I am professionally pharmacist. These slides for clinical subject especially for pharmacy department students.

1. Dr. Tahir Mehmood Khan
Associate Professor
Institute of Pharmaceutical Sciences
UVAS- Lahore

2. Pharmaceutical care plan

3. Pharmaceutical care plan
 The goal of Pharmaceutical Care is to optimize the
patient's health-related quality of life, and achieve
positive clinical outcomes, within realistic
economic expenditures.

4. Pharmaceutical care plan

5. Pharmaceutical care plan

6. Pharmaceutical care plan
Pharmaceutical care planning is a systematic,
comprehensive process with three primary functions:
 Identify a patient's actual and potential drug-
related problems.
 Resolve the patient's actual drug-related
problems.
 Prevent the patient's potential drug-related
problems

7. Defining Pharmaceutical care plan
 PC is individualized, comprehensive medication
therapy plan based on clearly defined therapeutic
goals.
 It is important that the physician be informed about
the care plan to ensure common goals.
 Patients should also be informed about the general
content of the care plan as means of gaining their
agreement regarding drug therapy.

8. Activities in pharmaceutical care
plan
Create patient database
 Patient demographics
 Diagnoses and past medical history
 Present medications and medication history
 Medication allergies/intolerances
 Smoking/alcohol/caffeine/drug use history
 Abnormal laboratory and physical exam results
 Renal and liver function

9. Activities in pharmaceutical care
plan
Assess drug-related problems
 Assess the patient for drug-related problems.
 Determine whether drug-related problems are being
treated.
 Determine whether current drug therapy is appropriate.
 Determine whether additional drug therapy is needed.
 Determine if any of the drug-related problems may have
been caused by medication.

10. Activities in pharmaceutical care
plan
Assess drug-related problems
Most drug-related problems are the result of:
 Not receiving an indicated drug
 Receiving the wrong drug
 Receiving too little of the drug
 Receiving too much of the drug
 Experiencing an adverse drug reaction
 Experiencing a drug interaction
 Not receiving the prescribed drug
 Receiving a drug for which there is no valid medical
indication

11. Activities in pharmaceutical care
plan
Establish therapeutic goals
Therapeutic goals should be definite, realistic and, if possible,
measurable. Most therapeutic goals relate to:
 Approach normal physiology (i.e., normalize blood
pressure).
 Slow progression of disease (i.e., slow progression of
cancer).
 Alleviate symptoms (i.e., optimize pain control).
 Prevent adverse effects.
 Control medication costs.
 Educate the patient about his or her medication

12. Activities in pharmaceutical care
plan
Specify monitoring parameters
 Finally, monitoring parameters must be specified so that the
patient's progress can be followed.
 Monitoring parameters must also include potential adverse
effects.
 Determine desired end points for each parameter and the
frequency of monitoring.

13. Activities in pharmaceutical care
plan
Document patient's progress
 The pharmacist evaluates and documents the patient's
progress in achieving the desired therapeutic goals and
avoidance of potential adverse effects.
 The pharmaceutical care plan is updated with each major
change in patient status

14. Activities in pharmaceutical care
plan
Follow up
 Reassess patient condition/ goals
 Medication reconciliation
 Potential interactions and medication counselling
 Specify monitoring parameters with end points and
frequency.
 Achieved therapeutic goals
 Check for adherence to therapy

15. Summary
PC is an essential step in direct patient care which
mainly emphasize o:
 Curing disease
 Slowing its progression
 Reducing its severity and symptoms
 Minimizing drug related problems
 Reducing the cost of therapy
 Ensuring adherence and follow up

16. What are the current addition to the PC
process; Medication therapy management
services

17. References
 Strand LM, Cipolle RJ, Morley PC. Drug-related problems; their
structure and function. Ann Pharmacother 1990;24:1093-7.
 Canady BR, Yarborough PC. Documenting pharmaceutical care:
creating a standard. Ann Pharmacother 1994;28:1292-6.
 Chase PA, Bainbridge J. Care plan for documenting pharmacist
actvities. Am J Hosp Pharm 1993; 50:1885-8.
 Rich DS. Pharmaceutical care plans. Hosp Pharm 1994;29(2);176-
8.
 Cameron KA. Preventing medication-related problems among
older Americans. Man Care Int 1998;11(10);74-85.
 Egging P. Implementing pharmaceutical care in the home
setting. Pharmaguide 1995; 8(4);1-9.

18. Dr. Tahir Mehmood Khan
Associate Professor
Institute of Pharmaceutical Sciences
UVAS- Lahore

19. Background
 The problem of poor adherence to medical treatment
is a well-recognized problem in the literature.
 Studies have shown that in the United States alone,
nonadherence to medications causes 125,000 deaths
annually and accounts for 10% to 25% of hospital and
nursing home admissions.
 This makes nonadherence to medications one of the
largest and most expensive disease categories

20. Common factors causing non-
adherance

21. Common factors causing non-
adherence

22. Specific interventions to improve
adherence

23. Specific interventions to improve
adherence

24. Way forward

25. Consequences of Poor Adherence
 For the individual—
 Treatment failure
 Drug resistance
 More complex treatment, more toxicity, more uncertain
prognosis
 From a public health perspective—
 Transmission of resistant virus (subsequent ART failure)
 From a health economics perspective—
 Negative impact on the established cost benefit of ART
 Increased morbidity and mortality

