Professor Strand said that she had heard from almost 40 pharmacists as a result of The Pharmaceutical Journal article on pharmaceutical care in Minnesota (PJ, June 28, 1987, p899). Most had asked how they could get started. The first thing that people had to do was to learn what pharmaceutical care was. The term had come to define almost anything.
Pharmacists redefined it so that they did not have to change what they were doing. But that sort of approach would not work any more. Pharmacists had to be educated to carry out pharmaceutical care. An eight-week certificate programme had been devised. It had been designed so that pharmacists could fit it around their normal working schedule.
Examining health care systems as they were today, Professor Strand said that there were two health care budget "buckets". One related to products, where payment was made for distribution, and the other related to patient care. Pharmacy, historically, had been in the product "bucket". Pharmacists had got their reimbursement through the product and their identity had been tied to it. The problem was that there was not a lot of money in that bucket. If the profession wanted to survive into the next millennium it had to move over to the other "bucket". It had to move to the patient care side.
The difficulty was in making that leap. The product side played by the capitalistic, competitive, marketing, technology driven rules and pharmacists were familiar with that, especially in community pharmacy. The patient care side had different rules. There had to be a patient care practice that was documented and evaluated. There had to be a reimbursement system that was patient care driven. Medicine, dentistry and nursing played by the patient care rules.
Pharmacy had never even asked what they were. It was cocooned within a passive product business and was not even market driven. The physician up the street wrote the prescriptions and pharmacists dispensed them. Pharmacists did not market their services because they passively acquired patients in their pharmacies. One reason was that they wanted to see themselves as patient care providers. But they were less than perfect in that respect, too. They provided services when they felt like it, whenever they wanted to and to whoever they thought was appropriate. There was not a patient care provider who was paid for patient care who acted that way anywhere in the world. It was irresponsible and unethical.
Professor Strand said that she used to think like most pharmacists, but had seen the error of her ways when she had sat in front of third party payers to try to get reimbursement for the pharmaceutical care service that they had created in Minnesota. The response had always been the same; when you sound like, act like and become a patient care provider we will pay you to provide patient care. Pharmacists could not get paid for patient care without a practice. Unless pharmacists ventured out of their cocoon and looked at themselves they would not survive the millennium as a profession.
In Minnesota, they had developed a practice that would survive the patient care service criteria and it was very different to what pharmacy was used to. Back in 1990, when she and Douglas Hepler had defined the concept of pharmaceutical care, they had not had a practice in mind. She thought that that was why the term had evolved to mean almost anything. Only in 1992 when she had returned to Minnesota had they started to define the practice that was consistent with the concept.
Pharmaceutical care was now defined as: "A practice in which the practitioner takes responsibility for a patient's drug related needs, and is held accountable for this commitment." Pharmacy was used to policing drug use activity through such systems as creating formularies and carrying out drug utilisation review. But that was always passing judgment on someone else's decisions. Pharmacy was going to have to begin assuming some responsibilities itself. Those responsibilities had to be at the patient-practitioner level. That was where pharmacists fitted in. Professor Strand said that she was not suggesting that pharmacists should cease to manage drug use at all levels but the greatest impact was going to be made at the practitioner-patient level.
Looking at the issue in the context of patient needs, Professor Strand said that if pharmacy was to have a share of the health care dollar it had to identify a set of patient needs that it could meet better than anyone else in the health care system. If pharmacy could not develop a practice that matched up to the position or the doctor, the dentist, or the nurse they would not have a role in patient care.
Pharmaceutical care reflected the same meeting of needs as medical care, dental care and nursing care, only it was focused on the drug related needs of a patient. What pharmacy could contribute was a rational decision making process for drug therapy decisions. It was that rational decision making process that was the foundation of the practice of pharmaceutical care.
A practice had three components: a philosophy; a patient care process; and a practice management system. Pharmacy did not have a philosophy of practice that was explicitly stated and taught to students and practitioners. It did not have a patient care process, even though the only way at being good at making decisions was to be systematic, comprehensive and thorough. The ambiguity, the lack of definition and the lack of consistency was what had made it impossible for pharmacists to convince others that they were capable of making health decisions for other people. A practice management system was needed to support the delivery of expert knowledge to the patient.
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Professor Strand said that pharmaceutical care was a completely different business to dispensing products. Only about 20 per cent of current pharmacists would ever practise it. There would be many dispensing pharmacists for a number of years. However, Professor Strand did not think it would be necessary to spend four years in an academic institution to create people to dispense medicines. If people were going to be educated for four, five or six years they had better contribute something to society.
Pharmaceutical care was separate from dispensing. Pharmacists could not dispense drugs and take care of patients at the same time. However, pharmaceutical care practices were being developed in community pharmacies because that is where the patients were and it was convenient for them.
The philosophy of pharmaceutical care had four basic components: "social need", "patient-centred care", "caring" and "pharmacist responsibilities". The social need was that pharmacists would assure that all the patients' drug therapy was appropriately indicated, effective, safe and convenient. The only way they could do that was one patient at a time. They were not meeting that need at the moment. Drug related morbidity and mortality was costing $81bn a year in the United States.
The "patient-centred" approach needed to see the patient as a whole. Pharmacists could not choose one disease or one set of patients. Pharmaceutical care was a generalist practice. Practitioners needed to use the same patient care process. That enabled them to communicate with each other. Community pharmacists, hospital pharmacists and long-term care pharmacists all had to use the same practice.
In the health care context, "caring" meant something very specific. There were three components. The first one was to assess the patient's needs. Then resources had to be brought to bear to meet those needs. Finally, there should be follow-up to determine whether what had been done was beneficial or otherwise. Without those three components, there was no pharmaceutical care.
