British Journal Article 6/28/97
This is a summary of an article published in the June 28, 1997 issue of The Pharmaceutical Journal, the official journal of the Royal Pharmaceutical Society of Great Britain
PHARMACEUTICAL CARE: THE MINNESOTA MODEL
Pharmaceutical care was defined by Douglas Hepler and Linda Strand as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life (Am J Hosp Pharm 1990; 47:533-43).
A pharmacist working to this new definition ascertains all the medicines that a patient is taking, from whatever source, assesses them for reasonableness and effectiveness in the light of the patient's condition, develops a care plan and follows up progress on a regular basis.
Now with the Peters Institute of Pharmaceutical Care at the University of Minnesota, Professor Strand's description of the institute's refined philosophy of pharmaceutical care emphasized that the pharmacist's real focus was the patient. Pharmaceutical care was a practice, just like any other health practitioner's practice. It had a philosophy, a patient care process and a management system. If there was a difference between pharmaceutical care and clinical pharmacy it was that pharmaceutical care had a management system and clinical pharmacy did not. Pharmaceutical care was a practice in which practitioners took responsibility for defining a patients needs and held themselves accountable for that.
Why was pharmaceutical care needed?
The unique problem of drug morbidity and mortality required the expertise of a pharmacist. Contrary to what might be expected, the study found that about 20 per cent of patients needed additional drug therapy.
Did money spent on pharmaceutical care lead to savings elsewhere?
Data showed that half of all patients entering a pharmacy had a drug therapy problem that needed to be addressed. Insurance companies and other health care providers should not want their patients to be taking unnecessary or ineffective drugs.
To change a profession, it would be necessary to change regulations, reimbursement, education, practice, patient expectations, relationships with physicians, the responsibilities of professional associations, the physical structure of pharmacies and the attitude of the pharmacist. The way forward could be to teach students pharmaceutical care as a practice. The Minnesota concept of pharmaceutical care worked because it set out to find problems and solve them. The institute was developing a curriculum to teach pharmaceutical care, but it would not be restricted to pharmacists, although the institute was not interested in creating a new professional. Pharmaceutical care did not eliminate dispensing or devalue it.
What was the pharmaceutical care process?
The care process was connected fully to the philosophy. It comprised three steps: assessment of a patient's drug therapy needs; a personalized care plan that embraced those needs; and a follow up evaluation to make sure those needs had been met. Pharmacists could not interfere with people's lives without full documentation.
Those steps had not been invented for the purposes of pharmaceutical care. They were part of every single health care practitioner's patient care process in every part of the world.
Would some pharmacists specialize in particular areas of therapy?
The institute had developed the practice of pharmaceutical care as a generalist practice in the community because that was where patients spent most of their time. As in other practices, the generalist might refer the patient to a specialist.
THE PROJECT
Pharmaceutical care as a concept has undergone a three-year trial in community pharmacy in Minnesota. The project was conducted by the Peters Institute of Pharmaceutical Care of the University of Minnesota, under the directorship of Dr. Robert Cipolle. The primary research question was: "Can the philosophy of pharmaceutical care be practiced in community pharmacy." The short answer: Yes.
Back in 1991, pharmaceutical care had just been a concept. The project, which ran from 1992 to 1996, had been an enormous success and, as well as proving the pharmaceutical care concept, it had generated a lot of valuable data about patients' care needs over a long period of time. The care process comprised assessment, care planning and evaluation.
A key component was the follow-up, where the pharmacist recorded outcomes, evaluated progress and reassessed treatment. If pharmacists did not follow up they did not care, it was that simple.
For pharmaceutical care to be effective, practitioners had to be disciplined. The average time for an assessment was about five minutes. A lot could be achieved in that time if the pharmacist was systematic.
It simply had not been feasible to record the necessary data on paper. As a result, a program had been developed by Health Outcomes Management Inc.
The program was designed to help pharmacists care for large numbers of people over long periods of time. Data from 10 pharmacies from November, 1994, to October, 1995 covered 5,480 patients (59 per cent female, 41 per cent male) and provided 12,376 encounters, averaging about 2.3 encounters per patient. Not all the patients at the pharmacies were receiving pharmaceutical care. Those that did were working adults and their families insured through Blue Cross/Blue Shield, who paid for the pharmaceutical care of the patients concerned during the project. Pharmacists identified and addressed 4,228 drug therapy problems in the year. The most frequent was that patients needed additional medicines (23 per cent). Unnecessary drugs accounted for 7 per cent of problems and adverse drug reactions 21 percent (899 problems). Most of the effort went where there was nothing wrong (3,000 patients) or one drug therapy problem (1,000). There was an average of 0.8 drug therapy problems per patient. The insurance companies should be willing to pay for pharmaceutical care. (A group in Iowa was running a pharmaceutical care project with an insurance company in that state.)
So far as outcomes were concerned, pharmaceutical care seemed to be having a positive effect. Drug therapy problems were being identified and resolved. This improvement was due to the pharmaceutical care offered by the pharmacists.
THE PRACTICES
Health Outcomes acquired Edina Pharmacy about eight months ago and it is being developed as a pharmaceutical care practice. In charge of the project is Dr Michael Frakes, a pharmacist and president of the subsidiary company of Health Outcomes that is developing the pharmacy system. Dr Frakes noted that, in general, patients were taking twice as many drugs as recorded in a pharmacy patient medication record system.
A personalized pharmaceutical care plan generated by the software was of value to the patient, and the patient could show their care plan to their physician or any other health professional treating them. Twenty-five patients had signed up for pharmaceutical care at the pharmacy so far. The patients paid a fee for pharmaceutical care.
There were several major hurdles. One was getting patients interested in pharmaceutical care and another was getting that care paid for. No one seemed to care that many treatments with medicines were not working.
For $10 a month per patient, pharmacists practicing pharmaceutical care could do everything that needed to be done. The tools had been developed for pharmaceutical care.
WHITE BEAR LAKE
The Bel-Aire pharmacy in White Bear Lake did not take part in the Minnesota pharmaceutical care project, but one of the pharmacists who now practices there, Mr Tony Bose, did. For the present, it was up to the individual pharmacist to make arrangements for a health maintenance organization to pay for pharmaceutical care or ask the patient to pay. So far, about 25 patients had been enrolled for pharmaceutical care. Forms had been developed to obtain medication information from other pharmacies used by the patient. Other pharmacists were willing to pass on such information.
Asked if he liked practising in this way, Mr Bose said: "I love it. It gives me the chance to feel I am doing something good for patients. I am really involved. Before, I only knew about patients superficially."
Mr Bose emphasised that support personnel were essential. Without them, pharmaceutical care would fail. Pharmaceutical care pharmacists had to be freed from the routine of dispensing. But pharmacists could not excuse themselves from pharmaceutical care on the basis that they did not have enough time.
He had no doubt in his mind: the pharmaceutical care model developed in Minnesota was the way to go. As more and more pharmacists practiced pharmaceutical care and suggested changes in treatment to benefit the patient, physicians would come to value their judgment. |
