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Developing Pharmaceutical Care Plans for Desired Outcomes
Developing Pharmaceutical Care Plans for Desired Outcomes The planning process can be built
into busy practice settings. by Dennis J. McCaliian, PharrnD, Bruce C. Carlstadt, PhD, and Michael T. Rupp, PhD
Learning Objectives Upon successful completion of this continuing education article, the pharmacist should be able to: • Describe a pharmaceutical care plan and explain how it is used. • Develop a pharmaceutical care plan for use in a community or institutional practice and illustrate the similarities of pharmaceutical care planning in both settings. • Discuss methods to integrate pharmaceutical care plans into a busy practice setting. • Identify therapeutic outcomes for patients with chronic di ea e using case study examples. • Explain the importance of outcomes assessment in pharmaceutical care. • List five types of outcomes that phannacists can monitor to evaluate therapy.
Program Preview A pharmaceutical care plan (PCP) is a vital component of the practice of pharmacy and of comprehensive phannaceutical care. This article illustrates a consistent methodology for formulating and implementing these plans and integrating the planning process into a busy community or institutional practice setting. Identification of therapeutic outcomes and appropriate mOnitoring parameters for patients with chronic diseases is also demonstrated through case study examples.
Journal of the American Pharmaceutical Association
Introduction
initiated, monitored, and m di.fi d
macists to identify, defin
int rv n CE Credit
CE Credit 1;'0 obtain two hours of contimr ing education credit (0.2 CEO) for c;ompleting "Developing Pharmaceutical Care Plans for Desired Outcomes," complete the assess'ment exercise and CE registration fottn and return it to APhA. A certificate will be awarded upon achieving a passing grade of 700/0 or better. Phannacists completing this article by April 30, 1999, can receive credit.
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The American Pharmaceutical
ll\ssosjJObion is approved by the American Council on Phannaceutical EducaIion as a provider of continuing pharmaceutical education.
~ APbA provider number is: '
el ping Phannaceutical Out Plans li r ired Outcomes" is part f th Dynami ofPhamJac uti al Care: Enriching Patients' Health ri for phannacists that appears in thejournal of the American Pbanruu;eutical ASSOciation. Developed by APhA, the ri is edited by Janet P. Engle, PhannD FAPhA, acting associate dean for academic affairs and clinical proli r of pharmaCY pra~ tice, University of Dlinois at Chicago, and supported by an educational grant from Merck Hrunan Health DiviSion. The Dynamic of Pharmaceutical Care: Enriching Patients' Health series was fonnerty known as the Value Added Service serie .
Apri1199 6 voL NS3
6N~ ,I
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process of resolving patient-specific problems. This process then provides a foundation for evaluating patient outcomes.
The Pharmaceutical Care Plan Nurses have prepared patient care plans for many years. Indeed, the nursing literature is replete with books and articles on the importance of care plans, and includes a recent article on computerized nursing care plans. 1 Respiratory therapists have also been involved in the preparation of respiratory care plans, which were recommended as a mechanism to reduce costS. 2 A basic tenet of phannaceutical care is the provision of pharmacy services to attain positive patient outcomes. 3 Therefore, it would seem obvious that, like these other health care professionals, the pharmacist should anticipate, plan for, monitor, and document outcomes in a systematic way. Reports on the recent Scope of Phannacy Practice Project, which was conducted by the Professional Examination Service, Inc., from 1992 to 1994, indicate that the formulation and ongoing evaluation of a patient-specific therapeutic plan are functions of providing pharmaceutical care. 4 Johnson and Rearson discuss the importance of giving phaffilacists-and all other health care professionals involved in patient-focused care- the authority to create care plans and document progress.5 Table 1
Selected Disease-Related Outcomes for Patients with Diabetes Mellitus Biologic/Physiologic function • Bl ood glucose. • Hemoglobin A1C. • Nephropathy. • Retinopathy. • Death. Symptom measurement • Neuropathy. • Gastroparesis. • Polyuria. • Polydipsia. • Polyphagia. Patient functioning • Functional status. • Health-related quality of life. UtilizationlEconomic • Physician office visits. • Emergency department visits. • Hospitalizations and lengths of stays. • Days of disability attributable to diabetes. • Referrals to specialists. • Medication compliance.
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However, a review of the literature reveals few documented instances of pharmaci t-prepared care plans for individual patients. 6,7 Although the Joint Commission on Accreditation of Healthcare Organizations requires pharmacists in home care practice to prepare care plans for their patients,8 there is no documentation of these plans and their effects on patient outcomes. Gold and Fedder advocate the philosophy of PCP preparation by the pharmacist but do not provide specific instances or practice settings in which PCPs should be used. 7 On the other hand, Johnson et al. have reported on the use of PCPs for their home intravenous therapy patients.6 At their institution, the pharmacist prepares a care plan when the patient is accepted by the home therapy service, enters the plan in the database , and places a hard copy with the patient's chart.
Linking PCPs to Patient Outcomes The intent of pharmaceutical care is to achieve "definite outcomes that improve a patient's quality of life. "3 Thus, PCPs should be structured around activities that have specific, predefined objectives that target meaningful, measurable, and manageable patient outcomes. Anything that is not intended to influence a specific patient outcome should not be included in a PCP. The health-related outcomes that are relevant to pharmaceutical care can be viewed as existing on a continuum of increasing biological, social, and psychological complexity.9 Although one might think that the only outcomes measure for diabetes mellitus is blood glucose, several types of complex outcomes for diabetes mellitus are shown in Table 1. Whereas an in-depth review of outcomes is beyond the scope of this article, a brief discussion will better frame the issue for the pharmacist. Measures of biological and physiological functions are basic to clinical practice. These measures focus on functions at the level of the cell, tissue, organ, or organ system. For example, in asthma, biological measures might include the results of clinical laboratory tests, such as arterial blood gas levels (partial pressures of dissolved oxygen and carbon dioxide in the blood), and physiological function measures might include peak expiratory flow rates (PEFRs). Although these measures traditionally have represented the cornerstone of patient assessment, they are often limited in providing the clinician with a picture of the patient's complete health status. To do this, it is necessary to shift the focus of outcomes measurement beyond the organ or organ system to the whole patient. As any seasoned clinician knows, biological and physiological measures are sometimes poor indicators of how a patient feels. In some cases, there is actually an inver se relationship. The patient with newly diagnosed hypertension offers a good example of this phenomenon. It is not uncommon journal of the American Pharmaceutical Association
to observe an increase in subjective symptomatology (i.e. , a worsening of how the patient feels) even as the physiological measures (i.e. , systolic and diastolic blood pressures) improve during the initial stages of therapy. For that reason, the regular assessment of subjective symptomatology should be part of a comprehensive PCP. Beyond how the patient feels, another issue of relevance to the clinician is the level of patient functioning, or the ability of the patient to perform particular roles or tasks. Patient functioning may be further subdivided into physical functiOning, social functiOning, role functioning, and psychological functioning. The measurement of functional status and health-related quality of life (HRQOL) was once the exclusive domain of academic researchers. Hence, some pharmacists might feel ill-prepared to assess their patients' functional abilities. However, technology and improvements in instnunentation are increasingly providing practical and efficient mechanisms for the collection and analysis of this information for use by the clinician. 10,11 Finally, patient satisfaction with care is an important outcome of any truly patient-focused approach. To what extent did the therapy meet the patient's (versus the pharmacist's) goals and expectations? Patient satisfaction can be justified not only from a philosophical perspective but also from a purely pragmatic perspective as well. For example, a satisfied patient is more likely to adhere to the PCP. Moreover, satisfied patients are less likely to engage in "provider shopping" or to dabble in unproven health practices.
Developing a Pharmaceutical Care Plan Patient care planning involves systematically assessing a patient's health problems and needs, setting objectives, perfOrming interventions, and evaluating results. Not all patients require a written PCP. Pharmacists must assess their own patients and identify specific areas on which to focus. For example, the pharmacist may want to identify patients with specific diseases (e.g. , asthma,"hypertension, diabetes mellitus, or hypercholesterolemia). The development of a PCP can be summarized as a fivestep process involving the SOAP format (Subjective data, Objective data, Assessment, and Plan of care). Using the example in Figure 1 for an asthma patient, the process can be described as follows:
Step 1. Gathering Information The pharmacist should gather an accurate medication history, including both prescription and nonprescription medications and the reasons the medications were prescribed or taken. The pharmacist will likely have to Journal of the American Pharmaceutical Association
obtain some information from the phYSiCian , such as laboratory test results and hospitalizations. If so, the pharmacist should get written permission from the patient before soliciting this information. Once this information is compiled, the preparation of a PCP can begin.
Step 2. Identifying Problems From the patient's medication profile in Figure 1, only one problem is evident: diagnosis of asthma. If applicable, other problems should also be listed. In Figure 1, subjective and objective findings correlated to the problem are listed. Subjective findings are those that the patient describes (e.g., "I feel tired all the time," "I feel bloated, " or "I woke up coughing"). References 12, 13, and 14 describe methods to ascertain this information. Objective fmdings are those that can be observed or measured by the pharmacist (e.g., patient appears tired, blood pressure is 180/105, pitting edema in ankles). In the patient with asthma, the phannacist would have the patient use a peak expiratory flow meter and record the results.
