Don’t Worry be Happy

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Over the past year I have asked my staff to pay particular attention to the reasons patients give for wanting to transfer their prescriptions over to our pharmacy.  Despite being a small, independent pharmacy and being surrounded by competitors offering incentives and points programs, patients regularly transfer their prescription files over to us from neighbouring pharmacies.  I consider these patient comments to be priceless information to guide the direction of our practice.

 

Here is what we hear most often about the pharmacies patients are leaving:

“When I go in there, I feel like I’m bothering them.”

“They said they couldn’t help me.”

“They don’t explain things to me.”

“They don’t seem to have time for me.”

“They didn’t seem to be listening when I was talking to them.”

 

There are many variations of the above sentiments, but what it points to is patients who feel a lack of care or empathy from the pharmacy staff.  While there can be many contributors to a patient’s poor experience in their previous pharmacy, I have looked as well to the reasons patient’s give for choosing our pharmacy.  Most often I hear from patients that my staff seem to really care about them, they go above and beyond to help them, they take time to really hear what is important to them.

Now, I’m no hiring wizard, and by no means am I able to always hire people who simply excel naturally at great customer service.  However, what I do think has been a key to our success is that, for the most part, my employees are happy.  They take pride in their work and genuinely care about the people we serve.

Let’s face it, your staff are the face of your business.  If your employees are not happy, your patients will know it!  Why are patients often treated poorly or made to feel like they are a bother?  Most often it is from interacting with employees who are unhappy in their jobs and would rather be elsewhere.

Your employees really are your best advertisers.  No matter what the message is on your website or your bag stuffers, your logos or slogans, a patient’s experience of your business all comes down to the staff they interact with.

Here are three key areas to increase staff positivity and retention:

  1. Allow staff to work to their full potential. Working to their fullest potential is empowering for pharmacists as well as technicians.  Move your professionals away from tasks best suited to support staff and provide the structure required for them to work at the top of their license.
  2. Provide vision and leadership. Team members are happier if they have purpose and meaning in their work.   Be sure to voice your vision and encourage your team to see the bigger picture in their daily tasks.
  3. Involve your staff in decision making. Having a say in some operational decisions creates a sense of ownership for team members.  Ultimately, they will be more satisfied with their position and more likely to stay with your business.

 

Lessons Learned

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When I left pharmacy school over 20 years ago, I thought I had attained all the knowledge I needed in order to care for patients.  The one thing that all those years of studying didn’t teach me was that my patients were going to become my greatest teachers.

Here are the five most important lessons I have learned from my patients.

 

  1. Listen first. In school we are often taught the importance of “telling” a patient what they need to know about a drug or a medical condition. We practice over and over imparting the top five or so points about a medication, from how to take it to the myriad of possible side effects.  How many times have I spit out the knowledge in my head, then after listening to the patient I realize that it was either too much information, not applicable to their daily life or they just didn’t understand.  Over the years I have become a much better listener.  My patients have taught me that each person and situation is unique and to truly care for them means to simply listen.

 

  1. Trust requires work. When a patient comes to me for advice, they are trusting my assessment of their current condition and medical history. They trust I am not simply giving them random advice; that what I advise is backed by science, is evidence based and supported by my education, training and experience. Upholding this trust requires work. As much as possible I need to keep up with recent guidelines, studies and lines of inquiry in evidence based medicine.

 

  1. Many patients over the years have demonstrated amazing perseverance throughout incredible pain, suffering and loss. They have taught me to keep finding the positive and most especially, to endeavor to live with a posture of gratitude.

 

  1. Look beyond the surface.  As health professionals we often don’t see beyond the immediate presentation of the person in front of us. A patient’s short temper, harsh words or impatience is often directed at us or our staff. Over the years I have learned that the root of behavior is far different from what I see. Patients have taught me that behind the behavior is often a myriad of other issues such as pain, inability to cope, grief, and other emotions or life circumstances that have nothing to do with me, so I don’t take it personally.

 

  1. Empathy goes a long way. Even if I cannot directly relate to being held captive by addiction or have unrelenting pain, I can still express empathy for the human suffering of my patients.  Even in tough situations such as a person going through narcotic withdrawal, the care I provide is much more effective and meaningful when patients feel that first, I am on their side, even when I have to say no or make a tough call.

 

Ultimately, the human side of patient care cannot be taught in school, it can only be taught to us by those we care for, and I look forward to my continued learning.

