Establishing an Active Patient Partnership

Establishing an Active Patient Partnership Pharmacists are finding that it is increasingly necessary to form partnerships with patients and other health care professionals. by Richard N. Herrier, PharrnD, and Robert W. Boyce

Program Preview This monograph discusses the changing nature of the relationships between patients and health care professionals and how it is affecting pharmacy practice. Services, opportunities, and skills that pharmacists can use to facilitate, develop, and implement active patient partnerships are outlined.

Learning Objectives Upon 'successful completion of this continuing education article, the pharmacist should be able to: • Apply the principles of active patient partnerships outlined in this program in pharmacy practice. • Describe the changing nature of the patient-health professional relationship. • Identify five major changes that the pharmacist will need to make in order to develop active patient partnerships. • list the types of opportunities and services that require the development or enhancement of phatmacist-patient partnerships. • List five professional skills that the pharmacist will need to strengthen, enhance, or refme in order to develop partnership-type services.

rapid movement toward organized health care delivery in a cost-conscious environment, third party payers are attempting to control costs by using restrictive formularies and more competitive reimbursement structures. The second major shift is from product orientation to patient orientation and is being fueled by technological advances and professional initiatives. Computers and other a9vances in automation are reducing pharmacists' need for prominent involvement in the prescription-dispensing process. Pharmaceutical care, aspects of which are now mandated by law, requires that the pharmacist provide more cognitive services, such as drug use review and patient counseling. The third paradigm shift involves the nature of the patientpharmacist relationship. As pharmacists become more engaged in providing patient-centered professional services, their

CE Credit

CE Credit To obtain two hours of continuing education credit (0.2 CEUs) for "Establishing an Active Patient Partnership," complete the assessment exercise and CE registt:ation form and return it to APhA. A certificate will be awarded upon achieving a passing grade of 70% or better. Pharmacists completing this article by April 30, 1998, can receive credit.

IFE ?C I Background The pharmacy profession is in the midst of three major paradigm shifts. The frrst involves the method and source of payment for pharmaceutical products and services. With the AMERICAN PHARMACY

The American Phannaceutical Association is ~ approved by the American Council on Pharmaceutical Education as a provider of continuing pharmaceutical education.

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"Establishing an Active Patient Partnership" is part of the continuing education program for pharmacists on Value Added Services appearing in American Pharma0'. The series has been developed by the American Pharmaceutical Association, edited by Janet P. Engle, PhannD, and supported by an educational grant from Merck Human Health Division. The opinions expressed are those of the authors and do not necessarily reflect the views of the Indian Health Service, the U.S. Public Health Service, or the Department of Health and Human Services.

APhA provider number is:

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patients will become active, assertive partners in all health care decisions rather than passive recipients of services. 1,2 Much of the current debate in the pharmacy profession is being driven by these three paradigm shifts. Some pharmacists see these changes as primarily negative and believe they may sound a death knell for the profession. With the pharmacist's traditional dispensing role being filled by technicians and automation, reduced compensation for prescription medications, a lack of reimbursement for cognitive services, greater demands to implement pharmaceutical care, and increasing consumerism among patients, pharmacy's future may indeed seem rocky. Others, however, view these changes as a great opportunity for the profession. First, they point out that release from traditional dispensing roles will provide the time they need to expand patient-centered pharmacy services. Problems with reimbursement for pharmacy-based services, moreover, are temporary. Current legislative, professional, and third party payer initiatives provide evidence that help is on the way. Finally, patient activism will provide strong support for expansion of pharmaceutical care. Regardless of where they stand on these issues, pharmacists concur that their ability to interact with patients in a professional but collaborative fashion will be a key element in determining the success of their current and future practices. Establishing and maintaining active patient partnerships is not only essential to maintaining professional survival, but it also represents an opportunity to return to pharmacy's traditional strengths, including personal professional services to patients. For many pharmacists, however, meeting the expectations of a "partner" may require fundamental changes in how they approach and deal with patients.

Changing Patient Roles During the past decade, the relationship between patient and health care provider has undergone marked changes. 1,2 In the past, patients depended on health care providers to diagnose, treat, and manage their diseases. Under this traditional model, care is provider centered. Health care providers, using knowledge and experience obtained through years of education and experience, make treatment decisions, because they know what is "best" for the patient. The patient's role is passive. Provider training has reinforced the dependent relationship between the health professional and the patient. Patients expect providers to make decisions regarding care; providers are trained to view treatment success as evidence of their competency. This model is consistent with widely held societal norms during most of the 20th century that placed high value on expertise, leaders and persons of Vol. NS35, No.4

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authority, and the importance of obedience and loyalty. 3 The influence of this traditional model can be seen today. The very term "noncompliance, " as well as the softer term "nonadherence," connotes failure of the patient to follow the provider's directions. Even the word "patient" implies a dependent relationship, leading some patient advocate groups to search for a more politically correct phrase. 4 Most of today's health care professionals view the traditional model as generally appropriate; in fact, many entered their profession because of the rewards inherent in such a relationship. Most, if not all, currently practicing health professionals have been strongly influenced by or espouse societal values that support this model and were trained by persons who reinforced the appropriateness of traditional provider-patient relationships. The modem model of a provider-patient relationship is, by contrast, one of partnership. The relationship is patient centered; the patient takes an active and assertive role. Patients bring their own "expertise" -their feelings, values, and desires-to the relationship. They want comprehensive information about their disorders, treatment options, and expected outcomes. They want to make informed decisions about what is best for them. In this model, the provider's role changes from decision maker to collaborator and patient advisor. 5 This partnership model is generally consistent with the value systems and current societal norms of people 40 years old and younger. 3 Many indicators of this change in relationship can be seen in both patient and provider actions. The amount of technical, medical, and pharmaceutical information available to the general public has grown dramatically. Many publications on prescription medications, such as the Physician's Desk Reference and the Merck Manual, formerly distributed only to health profeSSionals, can now be purchased at local bookstores. The American Medical Association (AMA) has even endorsed a lay person's guide to medical disorders. 6 As predicted by Toffler7 and Naisbitt,8 self-care by patients has increased markedly. Devices for self-diagnosis of disorders such as hypertension and hypercholesterolemia are readily available, as are pregnancy testing kits. Inexpensive otoscopes, along with pictorial guides to help parents diagnose otitis media and externa, have recently been marketed. Patient use of over-the-counter (OTC) products is rising, and the number of products switched from prescription to OTC status has increased. Currently, discussions are underway to detennine if H 2-receptor antagonists and antiviral medications for genital herpes should be switched to OTC status. The increased interest in alternative th~rapies, particularly vitamin and nutritional products and natural herbal remedies, and homeopathy are indicators of the increased emphasis on self-care. Providers, provider associations, and health care accrediting bodies all advocate or require a patient's bill of rights. Much of the professional literature deals with innovations in "patient focused" or "patient centered" health care delivery systems. Increasing emphasis in the classroom, continuing education (CE) programs, and the professional literature has AMERICAN PHARMACY