Step 3. Assessing Problems The pharmacist analyzes and integrates the information gathered in steps 1 and 2 and draws conclusions in preparation for developing a patient-specific PCP. For example, in the asthma case (Figure 1), the pharmacist may first inve stigate the etiology of the factors that exacerbated the asthma. The pharmacist does not have to be involved in skin testing, nor does the pharmacist have to conduct a detailed, extensive history of all of the factors that may have precipitated the asthma. However, the pharmacist should attempt to determine if drugs (e.g., aspirin, nonsteroidal anti-inflammatory agents, or beta-blockers) caused or exacerbated the asthma in the patient. Thus, the importance of an accurate and complete drug history becomes evident.12-14 N ext, the pharmacist assesses the severity o f the asthma. This could be accomplished (as shown in the plan) by determining the PEFR, examining the patient'S daily symptom and peak flow diary, or determining if the patient had been hospitalized and placed on steroids or a mechanical ventilator.
Step 4. Developing the Plan In step 4, the pharmacist establishes goals linked to each of the patient's problems and specifies a course of action aimed at meeting each goal. Each goal (i.e., desired improvtment~ " should be stated in terms of measurable outcomes that indi- 1. cate the extent to which the particular problem has been resolved. Often, the patient has several problems, and the plan must be comprehensive enough to have a positive effect on the overall health of the patient.
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Apri11996
Vol. NS36, No. 4
i
Figure 1
Patient Profile and PCP for an Ambulatory Patient with Asthma Last name: Address: City, State Zip: Telephone: Birth date: Allergies: Diagnosis(es): Other information:
Poplar First name: Hedda 201 E. Wabash Anytown, State 12345 555-1234 11-9-41 Ht: 64" Wt: 185 Ib Aspirin (bronchospasm) Asthma Smoker (cigarettes), obese
Initial: M.
Sex:F
Drug
Strength
Regimen
TheoOur
300 mg
1 tablet orally twice a day
Albuterol MOl
200 puffs/month
2 puffs every 4 hours as needed
Race: White
Quantity 100
2
Asthma
Problem(s)* Subjective and Objective Information Coughs at night, SOB on exertion, frequent exacerbations requiring MOl weekly, low HRQOL
Assessment
Plan(s)/Goal(s)
Evaluation/Outcome(s)
Poor asthma control perhaps aggravated by smoking, obesity, and undercompliance with medication regimen
Refer to smoking cessation program
Follow up with patient to evaluate cough, SOB on exertion, and number of exacerbations
Leads to decreased physical, social, and physiologic well-being PEFRs between 60% and 80% of personal best
Inadequate antiinflammatory medication
Refer to dietitian Check medication calendar and call to remind about refills
Review at next refi II: pill count, MOl usage, amount, technique
Suggest to physician that inhaled corticosteroid be added
Check to see if prescribed Review use with patient Determine if PEFR is more than 80% of personal best with PEFM
*Hedda Poplar is a 55-year-old white woman who presents at the pharmacy with new prescriptions for TheoOur and albuterol MOL You, the pharmacist, take a medication and symptom history, measure a PEFR, and complete the patient profile in Figure 1. On the basis of your information, you conclude that her main problem is asthma, but she is also overweight and smokes cigarettes. As you develop the PCP for the patient, you note her problem of asthma in column 1 and use the SOAP format ( Subjective and Objective information, Assessment, and Plan) to document the problem. Document the patient's Subjective and Objective information. Your Assessment (column 2) includes general ideas about why she has the problem of asthma. In column 3, you develop a general Plan to resolve the identified problem. Finally, in column 4, you list general and specific outcomes measures to ensure that your plan is being met. HRQOL = health-related quality of life; MOl = metered-dose inhaler; PCP = pharmaceutical care plan; PEFM = peak expiratory flow meter; PEFR = peak expiratory flow rate; SOB = shortness of breath.
Step 5. Evaluating the Achievement of Outcomes Outcomes that will be used to evaluate the success of the PCP treatment plan must be meaningful, measurable, and manageable. Outcomes are specific, measurable indicators for the goals of treatment. Thus, they should be identified in the planning process. Mullins et al. provide a more complete discussion of patient outcomes. 15 The outcomes listed for asthma would include, but not be limited to, lower frequency and severity of acute exacerbations, fewer physician office visits, elimination of side effects, PEFRs that never fall below 80% of previous personal-best predicted rates, fewer emergency department visits, and I maintenance of activities that enhance the patient's quality of life and may have been limited by the disease. Vol. NS36, No.4
April 1996
Documentation should include these components: 1. Patient data such as name, medical record number, location, date of hospital admission (if applicable), age, sex, height, weight, known medication or other allergies, and medication history. 2. Name of pharmacist(s) responsible for developing and implementing the PCP. 3. Patient problem(s) listed individually in order of potential pharmacotherapeutic impact (highest to lowest priority). Subjective and objective data that lead to identification of a specific problem and potential drug-related problems should also be included. 4. Date on which a patient problem is identified. Many diseases remain chronic throughout the patient ' s life. Problems such as urinary tract infection or upper respiratory tract infection usually resolve in 10 to 14 days. journal of the American Phannaceutical Association
ut a
m
or gals for
each p roblem, compared with desired or expected outcomes. 10. Notes such as more detailed explanations of intelVentions.
m nt f ach id ntified d for ach identi-
Implementation and Use of Pharmaceutical Care Plans
nt problem. m in impl m ntation of p lan, aluati n f actual patient outcomes for
PCPs are dynamic instruments that should be initiated at the phannacist's frrst encounter with the patient and modified in subsequent encounters. Figures 1 through 4 (pages 273-276) illustrate different approaches to PCPs using the SOAP format. Figure 2
Patient Profile and PCP for an Ambulatory Patient vvith Hypertension Last name: Address: City, State Zip: Telephone: Birth date: Allergies: Diagnosis(es): Other information:
Kassav ich First name: Norman 121 N . State S t. Anyto wn, Sta t e 23456 555-2345 1-9-43 Ht: 72" Wt: 202 Ib N o known d ru g a ll e rgies Hy pertension Smoker (cigarettes) , obese
D s te
Drug
4/2/96
Hydrochlorothiazide
4/2/96
Potassium chloride elixir
n 4/2/96
p
Itiv
f
ily hi tory
Strength
Initial: U.
Sex:M
Regimen
25 mg
1 tablet orally every morning
10%
15 mL twice a day with meals
Race: Black
Quantity 30
480mL
Assessment
Plan(s)/Goal(s)
Evaluation/OutcolTle(s)
W eig h t co ntrol programs have not b een effective to date
Refer to Weight Watchers
Follow up with patient t o determine weight loss
Lifestyle c h a nges have not been effective
Reeducate on lifestyle changes
Check weight, alcohol and salt intake, and exercise program
Suggest home BP monitoring kit and BP log Check medication calendar and call to remind about refills
---
Review use of BP log w ith patient and check log Follow up with patient review at next refill with pill count
"Norm K vlch i a 53-year-old black man who presents at the h . h t I. m ch'o~1 . li?
d.
BP - blood pressure; PCP
J
una)
pharmaceutical care plan .
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Vol. NS36, No.4
The SOAP format places the information into the more conventional format of care plans used by other health care professionals. The ftrst column of the PCP form identifies the problem
and the subjective and objective parameters used to identify the problem. The second column is an assessment of the problem, briefly detailing what factors should be examined as the causes of the problem, The third column Figure 3
Patient Profile and PCP for an Ambulatory Patient with Dyslipidemia Last name: Address:
City, State Zip: Telephone: Birth date: Allergies: Diagnosis(es): Other information:
Thruman First name: James 634 Elm St. Anytown, State 12345 555-3456 3-1-51 Ht: 70" Wt: 221 Ib Codeine (gastrointestinal upset) Dyslipidemia, chronic sinusitis
Initial: M.
Sex:M
Race: White
Date
Drug
Strength
Regimen
4/2/96
Cholestyramine
4 grams
1 packet three times a day
100
4/2/96
Amoxicillin
500 mg
1 capsule every 8 hours
30
Quantity
Hyperlipidemia Problem(s)* Subjective and Objective Information Total cholesterol 298 mg/dL at screening
Assessment
Plan(s)/Goal(s)
Evaluation/Outcome(s)
Poor hyperlipidemia control, perhaps aggravated by obesity and undercompliance with dietary measures
Patient education about cholestyramine
Follow up with patient for questions about cholestyramine
Refer to dietitian for low-fat diet Call physician or lab to obtain lipid profile Check medication calendar and call to remind about refills
Problem(s)· Subjective and Objective Information Chronic nasal discharge; headaches
Follow up with patient to determine if dietitian was consulted Check lab values in lipid profile Review at next refill with pill count
Assessment
Plan(s)/Goal(s)
Evaluation/Outcome(s)
Inadequate control with over-the-counter measures (nasal spray and oral decongestant! antihistamine)
Ensure that full 10-day course taken (ask patient to bring prescription bottle with him in 10 days or call him)
Follow up with patient at 10 days for pill courit Follow up to determine if headaches resolved
Suggest acetaminophen 1,000 mg orally every 4 to 6 hours when needed (no more than 4 grams/day) *James Thruman is a 46-year-old white man who presents at the pharmacy with n~w pres~rip~io~s for cholestyrami~e and amoxicillin. You, the pharmacist, take a medication and symptom history and com.ple~e th,e, pat~ent profll~ In Figure 3. On,the baSIS of your , information, you conclude that he has chronic dyslipidemia and chrOniC ~InUSltIS With nasal.dl.scha~ge for ~hlc~ ,h~ has been taking some over-the-counter medications. As you develop hjs PCP, you note hiS problems of dysllpldemla and SinUSitiS In column ~ an,d use the SQIAPf (S b' t' d Qb' t've'lnformation Assessment, and Plan) to document the problem. Document the patient s 1'1 ormat u jec Ive an jecI ' . " . . SubJ'ect'lve an d Qb'jectlve , ' f t' Y r Assessment (column 2) includes general Ideas about why he dysllpldemla even In orma Ion. ou , stili has , .. though h h b ' d' tary measures Apparently, these measures are not adequate In controlling hiS high serum e as een attempting some Ie . ." . .. . choleste I I I 3 d I eneral Aan to resolve the dysllpldemla and to resolve the current exacerbation of hiS chromc ro. nco umn , you eve op a g , , sinusitis. Finally, in column 4, you list general and specific outcomes measures to ensure that your plan IS being met,
PCP:::: pharmaceutical care plan.
