AMBULATORY CARE SERVICES

Transcription

1 AMBULATORY CARE SERVICES Roda Plakogiannis, BS, PharmD, BCPS, CLS Associate Professor of Pharmacy Practice Arnold & Marie Schwartz College of Pharmacy and Health Sciences & Clinical Pharmacy Manager-Primary Care Montefiore Medical Group Goals of Ambulatory Pharmacy Services Optimize drug therapy regimen Consider the most appropriate and effective medication Improve patient outcomes Ensure safety, compliance and proper therapy administration Provide the highest standards of pharmaceutical care Identify, resolve, and prevent medicationrelated problems Foster a collaborative approach to medication safety among all disciplines Expand and promote excellence in pharmacy education Ambulatory Pharmacy Services Anticoagulation monitoring Cholesterol management Hypertension management Diabetes management Smoking cessation counseling HIV clinic Movement clinic Compliance Medication education Getting Your Ambulatory Service Started FIND A NEED AND FILL IT! Allow time for staff to become Pharmacy managed or familiar with you and TRUST you collaborative Presentations Choose an area that interests you Brochures, flyers, business cards Identify practitioner(s) who are interested in your services or Attend grand rounds and give grand rounds collaboration Become certified in your area of Be visible and available specialty Keep up with literature in your area Educate patients Meeting Your Goals Obtain detailed medication history Identify potential drug/nutrient/disease -drug interaction and potential drug toxicities Conduct patient interview and counseling Provide drug & disease state education to the patient 1

2 Patient Name: Montefiore Medical Center Pharmacotherapy Clinic Clinic hours: Tues/Wed/Friday 10am to 12pm Dr. Roda Plakogiannis Medication Trade/Generic Strength Indication Morning Lunch Evening Bedtime Comment Anticoagulation Clinic Protocol Goals of Anticoagulation Clinic Provide safe, effective, and efficient medical management for patients on long-term and short-term anticoagulation with warfarin Utilize PharmDs to manage patients dosing and continued education about anticoagulation Provide a stable group of health care providers to work with patients to manage their anticoagulation therapy Increase the percentage of patients whose INR are in the therapeutic range Reduce time needed to achieve therapeutic INR Minimize complications of anticoagulation therapy Your clinic next appointment: Protocol: Scope of Anticoagulation Clinic Management of anticoagulation (warfarin only) Decisions about dose changes of warfarin will made by PharmD, who will consult with PCP on an as needed basis Criteria for Patient Referral Patients will be referred to pharmacotherapy clinic by PCP Patient must be willing and able to participate in Anticoagulation Clinic and follow instructions or have an advocate/guardian/health care giver who can assume responsibility for this Patient must have means of communication (telephone, address, or phone number of a neighbor, relative or guardian) Protocol: Patient Tracking All Anticoagulation Clinic visits will be recorded in patient chart Once stable, all patients must have INR check every 4-6 weeks at maximum exceptions can be made on an individual basis For patients with INR outside the therapeutic range, follow-up will be more frequent (based on guidelines) Will review No-Shows and attempt to reach patient by telephone, and/or letter Protocol: Flow of Clinic Visit Review current Rx and compliance Assess for bleeding complications Review diet Check for medication/nutrient/disease interactions Remind patient to inform clinic about new medications (including OTC, herbs, prescribed meds) Remind patient about how to contact clinic or PCP for any symptoms, problems, questions Review changes, if any, to warfarin dose Document all information in patient chart Schedule follow-up visit 2