been on educating health professionals in patient-provider communication skills. Preferred patient and provider relationships currently range along a continuum from a traditional parent-child role to a partnership-type interaction among equals. Patients who are most comfortable with the traditional model tend to be more than 45 years old and adhere to value systems that emphasize trust and respect for authority figures and experts. Younger patients are more skeptical, less trusting of authority figures, and more assertive in obtaining information and participating in the decision-making process. Thus, they generally prefer a partnership-style interaction. Issues other than age also significantly affect patient attitudes. Culture, parental teaching, the sex of the provider and patient, and religion all influence the degree to which the patient will desire an active partnership with health care providers. Patient attitudes, beliefs, and preferences concerning an appropriate level of involvement in care decisions are, moreover, not static. Life experiences, comfort with the provider, type of illness, degree of acceptance of a chronic illness, new knowledge, and traumatic experiences with the health care system may cause temporary fluctuations or permanent shifts in patient preferences. Patients who normally prefer a more passive role may at times insist on an active role in decision making, whereas patients who normally demand an active partnership may want a more passive role. 9

Active Patient Partnerships and the Pharmacist Partner is defmed as "one who shares, an associate or colleague" and partnership as "a relationship involving close cooperation between parties having specified and joint rights and responsibilities, as in a common enterprise." What do active patient partnerships mean for pharmacists? In his 1978 Harvey A.K. Whitney Lecture, "The Patient's Pharmacist," Allen]. Brands, former chief pharmacist of the Indian Health Service of the u.S. Public Health Service, described many aspects of the pharmacist's side of the patient partnership.IO He noted the need to focus on service to individual patients and their families, to understand the importance of patients' mental wellbeing in determining successful patient outcomes, to be fluent in four languages ("medical, nursing, pharmaceutical, and lay"), and to accept responsibility for patient outcomes involving use of medications. This blend of interpersonal and clinical skills will make the pharmacist an effective partner with patients. Given an apparently accelerated shift from the traditional model to active partnership as the preferred model of patientprovider relationship, what practice changes will pharmacists face? Changes essential to survival and success in this new environment can be summarized in eight broad categories. AMERICAN PHARMACY

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Responsibility for Patient Outcomes One requirement for becoming an active partner is accepting responsibility for patient outcomes involving drug use. This transition may be difficult for many pharmacists. Some still view themselves primarily as purveyors of prescription medications; others may be uncomfortable in assuming responsibility for patient outcomes. Many of these fears and concerns were raised by pharmacists during the debate over implementation of the Omnibus Budget Reconciliation Act of 1990 COBRA '90). However, patients are actively seeking assistance from pharmacists. The pharmacist's old standby, "You'll have to check with your doctor," in response to questions raised by patients, will have to be replaced by professional efforts to help patients solve their health problems. If the pharmacist does not step up to share responsibility with the patient in facilitating appropriate drug use, the patient will fmd someone else who will do so. That person, who might be the clerk at the local health food store, may not have the training and professional ethics of the pharmacist. Patient outcomes may suffer.

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A New Method of Giving Advice

Under a traditional model, the patient asks, "What's good for a cold?" and the pharmacist recommends a product. With the partnership model, the pharmacist questions the patient further, to make sure that the patient's self-assessment is accurate, then offers several therapeutic options, including nondrug treatments. The pharmacist states the advantages and disadvantages of each product and its cost before recommending a product and explaining the rationale behind it. The patient then makes the decision.

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The Patient's Role , ~:,' /,/ .,11 in Health Management Under the traditional model, the health professional's role is to diagnose and manage disease. As drug therapy managers, clinical pharmacists focus on blood levels, pharmacokinetic dosage calculations, and drug interactions. Guided by this focus on the technical aspects of patient care, health professionals often become frustrated if patients do not follow their instructions or if, despite their best efforts, treatment results are only partially satisfactory. The perception that health professionals manage the treatment of disease has never been accurate. The phannacist or provider truly manages treatment only when patients are actually in the physician's office, the hospital, or the phannacy. The rest of the time, patients manage their own disease treatment. One author suggests, for example, that noncompliance in diabetes mellitus is due in large part to providers' failure to recognize that their goal is not to treat the disease but to help the patient treat disease. I I That contention is supported by current medical literature on compliance, which links good communication and a partnership style of April1995

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patient-provider relationship to increased patient satisfaction, increased compliance, and better patient outcomes. 12,13 Failure to recognize the degree to which patients control their own illnesses, by contrast, has created tension in patient-provider relationships, provider frustration and anger, poor communication, poor patient outcomes, and medical-legal consequences that have contributed to rising health care costs. 12- 15 Pharmacists have the potential to have a major impact by reducing patient noncompliance.16 To do so, they must shift their goals and attitudes, from managing treatment to helping patients manage their treatment; in other words, they must shift from a traditional model to a partnership model. This philosophical shift will also be required if pharmacists are to be effective in other patient-focused roles, such as counseling on self-care and preventive health.

Increased Patient Demand for Information The explosion of medical information available to the public has occurred in response to patients' desire to be better informed. Better-informed patients are more assertive in obtaining information; they ask more sophisticated and difficult questions and demand responses from all of their health care providers. Referring requests for information to the physician is becoming increasingly less acceptable to patients. These changes will require pharmacists to increase their patient-education skills. Because adult learners strongly prefer interactive teaching methods to passive ones, courses on pharmacist counseling will have to be interactive; the traditional lecture format will be less acceptable. To handle difficult questions, pharmacists must also learn how people deal with disease, and they must build more sophisticated interpersonal skills.