 

 

Intake: Where it’s at

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Typical day in our pharmacy.  Pharmacists are at intake engaging with patients.  Yes, we did not tidy up before I snapped this candid of my staff!

When I graduated from pharmacy over 20 years ago, the buzz and excitement at the time was “pharmaceutical care”.  I can remember carrying to my first job a copy of Hepler and Strand’s “Opportunities and Responsibilities in Pharmaceutical Care”(1990).  Such was my enthusiasm to provide this type of care to patients.

What ensued was 20 years of practice where the majority of my time was spent signing my name on the plethora of prescriptions presented to me.  Mixed in with some counselling on new prescriptions or a smattering of other tasks such as dealing with drug plans, inventory, orders and narcotics, what’s striking is that about 80% of my time was spent on technical tasks which did not require the university degree I had worked so hard to attain.

Pharmacy practice has largely remained unchanged over the past 20 years.  Pharmacists still perform technical tasks a large majority of their time, tasks more suited to registered technicians and assistants.  Often the only interaction pharmacists have with patients is to give verbal and written information about new drugs.

It is not surprising that real change has not occurred in pharmacy practice as the profitability in pharmacy has historically depended on the drug product going out the pharmacy door as quickly as possible. Pharmacists, as the final check, were the rate limiting step for profitability, thus honing our skills for fast, efficient dispensing was paramount.

Today however, with the convergence of expanded scope practice and the changing landscape of pharmacy reimbursement, billable and cash paying services, the time is ideal for pharmacists to step out front and fully embrace our role as pharmaceutical care providers.  Medication reviews, care plans, adapting therapy, chronic disease management are all about optimizing drug therapy and solving drug related problems (DRPs).

However.…we simply cannot do this on the back end of work flow when we’re checking prescriptions.

Pharmaceutical care requires that we work WITH the patient, engaging them in their own care and decision making, becoming involved in their therapy, taking responsibility for drug therapy decisions and collaborating with other care providers.  To do this we need to be out front.  We need to dialogue with patients when they present to allow for assessment of their medications, chief complaints and chronic disease therapy.   The “pharmacist at intake” model has yet to be widely adopted, but initial pharmacist assessment is absolutely critical to providing patient centered care.  Here’s my top 5 reasons why:

  1. It is nearly impossible to find and resolve DRPs with only a patient profile and a prescription hard copy in front of you (ie: the most common “pharmacist checking” scenario). The vast majority of problems are not discovered due to a lack of discussion with the patient. Assessment of the patient (not just the patient’s file) and shared decision making along with the patient are essential.
  2. Checking prescriptions can be done at a fraction of the cost by a registered technician. Pharmacists are no longer needed for back end checking. Therapeutic assessment of the prescription can be done on the front end of work flow along with the patient.
  3. If our only interaction with a patient is to provide information (ie: counselling), we will shortly be regarded as irrelevant. This is the information age and approximately 92% of adults aged 18-39 now carry a computer in their pocket.  Information is at our patients’ fingertips and pharmacists are no longer the only source of drug information.
  4. Profitability from drug product is shrinking (low fees/margin, PPNs, loss of rebates/pan-Canadian, cuts on short fills/blister packaging). Profitability from expanded services is increasing.  Identifying opportunities and providing expanded scope service requires assessment and engagement of the patient by the pharmacist.
  5. Pharmacist on the back end is highly in-efficient.  If a pharmacist does discover a DRP through back-end counselling, the prescription has already been entered, prepared, checked, and the patient has waited.  Now the team must go through the entire process again to fix the problem and the patient waits yet again.  This is a highly inefficient use of staff resources.

 

Pharmacists have an incredible opportunity to step into their true role. No other profession has the expertise to guide patients and engage in shared decision making to optimize drug therapy.  Pharmacists have unique knowledge of therapeutic guidelines, patients’ current drug therapy, alternative drug therapy options, drug benefit lists, drug administration solutions, and previous response to medications. We cannot afford to wait another 20 years.  We need to step out from behind the counter and engage our patients where they’re at.

The Hurdle of Uncertainty

Hurdles ccMelindaHuntley

“You should check with your doctor on that.”

“Let me just fax your doctor and I will get back to you.”

“This medication interacts with one of your other pills.  I will just call your doctor and see what he wants to do.”

“This dose isn’t quite right. Let me fax your dentist and check with her.”