VoL NS36, No. 4 Apri11996
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Figure 4
Patient Profile and PCP for a Hospitalized Patient with HF and Depression Last name: Hospital number: Room: Birth date: Allergies: Oiagnosis(es): Other information:
First name: Cosgroff 2117445-1 A456 Ht:62" 7-21-34 No known drug allergies HF, history of hypertension Depression
Thelma Initial: P.
Wt: 132 Ib
Sex: F
Race: White
Interval
Date
Drug
Strength
Route
4/2/96 4/2/96 4/2/96 4/2/96 4/2/96
Digoxin Furosemide Isosorbide dinitrate Enalapril Nitroglycerin (sublingual) Amitriptyline
0.25 mg 40mg 20 mg 5mg 0.4mg
Orally Orally Orally Orally Sublingual
Every other day Twice a day Three times a day Twice a day As needed for chest pain
Orally
Daily at bedtime
4/2/96
25 mg
~<
Heart failure Problem(s)* Subjective and Objective Information
Fatigue, shortness of breath, dyspnea on exertion, cough, cannot walk as far as 2 weeks ago, 1+ ankle edema, slight rales, tachycardia
Assessment
Plan(s)/Goal(s)
Evaluation/Outcome(s)
HF exacerbation perhaps caused by:
Obtain brief diet history, especially salt-containing foods and refer to dietitian
Follow up with patient f or dietary changes
Use of OTC medications
Medication history for OTC medication regimens (NSAIDs or salt-containing)
Follow up with patient to determine changes in OTC drug use
Noncompliance with medication regimens
Check medication calendar and call to remind about refills
Review at next refill with pill count
Recommend checking digoxin and potassium levels to physician
Check to see if ordered
Noncompliance with diet
Depression Problem(s)* Subjective and Objective Information
Tired, does not want to socialize
J.
Assessment
Plan(s)/Goal(s)
Evaluation/Outcome(s)
Depressive symptoms perhaps caused by digoxin and/or undercompliance with medication regimen
Recommend to physician to check digoxin level
Follow up with patient about symptoms by calling her in 2 to 3 weeks
Review refills and medication calendar
Tiredness may be muscle weakness caused by low potassium levels
Follow up with patient at next refill with pill count
*Thelma Cosgroff is a 62-year-old white woman who was hospitalized today. You, the pharmacist, take a medication and symptom history and complete the patient profile in Figure 4. On the basis of your information, you conclude that her main problem is heart failure, but she also has depression. Her history of hypertension is not active at this time, so you have not included it in her PCP. As you develop her PCP, you note her problems of heart failure and depression in column 1 and use the SOAPformat (Subjective and Objective information, Assessment, and Plan) to document the problem. Document the patient's Subjective and Objective information. Your Assessment (column 2) includes general ideas about why she has the problem of an exacerbation of heart failure and why her depressive symptoms have not resolved. In column 3, you develop a general Plan to resolve these identified problems. Finally, in column 4, you list general and specific outcomes measures to ensure that your plan is being met. Some of these outcomes measures will be transmitted to the pharmacist caring for her in t~e community setting, because they are more long term than would be seen in the hospital. . HF = heart failure; NSAIDs = nonsteroidal anti-inflammatory drugs; OTC = over the counter; PCP
Journal of the American Phannaceutical Association
= pharmaceutical care plan.
April1996
Vol. NS36, No. 4
includes the plan and goals, and the fourth column indicates the evaluation means or methods that will be used to achieve the desired outcomes. Follow-up monitoring visits require a question-and-answer assessment format (previously described by Boyce and Herrier,12 Isetts ,13 and Ro driguez de Bittner and Michocki 14). All data obtained , assessments, changes in plans, and intervenI tions are noted on the form. Using PCPs is a skill that is acquired through experience; the pharmacist's training starts with a commitment to one patient. Moreover, PCPs should not be formulated in a vacuum-each patient's PCP should be developed in cooperation with the patient's physician(s). A suggested starting point is to choose one disease, identify one patient, and "just do it." You will then be able to build on successes and expand to additional patients and/or diseases.
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The pharmaceutical care plan provides the pharmacist with an organized, logical mechanism to structure the delivery and evaluation of care to patients. However, the most important component of the PCP is the relentless commitment of the pharmacist to providing optimal care to individual patients according to their unique needs. Dennis J McCallian, PhannD, is president, Family PharmaCare Center, Inc., West Lafay ette, Ind. Bruce C Carlstedt, PhD, is associate professor of clinical phannacy and Michael T. Rupp, PhD, is assodate professor ofphannacy administration, School of Pharmacy and Pharmacal Sdences, Purdue University, West Lafay ette, "Ind.
References 1. Larrabee JH, Rodgers VO, Corsey R, et aL Developing and implementing computer-generated nursing care plans. J Nurs Care Qual. 1992;6(2):56-62.
Integration of PCPs into Practice
2. Pierce M, Malloy R, McElroy P. Reducing unnecessary care with the "respiratory care plan." AARC Times. 1993;17(6):67-9. 3. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533-43.
At the Family PharmaCare Center in West Lafayette, I Ind., professional staff use PCPs as part of an ongoing pharmaceutical care program. Not all patients require written P CPs , however , and we focus primarily on patients w ho are at high risk or who were referred to us. We develop and implement PCPs for patients with asthma, diabetes, h ypercholesterolemia, and hypertension. 16 In addition, w e have developed protocols for formulating PCPs, mon itoring patients, providing patient education, and helpi ng patients improve their health. These protocols provide for quality assurance and continuity of care in the services we provide. Private and semiprivate patient care areas are available for professional staff to assess and counsel patients. Still, integrating pharmaceutical care planning and disease management into a busy practice is challenging. Recently, we launched an initiative with our computer system vendor, HealthCare Computer Corporation, that will greatly improve our ability to offer consistently highquality care. The project involves developing practice support software that provides pharmacists with detailed on·line system prompts related to targeted conditions. It is currently in the beta-phase of testing and development. These system prompts provide the pharmacist with real. time reminders and recommendations related to the care of individual patients. Although not a replacement for Iprofessio n a l judgment , such support technology is certainly a helpful supplement. APhA is also developing disease-specific programs and pharmaceutical care protocols to assist pharmacists in their preparation and use of PCPs and in disease management. These resources should soon be available. I
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4. Summary of the final report of the Scope of Pharmacy Practice Project. Am J Hosp Pharm. 1994;51:2179-82. 5. Johnson PE, Rearson MB. Pharmacy's role within a multidisciplinary, patient-focused model for health care. Top Hosp Pharm Manag. 1991;10(4):67-74. 6. Johnson KA, Bergstedt HA, Roberts TW. Use of pharmaceutical care plans in home LV. therapy. Am J Hosp Pharm. 1993;50:2173-4. 7. Gold ML, Fedder ~O. Developing a pharmaceutical care plan. US Pharmacist. 1992;53-60,84.
8. Rich OS. Pharmaceutical care plans. Hosp Pharm. 1994;29(2):17EH3. 9. Wilson IB, Cleary PO. Linking clinical variables with health-related quality of life. JAMA. 1995;273:59-B5. 10. Ware JE. SF-36 health survey: manual and interpretation guide. Boston: The Health Institute, New England Medical Center; 1993. 11. Juniper EF, Guyatt GH, Ferrie PJ, et aL Measuring quality of life in asthma. Am Rev Respir Dis. 1993;147:832-8. 12. Boyce RW, Herrier RN. Obtaining and using patient data. Am Pharm. 1991;NS31:517-23. 13.lsetts BJ. Monitoring and managing patient care . Am Pharm. 1992;NS32:77-84. 14. Rodriguez de Bittner M, Michocki R. Establishing a pharmaceutical care database. JAm Pharm Assoc. 1996;NS36:60-71. 15. Mullins CD, Baldwin R, Perfetto, EM. What are outcomes? JAm Pharm Assoc. 1996;NS36:39-49. 16. McCaliian OJ, Carlstedt BC, Rupp MT. Caring for asthma patients in a community pharmacy. Am Pharm. January 1994;NS34:64-75.
Assessment Questions
Instructions: For each question, blacken the letter on the answer sheet corresponding to the answer you select as being correct. Please review all answers to be sure you have blackened the proper spaces. There is only one correct answer to each question. journal of the American Phannaceutica1 Association
1.