Increased Record Keeping and Confidentiality Issues As pharmacists assume increased responsibility for patient outcomes, documentation of professional activities will be required to provide consistent, high-quality care; obtain compensation from third party payers; and ensure that information is available for medical and legal purposes. OERA '90 A Practical Guide to Effecting Pharmaceutical Care, a recent publication of the American Pharmaceutical Association (APhA) , describes a method of documenting such pharmaceutical care activities. 17 To assume greater responsibility for patient outcomes, pharmacists will require more detailed information about patient diseases, symptoms, physical [mdings, and laboratory test results. This increased access to patient information will require markedly increased attention to protecting confidentiality of patient information, i.e., restricting access to persons with legitimate need to know. VoL NS35, No.4

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Increased Privacy

The provision of pharmaceutical care and active pharmacist-patient partnerships will require private areas in pharmacies for interviewing and educating patients. Designs for new pharmacies that facilitate pharmaceutical care include such areas or rooms. The IRS has designed and used private consultation rooms and booths in its pharmacies for more than 25 years.

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Increased Interaction with Patients In the past, the pharmacist's competence and success were based primarily on technical knowledge and expertise. In the future, active patient-partnerships will require a blend of technical expertise with knowledge of interpersonal communication, human behavior, and education. Knowing the right answer will not be enough; pharmacists will also have to make recommendations in a manner that is readily understood and that encourages the patient to comply. i

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Incre?sed Educational ReqUirements Given the magnitude of the changes faCing pharmacy, all pharmacists will need higher levels of interpersonal and clinical skills. This does not mean a total restructuring of pharmacy education, nor does it mean that every pharmacist will need a PharmD degree. In many cases, pharmacists already have the basic knowledge and skills. Most need only to fine-tune them, to add a few new variables that will increase their existing competence, or to use old skills in new ways. For many, exchanging established communication habits for new and more effective techniques will be the most difficult requirement. The perception that a PharmD degree plus specialization is required to practice as a clinical pharmacist has been inadvertently fostered by the clinical pharmacy movement. Pioneers and innovators in the clinical pharmacy movement, however, did not have clinically based PharmD degrees; most held bachelor's degrees or nonclinical PharmDs. They decided to assume responsibility for patient outcomes and were largely self-taught. The most comprehensive ambulatory pharmaceutical care program in ex istence today, the IRS Pharmacy Program, primarily uses pharmacists with bachelor of science degrees ; pharmacists with PharmDs make up only 20 % of the staff. 18 For almost three decades , these BS-Ievel IRS pharmacists have been delivering pharmaceutical care . They hold prescriptive authority, provide patient consultation, and participate in prospective drug use review with their PharmD-level colleagues. ~~

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AMERICAN PHARMACY

IHS has been formally enhancing pharmacists' skills in pharmaceutical care since 1984 through the IHS Clinical Pharmacy Training Program. Using home study, a oneweek course devoted primarily to skill practice, and a postcourse, on-the-job mentorship, IHS develops pharmacists' skills to enable them to practice in the IHS model. IHS has shared many of its materials and methods with colleges of pharmacy, and they are currently used to train both practicing pharmacists and pharmacy students. Several colleges of pharmacy, as well as several proprietary pharmaceutical firms, have implemented or are implementing similar programs for practicing pharmacists. These programs require 100-300 contact hours, which are completed outside normal working hours. With the advent of the information superhighway, pharmacists will have access to many of these training opportunities without leaving home or work.

Opportunities for Implementing Active Patient Partnerships The pharmaceutical care movement offers pharmacists opportunities to implement active patient partnerships in areas such as managing self-care and self-diagnosis of acute and chronic diseases, as well as preventive services. Regardless of practice setting or type of service contemplated, the common thread among all these opportunities is the requirement that the pharmacist work more closely with both the provider and the patient and share more responsibility for outcomes.

Self-Care and Self-Diagnosis In rural America, before passage of the Durham-Humphrey Act, which created a class of prescription-only drugs, almost every town had a pharmacist, but not necessarily a physician. Two of the pharmacist's primary roles have always been to help patients self-diagnose and treat minor acute ailments and to refer patients with more serious problems to the more distant medical care provider. These traditional roles are even more important today, given the focus on cost-containment and increased consumer interest in self-care. Several factors will influence the expansion of these self-care services. The flfSt factor is patient access. The patient has easier access to, and more frequent contact with, pharmacists than with any other care providers. Thus, expanding the pharmacist's capability and use as a primary care advisor and provider is a logical step in improving the efficiency and reducing the cost of health care. The development of private consultation areas to help meet OBRA '90 requirements for counseling patients about medications can also facilitate expansion of selfAMERICAN PHARMACY

care services. These spaces can be used to interview and advise patients regarding self-care. In general, the greater the privacy, the wider the variety of problems patients are willing to discuss. 19 Increased privacy in the pharmacy can lead to increased sales volume as well. One innovative proprietary pharmaceutical care system for counseling, PharmCare in Waco, Tex., has found that the development and use of these private areas has led to significant increases in OTC sales. Another factor facilitating expansion of the pharmacist's role in self-care is the shifting of more pharmaceuticals from prescription to nonprescription status. This trend will expand the armamentarium available to the pharmacist to treat certain illnesses and will expand the scope of disorders about which the pharmacist can advise patients. For example, currently under discussion is the shift of oral acyclovir to OTC status. If the switch is ultimately approved, the treatment of sexually transmitted diseases (Sills) and shingles will be added to the list of illnesses for which patients will seek advice from the pharmacist. As the pharmacist's role as primary care advisor expands, enhanced patient assessment skills, including interviewing and physical assessment skills, will be essential. The pharmacist can also help patients with self-diagnosis, screening, and monitoring of chronic illnesses. Hypertension, diabetes, and hypercholesterolemia monitoring and screening services can foster active patient partnerships. Although federal regulations may complicate setting up a diagnostic laboratory within the pharmacy, contract arrangements with sanctioned institutions can be substituted for in-house capabilities. Another logical opportunity for increasing pharmacists' involvement in active patient partnerships lies in expanding self-care triage functions. When patients come to the pharmacy with signs and symptoms that indicate a need for physician referral, the pharmacist, through advanced visit planning, can markedly improve physician productivity and reduce patient waiting time. 20 For these patients, the pharmacist can document findings on a referral form, arrange a physician appointment, and order appropriate laboratory or radiological procedures. When the patient arrives for the appointment, the physician will already have the pharmacist's patient history and the test results needed to make a defmitive diagnosis. The availability of the pharmacist's interview fmdings and test results at the time of initial patient contact will enable the primary provider to make an accurate assessment more quickly. The efficacy and acceptability of these expanded primary care and triage roles for pharmacists have been demonstrated by the IHS Pharmacy Program since the 1970s. 21 Within IHS, pharmacists are the primary care providers for 15-20% of outpatient visits. 21 These pioneering efforts will now have direct economic benefit, especially in the managed care setting, where expansion of traditional pharmacist roles will both increase physician productivity and decrease the number of patient visits. April1995