Pharmacists face many challenges in their day, and solving drug related problems is one of the biggest.  Historically, without the power to enact change for our patients, we abdicated the responsibility for drug therapy problems back to our physician colleagues.   With the changing scope of practice sweeping across the country, many pharmacists are faced with having to use their skills to make clinical decisions which previously they would have deferred to another prescriber.

Pharmacists take patient safety as one of the pillars of practice.  We double and triple check everything, look into more than one reference when we’re unsure and refer when we don’t have a clear picture of the patient’s health.  This tendency towards “needing to be sure” is both an asset and a hurdle.

When I ask pharmacists what barriers they are experiencing that has them directing patients back to another prescriber for drug therapy problems they could easily solve within their scope of practice, I hear things like:  “I’m just not sure.”  “What if it’s something more serious?” “The references don’t agree.”  “I don’t want to take responsibility for that.”  “What if I make the wrong choice?”

While I always advocate for clinicians to care for patients within their scope of knowledge and skill, in many cases pharmacists have both the expertise and the ability and still choose to refer.  It is the hurdle of uncertainty.

Today I heard one of the most impressive explanations of the learning shift that one pharmacist has moved through on the road of practice change.

The most important thing I learned is that uncertainty is a natural part of our clinical decisions and that taking responsibility for our decisions and following up with patients can alleviate the burden of it.

Uncertainty will always be with us as medicine is both a science and an art.  Objective and subjective data collection, patient assessment, making clinical decisions, follow up…. all involve a combination of knowledge, experience and skill and the ability to make a decision that we take responsibility for.  The relationship with the patient and ability to follow up on the results of our decisions not only make us more effective at solving drug related problems, but provides a wealth of additional experience and knowledge to improve our practice and ultimately the care of our patients.

Beyond Renewal->Adapting

"No matter where you go, there you are." -Buckaroo Bonzai

cc licensed ( BY ) flickr photo by Stefan Andrej Shambora: http://flickr.com/photos/st_a_sh/493343628/

Many colleagues have asked for examples of where they can adapt in their practice.  While expanded scope of practice is in different stages in each province, most provinces already have, or will soon have, changes in pharmacy legistlation to allow for pharmacists to adapt prescriptions.  Before we get into practice examples, let’s define adapting a prescription as the following*:

  • Renewing a current prescription without having a refill authorized by a prescriber.
  • Changing a dose, formulation or regimen of a prescription
  • Substituting another drug that is expected to have a similar therapeutic effect.

*(this most closely matches the legislation in Alberta)

Most pharmacists have no trouble renewing existing therapy.  Usually, the perception being that there is little risk in renewing for the short term a medication the patient is already on.  Where pharmacists hesitate is when they are faced with therapy that they feel is either inappropriate or less than ideal for their patient and making the decision to change therapy.

Caring for patients is complex business.  It requires patient assessment, drawing up of a care plan, making clinical decisions, ensuring any necessary follow up is done and collaboration with other health professionals.  As the level of care and decision making rises, so does risk.  Pharmacists often ask me about how to protect themselves against risk when making decisions.  While there is no fail safe, and there will be at some point a decision you will second guess or perhaps realize was in error, it is important to know that all clinicians make errors.  The primary concern of course is patient safety, and keeping our clinical decisions within bounds of our own personal knowledge and skills is essential.

So where to start?  If you are a pharmacist who hasn’t moved beyond extending prescriptions and is feeling uncomfortable with moving forward in clinical decision making, what do you do?  It is undoubtedly the way of the future, so how do you move forward?

One way pharmacists have moved forward in adapting and even further into independent prescribing is to take on a specialty.  There are many out there, for example: Certified Diabetes Educator, Certified Respiratory Educator, Certificate in Travel Medicine, etc.  These certifications often give pharmacists the confidence to make clinical prescribing decisions.

However, not everyone wants to obtain certification or write an exam.  For those who are in community or hospital practice, the confidence and ability to move forward can be gained, and the way to start is to just jump in.  It can seem overwhelming to look at your entire practice and scope of knowledge and pick out where you need to brush up or improve your skills.  What I often tell pharmacists is to start with ONE area.  Choose a therapeutic area that you are interested in or used to be interested in and start with that.