3 Steps to a Successful Ambulatory Care Clinic Identify and resolve polypharmacy issues Provide pharmacokinetic dosing consults Improve medication adherence Communicate with health care professionals regarding drug therapy Decrease disease and drug Complications Improve QOL and overall patient well being Montefiore Pharmacotherapy Clinic Referrals: anticoagulation, diabetes, hyperlipidemia, hypertension, noncompliance, and other chronic diseases Review patient charts Make pharmacotherapy recommendations using evidence based guidelines Patient counseling Document visit in patient chart utilizing FARM note Anticoagulation dose adjustments (collaborative agreement) Recommendation(s) on optimizing drug therapy Date: PharmCare Clinic Anticoagulation Assessment PCP: F: Pt name: MR# Age: 75 y/o Ethnicity: AAF Allergies/ADR: accupril induced cough Alcohol/Smoking: denies/denies Indication: 2nd episode of DVT PMH: HTN, seizure disorder, hepatitis, hyperlipidemia, asthma, osteoarthritis, CRI, gout Duration: indefinite S/S of bleeding/bruising: denies Missed doses: denies Capillary INR: Target INR: 2.0 to 3.0 Current Dose: 7.5 mg on Mon/Wed/Friday 15mg (2 tablets) other days (TWD: 82.5 mg) OTC/herbal supplements: denies Potential drug/nutrient/disease interactions: PHT and warfarin Morning meds: Phenytoin sodium ER 100 mg 1 BID Paroxetine 10 mg daily Altace 5 mg daily Diovan 160 mg daily Furosemide 40 mg daily Amlodipine 10 mg daily Atenolol 100 mg daily Pletal 100 mg bid Afternoon meds: Evening meds: Warfarin 7.5 mg UD Lipitor 20 mg daily Phenytoin sodium ER 100 mg 1 BID Colchicine 0.6mg 1 daily Pletal 100 mg bid PRN meds Nitroglycerin PRN chest pain Albuterol inhaler 1 inhale PRN Ranitidine 150 mg daily Diphenhydramine 50 mg Date INR Regimen mg Mon/Fri; 15mg (2 tablets) all other days (TWD: 90 mg) TWD: 90 mg mg (2 tabs) daily (TWD: 105 mg) mg on Mon/Friday; 15mg (2 tablets) other days (TWD: 90 mg) TWD: 82.5 mg TWD: 82.5 mg mg on Mon/Wed/Friday 15mg (2 tablets) other days (TWD: 82.5 mg) mg Mon/Wed/Fri; 7.5 mg all other days (75 mg) mg Mon,Tues; 7.5 mg all other days (TWD: 67.5 mg) TWD: mg mg daily (TWD: 52.5 mg) TWD of mg mg (2 tablets of 7.5 mg) on Mon/Fri; 7.5mg (1 tablet) on all other days (TWD of 67.5 mg) 10/26/ mg (1.5 tablet) on Mon/Wed/Fri; 7.5mg (1 tablet) on all other days (TWD of mg) 10/19/ mg (1.5 tablet) Tues/Thurs; 7.5mg (1 tablet) on all other days (TWD=60mg) 10/09/ mg (1.5 tablet) x2 days; 7.5 mg all other days (TWD=60mg) 3

4 Date BP Pulse ABW IBW CrCl TSH PHT / /80 (L) / mg/dl / ml/min TC LDL HDL nonhdl TG AST/ALT Tbili Dbili / Na K BUN Scr BS Hba1c Albumin Uric Acid FARM : Assessment DVT: Goal INR is 2.0 to 3.0; INR today is therapeutic (2.3). Pt denies missing any warfarin dose(s) or change in medication regimen. Per Dr. Smith patient is to take 7.5 mg Mon/Fri; 15mg (2 tablets) all other days (TWD: 90 mg). Compliance: Filled up medication boxes for four weeks. Pt will be returning to clinic and pharmacy resident will continue to fill up weekly medication boxes to assist in compliance. a.atenolol not placed into med boxes, since pt reports that she was instructed to hold her atenolol d/t upcoming scheduled allergy exam HTN: Goal BP < 140/80 mmhg. BP today is above goal(145/70mmhg). Pt denies headache, peripheral edema, fatigue, cough, and/or lightheadedness. Pt has been instructed to hold the atenolol d/t an upcoming allergy test(?)-perhaps the reason for her elevated BP and reports to have not taken any BP medication this morning. FARM : Assessment Lipids: Goals: TC<200, LDL <130, HDL >50, TG < 150. Per most recent lipid panel, pt is at goal with the exception of the total-c and TG, which are above goal. Will reassess in one month. Anticipate an improvement, d/t increase medication compliance. Seizure:Pt denies having any episodes of seizures. Will continue PHT 100 mg BID. Asthma: pt reports to utilize advair appropriately (1 puff bid); and reported no need for albuterol. Gout: Pt denies any gouty attack. Flu shot: (+) Next visit: April 25,

5 Become A Specialist Board Certified Pharmacotherapy Specialist (BCPS) Diplomate of the Accreditation Council for Clinical Lipidology (ACCL) Clinical Lipid Specialist (CLS) 5