The phannaceutical care plan (PCP) has been defmed as a dynamic outline for the provision of drug therapy, which is: a. Initiated by the phannacist as needed for a specific patient. b. Monitored by the phannacist as needed for a specific patient. c. Modified by the pharmacist as needed for a specific patient. d. All of the above are correct. e. None of the above are correct.
2.
Which one of the following statements is true? a. PCPs are patient specific, not practice-site specific. b. PCPs provide a consistent plan of care that can be applied to institutional and ambulatory care as the patient is treated in various environments. c. PCPs are 100% guaranteed for reimbursement from all third party payers. d. Both a and b are true. e. None of the above are true.
3.
4.
5.
6.
7.
8.
9.
Patient care planning involves which one of the following? a. Systematically identifying and assessing a patient's problems. b. Setting goals. c. Establishing interventions. d. Evaluating results. e. All of the above. The first step in initiating a PCP is to: a. Establish patient outcomes. b. Assess each identified problem. c. Gather patient data. d. Identify patient problems. e. Formulate a plan for each identified problem. Which area of pharmacy practice is currently required by the Joint Commission on Accreditation of Healthcare Organizations to prepare PCPs for patients? a. Hospital pharmacy practice. b. Nursing home pharmacy practice. c. Community pharmacy practice. d. Home care pharmacy practice. e. None of the above. The most important component of formulating a PCP is: a. Where the pharmacist practices. b. The degree held by the pharmacist. c. The relentless commitment of the pharmacist to providing optimal drug therapy to individual patients according to their unique needs. d. Where the patient is being cared for. e. All of the above are equally important. PCPs are dynamic instruments that should be: a. Filed away once completed. b. Initiated at the first encounter. c. Modified in subsequent encounters. d. Both b and c are correct. e. None of the above are correct. Why should pharmaceutical care planning always be done with outcomes in mind? a. Achieving desired outcomes is the primary goal of pharmaceutical care. b. Future compensation may be tied in part to achieving patient outcomes. c. Patient outcomes will be used to evaluate pharmacy penorrnance. d. All of the above are correct. e. None of the above are correct. Which one of the following is not commonly used to assess patient health outcomes? a. Biological factors. b. Physiological factors. c. Symptoms. d. Physical functioning. e. All of the above are used.
Joumal of the American Phannaceutical Association
10.
Blood glucose is an example of which type of patient health outcomes measure? a. Biological function b. Physiological function c. Symptom d. Physical functioning e. Role functioning
11.
Peak expiratory flow is an example of which type of patient health outcomes measure? a. Biological function b. Physiological function c. Symptom d. Physical functioning e . Role functioning
12.
Which one of the following is not a measure of patient functioning? a. Physical functioning b. Social functioning c. Role functioning d. Psychological functioning e. Patient satisfaction
13.
Why is patient satisfaction an important outcome to measure when evaluating the effectiveness of pharmaceutical care? a. It demonstrates a true patient orientation to care. b. It is often correlated with other desired outcomes such as compliance. c. It is always strongly correlated with clinical outcomes measures. d. Both a and b are correct. e. All of the above are correct.
For Questions 14 through 20, identif.y the word or phrase with the appropriate part of a PCP. 14. "Asthma": a. b. c. d. e.
Problem Goal Plan Monitoring parameter Outcome
15.
"Assess severity": a. Problem b. Goal c . Plan d. Monitoring parameter e. Outcome
16.
"Minimize side effects or adverse reactions of drug therapy": a. Problem b. Goal c. Plan d. MOnitoring parameter e. Outcome
17.
"Obtain serum theophylline concentration at next physician visit ": a. Problem b. Goal c. Plan d. Monitoring parameter e. Outcome
18.
"Take a medication history": a. Problem b. Goal c. Plan d. Monitoring parameter e . Outcome
19. "Decreased hospitalizations": a. Problem b. Goal c. Plan d. Monitoring parameter e. Outcome 20.
"Increase exercise tolerance ": a. Problem b. Goal c. Plan d. Monitoring parameter e. Outcome April1996
Vol. NS36, No.4
Instructions To receive two hours of continuing education credit (0.2 CEU) for successful completion of this program, you must:
1. Complete answer sheet and type or print your name, address, and Social Security number in the space provided. 2. Mail your completed answer sheet with the correct handling fee ($5 for APhA members; $15 for nonmembers; no additional charge for current 12-exam continuing program members) to: Processing DesklEducation American Pharmaceutical Association 2215 Constitution Ave., NW Washington, DC 20037-2985
Developing Pharmaceutical Care Plans APhA provider number for this program is: 202-000-96-002-H04. Make checks payable to "APhA ":
D
5 fee enclo ed (member rate).
D $15 fee enclosed (nonmember rate).
D
$45 12-exam continuing education program fee enclosed.
D $45 12-exam continuing education program fee paid earlier. Nrune _______________________________________
Adilless,______________________________________ City ___________________ State
ZIP _ _ _ _ __
Social Security #-__________________________
Certificates will be issued to those who score 70% or higher. Those who score below 70% will be notified, and no credit will be recorded. Allow Jour
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weeks for processing. Expiration date: April 30, 1999 Answer Sheet
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DUR continued from p. 261
Conclusion In the future, managed care will assume a larger role in the delivery of health care services. The interest of private-sector and government health insurance administrators in interceding in prescribing and reimbursement has fueled this expansion. Changes that occur will be based, in part, on analysis of retrospective claims that identify and review patterns of drug use. Improved information systems and the collection of patient-related data, rather than diagnosis and medication histories, will aid pharmacists in improving therapeutic regimens and efficient use of prescription expenditures.
Renee T. Kubacka, PharmD, is adjunct associate professor,
I
I University of Pittsburgh School of Pharmacy, Pittsburgh, and clinical education coordinator, Pfizer Inc., New York, NY.
I
IReferences 1. Health Insurance for the Aged Act. Pub L No. 89-97, 79 Stat 290, Social Security Amendments. 18:42§ USC §1395; 19:42§ USC §1396 (1988). 2. Final Report, Task Force on Prescription Drugs. Washington: Department of Health, Education and Welfare; 1969;48. 3. Jinko MJ, Baker DE, Haber E. Reducing unused as-needed orders in long-term care facilities. Consult Pharm. 1989;4:263-6. 4. Cooper JW. Effect of initiation, termination and reinitiation of cor~~ul tant clinical pharmacist services in a geriatric long-term care facility. Med Care. 1985;23:84-8. 5. Cheung A, Kayne R. An application of clinical pharmacy services for extended care facilities. Calif Pharm. 1975;23:22-43.
I Vol. NS36, No.4
April1996
Program Evaluation Excellent Overall quality 5 Relevance to practice 5 Value of content 5 Agree Important to pharmacists 5 Increased my knowledge 5 Achieved stated objectives 5 Did not promote particular product or company 5 It took me hours and complete the assessment questions.
4 4 4
3
4 4 4
3
4
3 3
3 3
2 2 2 2 2 2
Poor 1 1 Disagree 1 1 1
2 3 minutes to read this article and
6. Thompson J, Floyd R. Cost-analysis of comprehensive consultant pharmacist services in the skilled nursing facility: a progress report. Calif Pharm. 1978;25:22-6. 7. Kidder SW. Cost-benefit of pharmacist-conducted drug regimen reviews. Consult Pharm. 1987;2:394-8. 8. Accreditation Manual for Hospitals 1994. Chicago: Joint Commission on Accreditation of Healthcare Organizations; 1993. 9. Longo DR, Wilt JE, Laubenthal RM. Hospital compliance with Joint Commission standards: findings from 1984 surveys. Quality Rev Bull. 1986;12:388--94. 10. Roseman AW, Sawyer WT. Population-based drug use evaluation. Top Hosp Pharm Manage. 1988;8:7~92. 11. Brodie DC, Smith WE. Constructing a conceptual model of drug utilization review. Hospitals. 1976;50(6):143-4,6,8,150. 12. Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals 1995. Chicago: Joint Commission on the Accreditation of Healthcare Organizations; 1994. 13. Wenzloff NJ, Boyd EL. Utilization of computerized patient profiles in the prevention of drug-drug interactions. Mich Pharm. 1984;22(7):4-9. 14. Woolf SH. Practice guidelines: a new reality in medicine. Arch Intern Med. 1990;150:1811-8. 15. Kreling DH , Knocke OJ, Hammel RW. The effects o~ an i~tern.al analgesic formulary restriction on Medicaid drug expenditures In WISconsin. Med Care. 1989;27:34-44. 16. Weintraub M, Singh S, Byrne L, et al. Consequences of the state triplicate benzodiazepi ne prescri ption reg u lations. JAMA. 1991 ;266:2392-7. 17. Craig WA, Uman SJ, Shaw WR, et al. Hospital use of antimicrobial drugs: survey of 19 hospitals and results of antimicrobial control program. Ann Intern Med. 1978;89:793-5. 18. Sandusky M. DUR intervention letters: how pharmacists respond. Am Pharm. November 1993;NS33:58-64. 19. Avorn J, Soumerai SB. Improving drug-therapy decisions through educational outreach. N Engl J Med. 1983;308:1457-63. 20. Soumerai SB, Avorn J. Principles of educational outreach ('academic detailing') to improve clinical decision making. JAMA. 1990;263:549-56. 21. Wertheimer AI, Kralewski J. OUR programs: current trends and future directions. Am Pharm. February 1993;NS33:37-42.