If you happen to have an interest in cardiovascular meds then choose learning in that area and focus on it.  Become familiar with the CCS guidelines for atrial fibrillation, dyslipidemia, heart failure, etc.  Or start with the newest hypertension guidelines.  Then, the most important step is to start applying your knowledge to your patients.   If it’s hypertension you have chosen then make a point of talking with every patient on an antihypertensive to see if they know what their goal blood pressure is.  Ask if they home monitor and teach them what their goal should be.  Ask patients to bring in a history of their home blood pressure monitoring numbers so you can assess whether their therapy is working for them. Once you start engaging patients and are confidant in your knowledge of the current guidelines, it will flow naturally to be assessing whether their antihypertensive therapy is appropriate and keeping them at target.  From there you will find yourself making clinical recommendations for changes in therapy.  So many patients fall through the cracks in pretty much every therapeutic area that there will be no lack of opportunity to make drug therapy decisions.

If you don’t know what your passion is, I usually suggest you start with something like pediatric dosing of antibiotics.  This is an easy foray into adapting doses with fairly clear guidelines for therapy.  Start with every pediatric otitis case you see and check if the drug being prescribed is actually indicated for otitis and whether it is indeed being prescribed at the correct dose.  Make ‘Bugs’n Drugs’ your best friend and double check in a second or even third resource when you start out.  It won’t be long before you won’t have to look up when to use high dose amoxil and what the dose actually is.  In a busy practice you will find yourself seeing many prescriptions that require adapting and it will soon become second nature for you to adapt them.  The first few times you may struggle on the wording of your notification to the prescriber, but soon it becomes second nature.

“Dr._______  I adapted the dose of amoxiciliin to 90mg/kg/day x 5 days for this patient with otitis media; she had antibiotic exposure two months ago and attends daycare (as per Bugs & Drugs 2012).  I have advised the mother on possible adverse reactions and will follow up with her in 5 days to see if symptoms have resolved.   Patient weight= 15kg”

Amoxicillin 450mg tid x 5 days

Joe Pharmacist BscPharm

December 13, 2013

Of course, taking responsibility for the clinical decision and prescribing means you have assessed the patient adequately.  This doesn’t take as long as you might think and becomes quicker and seamlessly part of your work flow the more you do it.  After assessing and adapting the prescription, the part where most pharmacists groan is in documentation.  Yes, you have to notify the prescriber (example above) and document your decision in the patient record.  Again, the more you do it the easier it becomes and the less time it takes.   Pharmacists document in all sorts of ways: DAP, SOAP, narrative, etc.  Something as simple as:  “Patient seen today with chief complaint of otitis media.  Has had one course of cefixime two months ago, attends daycare.   Rx was written at 30mg/kg/day x 10 days.  I adapted dose to 90mg/kg/day x 5 days as per Bugs and Drugs.  Follow up scheduled for 5 days for efficacy and ADRs.”

Of course you must ensure you follow all the regulations and Standards of Practice for your particular province.  Make yourself familiar with them and figure out how to meet requirements in an efficient manner that puts the least amount of stress on your work flow.

Moving out of our comfort zones is scary…that’s why they’re comfort zones, because we’re nice and comfortable where we are.  But guaranteed, once you start expanding your practice, professional satisfaction grows incrementally along with great patient care.

What’s In Store : The Future of Pharmacy Practice

Future Up ahead sign

cc licensed ( BY SA ) flickr photo by OTA Photos: http://flickr.com/photos/101332430@N03/9681096812/

 

During an interview last week I was asked what pharmacy practice would look like 5-10 years from now. Seems to be the burning question these days…..change is here (whether we want it or not!)

  • rebates are disappearing
  • financial pressures are increasing
  • alternative reimbursement structures are popping up in every province
  • expanded scope of practice is moving forward
  • new roles for technicians

When the dust settles, where will the practice of Pharmacy end up?

The various points of influence and pressure are propelling pharmacy practice towards the focal point of patient assessment.

Of course, assessment has always been a part of pharmacy, usually coming second to dispensing, but we’re at the cusp of seeing assessment become our driving focus.

What do I mean by that?

Historically, decisions on drug therapy have mostly been made by physicians, dentists and more recently, nurse practitioners. Pharmacists have assumed the prescription was appropriate and should be the best drug for the patient. Our role was to maximize the benefit and reduce the risk for the patient (by checking dosing, drug interactions, counseling and suggesting compliance strategies, etc.)

This jived well with profitability in community pharmacy which has historically been fueled by filling prescriptions as fast as possible. Most pharmacists, overwhelmed with the basic necessities of checking the processing and accuracy of the prescription, have not been given the time or workflow ability to assess the patient.