26. Methods of Measuring Adherence (1)
 Self-reporting
 Pill counts
 Pharmacy records
 Provider estimate
 Pill identification test
 Electronic devices—MEMS
 Biological markers—Viral load
 Measuring medicine levels—TDM
micro-electromechanical systems

27. Methods of Measuring Adherence (2)
Method Advantages Disadvantages Potential
Bias
Physician’s
assessment
▪Simple, cheap,
requires no
structured tool
▪Subjective,
inaccurate:
estimates affected
by doctor-patient
relationship
▪No particular
bias
▪Study showed
correct est. in
only 40%
Patient self-
report
▪ Simple, cheap,
qualitative
assessment
possible
▪Subjective,
inaccurate: poor
patient recall, lack
of candor
▪ Overestimates
adherence
▪ Most widely
used currently
Pill counts ▪ Simple, cheap,
objective
▪Pill dumping, pill
sharing, timing of
doses unknown,
bottles needed
▪ Overestimates
adherence

28. Methods of Measuring Adherence (3)
Method Advantages Disadvantages Potential Bias
Pharmacy refill
records
▪Objective ▪Pill dumping, pill
sharing, timing of doses
unknown; good records,
patient tracking, and
overtime needed
▪Overestimates
adherence
Drug level
monitoring
▪Objective ▪Expensive, requires lab,
invasive, unknown
timing of doses; PK
profile of population
needed
▪Can over- or
underestimate
depending on
behavior
immediately prior to
test; genetic
variations in drug
metabolism
Electronic drug
monitoring
(EDM)
▪Objective,
data on timing
of doses,
monitoring
over longer
periods
▪Pill dumping, pill
sharing, timing of doses
unknown
▪Underestimates
adherence; taking
out multiple doses
for later use

29. Strategies and Tools to
Enhance Adherence (1)
Pretreatment strategies—
 Identify the potentially non-adherent client/patient and address
the barriers to adherence during counseling before prescription.
Especially for anti-retroviral therapies
 Identify an adherence partner or buddy, or a peer educator.
 Ask the client/patient to demonstrate adherence ability.
 Identify reminders or tools to help in taking pills.

30. Strategies and Tools to
Enhance Adherence (2)
Ongoing treatment strategies—
 Generate daily-due review and refill list, and “flag”
absent clients/patients.
 Refer to community-based health care workers and
NGOs.
 Use DAART or modified DOT (practiced at health
centers, CBOs, or at client’s/patient’s home).
 Use incentives and enablers (e.g., having income-
generating projects for caregivers, providing transport on
clinic days, or providing food).

31. Strategies and Tools to Enhance Adherence
(3): Example from Ghana*
Monitoring adherence at the sites—
 Routinely measure adherence using patient self-reports,
pharmacy records, and pill counts.
 7-day recall used for self-reports.
 Client exit interviews.
 Viral load measurements as surrogate marker.
*Source: Amenyah, R., and K. Torpey. 2005. The Challenges of Monitoring Antiretroviral Adherence:
Strategies for Improved Patient Adherence to Therapy. Presentation given at the 2005 Strategies for
Enhancing Access to Medicines (SEAM) Conference, Accra, Ghana, June 18–20. Arlington, VA:
Family Health International.

32. SLEPT
IN
AWAY
FROM
HOME
RAN
OUT
OF
PILLS
FELT
ILL
FELT
BETTER
PILLS DO
NOT
HELP
FEAR
SIDE
EFFECTS
DID NOT
WANT
OTHERS
TO SEE
FAMILY SAID
NOTO
MEDICATION
FORGOT
orTOO
BUSY
DID NOT
UNDERSTAND
INSTRUCTION
S
MISSED DOSES
WHATTO DO?
TAKING
PILL
HOLIDAYS UNABLE
TO CARE
FOR
SELF
• No double dose
• Within 3 hours, take the
missed dose
• If >3 hours, go for the next
Counseling for Adherence Problems
WENT
FOR
PRAYERS
AND GOT
CURED

33. Self Management Support
 Demonstrating new skills
 Praise & Feedback

34. Self-Management

35. Health Care System
 Provider-Patient Relationship

36. Element of patient care

37. References
 Agency for Healthcare Research and Quality. (2002). Preventing Disability
in the Elderly with Chronic Disease. Retrieved May 15, 2010, from
http://www.ahrq.gov/research/elderdis.htm.
 Chronic Care Model (2010). The Chronic Care Model. Retrieved June 15,
2010, from
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Mo
del&s=2
 Goldberg, E., Dekoven, M., Schabert, V., et al. (2009). Patient Medication
Adherence: The Forgotten Aspect of Biologics. Biotechnology Healthcare,
39-44.
 Murray, M., Morrow, D., Weiner, M., et al. (2004). A Conceptual
Framework to Study Medication Adherence in Older Adults. The American
Journal of Geriatric Pharmacotherapy, 2(1), 36-43

38. References continued.
 Ruppar, T., Conn, V., & Russell, C. (2008). Medication Adherence
Interventions for Older Adults: Literature Review. Research and Theory for
Nursing Practice: An International Journal, 22(2) 114-147.
 Sherman, B., Frazee, S., Fabios, R., et al. (2009). Impact of Workplace
Health Services on Adherence to Chronic Medications. The American
Journal of Managed Care, 15(7), 53-59.
 Simpson, R. (2006). Challenges for Improving Medication Adherence. The
Journal of the American Medical Association, 296(21), 2614-2616.
 World Health Organization. Adherence to Therapies: Evidence for Action.
Geneva: World Health Organization, 2003

39. Thank
you