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Treating Acute Illnesses Patients with acute illnesses are another group that offers opportunities for active patient-pharmacist relationships. One at the primary responsibilities of Allen Brands's "patient's pharmacist" is to review a prescription order for appropriateness of therapy. 10 The extent of this review depends on the amount of patient data available to the pharmacist. At the most basic level, the prescription order and the patient profile allow the pharmacist to ensure that the dose, dosage tonn, and directions are appropriate, that the patient is not allergic to the new medication, and that the new medication will not negatively interact with medications the patient is already taking. Because many chronic health problems can be deduced from the treatment being used, potential drugdisease interactions can also be reviewed. The availability of a diseased-based problem list would further enhance the scope and accuracy of this type of prospective drug use review. With more complete patient records, including current diagnosis, laboratory values, and physician notes, the pharmacist can review the prescription order for choice of agent, ascertain that needed follow-up is planned, and evaluate dosages on the basis of information about the patient's ability to metabolize and excrete drugs. If potential problems are identified during this review, the pharmacist can request additional information from the patient or contact the prescriber before dispensing the medication, thus ensuring that the therapy is both safe and cost-effective. Once the prescription order is processed, the pharmacist must verify that the patient understands how to use the medication properly. In addition to traditional drug-related consultation issues required by OBRA '90, several other important items should be reviewed with the patient. First, the patient must understand what to expect from the prescribed treatment, including when disease manifestations can be expected to disappear and what to do if they do not or if symptoms worsen. The patient should also understand the possibility of unexpected effects and how to manage them. Still another value added item is education about ancillary treatments, such as how to administer medications to infants and toddlers; how to use cold packs, elastic wraps, and crutches for musculoskeletal injuries; and how to use pads and bandages for wounds or sores. Another additional service is a follow-up phone call to the patient 24-48 hours after the pharmacy visit to check on treatment effectiveness, potential compliance problems, or side effects.

Long-Term Drug Therapy For patients who require long-term medication therapy, the pharmacist can improve the effectiveness of prescribed treatment through several activities, including compliance enhancement, patient education, and drug therapy monitoring. The pharmacist can also serve as the patient's primary provider between physician visits and, in many cases, make Vol NS35, No.4

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the need for such visits less frequent. Reviewing prescription orders for appropriateness and ver· ifying patient understanding of new medication use or other changes in existing regimens are the most basic services that pharmacists provide to these patients. The next level is counseling patients when they pick up prescription refills. OBRA '90 does not require counseling at this point, and some view it as unnecessary. Nevertheless, this valuable service provides myriad opportunities to develop partnerships with regular customers. Contrary to some pharmacists' beliefs, patients on chronic therapy for a disease with minimal symptoms often have difficulty maintaining compliance for pro· longed periods; for example, more than 50% of initially compliant hypertensive patients will not be under treatment one year later. 22 Counseling patients provides opportunities to recognize and reinforce compliance as well as to detect problems early on that may affect long-term compliance. Using "Show and Tell," the IHS interactive patient counseling technique that is specifically designed for prescription refills, pharmacists can verify proper compliance and detect potential problems in 15-30 seconds per prescription. 23 Another minimal expansion of basic services is the education of patients on proper use of supplies, devices, and equipment needed to manage chronic diseases. Advising patients on proper use of home blood glucose and blood pressure devices can build the rapport and trust that contribute to an active patient partnership. Sinlilarly, the pharmacist's role as a compliance enhancer can be easily expanded. Phone or mail reminders of upcoming refills or physician visits improve compliance and help patients fit medication-taking into their daily routine. A logical step on the continuum is to move from an indirect, supportive role as a patient advocate, educator, and compliance enhancer to a more direct role as manager or provider of patient care between physician visits. A variety of effective examples of this type of service exist and, in some cases, have existed for decades . Current professional practice in the IRS, the Department of Veterans Affairs, health maintenance organizations, and private community pharmacies demonstrate a full range of scope and sophistication of these types of programs. 21 ,24-26 These interim manager/provider models require: (1) formal partnerships with phYSicians that include treatment guidelines or protocols, (2) availability of patient health records, (3) simple and direct methods of pharmacist-physician communication, and (4) a private environment for pharmacist-patient interaction. At their Simplest, these models involve pharmacist responsibility for monitoring patient compliance, disease control, and complications from the disease or the drug therapy compliance. In more complex models, pharmacists assume responsibility for patient assessment, which includes physical examination, and privileges to prescribe and order tests necessary to evaluate patient AMERICAN PHARMACY

progress. 21 Patients who develop complications or unusual problems are referred to the physician for further assessment or consultation. The need for physician visits may be reduced when such arrangements are in place; the degree of reduction depends on pharmacist capability, the complexity of the disease, and the ease of physician-pharmacist communication and referral. Successful programs have been demonstrated for patients on oral anticoagulants or oral contraceptives and patients with disorders for which drug therapy is the primary treatment mode, such as diabetes mellitus, hypertension, epilepsy, seizures, anemia, tuberculosis, and mild, uncomplicated cardiac disorders. 21 Another aspect of this role as primary health care provider, seen in governmental and managed care practice, is overseeing refill programs. 20 In these programs, patients who run out of medications because of missed or changed appointments come to the pharmacy, where they are evaluated by a pharmacist. If the patient's condition is stable or under reasonable control, the pharmacist refills the prescription with enough medication to last until the next available physician appointment. Patients whose conditions are in poor control or who lack adequate physician follow-up are promptly referred for medical attention. These services eliminate phone calls for prescription renewals, simplify patient efforts to remain compliant, and improve the coordination and quality of care. A similar opportunity for pharmacists exists in home health care. Many pharmacists already supply medication for and train patients in the administration and home use of longterm parenteral therapy or home dialysis. Expanding existing services to enable the pharmacist to manage the care of patients with chronic diseases would be a natural extension. The physician, with pharmacist input, would devise the home therapy. The pharmacist would monitor the patient's treatment and handle simple problems or adjustments to the therapeutic regimen. More complex problems would be referred to the supervising physician. These partnerships with patients on long-term drug therapy have already demonstrated significant economic benefit to patients, the health care delivery system, and pharmacists. 21 ,25,26 In managed care settings, such role extension reduces the number of physician visits, improves productivity, and reduces per capita costs while maintaining or improving the overall quality of care. Direct reimbursement of the pharmacist is allowable for certain programs providing extensive patient training and assistance in home health care and for managing diabetes mellitus. (The pharmacist must be a certified diabetes educator to obtain reimbursement.) The results of several demonstration projects, now near completion, will provide a clearer picture of third party payers' willingness to reimburse pharmacists for other pharmaceutical care services. AMERICAN PHARMACY