One of a pharmacist’s main responsibilities has always been to assess whether a drug is appropriate for the indication and is indeed the best choice for that patient. It’s a core standard of practice, but one that hasn’t reached it’s full potential. (A practice consultant at the College of Pharmacists in Alberta recently told me she “almost never” sees a notation on the prescription about the patient’s indication.)

As the pressure to change increases and pharmacy moves forward, what we will see is pharmacists taking on the role more and more of prescriber, and at the core of prescribing is patient assessment.

We are seeing this already in the ability to extend, adapt or change a prescription. This role is expanded in some jurisdictions with the ability to apply for full prescriber or initial prescribing status.

However, the uptake in adapting/prescribing has been slow in provinces where pharmacists have the ability to do so. Billing statistics show that pharmacists will more easily extend (renew) a prescription rather than change one. They will also more easily extend a prescription for one week than for three months. It seems the more assessment required (and the more risk), the less likely pharmacists are to prescribe.

Prescribing DOES involve more risk. It also requires time to assess a patient and do the proper documentation to go along with it. So in an already busy practice, why is this change in practice paradigm coming and why should we care?

Here’s why:

Good for PROFITABILITY

Let’s face it, we don’t have a job if our pharmacies are not profitable. It doesn’t matter if you are independent or corporate, staff or owner. Health care is a business and no business survives running in the red. Right across the country pharmacy sustainability is being shaken up. Profitability of pharmacy has always rested on script count. The more prescriptions we could pump out, the more profitable we were. This led to pharmacists coming out of school, being thrown into primarily a dispensing role, and over the years losing their clinical skills and confidence in patient assessment. Some pharmacists even found themselves being told by employers to “cut down on counseling” to get back to checking.

With rebates disappearing, the profitability of the prescription mill is going down. However, reimbursement for expanded clinical services is increasing. Being reimbursed to extend, adapt, assess, independently prescribe, do med reviews and follow ups, treat minor ailments, etc will put financial pressure on pharmacy practice to change. To provide these services efficiently, our assessment and documentation skills need to be dusted off and sharpened up.

Good for PATIENTS

Pharmacists as prescribers are in a very unique position. We have immense background knowledge of evidence based practice, clinical guidelines, drug availability, plan coverage and clinical experience with patient factors such as kidney function and weight. We can see the entire picture for that patient, for the third party payer and for our practice. Indeed, that puts us in the best position for deciding on drug therapy for our patients.

Pharmacists as prescribers also have the best arsenal to improve patient adherence. The ability to change a patient’s therapy and follow up in a timely manner provides efficient patient care which improves patient satisfaction with their therapy (which increases adherence). Providing short supplies of new medications, following up and then adjusting a patient’s dose, regimen, or switching to an entirely new medication results in a tailored drug regimen that fits with the patient’s lifestyle, expectations, drug coverage and overall medication regimen. This actually goes beyond adherence as you are partnering with the patient to provide shared care.

A quick example: Patients starting on gabapentin for neuropathy often stop therapy due to adverse effects or perceived ineffectiveness. It is time consuming and frustrating to book appointments over and over again with a physician until the dose is adjusted correctly. Patients will often give up due to adverse effects or thinking it just isn’t working for them. If that patient is followed up every week by their pharmacist, the pharmacist can work with the patient to fine tune therapy. (Experiencing too much drowsiness? Slow down on the taper up. Tolerating fine but pain relief not there? Taper up towards max dose.) We can fine tune a patient’s medication, improve adherence and bill for follow up services which makes the service profitable.

Good for THIRD PARTY PAYERS and GOVERNMENT

No shocker here, but government and third party payers want to save money. We’re constantly hearing that drugs are the leading driver of rising health costs. Pharmacists are in an ideal position to save payers HUGE dollars. (Your patient needs an ACEI. Should you choose Mavik or ramipril, both of which have the same therapeutic response?) When most pharmacists consider cost they are usually looking at what it is going to cost the patient. Not as much thought goes into what it is costing the third party payer. (If Mavik and ramipril are both covered, the cost difference to the patient is often minimal. The cost difference to a third party payer over time is immense.) Pharmacists have extensive background knowledge on drug cost and evidence based interchangeability (as opposed to just pharmacokinetic interchangeability). It’s the ability to save the patient and the payer huge dollars. There is a big role for pharmacists that third party payers are missing. The ability for pharmacists to save on drug costs is an emerging partnership that will have greater impact as pharmacist prescribing continues to increase.

