This document discusses ambulatory care services provided by pharmacists. It defines ambulatory care as health services for patients who do not require overnight hospital stays. The value of ambulatory pharmacy services includes increasing physician availability, decreasing hospitalization rates, and improving quality of care. Pharmacists play roles in health screening, medication management, and patient education in areas such as diabetes and falls prevention. Studies show pharmacist telephone follow-ups with seniors reduce drug-related problems. Future opportunities for ambulatory care include expanding reimbursement models and measuring quality and patient outcomes.

1. Ambulatory Care Services
In Hospital Pharmacy
Anas Bahnassi PhD RPh

2. Lecture Objectives:
Upon completion of this lecture the student should
be able to:
1. Describe ambulatory care practice
2. Describe the impact of ambulatory care practices
3. Provide examples of activities provided through
ambulatory care services
4. Identify future opportunities and challenges

3. No Need
Define Ambulatory Care
for
Overnight “all health-related services for
Stay
patients who walk to seek their
care”
Seaton, Ambulatory Care, PSAP
Ambulatory Clinics Free Standing
Pharmacies
general (primary
care);
Hospital
Assisted Living
Outpatient
Centers
Departments
specialty (day
surgery,
chemotherapy)

4. Rationale of Ambulatory Care
• Shift from Hospital Ambulatory care:
– Managed Care requiring decreasing long hospital stays.
– Increased outpatient procedures especially for elderly with
multiple chronic conditions
– More focus on preventive medicine and patient education
– The Goal is to decrease health care costs
• Continuity of care:
– bridging the gaps
– secondary prevention clinics

5. Value of Ambulatory Pharmacy
Services
o Increase physician availability
o Increase # patient visits
o Decrease hospitalization rates: Asthma clinic, Pauley et al, 1995
o Drug cost savings: Jones et al, 1991
o Improve quality of care:
o More thorough work-up
o Address adherence issues: Ulcers: Lee et al, 1999
o Better treatment outcomes:
o Anticoagulant control, Chiquette et al, 1998
o Hypertension, Erickson et al, 1997
o Diabetes, Coast-Senior et al, 1998
o Fewer adverse drug reactions: Miller et al, 1996

6. First
Contact
Continuity of
Care
Comprehensive
Care
Primary Care
Individualization
Disease
Ambulatory Prevention
Care
Patient
Education
Particular
Organ
Secondary Disease
Care Prevention
Specialized
Training

7. Pharmacist: Roles & Responsibilities in
Ambulatory Care Services
• Screening and early detection
– dyslipidemia
– hypertension
– diabetes
– osteoporosis
• Health promotion and disease prevention
– immunization
– smoking cessation
– general wellness

8. Pharmacist: Roles & Responsibilities in
Ambulatory Care Services
• Medication history and assessment
– disease specific
– efficacy, toxicity, adherence
– medication management
– herbal products
• Pharmacotherapeutic interventions
– identification/prevention of drug-related problems
– establishing goals and outcomes
– initiate Pharmacy
– modify Care plan
– discontinue
– monitor drug therapy

9. Implementation of Pharmaceutical
Care Plan
 Documentation
 Communication
– With Who:
• physician
• Health care team
• community pharmacy
• community agencies (e.g. VON)
– How to:
• chart
• team rounds
• telephone

10. Documented Study on the Impact of
Ambulatory Care Services
Telephone follow-ups reduce seniors' drug-related problems
Patients aided by pharmacist calls
By Lynn Haley
VANCOUVER – Telephone followup can greatly reduce drug-
related problems (DRPs) in geriatric patients, researchers at
the Toronto Rehabilitation Institute reported at the recent
17th World Congress of the International Association of
Gerontology.
The Medical Post, VOLUME 37, NO. 28, August 21, 2001
Kwan, Alibhai, Papastavros, Armesto, Toronto Rehab Institute

11. Additional Drug-related problems identified
during Telephone follow-up:
4% Non-adherence
10% 27%
Adverse reaction
17%
Pt unclear about med.
regimen
Inappropriate
dosing/administration
Additional drug req'd
*20% 22% Unclear indication
* new category that emerged during follow-up

12. •101 interventions were carried out
• 66% of interventions were provided by the
pharmacist over the telephone 
Intervention type % Total
1. Medication education  41.6%
2. Dosing regimen modification  20.0%
(e.g. timing, use of compliance aids)
3. Therapeutic recommendation 12.9%
(resulting in new prescription)
4. Consult Geriatrician 11.8%
5. Refer to community resources  8.0%
(e.g. community pharmacy, VON)
6. Earlier clinic follow-up visit 4.9%

13. Initiating Ambulatory Care Practices
Multidisciplinary falls clinic:
• Medications contribute to falls
• Role of the pharmacist:
– interventions will be patient specific
– weighing risk vs. benefit
– preventive measures (e.g. osteoporosis)
– education of the patient informed choices

14. Challenges
1. Team dynamics:
– overlapping scopes of practice (health teaching)
– clarify roles and responsibilities
– key messages
2. Marketing your services:
– education of patients and health care providers, re: scope
of practice
– when to refer

15. Challenges
3. Delivering patient education
– effectiveness and impact
– adult vs. student education
– group education - interactive vs. didactic
– multi-cultural aspects
– varying levels of education
– handouts
4. Changing the public’s perception
– creating a demand for cognitive services

16. ASHP Standards
Minimum standards for pharmaceutical care services in
ambulatory care:
1. Leadership and Practice management
2. Medication therapy and pharmaceutical care
3. Drug distribution and control
4. Facilities, equipment and other resources
http://www.ashp.org

17. Future Opportunities
• Reimbursement
• Credentialing (value added)
– residency
– Pharm.D.
– fellowship
– specialty certification

18. Future Opportunities
• Measuring quality of care
– identifying representative markers of care
(e.g. BP, lipid levels)
• Measuring patient satisfaction
– timeliness, efficiency, communication
• Impact on long term outcomes
– e.g. diabetes education- > control BS -> impact on
complications?

19. Summary
Tremendous opportunity for growth
Multidisciplinary team resources available
Dedicated time for direct patient care and
follow-up
Taking the lead in care - primary liaison
Opportunity to try new ideas!

20. Hospital Pharmacy
Anas Bahnassi PhD RPh
abahnassi@gmail.com
http://www.linkedin.com/in/abahnassi
http://www.slideshare.net/abahnassi
http://www.udemy.com/hospital-pharmacy
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