Preventive Care Involvement in pharmacy- or community-based preventive health programs is a relatively untapped method for pharmacists to increase their involvement in patientcentered activities. Although pharmacists have participated for years in "brown bag" sessions for the elderly, poison prevention activities for children, and screening programs, their involvement in programs on contraception and STD prevention has been limited. Even less common are pharmacist programs in prenatal education, especially regarding drug use during pregnancy. Opportunities exist for educating new mothers about appropriate use of OTC medications, medication administration techniques for infants and toddlers, and poison prevention. Several pharmacies in Tucson and Phoenix, Ariz., have used the pharmacy as a site for influenza and pneumococcal vaccinations before the winter cold and flu season. Expanding on that concept, pharmacies could also offer routine infant and adult immunizations. Because improper storage of heat-labile live-virus vaccines has been linked to deterioration of potency and lack of vaccine immunogenicity, professional oversight of both storage and administration of these products would be a valuable pubHe service. One of the strongest advocates of pharmacybased public health and prevention activities is Pharmacists Planning Service Inc. (PPSI) in Sausalito, Calif. , founded by pharmacist Frederick Mayer. For a nominal fee, PPSI will send pharmacists materials that identify many preventive activities. Materials available through PPSI are included in the package.

Enhancing Skills to Facilitate Active Patient Partnerships Implementing pharmaceutical care and developing active partnerships with patients require varying levels of skill enhancement. In most cases, the pharmacist's knowledge base about drugs will require minimal augmentation; the focus should be on applying that knowledge to specific situations or increasing the depth of knowledge or skill concerning a particular disorder. For example, a pharmacist planning to offer hypertension screening and monitoring services would need updated information on diagnosis, pathophysiology, current national standards, indications for treatment, use and accuracy of home/ambulatory blood pressure measuring devices, and side effects of commonly used drugs. Although most pharmacists will require only minimal enhancement of technical skills, almost all will need significant training in "people" skills (i.e., communication and behavior) in order to develop active patient partnerships. April1995

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Putting the Meare' in Pharmaceutical Care Regardless of age, patients generally want personalized, caring relationships with their health care providers.27 They want health professionals to listen to and respect their perspectives about their health. They want to be well informed and to participate in decisions on their treatment. 2 ,12,27,28 Patient satisfaction with health care providers is determined primarily by how well the providers meet the patient's desires for personalized, caring, respectful, and informative interactions. 29 Patient satisfaction levels, irl tum, have a major inlpact on compliance, the frequency of use of a particular pharmacy, and the potential for litigation, i.e., the greater the level of patient satisfaction, the better the compliance, the more the patient will use the provider, and the lower the chance for litigation.1- 15,28 ,29 Most pharmacists feel that they express caring attitudes , and many do an excellent job. However, in three areas , the "care" aspect is a major factor that may need to be improved to facilitate successful, active patient partnerships. The first is in demonstrating a willingness to help the patient. Having the right answer to every question is not necessary, yet for some pharmacists, fear of not having the right answer or of giving a less than perfect answer is a major barrier to involvement in partnership-type relationships. When patients ask questions, a caring pharmacist will not respond, "You 'll have to check with your doctor about that. " Instead, the pharmacist will encourage such patients to disclose their problems, concerns, and feelings more fully before formulating a response. Even if the end result is the admission of uncertainty and a recommendation that the patient contact the physician, these patients will view the pharmacist who does not immediately dismiss their questions as concerned, caring, and respectful. Improving listening skills is a second key to demonstratirlg a caring attitude. Classes in "active" listening, dealing with difficult people, parentirlg, and customer service all teach the same basic techniques; they are simply applied to different situations. The second part of Pfizer Inc.'s Pharmacist-Patient Consultation Program (pPCP 11), "Counseling Patients in Challenging Situations," teaches pharmacists how to use listening skills to facilitate patient counseling.30 These techniques are also easily applied to other pharmaceutical care situations. The third technique is to change the traditional method of giving advice. When asked to recommend something for a cold, many pharmacists respond with a specific , single recommendation . In the era of partnerships, pharmacists should first clarify the exact nature of the cold symptoms and then offer several alternatives , listing the advantages of each, and pausing to allow the patient to absorb the information. If the patient prefers a product listed by the pharmacist, the pharmacist should then make a recommendation and give the reason for it . Vol. NS35, No.4

April1995

If the patient prefers a product that the pharmacist feels

is not appropriate, a general statement, along with the rationale for the alternative recommendation, can be offered, e .g ., "Most of my patients say they get good response from product Y, plus it 's a little cheaper and doesn't cause as much drowsiness."

Self-Care Skills One important skill that improves the pharmacist's ability to advise patients irl this era of active patient partnerships is "chief complaint" medical interviewing. An open-ended, question-based irlterview approach, it allows the pharmacist to discover needed information about the patient's signs and symptoms quickly and completely. An earlier article in this series, "Obtaining and USing Patient Data," describes the technique and its proper use.31 Pfizer has an excellent video program for physicians that demonstrates the technique. 32 This same technique, with slight modifications, can also be used to obtain a medication and health history from new pharmacy patients. The pharmacist also must be able to irlterpret the information collected durirlg the patient interview, i.e., to determine which patients should be referred to the physician and which can safely treat themselves with OTC products. Several texts, irlcludirlg the APhA Handbook of Nonprescription Drugs33 and the American Medical Association Family Medical GUide,6 provide detailed irlformation on the signs and symptoms of common mirlor ailments and those that irldicate the need for physician referral. Pharmacists normally function as secondary educators when counseling patients about prescription drugs; their objective is to verify patients' understanding and fill in their knowledge gaps. In self-care practice, however, pharmacists function as primary educators. Unfortunately, no practical irlstructional guidelirles or techniques for treatment of minor acute illnesses have been developed for the primary educator. Common sense would irldicate a need to make sure that the patient understands proper dosing and administration of all medications, plus any potential side effects. The patient must also understand how to monitor disease progression and recognize signs and symptoms that irldicate the need for urgent medical attention. The U.S. Pharmacopeia's Ad Hoc Task Force on Medication Counseling Behaviors is developirlg guidelines for this activity.