Journal of the American Phannaceutical Association
into busy practice settings. by Dennis J. McCaliian, PharrnD, Bruce C. Carlstadt, PhD, and Michael T. Rupp, PhD
Learning Objectives Upon successful completion of this continuing education article, the pharmacist should be able to: • Describe a pharmaceutical care plan and explain how it is used. • Develop a pharmaceutical care plan for use in a community or institutional practice and illustrate the similarities of pharmaceutical care planning in both settings. • Discuss methods to integrate pharmaceutical care plans into a busy practice setting. • Identify therapeutic outcomes for patients with chronic di ea e using case study examples. • Explain the importance of outcomes assessment in pharmaceutical care. • List five types of outcomes that phannacists can monitor to evaluate therapy.
Program Preview A pharmaceutical care plan (PCP) is a vital component of the practice of pharmacy and of comprehensive phannaceutical care. This article illustrates a consistent methodology for formulating and implementing these plans and integrating the planning process into a busy community or institutional practice setting. Identification of therapeutic outcomes and appropriate mOnitoring parameters for patients with chronic diseases is also demonstrated through case study examples.
Journal of the American Pharmaceutical Association
Introduction
initiated, monitored, and m di.fi d
macists to identify, defin
int rv n CE Credit
CE Credit 1;'0 obtain two hours of contimr ing education credit (0.2 CEO) for c;ompleting "Developing Pharmaceutical Care Plans for Desired Outcomes," complete the assess'ment exercise and CE registration fottn and return it to APhA. A certificate will be awarded upon achieving a passing grade of 700/0 or better. Phannacists completing this article by April 30, 1999, can receive credit.
If£ K":
The American Pharmaceutical
ll\ssosjJObion is approved by the American Council on Phannaceutical EducaIion as a provider of continuing pharmaceutical education.
~ APbA provider number is: '
el ping Phannaceutical Out Plans li r ired Outcomes" is part f th Dynami ofPhamJac uti al Care: Enriching Patients' Health ri for phannacists that appears in thejournal of the American Pbanruu;eutical ASSOciation. Developed by APhA, the ri is edited by Janet P. Engle, PhannD FAPhA, acting associate dean for academic affairs and clinical proli r of pharmaCY pra~ tice, University of Dlinois at Chicago, and supported by an educational grant from Merck Hrunan Health DiviSion. The Dynamic of Pharmaceutical Care: Enriching Patients' Health series was fonnerty known as the Value Added Service serie .
Apri1199 6 voL NS3
6N~ ,I
v
process of resolving patient-specific problems. This process then provides a foundation for evaluating patient outcomes.
The Pharmaceutical Care Plan Nurses have prepared patient care plans for many years. Indeed, the nursing literature is replete with books and articles on the importance of care plans, and includes a recent article on computerized nursing care plans. 1 Respiratory therapists have also been involved in the preparation of respiratory care plans, which were recommended as a mechanism to reduce costS. 2 A basic tenet of phannaceutical care is the provision of pharmacy services to attain positive patient outcomes. 3 Therefore, it would seem obvious that, like these other health care professionals, the pharmacist should anticipate, plan for, monitor, and document outcomes in a systematic way. Reports on the recent Scope of Phannacy Practice Project, which was conducted by the Professional Examination Service, Inc., from 1992 to 1994, indicate that the formulation and ongoing evaluation of a patient-specific therapeutic plan are functions of providing pharmaceutical care. 4 Johnson and Rearson discuss the importance of giving phaffilacists-and all other health care professionals involved in patient-focused care- the authority to create care plans and document progress.5 Table 1
Selected Disease-Related Outcomes for Patients with Diabetes Mellitus Biologic/Physiologic function • Bl ood glucose. • Hemoglobin A1C. • Nephropathy. • Retinopathy. • Death. Symptom measurement • Neuropathy. • Gastroparesis. • Polyuria. • Polydipsia. • Polyphagia. Patient functioning • Functional status. • Health-related quality of life. UtilizationlEconomic • Physician office visits. • Emergency department visits. • Hospitalizations and lengths of stays. • Days of disability attributable to diabetes. • Referrals to specialists. • Medication compliance.
Vol. NS36, No.4
Ap ril1996
However, a review of the literature reveals few documented instances of pharmaci t-prepared care plans for individual patients. 6,7 Although the Joint Commission on Accreditation of Healthcare Organizations requires pharmacists in home care practice to prepare care plans for their patients,8 there is no documentation of these plans and their effects on patient outcomes. Gold and Fedder advocate the philosophy of PCP preparation by the pharmacist but do not provide specific instances or practice settings in which PCPs should be used. 7 On the other hand, Johnson et al. have reported on the use of PCPs for their home intravenous therapy patients.6 At their institution, the pharmacist prepares a care plan when the patient is accepted by the home therapy service, enters the plan in the database , and places a hard copy with the patient's chart.
Linking PCPs to Patient Outcomes The intent of pharmaceutical care is to achieve "definite outcomes that improve a patient's quality of life. "3 Thus, PCPs should be structured around activities that have specific, predefined objectives that target meaningful, measurable, and manageable patient outcomes. Anything that is not intended to influence a specific patient outcome should not be included in a PCP. The health-related outcomes that are relevant to pharmaceutical care can be viewed as existing on a continuum of increasing biological, social, and psychological complexity.9 Although one might think that the only outcomes measure for diabetes mellitus is blood glucose, several types of complex outcomes for diabetes mellitus are shown in Table 1. Whereas an in-depth review of outcomes is beyond the scope of this article, a brief discussion will better frame the issue for the pharmacist. Measures of biological and physiological functions are basic to clinical practice. These measures focus on functions at the level of the cell, tissue, organ, or organ system. For example, in asthma, biological measures might include the results of clinical laboratory tests, such as arterial blood gas levels (partial pressures of dissolved oxygen and carbon dioxide in the blood), and physiological function measures might include peak expiratory flow rates (PEFRs). Although these measures traditionally have represented the cornerstone of patient assessment, they are often limited in providing the clinician with a picture of the patient's complete health status. To do this, it is necessary to shift the focus of outcomes measurement beyond the organ or organ system to the whole patient. As any seasoned clinician knows, biological and physiological measures are sometimes poor indicators of how a patient feels. In some cases, there is actually an inver se relationship. The patient with newly diagnosed hypertension offers a good example of this phenomenon. It is not uncommon journal of the American Pharmaceutical Association
to observe an increase in subjective symptomatology (i.e. , a worsening of how the patient feels) even as the physiological measures (i.e. , systolic and diastolic blood pressures) improve during the initial stages of therapy. For that reason, the regular assessment of subjective symptomatology should be part of a comprehensive PCP. Beyond how the patient feels, another issue of relevance to the clinician is the level of patient functioning, or the ability of the patient to perform particular roles or tasks. Patient functioning may be further subdivided into physical functiOning, social functiOning, role functioning, and psychological functioning. The measurement of functional status and health-related quality of life (HRQOL) was once the exclusive domain of academic researchers. Hence, some pharmacists might feel ill-prepared to assess their patients' functional abilities. However, technology and improvements in instnunentation are increasingly providing practical and efficient mechanisms for the collection and analysis of this information for use by the clinician. 10,11 Finally, patient satisfaction with care is an important outcome of any truly patient-focused approach. To what extent did the therapy meet the patient's (versus the pharmacist's) goals and expectations? Patient satisfaction can be justified not only from a philosophical perspective but also from a purely pragmatic perspective as well. For example, a satisfied patient is more likely to adhere to the PCP. Moreover, satisfied patients are less likely to engage in "provider shopping" or to dabble in unproven health practices.
Developing a Pharmaceutical Care Plan Patient care planning involves systematically assessing a patient's health problems and needs, setting objectives, perfOrming interventions, and evaluating results. Not all patients require a written PCP. Pharmacists must assess their own patients and identify specific areas on which to focus. For example, the pharmacist may want to identify patients with specific diseases (e.g. , asthma,"hypertension, diabetes mellitus, or hypercholesterolemia). The development of a PCP can be summarized as a fivestep process involving the SOAP format (Subjective data, Objective data, Assessment, and Plan of care). Using the example in Figure 1 for an asthma patient, the process can be described as follows:
Step 1. Gathering Information The pharmacist should gather an accurate medication history, including both prescription and nonprescription medications and the reasons the medications were prescribed or taken. The pharmacist will likely have to Journal of the American Pharmaceutical Association
obtain some information from the phYSiCian , such as laboratory test results and hospitalizations. If so, the pharmacist should get written permission from the patient before soliciting this information. Once this information is compiled, the preparation of a PCP can begin.
Step 2. Identifying Problems From the patient's medication profile in Figure 1, only one problem is evident: diagnosis of asthma. If applicable, other problems should also be listed. In Figure 1, subjective and objective findings correlated to the problem are listed. Subjective findings are those that the patient describes (e.g., "I feel tired all the time," "I feel bloated, " or "I woke up coughing"). References 12, 13, and 14 describe methods to ascertain this information. Objective fmdings are those that can be observed or measured by the pharmacist (e.g., patient appears tired, blood pressure is 180/105, pitting edema in ankles). In the patient with asthma, the phannacist would have the patient use a peak expiratory flow meter and record the results.
