Assess  What would you assess?  He has no other symptoms (ie: fever, cough)  You peer into his ear and it appears red and inflamed Plan  You make a plan to recommend  Ibuprofen 400mg PO q6 PRN for inflammation and ear pain AND  Carbamide paroxide 6.5% 5-10 drops BID for up to 4 days for ear wax removal Implement  What would you tell the patient?  What the medication is for:  How to take:  What to monitor for: 3 Prime Questions! Follow Up  When should the patient come back?  Recommend patient see a provider if the symptoms do not resolve in 48 hours OR  Immediately if he has an adverse reaction to therapy Points to Remember  Gather ALL pertinent health information  Why is the patient REALLY here  Give clear recommendations and instructions  3 PRIME QUESTIONS: (1) what are you taking it for (2) how are you taking it (3) what can you expect  Realistic and clear follow up Patient Case Example #2  A.L. is a mother of 3 presenting to your pharmacy counter today because she thinks her son has poison ivy Collect  What questions do you want to ask A.L?  Has she tried anything for him yet yet  Does her son have any allergies  Does her son have any significant past medical history  Does he take any medications regularly  Is he up to date on his immunizations  No labs are available to you Collect  A.L. states he only takes Claritin during the spring and fall for allergies to pollen  She also states he has no other allergies, significant PMH and is up to date on all of his immunizations  She is concerned he got it while outside playing at a friends house and does not want to spread the rash to her other children Assess  What would you assess?  Her son has no other symptoms  You can visibly see a red raised rash on both of the child's forearms  He reports it is very itchy Plan  You make a plan to recommend  Calamine lotion 8% apply to affected area externally as often as is needed  Diphenhydramine 25mg PO at bedtime if needed  Wash the area with mild soap and warm water as well as continue to keep the area clean and dry to avoid infection Implement  What would you tell the patient?  What the medication is for:  How to take:  What to monitor for: 3 Prime Questions! Follow Up  When should the patient come back?  Recommend to A.L. see a provider if rash continues to spread, reaches his eyes, or any other symptoms develop  Immediately if he has an adverse reaction to therapy Points to Remember  Non pharmacologic counseling points are often JUST AS important as pharmacologic counseling  Clearly communicate your recommendation to the patient (ie: verbal, written, etc.)  Collaborate with other providers if necessary Clinical Thinking  Definition  ACCP’s definition of clinical pharmacy:  “Clinical pharmacy is that area of pharmacy concerned with the science and practice of rational medication use”  Comprehensive therapeutic knowledge  Experience  Problem-solving skills  Judgment http://www.accp.com/docs/positions/whitePapers/CliniPharmCompTFfinalDraft.pdf Where are you now vs. long term goal?  Clinical Pharmacist Duties  Identify patient problems  Implement and manage patient pharmacotherapy  Dispense and administer medications as needed  Educate patients  Monitor drug therapy  Consult with other patient care providers to improve patient outcomes http://www.accp.com/docs/positions/whitePapers/CliniPharmCompTFfinalDraft.pdf Monitoring Therapy Befor Durin e g After What Questions Would you Ask?  Mrs. B is a regular patient at College Hometown Pharmacy  She comes to you this morning stating that she has had a persistent cough for the past 2 weeks that will not go away  She wants YOUR help  Take 2 minutes Make a list of questions you would ask….? Example Questions  Age  What has she tried?  Comorbidities  Does anything make it  PMH (past medical worse? history)  Does anything make it  SH (social history) better?  Medications  Quality of cough?  Allergies  Dry or wet cough?  MORE…. Conclusion  Collect -> Assess -> Plan -> Implement -> Follow Up: Monitor/Evaluate  Document ALL activities  Collaborate and communicate with other members of the healthcare team  3 prime questions  Be comfortable with reading a patient case…..  Questions? Jacqueline Cleary, PharmD, BCACP Associate Professor Pharmacy Practice [email protected] OB210D