Defining pharmacists' responsibilities, Professor Strand said that they had to be able to identify a patient's drug related needs and meet those needs better than anybody else. If they did not do so, they would not be paid as a patient care provider. Pharmacists had to build a practice just as a dentist or a physician would one patient at a time.
The first step for pharmaceutical care was to define what a patient's drug related needs were.
To aid that, in Minnesota they had developed a pharmacist's "work up". Drug related needs should be identified in terms of indication, effectiveness, safety and compliance. Acting on that information, pharmacists had to embark on a problem solving process. There were seven categories of drug therapy problem, regardless of the drug, disease or the patient. These were: need additional drug therapy, unnecessary drug therapy, wrong drug, dosage too low, adverse drug reaction, dosage too high and compliance problem.
Again, in order to do all this systematically and in a matter of minutes a process was needed. To take care of a patient, an assessment of their needs was required, followed by the development of a care plan and a follow up. Every patient care provider in the world was only paid for providing those three things. If the payer could not identify the assessment, the care plan and the evaluation the practitioners would not be paid. Pharmacists had a choice. They could be a patient care provider or not. If they did not want to be they should distribute drug product in the most efficient and effective way possible.
The purpose of pharmaceutical care practice was to ensure that all the patient's drug therapy was indicated, effective, safe and convenient. The order was important. There was no point in making a patient comply with inappropriate treatment.
The care plan was a structure that enabled the pharmacist to work with the patient, who might have a value system or set of expectations and understanding different from those of the pharmacist. It was a plan to meet the goals of therapy and to resolve problems and to prevent future ones from developing. The care plan was a schedule that outlined what the pharmacists were going to do and what the patient was going to do. It was vital because it would determine what the goals of therapy were. Those data had to precede any outcome data being collected about drug therapy. However, it was only when pharmacists followed up that they demonstrated that they cared for patients.
Professor Strand said that telephone calls to patients were made in pharmaceutical care practices to determine whether the goals of therapy were met, whether problems had developed and what had actually occurred in respect of patients. That follow up link was completely missing from current health care systems. There was really no knowledge or understanding about how drugs were used and about the impact that drugs had on society
With the information she had presented so far, Professor Strand had defined a patient care practice that met the expectations and standards of medicine, nursing, dentistry and veterinary medicine. All the terminology she had used was consistent with the health care system generally. It was foreign to pharmacy currently because generally they had not played by that set of rules.
Describing the Minnesota project which had tested pharmaceutical care in community pharmacies, Professor Strand said that almost half of the patients had drug therapy problems that needed to be resolved immediately. The most common problem was that patients needed drug therapy that they were not receiving. This applied to 23 per cent of the patients in one year of the Minnesota project. An example was the physician forgetting about the pain associated with particular conditions and not offering treatment for it. Ineffective drug therapy was found in almost one in four situations. Some 16 per cent of drug therapy problems related to the wrong drug. The total for adverse drug reactions was 21 per cent.
Inappropriate compliance represented 12 per cent of drug therapy problems. This was way below the 60 or 70 per cent reported elsewhere in the literature. This suggested that most patients were non-compliant for really good reasons.
Pharmacists did not need special qualifications to find drug therapy problems. All they needed was a philosophy and a practice that said it was their responsibility, and a management system that let them develop this type of care.
They had found in Minnesota that, in three quarters of the situations, they had been able to resolve the problems with the patients. There had been no need to involve the prescriber. Patients were empowered to take care of themselves these days. The pharmacists needed to take advantage of that.
Another point was that patients were ambulatory. This meant that problems did not have to be solved immediately. Pharmacists had time.
Discussing outcomes, Professor Strand said that there were not any standard definitions in the literature. In Minnesota they had defined their own. These were: "resolved", "stable", "improved", "partial improvement", "unimproved", "worsened", "failure", "expired" (patient died while receiving therapy). Outcomes needed to be consistently defined. It allowed recording of the practice.
Professor Strand said that they had calculated a cost-benefit ratio for pharmaceutical care practice based on 1,000 elderly patients that were part of their study. For this group the ratio was 10.4:1. For the entire group it went up to 11:1. This was one of the highest cost-benefit ratios they had found in the literature. It was not surprising when the type of drug therapy problems was considered. Pharmacists could stop ineffective drug therapy and take patients off the wrong drug therapy. In the light of that, payers did not have any trouble believing the practice was valuable and should be paid for. The difficulty was getting pharmacists actually to deliver the practice on a broad enough basis that patients could have access to it.
Professor Strand made it clear that the benefits she was describing were only delivered by pharmaceutical care practice.
Professor Strand said that the question for all pharmacists was what was their unique contribution. How did they deliver their knowledge to a patient in a way society could measure and be reinforced by it? That was the challenge.
Answering questions, Professor Strand said that there was no database in the United States linking indication to drug therapy in the ambulatory patient. These data were provided by pharmaceutical care.
Asked how long it took for patients' perceptions of the pharmacist to change when they were in receipt of pharmaceutical care, Professor Strand said it took just one encounter. Patients needed this service so badly.
Asked how long it would take to build a practice, Professor Strand said that it would take about two years to reach the optimum number. A pharmacist could take care of about 20 to 30 patients a day, depending on patient type and the proficiency of the pharmacist.
The pharmacist could not run a business any more in the United States on dispensing alone. They could not afford not to move into pharmaceutical care. It was the only activity that would truly generate revenue for the pharmacist. Dispensing prescriptions no longer did that because the dispensing fee was so low.