Step 3. Assessing Problems The pharmacist analyzes and integrates the information gathered in steps 1 and 2 and draws conclusions in preparation for developing a patient-specific PCP. For example, in the asthma case (Figure 1), the pharmacist may first inve stigate the etiology of the factors that exacerbated the asthma. The pharmacist does not have to be involved in skin testing, nor does the pharmacist have to conduct a detailed, extensive history of all of the factors that may have precipitated the asthma. However, the pharmacist should attempt to determine if drugs (e.g., aspirin, nonsteroidal anti-inflammatory agents, or beta-blockers) caused or exacerbated the asthma in the patient. Thus, the importance of an accurate and complete drug history becomes evident.12-14 N ext, the pharmacist assesses the severity o f the asthma. This could be accomplished (as shown in the plan) by determining the PEFR, examining the patient'S daily symptom and peak flow diary, or determining if the patient had been hospitalized and placed on steroids or a mechanical ventilator.
Step 4. Developing the Plan In step 4, the pharmacist establishes goals linked to each of the patient's problems and specifies a course of action aimed at meeting each goal. Each goal (i.e., desired improvtment~ " should be stated in terms of measurable outcomes that indi- 1. cate the extent to which the particular problem has been resolved. Often, the patient has several problems, and the plan must be comprehensive enough to have a positive effect on the overall health of the patient.
I
Apri11996
Vol. NS36, No. 4
i
Figure 1
Patient Profile and PCP for an Ambulatory Patient with Asthma Last name: Address: City, State Zip: Telephone: Birth date: Allergies: Diagnosis(es): Other information:
Poplar First name: Hedda 201 E. Wabash Anytown, State 12345 555-1234 11-9-41 Ht: 64" Wt: 185 Ib Aspirin (bronchospasm) Asthma Smoker (cigarettes), obese
Initial: M.
Sex:F
Drug
Strength
Regimen
TheoOur
300 mg
1 tablet orally twice a day
Albuterol MOl
200 puffs/month
2 puffs every 4 hours as needed
Race: White
Quantity 100
2
Asthma
Problem(s)* Subjective and Objective Information Coughs at night, SOB on exertion, frequent exacerbations requiring MOl weekly, low HRQOL
Assessment
Plan(s)/Goal(s)
Evaluation/Outcome(s)
Poor asthma control perhaps aggravated by smoking, obesity, and undercompliance with medication regimen
Refer to smoking cessation program
Follow up with patient to evaluate cough, SOB on exertion, and number of exacerbations
Leads to decreased physical, social, and physiologic well-being PEFRs between 60% and 80% of personal best
Inadequate antiinflammatory medication
Refer to dietitian Check medication calendar and call to remind about refills
Review at next refi II: pill count, MOl usage, amount, technique
Suggest to physician that inhaled corticosteroid be added
Check to see if prescribed Review use with patient Determine if PEFR is more than 80% of personal best with PEFM
*Hedda Poplar is a 55-year-old white woman who presents at the pharmacy with new prescriptions for TheoOur and albuterol MOL You, the pharmacist, take a medication and symptom history, measure a PEFR, and complete the patient profile in Figure 1. On the basis of your information, you conclude that her main problem is asthma, but she is also overweight and smokes cigarettes. As you develop the PCP for the patient, you note her problem of asthma in column 1 and use the SOAP format ( Subjective and Objective information, Assessment, and Plan) to document the problem. Document the patient's Subjective and Objective information. Your Assessment (column 2) includes general ideas about why she has the problem of asthma. In column 3, you develop a general Plan to resolve the identified problem. Finally, in column 4, you list general and specific outcomes measures to ensure that your plan is being met. HRQOL = health-related quality of life; MOl = metered-dose inhaler; PCP = pharmaceutical care plan; PEFM = peak expiratory flow meter; PEFR = peak expiratory flow rate; SOB = shortness of breath.
Step 5. Evaluating the Achievement of Outcomes Outcomes that will be used to evaluate the success of the PCP treatment plan must be meaningful, measurable, and manageable. Outcomes are specific, measurable indicators for the goals of treatment. Thus, they should be identified in the planning process. Mullins et al. provide a more complete discussion of patient outcomes. 15 The outcomes listed for asthma would include, but not be limited to, lower frequency and severity of acute exacerbations, fewer physician office visits, elimination of side effects, PEFRs that never fall below 80% of previous personal-best predicted rates, fewer emergency department visits, and I maintenance of activities that enhance the patient's quality of life and may have been limited by the disease. Vol. NS36, No.4
April 1996
Documentation should include these components: 1. Patient data such as name, medical record number, location, date of hospital admission (if applicable), age, sex, height, weight, known medication or other allergies, and medication history. 2. Name of pharmacist(s) responsible for developing and implementing the PCP. 3. Patient problem(s) listed individually in order of potential pharmacotherapeutic impact (highest to lowest priority). Subjective and objective data that lead to identification of a specific problem and potential drug-related problems should also be included. 4. Date on which a patient problem is identified. Many diseases remain chronic throughout the patient ' s life. Problems such as urinary tract infection or upper respiratory tract infection usually resolve in 10 to 14 days. journal of the American Phannaceutical Association
ut a
m
or gals for
each p roblem, compared with desired or expected outcomes. 10. Notes such as more detailed explanations of intelVentions.
m nt f ach id ntified d for ach identi-
Implementation and Use of Pharmaceutical Care Plans
nt problem. m in impl m ntation of p lan, aluati n f actual patient outcomes for
PCPs are dynamic instruments that should be initiated at the phannacist's frrst encounter with the patient and modified in subsequent encounters. Figures 1 through 4 (pages 273-276) illustrate different approaches to PCPs using the SOAP format. Figure 2
Patient Profile and PCP for an Ambulatory Patient vvith Hypertension Last name: Address: City, State Zip: Telephone: Birth date: Allergies: Diagnosis(es): Other information:
Kassav ich First name: Norman 121 N . State S t. Anyto wn, Sta t e 23456 555-2345 1-9-43 Ht: 72" Wt: 202 Ib N o known d ru g a ll e rgies Hy pertension Smoker (cigarettes) , obese
D s te
Drug
4/2/96
Hydrochlorothiazide
4/2/96
Potassium chloride elixir
n 4/2/96
p
Itiv
f
ily hi tory
Strength
Initial: U.
Sex:M
Regimen
25 mg
1 tablet orally every morning
10%
15 mL twice a day with meals
Race: Black
Quantity 30
480mL
Assessment
Plan(s)/Goal(s)
Evaluation/OutcolTle(s)
W eig h t co ntrol programs have not b een effective to date
Refer to Weight Watchers
Follow up with patient t o determine weight loss
Lifestyle c h a nges have not been effective
Reeducate on lifestyle changes
Check weight, alcohol and salt intake, and exercise program
Suggest home BP monitoring kit and BP log Check medication calendar and call to remind about refills
---
Review use of BP log w ith patient and check log Follow up with patient review at next refill with pill count
"Norm K vlch i a 53-year-old black man who presents at the h . h t I. m ch'o~1 . li?
d.
BP - blood pressure; PCP
J
una)
pharmaceutical care plan .
n April1996
Vol. NS36, No.4
The SOAP format places the information into the more conventional format of care plans used by other health care professionals. The ftrst column of the PCP form identifies the problem
and the subjective and objective parameters used to identify the problem. The second column is an assessment of the problem, briefly detailing what factors should be examined as the causes of the problem, The third column Figure 3
Patient Profile and PCP for an Ambulatory Patient with Dyslipidemia Last name: Address:
City, State Zip: Telephone: Birth date: Allergies: Diagnosis(es): Other information:
Thruman First name: James 634 Elm St. Anytown, State 12345 555-3456 3-1-51 Ht: 70" Wt: 221 Ib Codeine (gastrointestinal upset) Dyslipidemia, chronic sinusitis
Initial: M.
Sex:M
Race: White
Date
Drug
Strength
Regimen
4/2/96
Cholestyramine
4 grams
1 packet three times a day
100
4/2/96
Amoxicillin
500 mg
1 capsule every 8 hours
30
Quantity
Hyperlipidemia Problem(s)* Subjective and Objective Information Total cholesterol 298 mg/dL at screening
Assessment
Plan(s)/Goal(s)
Evaluation/Outcome(s)
Poor hyperlipidemia control, perhaps aggravated by obesity and undercompliance with dietary measures
Patient education about cholestyramine
Follow up with patient for questions about cholestyramine
Refer to dietitian for low-fat diet Call physician or lab to obtain lipid profile Check medication calendar and call to remind about refills
Problem(s)· Subjective and Objective Information Chronic nasal discharge; headaches
Follow up with patient to determine if dietitian was consulted Check lab values in lipid profile Review at next refill with pill count
Assessment
Plan(s)/Goal(s)
Evaluation/Outcome(s)
Inadequate control with over-the-counter measures (nasal spray and oral decongestant! antihistamine)
Ensure that full 10-day course taken (ask patient to bring prescription bottle with him in 10 days or call him)
Follow up with patient at 10 days for pill courit Follow up to determine if headaches resolved
Suggest acetaminophen 1,000 mg orally every 4 to 6 hours when needed (no more than 4 grams/day) *James Thruman is a 46-year-old white man who presents at the pharmacy with n~w pres~rip~io~s for cholestyrami~e and amoxicillin. You, the pharmacist, take a medication and symptom history and com.ple~e th,e, pat~ent profll~ In Figure 3. On,the baSIS of your , information, you conclude that he has chronic dyslipidemia and chrOniC ~InUSltIS With nasal.dl.scha~ge for ~hlc~ ,h~ has been taking some over-the-counter medications. As you develop hjs PCP, you note hiS problems of dysllpldemla and SinUSitiS In column ~ an,d use the SQIAPf (S b' t' d Qb' t've'lnformation Assessment, and Plan) to document the problem. Document the patient s 1'1 ormat u jec Ive an jecI ' . " . . SubJ'ect'lve an d Qb'jectlve , ' f t' Y r Assessment (column 2) includes general Ideas about why he dysllpldemla even In orma Ion. ou , stili has , .. though h h b ' d' tary measures Apparently, these measures are not adequate In controlling hiS high serum e as een attempting some Ie . ." . .. . choleste I I I 3 d I eneral Aan to resolve the dysllpldemla and to resolve the current exacerbation of hiS chromc ro. nco umn , you eve op a g , , sinusitis. Finally, in column 4, you list general and specific outcomes measures to ensure that your plan IS being met,
PCP:::: pharmaceutical care plan.