Acute Care Skills The skills needed to review the patient's prescription order and profIle are generally specific to the database being used. However, an excellent general reference, Systematic Medication Profile Review-A Self-Study Guide for the Phannacist, provides a format and practice opportunities for honing prospective drug use review skills. 34 AMERICAN PHARMACY

Once problems are detected, a comfortable and mutually respectful relationship with a physician is key to successful interventions on behalf of the patient. No course or text adequately covers this process; however, general principles can be used in all cases, including the use of "I" messages: structuring the message as would a physician calling a colleague to clarify a requested consult, and phrasing the problem and potential solutions clearly and concisely. Verifying patient understanding of proper prescription medication use is one of the most important skills needed, not only to improve patient compliance but also to facilitate development of active patient partnerships. Pfizer's videotape-based workshop with workbook, PPCP I, teaches the IHS Pharmacy Program's interactive patient consultation technique, which uses structured, open-ended questions to create a brief dialogue with the patient that verifies the patient's understanding and fills in any knowledge gaps.23 This technique minimizes time spent counseling and allows the pharmacist to demonstrate the caring attitude that maximizes patient satisfaction and fosters partnerships.

Chronic Care Skills The phannacist must also strengthen skills in monitoring chronic diseases, perfonning physical assessments, detecting noncompliance, and supporting compliance. Monitoring skills are primarily disease-specific but have several things in common. At each visit of a patient with a chronic illness who requires continuous medication, the pharmacist should check the "4 Cs": completeness, compliance, control, and complications. Completeness refers to ensuring that the patient is picking up all medications at the same time. This reduces pharmacist workload, physician interruption, and patient waiting time, while helping patients keep track of medication use and promoting compliance. Compliance refers to assessing the patient's compliance through counseling and record review. A third pflZer workshop (pPCP Ill), due to be released in spring 1995, outlines a structured process to detect and verify compliance problems when patients return for prescription refills. Control refers to assessing the level of control of the patient's disease by record review and patient interview. Complications refers to detecting complications caused by the disease or the drug therapy. Disease-specific criteria can be found in several textbooks and are taught in numerous CE programs. Methods for developing written monitoring criteria and organizing them effiCiently can be found in the literature. 35 The development of disease-specific physical assessment skills, especially those involving observation, will augment the pharmacist's ability to evaluate the 4 Cs at each visit. Textbooks on this subject are available. 36,37 To obtain a broad knowledge of physical assessment skills, pharmacists can enroll in colleges of nursing or community colleges that offer evening and weekend courses as part of certificate programs for nurse practitioners. AMERICAN PHARMACY

Medical interviewing skills learned for managing patient self-care are also used to monitor patient progress and to investigate therapy- or disease-related problems. When calling a physician to discuss a problem, the phannacist's use of the "Holy 7" interview format, described in an earlier article in this series,31 to organize fmdings will enhance the physician's receptivity to the pharmacist'S concerns, because physicians also use this method to organize communications about patient problems. Finally, to fulfill their roles as compliance enhancers, pharmacists must become familiar with the literature concerning how and why patients comply with prescribed treatments, techniques for detection of compliance problems, and techniques for facilitating compliance. No single text, CE program, or reference is available on this subject. The pharmacist must become well versed in applied human behavior and communication as it relates to compliance. Concepts such as "lay theory," "self-efficacy," "locus of control," and "health belief model" are the theoretical foundations for practical approaches to aid compliance. 2 ,38,39 These, combined with a new focus on the nuances of patientprovider relationships, will be new tools of phannacists in compliance-support roles. 12

Prevention Skills Because prevention means helping patients comply with healthful behaviors, the pharmacist who engages in it needs strong skills in applied human behavior and communication. Expanding knowledge of prevention resource materials requires contacting specific disease-related organizations, such as the American Heart Association, or a clearinghouse, such as PPSI.

VVhere to Begin To develop effective pharmacist-patient partnerships, begin by stepping back and looking at current activities and the types of patients who use your facility. In all likelihood, many have already made some steps toward partnership activities. Inventory your strengths. What do you already do well? What things interest you most? Perhaps a relative or friend has diabetes, and you have already developed interest and expertise in that area. Start small. Build on your existing strengths and interests or on things that seem easiest to accomplish. For example, if you are interested in compliance enhancement, identify your patients' most common diseases and begin by focusing on one of them. You might also begin with a simple reminder service for all refills. As these programs develop, begin enhancing staff skills. Do not expect perfection; problems always occur when impleApril1995

Vol. NS35, No.4

menting new programs. Generally, the smaller the change, the smaller and less troublesome the problems will be. Phannacists frequently attempt too large a change and expect it to go perfectly. When that does not happen, frustration and discouragement set in. In many cases, the effort is terminated because the pharmacist believes it simply "can't be done."

9. Herrier RN, Boyce RW. Compliance with prescribed drug regimens. In: Bressler R, Katz M, eds. Geriatric Pharmacology. New York: McGrawHill; 1993:63-77. 10. Brands AJ. The patient's pharmacist. Am J Hasp Pharm. 1979;36(3): 311-5. 11. Anderson RM. Is the problem of noncompliance all in our heads? Diabetes Educ. 1985;11 :31-4. 12. DiMatteo MR. The physician-patient relationship: effects on quality of health care. Clin Obstet Gynecol. 1994;37:149-61. 13. Viinamaki H. The patient-doctor relationship and metabolic control in patients with type 1 (insulin-dependent) diabetes mellitus. Int J Psychiatry Med. 1993;23:265-74.