We know change is upon us. In a nut shell, we are going from “How do I make someone else’s choice of medication work best for this patient” to “What IS the best choice of medication therapy for this patient” and taking an active role in assessment, prescribing and adjusting patients’ medication therapy.

Guaranteed that every pharmacist could name several barriers to this change in practice. Conversations with colleagues and implementing change in my own practice has uncovered many obvious and not so obvious ones. There is no doubt that much needs changing in the structure of our practices and the environment of health care to facilitate pharmacy moving forward. These will be looked at in “Navigating Change in Pharmacy Practice.”

Picture this: FUTURE PRACTICE

Pharmacist is sitting at an intake desk. Patient sits down and pharmacist proceeds with assessment. “What did you see your doctor for today?” Pharmacist assesses indication, history of chief complaint, and (if not already on file) any allergies, medical conditions and current meds. Pharmacist checks the provincial system for additional information (labs, kidney function, medications), decides the ciprofloxacin being prescribed is not a good choice given patient’s advanced age and medications. As well, the UTI ( without a urine screen) is better treated empirically with cefixime. Pharmacist can adapt the Rx, bill for the assessment and counsel at intake. The patient is handed the pharmacist’s business card and advised to call if any issues crop up with the therapy and the pharmacist enters a phone follow up reminder into the computer software to pop up in 7 days. The pharmacist writes up the adapted prescription and passes the Rx back to a technician and doesn’t see it again. The pharmacist then moves onto the next patient.

This may sound unreal in a busy pharmacy where patients are lined up. However, the current work flow set up with the pharmacist at the back end of dispensing is highly inefficient and unprofitable with the new framework. If a drug related problem (DRP) is uncovered when checking or counseling, or the patient requires additional therapy or it really should be a refusal to fill….. think of all the time wasted inputting, processing, preparing… perhaps for nothing! And all that time the patient waited; only to wait again after you assess their drug related problem and provide them what they REALLY need. The biggest problem with pharmacists at the back end of work flow is that the majority of DRPs are completely missed due to a lack of patient assessment….and so are the billing opportunities.

It requires a paradigm shift in the role of the pharmacist. A lot of time is wasted in pharmacy by the pharmacist only coming in at the end to check and counsel. That time can be put in at the front end. It requires a change in employer and patient expectations. Yes, it may take longer at intake, but that pharmacist may provide professional services billing that exceeds dispensing fees, gains a loyal patient and provides more billing opportunities by scheduling follow ups into the system during assessment. Once used to the change, patients are more than happy to wait when they know they will have a conversation with the pharmacist and be assured their therapy is appropriate.

Assessing a patient can also seem time consuming, especially when you are not accustomed to this type of work flow. However, like anything, the more you assess and document, the more comfortable it becomes and more efficient the process. Pharmacist initial assessment of the patient is necessary for the new framework to be profitable. It cannot be left up to the technician to decide if there is a problem or expanded service billing opportunity. At intake the pharmacist can immediately assess the appropriateness of the prescription in front of them, the needs of the patient, can pull up patient history and determine right then what is needed. Does the patient need an adapt? Do they need an additional drug prescribed? Do they need nothing at all today? Do they need a med review scheduled? Do your previous notes indicate they’re due for an A1C? Was there a missed follow up that can be completed and billed? When was their last blood pressure check?

A quick example: If you’re at intake, it’s easy to assess a patient who has high cardiovascular risk being prescribed diclofenac for acute pain as benefiting from a change to naproxen. Adapting that Rx is within every pharmacists’ scope of practice in Alberta (and most provinces, if not now, then in the future). So you’ve improved patient care, reduced risk, and billed for a professional service. (And that Rx was handed off to the tech, and given to the patient on the back end because you’ve already counseled them during your assessment.)

As pharmacists get more used to documenting and triage this takes less and less time. The pharmacist can then write up a prescription (and note which clinical service to bill), or if deemed the Rx is fine, send it back to the tech to prepare and have it checked by a registered technician. Technicians on the back end of pharmacy makes sense. Technicians can teach patient devices like inhalers, blood pressure and blood glucose meters, how to draw up liquid medications, etc. These are all technical functions. When fortunate enough to have pharmacist overlap, the second pharmacist can handle any unanswered questions. Most often, with this type of patient care, additional questions or problems that may come up can be answered in a phone or email follow up (and billed as a follow up service).