VoL NS36, No. 4 Apri11996
Journal of the American Pharmaceutical Association
Figure 4
Patient Profile and PCP for a Hospitalized Patient with HF and Depression Last name: Hospital number: Room: Birth date: Allergies: Oiagnosis(es): Other information:
First name: Cosgroff 2117445-1 A456 Ht:62" 7-21-34 No known drug allergies HF, history of hypertension Depression
Thelma Initial: P.
Wt: 132 Ib
Sex: F
Race: White
Interval
Date
Drug
Strength
Route
4/2/96 4/2/96 4/2/96 4/2/96 4/2/96
Digoxin Furosemide Isosorbide dinitrate Enalapril Nitroglycerin (sublingual) Amitriptyline
0.25 mg 40mg 20 mg 5mg 0.4mg
Orally Orally Orally Orally Sublingual
Every other day Twice a day Three times a day Twice a day As needed for chest pain
Orally
Daily at bedtime
4/2/96
25 mg
~<
Heart failure Problem(s)* Subjective and Objective Information
Fatigue, shortness of breath, dyspnea on exertion, cough, cannot walk as far as 2 weeks ago, 1+ ankle edema, slight rales, tachycardia
Assessment
Plan(s)/Goal(s)
Evaluation/Outcome(s)
HF exacerbation perhaps caused by:
Obtain brief diet history, especially salt-containing foods and refer to dietitian
Follow up with patient f or dietary changes
Use of OTC medications
Medication history for OTC medication regimens (NSAIDs or salt-containing)
Follow up with patient to determine changes in OTC drug use
Noncompliance with medication regimens
Check medication calendar and call to remind about refills
Review at next refill with pill count
Recommend checking digoxin and potassium levels to physician
Check to see if ordered
Noncompliance with diet
Depression Problem(s)* Subjective and Objective Information
Tired, does not want to socialize
J.
Assessment
Plan(s)/Goal(s)
Evaluation/Outcome(s)
Depressive symptoms perhaps caused by digoxin and/or undercompliance with medication regimen
Recommend to physician to check digoxin level
Follow up with patient about symptoms by calling her in 2 to 3 weeks
Review refills and medication calendar
Tiredness may be muscle weakness caused by low potassium levels
Follow up with patient at next refill with pill count
*Thelma Cosgroff is a 62-year-old white woman who was hospitalized today. You, the pharmacist, take a medication and symptom history and complete the patient profile in Figure 4. On the basis of your information, you conclude that her main problem is heart failure, but she also has depression. Her history of hypertension is not active at this time, so you have not included it in her PCP. As you develop her PCP, you note her problems of heart failure and depression in column 1 and use the SOAPformat (Subjective and Objective information, Assessment, and Plan) to document the problem. Document the patient's Subjective and Objective information. Your Assessment (column 2) includes general ideas about why she has the problem of an exacerbation of heart failure and why her depressive symptoms have not resolved. In column 3, you develop a general Plan to resolve these identified problems. Finally, in column 4, you list general and specific outcomes measures to ensure that your plan is being met. Some of these outcomes measures will be transmitted to the pharmacist caring for her in t~e community setting, because they are more long term than would be seen in the hospital. . HF = heart failure; NSAIDs = nonsteroidal anti-inflammatory drugs; OTC = over the counter; PCP
Journal of the American Phannaceutical Association
= pharmaceutical care plan.
April1996
Vol. NS36, No. 4
includes the plan and goals, and the fourth column indicates the evaluation means or methods that will be used to achieve the desired outcomes. Follow-up monitoring visits require a question-and-answer assessment format (previously described by Boyce and Herrier,12 Isetts ,13 and Ro driguez de Bittner and Michocki 14). All data obtained , assessments, changes in plans, and intervenI tions are noted on the form. Using PCPs is a skill that is acquired through experience; the pharmacist's training starts with a commitment to one patient. Moreover, PCPs should not be formulated in a vacuum-each patient's PCP should be developed in cooperation with the patient's physician(s). A suggested starting point is to choose one disease, identify one patient, and "just do it." You will then be able to build on successes and expand to additional patients and/or diseases.
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The pharmaceutical care plan provides the pharmacist with an organized, logical mechanism to structure the delivery and evaluation of care to patients. However, the most important component of the PCP is the relentless commitment of the pharmacist to providing optimal care to individual patients according to their unique needs. Dennis J McCallian, PhannD, is president, Family PharmaCare Center, Inc., West Lafay ette, Ind. Bruce C Carlstedt, PhD, is associate professor of clinical phannacy and Michael T. Rupp, PhD, is assodate professor ofphannacy administration, School of Pharmacy and Pharmacal Sdences, Purdue University, West Lafay ette, "Ind.
References 1. Larrabee JH, Rodgers VO, Corsey R, et aL Developing and implementing computer-generated nursing care plans. J Nurs Care Qual. 1992;6(2):56-62.
Integration of PCPs into Practice
2. Pierce M, Malloy R, McElroy P. Reducing unnecessary care with the "respiratory care plan." AARC Times. 1993;17(6):67-9. 3. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533-43.
At the Family PharmaCare Center in West Lafayette, I Ind., professional staff use PCPs as part of an ongoing pharmaceutical care program. Not all patients require written P CPs , however , and we focus primarily on patients w ho are at high risk or who were referred to us. We develop and implement PCPs for patients with asthma, diabetes, h ypercholesterolemia, and hypertension. 16 In addition, w e have developed protocols for formulating PCPs, mon itoring patients, providing patient education, and helpi ng patients improve their health. These protocols provide for quality assurance and continuity of care in the services we provide. Private and semiprivate patient care areas are available for professional staff to assess and counsel patients. Still, integrating pharmaceutical care planning and disease management into a busy practice is challenging. Recently, we launched an initiative with our computer system vendor, HealthCare Computer Corporation, that will greatly improve our ability to offer consistently highquality care. The project involves developing practice support software that provides pharmacists with detailed on·line system prompts related to targeted conditions. It is currently in the beta-phase of testing and development. These system prompts provide the pharmacist with real. time reminders and recommendations related to the care of individual patients. Although not a replacement for Iprofessio n a l judgment , such support technology is certainly a helpful supplement. APhA is also developing disease-specific programs and pharmaceutical care protocols to assist pharmacists in their preparation and use of PCPs and in disease management. These resources should soon be available. I
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4. Summary of the final report of the Scope of Pharmacy Practice Project. Am J Hosp Pharm. 1994;51:2179-82. 5. Johnson PE, Rearson MB. Pharmacy's role within a multidisciplinary, patient-focused model for health care. Top Hosp Pharm Manag. 1991;10(4):67-74. 6. Johnson KA, Bergstedt HA, Roberts TW. Use of pharmaceutical care plans in home LV. therapy. Am J Hosp Pharm. 1993;50:2173-4. 7. Gold ML, Fedder ~O. Developing a pharmaceutical care plan. US Pharmacist. 1992;53-60,84.
8. Rich OS. Pharmaceutical care plans. Hosp Pharm. 1994;29(2):17EH3. 9. Wilson IB, Cleary PO. Linking clinical variables with health-related quality of life. JAMA. 1995;273:59-B5. 10. Ware JE. SF-36 health survey: manual and interpretation guide. Boston: The Health Institute, New England Medical Center; 1993. 11. Juniper EF, Guyatt GH, Ferrie PJ, et aL Measuring quality of life in asthma. Am Rev Respir Dis. 1993;147:832-8. 12. Boyce RW, Herrier RN. Obtaining and using patient data. Am Pharm. 1991;NS31:517-23. 13.lsetts BJ. Monitoring and managing patient care . Am Pharm. 1992;NS32:77-84. 14. Rodriguez de Bittner M, Michocki R. Establishing a pharmaceutical care database. JAm Pharm Assoc. 1996;NS36:60-71. 15. Mullins CD, Baldwin R, Perfetto, EM. What are outcomes? JAm Pharm Assoc. 1996;NS36:39-49. 16. McCaliian OJ, Carlstedt BC, Rupp MT. Caring for asthma patients in a community pharmacy. Am Pharm. January 1994;NS34:64-75.
Assessment Questions
Instructions: For each question, blacken the letter on the answer sheet corresponding to the answer you select as being correct. Please review all answers to be sure you have blackened the proper spaces. There is only one correct answer to each question. journal of the American Phannaceutica1 Association
1.