SumlDary Pharmacists face many changes in the coming decade, some of which threaten their professional survival. Although uncertainty may currently prevail, one of these changes, the shift in the patient-health care professional relationship from the patient taking a passive role to an active partnering role, provides pharmacists with many opportunities to realize the vision of patient-centered care that has been advocated by pharmacy innovators and leaders for almost three decades. To take advantage of these changes, pharmacists must modify their practice paradigms and use their existing strengths, such as easy patient access and high levels of patient trust, to help develop a new model of pharmaceutical care. The concern that the magnitude of these changes will prevent successful practice transformations may be exaggerated. In reality, these proposed "new" roles have been in existence for much of this century. Most pharmacists can expand and enhance their traditional roles as self-care advisors and patient educators simply by incremental improvements in interpersonal and clinical skills. Rather than a Star Trek approach to "go where no man has gone before," the profession needs only a pharmaceutical sequel to Back to the Future. Richard N. Herrier, PharmD, is assistant professor, Department of Pharmacy Practice, College of Pharmacy, University ofArizona, Tucson. Robert W (Bill) Boyce is chief, Pharmacy Services, Chemewa Indian Health Center, Indian Health Service, Salem, Oreg.

References 1. Rees AM. Communication in the physician patient relationship. Bull Med Libr Assoc. 1993;81(1):1-10. 2. Steele DJ. Beyond advocacy; a review of the active patient concept. Patient Educ Couns. 1987;10:3-23. 3. Massey M. The People Puzzle: Understanding Yourself and Others. Reston, Va: Reston Publishing; 1979.

4. Golodner LF. Consumer Perspective. Presented at Open Conference on Communicating Risk to Patients, United States Pharmacopeial Convention; September 20,1994; Reston, Va. 5. Ballard-Reisch DS. A model of participative decision making for physician-patient interaction. Health Communication. 1990;2:91-104. 6. Kunz JR, Finkel AJ. American Medical Association Family Medical Guide. New York: Random House; 1987. 7. Toffler A. Powershift. New York: Bantam Books; 1990. 8. Naisbitt J. Mega tren ds. New York: Warner Books; 1982.

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14. Beckman HS. The doctor patient relationship and malpractice: lessons from patient dispositions. Arch Intern Med. 1994;154:1365-70. 15. Anderson LA, Zimmerman MA. Patient and physician perceptions of their relationship and patient satisfaction: a study in chronic disease management. Patient Educ Couns. 1993;20:27-36. 16. The Role of the Pharmacist in Comprehensive Medication Use Management. Washington: American Pharmaceutical Association; May 1992. 17. Canaday BR, ed. OBRA '90 A Practical Guide to Effecting Pharmaceutical Care. Washington: American Pharmaceutical Association; 1994. 18. Church RM. Pharmacy practice in the Indian Health Service. Am J Hosp Pharm.1987;44:771-5. 19. Tindall WN, Beardsley RS, Kimberlin CL. Communication Skills in Pharmacy Practice. Philadelphia: Lea & Febiger; 1989. 20. Koertvelyessy A, Schorr G. Advanced visit planning: a concurrent quality assurance of IHS outpatient care. In: Bushy A, ed. Rural Nursing. Vol. 2. Newbury Park, Calif: Sage Publications; 1991 :41-52. 21. Herrier RN, Boyce RW, Apgar DA. Pharmacist-managed patient care services and prescriptive authority in the U.S. Public Health Service. Hosp Form. 1990;25:67-80. 22. Eraker SA, Kirscht JP, Becker MH. Understanding and improving patient compliance. Ann Intern Med. 1984;100:258-68. 23. Boyce RW, Herrier RN, Gardner M. Pharmacist-Patient Consultation Program, Part I: An Interactive Approach to Verify Patient Understanding. New York: Pfizer Inc; 1991. 24. Brychell R. Patient-oriented pharmacist. Am Pharm. 1990;NS30:211-3. 25. Borgsdorf LR, Miano JS, Knapp KK. Pharmacist-managed medication review in a managed care system. Am J Hosp Pharm. 1994;51:772-7. 26. Garabedien-Ruffalo SM, Gray DR, Sax MJ, et al. Retrospective evaluation of a pharmacist-managed warfarin anticoagulation clinic. Am J Hosp Pharm. 1985;42:304-8. 27. Smith RC, Hoppe RB. The patient's story: integrating the patient and physician centered approaches to interview. Ann Intern Med. 1991 ;115:470-4. 28. Morris LS, Schulz RM. Medication compliance: the patient's perspective. Clin Ther. 1993;15:593-606. 29. Burtakis KD, Peter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract. 1991;32:175-81. 30. Pharmacist-Patient Consultation Program, Part II: Counseling Patients in Challenging Situations. New York: Pfizer Inc; 1993. 31. Boyce RW, Herrier RN. Obtaining and using patient data. Am Pharm. 1991;NS31:517-23. 32. Communication Strategies in the Medical Interview [videotape]. New York: Pfizer Inc; 1994. 33. Self TH, Srnka OM. Systematic Medication Profile Review-A Self-Study Guide for the Pharmacist. Alexandria, Va: American College of Apothecaries; 1991. 34. McKenney JM, Wyant SL, Atkins D, et al. Drug therapy assessments by pharmacists. Am J Hasp Pharm. 1980;37:824-8. 35. Longe RL, Calvert JC. Physical Assessment: A Guide for E'!aluating Drug Therapy. Vancouver, British Columbia: Applied Therapeutics; 1994. 36. Bates B. A Guide to Physical Examination and History Taking. Philadelphia: JP Lippincott; 1995. 37. Becker MH. Patient adherence to prescribed therapies. Medical Care. 1985;23:539-55. 38. Leventhal H. The role of theory in the study of adherence to treatment and doctor-patient interactions. Medical Care. 1985;23:556-63. 39. Pharmacists Planning Service Inc, PO Box 1336, Sausalito, CA 94966.

AMERICAN PHARMACY

Assessment Questions

Instructions: For each question, blacken the letter on the answer sheet corresponding to the answer you select as being the correct one. Please review all of your answers to be sure you have blackened the proper spaces. There is only one correct answer to each question.

8.

Which of the following will not increase pharmacists' capabilities in self-care? a. Weekly specials on popular OTC items. b. "Chief complaint" interviewing skills. c. Increased privacy. d. The shift of more products from prescription to OTC status. e. limited physical assessment skills.

9.

1.