It can be comfortable being in the back of the dispensary, being called forward by a technician for counseling or if they encounter what they determine to be a problem. Assessing at intake can seem daunting if you feel out of practice or it’s out of your comfort zone. However, steps can be taken to develop skills, knowledge and confidence while pharmacists are still at the back end, to prepare for the shift to more focused patient assessment.

I would argue that pharmacists are returning to the role they were trained for. Pharmacy schools are preparing their grads for patient assessment and drug therapy decision making. Many of them are coming out ready to embrace that role. What they are finding is that the the majority of practices have not changed.

However, the financial pressures and changing reimbursement and scope of practice structures will force change. We MUST change for the profession to be viable. Technicians can dispense, check prescriptions, teach devices and manage inventory. More and more patients use mobile devices or the internet to learn about their drugs. Assessing drug therapy, tailoring a patient’s drug regimen, solving drug related problems and providing timely follow up is a pharmacist’s expertise, and an essential component of health care that cannot be replaced.

Disillusioned?

ccFlickr shared by MacQ

I remember the day I realized I was caught in the prescription mill and it seemed there was no way out. I was standing in the pharmacy, just a couple years out of university, with some of Linda Strand’s writing in my hand. I knew without a doubt that “Pharmaceutical Care” was what I should be doing. I also knew that I had no idea how to “do” medication management. I didn’t know any pharms who were doing it, was not really taught it in university, and I had ALL these prescriptions to deal with non-stop all day.

Okay, so that was 1996… but I know I’m not the only one who had a rude awakening once they started their professional practice. Wasn’t I supposed to help patients manage their medications and optimize their therapy? Make sure patients who needed drug therapy received it and those that were receiving unnecessary drugs were identified?

Yup, that’s really our job. The prescription mill? A trained tech can produce an accurate Rx from a hard copy. As a matter of fact there’s probably a computer out there that can read an Rx and spit out an accurate product. It’s not rocket science.

But looking at the over all picture of a patient from their labs, self reporting of chief complaint, previous response to meds and current drug therapy, etc. and deciding whether the Rx in front of you is really the BEST therapy for that patient…or if they really even need drug therapy at all? That’s the art and science of Pharmacy. Making the clinical decision to adapt (change) that prescription or prescribe for that patient, when you know therapy can be improved, then following up on that care…no machine can manage that. It takes knowledge, clinical experience, triage skills, sourcing of info, patient interview skills, ability to refer and knowledge of your own personal skill set and boundaries.

In considering all that, what I often hear from colleagues is that it isn’t possible. We have no time, not enough support staff, our software isn’t capable of what we need it to do, it takes too much paperwork, etc.

And really…when you’re stuck churning out hundreds of scripts a day it’s easy to slowly drift into apathy, or feel burnt out…tuck your head down and do a great job of at least searching out drug interactions (or assessing the clinical validity of the ones the computer caught), checking doses that look way out there, answer patient’s questions… Just be accurate, make no mistakes and go home.

Over the years as I worked at top speed in the mill, I lost a lot of my clinical skills. What you don’t use you lose, right?  I hadn’t looked up an A1C on a patient or applied the newest Otitis guidelines in so long I was afraid to start.

If I was given the perfect circumstances, all the time I needed, the ideal practice setting…would I be able to do the job I wanted to? Could I take responsibility for a patient’s medication management, make recommendations on drug therapy, solve complex drug related problems? Well…I wasn’t sure.

We know that care of the patient is our primary task.  Pharmacists have no problem putting patient’s first. I see it every day. We’ve never been paid to talk to patients or assess medical issues and make recommendations, but we do it.

Where we can be our own worst enemy is in lacking the confidence to make the shift into medication management:  to take responsibility for clinical decisions, make the call, sign our name to the decision.  And sometimes we know that our skills need to be sharpened and our knowledge refreshed but we don’t know where to start.

Mentorship and good learning opportunities are essential for practice change;  Assessing for yourself what you need in order to shift your practice and feel comfortable doing it, and finding the energy and passion to embrace change.

We now have the framework, have a start at being paid to manage patients’ medication therapy, not just handle prescriptions; and it’s up to us as a profession whether we take it up, change our mind set, our focus and move forward.

Patient Gratitude

A few weeks ago a colleague warned me that in the first year of owning and running a new pharmacy I would conclude that I had made a huge mistake.

Yup….that happened well before turning the sign to “open”!