The phannaceutical care plan (PCP) has been defmed as a dynamic outline for the provision of drug therapy, which is: a. Initiated by the phannacist as needed for a specific patient. b. Monitored by the phannacist as needed for a specific patient. c. Modified by the pharmacist as needed for a specific patient. d. All of the above are correct. e. None of the above are correct.
2.
Which one of the following statements is true? a. PCPs are patient specific, not practice-site specific. b. PCPs provide a consistent plan of care that can be applied to institutional and ambulatory care as the patient is treated in various environments. c. PCPs are 100% guaranteed for reimbursement from all third party payers. d. Both a and b are true. e. None of the above are true.
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7.
8.
9.
Patient care planning involves which one of the following? a. Systematically identifying and assessing a patient's problems. b. Setting goals. c. Establishing interventions. d. Evaluating results. e. All of the above. The first step in initiating a PCP is to: a. Establish patient outcomes. b. Assess each identified problem. c. Gather patient data. d. Identify patient problems. e. Formulate a plan for each identified problem. Which area of pharmacy practice is currently required by the Joint Commission on Accreditation of Healthcare Organizations to prepare PCPs for patients? a. Hospital pharmacy practice. b. Nursing home pharmacy practice. c. Community pharmacy practice. d. Home care pharmacy practice. e. None of the above. The most important component of formulating a PCP is: a. Where the pharmacist practices. b. The degree held by the pharmacist. c. The relentless commitment of the pharmacist to providing optimal drug therapy to individual patients according to their unique needs. d. Where the patient is being cared for. e. All of the above are equally important. PCPs are dynamic instruments that should be: a. Filed away once completed. b. Initiated at the first encounter. c. Modified in subsequent encounters. d. Both b and c are correct. e. None of the above are correct. Why should pharmaceutical care planning always be done with outcomes in mind? a. Achieving desired outcomes is the primary goal of pharmaceutical care. b. Future compensation may be tied in part to achieving patient outcomes. c. Patient outcomes will be used to evaluate pharmacy penorrnance. d. All of the above are correct. e. None of the above are correct. Which one of the following is not commonly used to assess patient health outcomes? a. Biological factors. b. Physiological factors. c. Symptoms. d. Physical functioning. e. All of the above are used.
Joumal of the American Phannaceutical Association
10.
Blood glucose is an example of which type of patient health outcomes measure? a. Biological function b. Physiological function c. Symptom d. Physical functioning e. Role functioning
11.
Peak expiratory flow is an example of which type of patient health outcomes measure? a. Biological function b. Physiological function c. Symptom d. Physical functioning e . Role functioning
12.
Which one of the following is not a measure of patient functioning? a. Physical functioning b. Social functioning c. Role functioning d. Psychological functioning e. Patient satisfaction
13.
Why is patient satisfaction an important outcome to measure when evaluating the effectiveness of pharmaceutical care? a. It demonstrates a true patient orientation to care. b. It is often correlated with other desired outcomes such as compliance. c. It is always strongly correlated with clinical outcomes measures. d. Both a and b are correct. e. All of the above are correct.
For Questions 14 through 20, identif.y the word or phrase with the appropriate part of a PCP. 14. "Asthma": a. b. c. d. e.
Problem Goal Plan Monitoring parameter Outcome
15.
"Assess severity": a. Problem b. Goal c . Plan d. Monitoring parameter e. Outcome
16.
"Minimize side effects or adverse reactions of drug therapy": a. Problem b. Goal c. Plan d. MOnitoring parameter e. Outcome
17.
"Obtain serum theophylline concentration at next physician visit ": a. Problem b. Goal c. Plan d. Monitoring parameter e. Outcome
18.
"Take a medication history": a. Problem b. Goal c. Plan d. Monitoring parameter e . Outcome
19. "Decreased hospitalizations": a. Problem b. Goal c. Plan d. Monitoring parameter e. Outcome 20.
"Increase exercise tolerance ": a. Problem b. Goal c. Plan d. Monitoring parameter e. Outcome April1996
Vol. NS36, No.4
Instructions To receive two hours of continuing education credit (0.2 CEU) for successful completion of this program, you must:
1. Complete answer sheet and type or print your name, address, and Social Security number in the space provided. 2. Mail your completed answer sheet with the correct handling fee ($5 for APhA members; $15 for nonmembers; no additional charge for current 12-exam continuing program members) to: Processing DesklEducation American Pharmaceutical Association 2215 Constitution Ave., NW Washington, DC 20037-2985
Developing Pharmaceutical Care Plans APhA provider number for this program is: 202-000-96-002-H04. Make checks payable to "APhA ":
D
5 fee enclo ed (member rate).
D $15 fee enclosed (nonmember rate).
D
$45 12-exam continuing education program fee enclosed.
D $45 12-exam continuing education program fee paid earlier. Nrune _______________________________________
Adilless,______________________________________ City ___________________ State
ZIP _ _ _ _ __
Social Security #-__________________________
Certificates will be issued to those who score 70% or higher. Those who score below 70% will be notified, and no credit will be recorded. Allow Jour
I hereby certify that I have taken this test: (signature)
weeks for processing. Expiration date: April 30, 1999 Answer Sheet
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DUR continued from p. 261
Conclusion In the future, managed care will assume a larger role in the delivery of health care services. The interest of private-sector and government health insurance administrators in interceding in prescribing and reimbursement has fueled this expansion. Changes that occur will be based, in part, on analysis of retrospective claims that identify and review patterns of drug use. Improved information systems and the collection of patient-related data, rather than diagnosis and medication histories, will aid pharmacists in improving therapeutic regimens and efficient use of prescription expenditures.
Renee T. Kubacka, PharmD, is adjunct associate professor,
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I University of Pittsburgh School of Pharmacy, Pittsburgh, and clinical education coordinator, Pfizer Inc., New York, NY.
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IReferences 1. Health Insurance for the Aged Act. Pub L No. 89-97, 79 Stat 290, Social Security Amendments. 18:42§ USC §1395; 19:42§ USC §1396 (1988). 2. Final Report, Task Force on Prescription Drugs. Washington: Department of Health, Education and Welfare; 1969;48. 3. Jinko MJ, Baker DE, Haber E. Reducing unused as-needed orders in long-term care facilities. Consult Pharm. 1989;4:263-6. 4. Cooper JW. Effect of initiation, termination and reinitiation of cor~~ul tant clinical pharmacist services in a geriatric long-term care facility. Med Care. 1985;23:84-8. 5. Cheung A, Kayne R. An application of clinical pharmacy services for extended care facilities. Calif Pharm. 1975;23:22-43.
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Program Evaluation Excellent Overall quality 5 Relevance to practice 5 Value of content 5 Agree Important to pharmacists 5 Increased my knowledge 5 Achieved stated objectives 5 Did not promote particular product or company 5 It took me hours and complete the assessment questions.
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6. Thompson J, Floyd R. Cost-analysis of comprehensive consultant pharmacist services in the skilled nursing facility: a progress report. Calif Pharm. 1978;25:22-6. 7. Kidder SW. Cost-benefit of pharmacist-conducted drug regimen reviews. Consult Pharm. 1987;2:394-8. 8. Accreditation Manual for Hospitals 1994. Chicago: Joint Commission on Accreditation of Healthcare Organizations; 1993. 9. Longo DR, Wilt JE, Laubenthal RM. Hospital compliance with Joint Commission standards: findings from 1984 surveys. Quality Rev Bull. 1986;12:388--94. 10. Roseman AW, Sawyer WT. Population-based drug use evaluation. Top Hosp Pharm Manage. 1988;8:7~92. 11. Brodie DC, Smith WE. Constructing a conceptual model of drug utilization review. Hospitals. 1976;50(6):143-4,6,8,150. 12. Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals 1995. Chicago: Joint Commission on the Accreditation of Healthcare Organizations; 1994. 13. Wenzloff NJ, Boyd EL. Utilization of computerized patient profiles in the prevention of drug-drug interactions. Mich Pharm. 1984;22(7):4-9. 14. Woolf SH. Practice guidelines: a new reality in medicine. Arch Intern Med. 1990;150:1811-8. 15. Kreling DH , Knocke OJ, Hammel RW. The effects o~ an i~tern.al analgesic formulary restriction on Medicaid drug expenditures In WISconsin. Med Care. 1989;27:34-44. 16. Weintraub M, Singh S, Byrne L, et al. Consequences of the state triplicate benzodiazepi ne prescri ption reg u lations. JAMA. 1991 ;266:2392-7. 17. Craig WA, Uman SJ, Shaw WR, et al. Hospital use of antimicrobial drugs: survey of 19 hospitals and results of antimicrobial control program. Ann Intern Med. 1978;89:793-5. 18. Sandusky M. DUR intervention letters: how pharmacists respond. Am Pharm. November 1993;NS33:58-64. 19. Avorn J, Soumerai SB. Improving drug-therapy decisions through educational outreach. N Engl J Med. 1983;308:1457-63. 20. Soumerai SB, Avorn J. Principles of educational outreach ('academic detailing') to improve clinical decision making. JAMA. 1990;263:549-56. 21. Wertheimer AI, Kralewski J. OUR programs: current trends and future directions. Am Pharm. February 1993;NS33:37-42.
Journal of the American Phannaceutical Association