Which of the following is not a factor in the three paradigm shifts that are forcing changes in pharmacy practice? a. Technological advances. b. Improved reimbursement for prescriptions. c. Shift from a dependent to an assertive patient role. d. Managed care's attempts to reduce costs. e. Professional initiatives in pharmaceutical care.

The economic and quality-of-care benefits of expanded phannacist roles in self-care, triage, and mOnitoring or managing chrO!} ic drug therapy have been least well documented in which of the following practice settings? a. Indian Health Service. b. Department of Veterans Affairs. c. UniverSity-based pharmacy programs. d. Community pharmacies. e . Health maintenance organizations.

2.

Which of the following is not a characteristic of a traditional patient-provider relationship? a. The health professional knows what is best. b. The patient has no "expertise." c. It is consistent with the societal norms of 1910-70. d. It is patient centered. e. The patient is "treated" by the provider.

10. Many of the expanded pharmaceutical care roles have been practiced by pharmacists since: a. 1990. b. Implementation of OBRA '90. c. Before the Durham-Humphrey Act. d. The advent of clinical pharmacy. e. The doctor of pharmacy degree was initiated.

3.

Which of the following is not characteristic of a partnership style of patient-provider relationship? a. It is provider centered. b. The patient wants to be part of the decision-making process. c. The patient has greater access to health-related information. d. It is consistent with societal norms of the late 20th century. e. The patient is an active participant in the treatment.

11. Which action is not consistent with the new method of giving advice on patient problems? a. Strongly recommending a specific product. b . Collecting information before advising. c. Offering several options. d. listing the advantages of each choice. e. None of the above.

4.

5.

6.

7.

Which of the following is not evidence of the changing nature of the health professional-patient relationship? a. A marked increase in patient access to medical information. b. Increased interest in self-care. c. A patient's bill of rights. d. Health care reform. e. Increased interest in "alternative" remedies. The statement, "Patients more than 45 years old are most comfortable with the traditional medical model," is: a. Always true. b. Never true. c. Changeable, with type of illness. d. A myth. e. None of the above. What changes must the pharmacist make to be successful in the new era of pharmaceutical care and active patient partnerships? a. Accept responsibility for patient outcomes. b. Change method of giving advice. c. Document professional services. d. Improve communication skills. e. All of the above. The perception that health professionals manage the patient's disease: a. Is accurate only during office visits and hospitalizations. b. Does not affect compliance. c. Fosters active patient partnerships. d. Decreases provider frustration when outcomes are not optimal. e. Is consistent with the patient-provider partnership model.

AMERICAN PHARMACY

12. Which of the following is not one of the "4 Cs" of chronic care monitoring? a. Compliance b. Control c. Complications d. Consultation e. Completeness

13. Comprehensive self-instruction resources for pharmacists are readily available on which of the following topics? a. Compliance enhancement. b. Effective interaction with physicians. c. Primary patient education. d. Patient counseling on prescribed medications. e. Compliance problems. 14. Which of the following factors or concepts is the least important in assisting patients' efforts to be compliant? a. Age of patient. b. Self-efficacy. c . Patient theories regarding health. d. Health-belief model. e. Partnership approach by the provider. 15 . Successful implementation of partnerships that facilitate pharmaceutical care services should be characterized by: a. Scheduling a mandatory six-month planning and training period before implementation. b. Maintaining high expectations for trouble-free implementation. c. Beginning with a small expansion of existing services. d. Promoting a comprehensive, totally new service as the first attempt. e. Completely renovating existing facility.

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Vol. NS35, No.4

16. Which of the following preventive health care services is offered least by phannacists? a. Poison prevention services. b. Well-child vaccination services. c. "Brown bag" sessions. d. Blood pressure screening programs. e. SID prevention and contraception education.

To receive two hours of continuing education credit (0.2 CEUs) for successful completion of this program, you must:

17. Of the following , which will improve physician efficiency but is not part of expanded self-care triage roles for the phannacist? a. Documentation and transmission of phannacist fmdings to the physician. b. Ordering of diagnostic tests. c. Making medical appointments for referred patients. d. Previsit planning. e. Pharmacist prescribing.

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 Desk/Education American Phannaceutical Association 2215 Constitution Ave., NW Washington, DC 20037-2985

18. Which of the following patient communication techniques/ skills is most likely to foster active patient partnerships? a. Computer literacy. b. Better organization of educational materials. c. Use of sophisticated audiovisual aids. d. Active listening skills. e. A toll-free telephone service for drug infonnation.

19. Which of the following factors is least likely to affect a patient's interest in an active patient partnership? a. Cultural background b . Religion c. Economic status d. Patient age e. Patient sex

Instructions

1. Complete answer sheet and type or print your name, address, and Social Security number in the space provided.

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 four weeks for processing. Expiration date: April 30, 1998

Answer Shei!t

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5. 6. 7.

20. Which of the following is not associated with putting the "care"

8.

in phannaceutical care? a. Improving listening skills. b. Increasing use of phannacy services. c. Improving compliance. d. Reducing risk of litigation. e. Quickly referring patients to their physicians for advice or answers to questions.

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Establishing an Active Patient Partnership APhA provider number for this program is: 680-202-95-005. Make checks payable to "APhA ":

D D D D

In the next issue ..... .

Physical Assessment in the Community PharlTlacy With health care delivery s}laiigip.g"~fl,1phhsiS is being placed on the health caf,(~~ ie.am~ s« ability to manage a patient's total health. The ne~! continuing !edpcation aq:i. de will help pharmac~sts develop their ro~e ~~ care mapagers and gather objectiv~ and subjective infprmation to evaluate a patient's l?hysical condition. /

>;~~"

$5 fee enclosed (member rate). $15 fee enclosed (nonmember rate). $45 12-exam continuing education program fee enclosed. $45 12-exam continuing education program fee paid earlier.

Name __________________________________________ Address,_________________________________________ ZIP ________

City ____________________ State

Social Security #.____________________________ I hereby certify that I have taken this test: (signature)

-.;:;:.

Program Evaluation Poor

Excellent Overall quality Relevance to practice Value of content

5 5 5

4 4 4

3 3 3

2 2

2

Disagree Agree 1 2 4 Important to pharmacists 3 5 1 2 4 Increased my knowledge 5 3 2 4 Achieved stated objectives 5 3 2 4 Did not promote particular 5 3 product or company It took me hours and _____ minutes to read this article and complete the assessment questions.

Vol. NS35, No.4

April 1995

AMERICANPHARMACY