The two weeks leading up to my opening day were chaos.  I’ve never slept so minimally, had my “to do”list grow so fast, nor seen my children so little.  As I heard repeatedly, “Mom, are you coming home late again today?” I figured I had made a mistake.  I am a clinician; I love the “care” part of health care, and here I was, steeped in putting a business together. Spending hours on end away from my family, and even when with them my mind was racing with all the things I needed to handle.

So when I walked into my brand new pharmacy on day one and flipped the sign to open, I wondered whether I had jumped into something I would resent, or at the very least not enjoy.

Then came patients through my door.  Just a few at first, and a few more each day, and I found myself in a place of privilege.  As I provided health care, I heard their stories.  Stories about caring for terminally ill spouses, stories of how difficult it is to live with chronic pain, journeys through chemo and disappointment with the system.  Even stories of past jobs and places they had visited in their life time.  As I immunized many against the flu I also shared a lot of my own story.  How I came to be in this new pharmacy, growing up in Saskatchewan, how I had started a pharmacy in Chemainus when I was very young.

It struck me once again that the connection made and the care given are what brings me joy.  Having my own pharmacy means I can structure and set up to practice the way I want.  I have control over how I care for the people who walk through my door.  There is no one to tell me I must meet a certain quota or promote sketchy treatments or unproven products.  In the end, it is worth all the headaches that I am sure will come.  So it is to the people who came through my door this week that I am grateful to, for reminding me what it’s all about.

Care of the Patient

cc Flickr shared by By Pulpolux !!!

This post has stuck with me for weeks, and while I blogged about it on my personal site, I feel it has a lot to say to me as a health professional.  So often, as we concentrate on our patient’s heath issues, solving drug related problems and working to optimize their therapy, we can overlook the big picture.  We forget that what is simple to us can often be overwhelming or beyond understanding for our patient.

A Reason To Celebrate

–posted by Dodo on Jul 7, 2012

Numbly, I left my husband, Marty, at the hospital where I had been visiting two of my children and headed for the grocery store. Since it was eleven p.m., I drove to the only store I knew was open twenty-four hours a day. I turned my car motor off and rested my head against the seat.

What a day, I thought to myself. With two of my young children in the hospital, and a third waiting at Grandma’s, I was truly spread thin. Today I had actually passed the infant CPR exam required before I could take eight-week-old Joel home from the hospital. Would I remember how to perform CPR in a moment of crisis? A cold chill ran down my spine as I debated my answer.

Exhausted, I reached for my grocery list that resembled more of a scientific equation than the food for the week. For the past several days, I’d been learning the facts about juvenile diabetes and trying to accept Jenna, my six-year-old daughter’s, diagnosis.  In addition to the CPR exam I’d spent the day reviewing how to test Jenna’s blood and give her insulin shots. Now I was buying the needed food to balance the insulin that would sustain Jenna’s life.

“Let’s go, Janet,” I mumbled to myself while sliding out of the car. “Tomorrow is the big day! Both kids are coming home from the hospital. … It didn’t take long before my mumbling turned into a prayer.

“God, I am soooo scared! What if I make a mistake and give Jenna too much insulin, or what if I measure her food wrong, or what if she does the unmentionable—and sneaks a treat? And what about Joel’s apnea monitor? What if it goes off? What if he turns blue and I panic? What if? Oh, the consequences are certain to be great!”

With a shiver, my own thoughts startled me. Quickly, I tried to redirect my mind away from the what ifs.

Like a child doing an errand she wasn’t up for, I grabbed my purse, locked the car, and found my way inside the store. The layout of the store was different than what I was used to. Uncertain where to find what I needed, I decided to walk up and down each aisle.

Soon I was holding a box of cereal, reading the label, trying to figure out the carbohydrate count and sugar content. “Would three-fourths a cup of cereal fill Jenna up?” Not finding any “sugar free” cereal, I grabbed a box of Kellogg’s Corn Flakes and continued shopping. Pausing, I turned back. Do I still buy Fruit Loops for Jason? I hadn’t even thought how Jenna’s diagnosis might affect Jason, my typical four-year-old.  Is it okay if he has a box of Fruit Loops while Jenna eats Kellogg’s Corn Flakes?”

Eventually I walked down the canned fruit and juice aisle. Yes, I need apple juice, but, how much? Just how often will Jenna’s sugar “go low” so she will need this lifesaving can of juice? Will a six-year-old actually know when her blood sugar is dropping? What if…? I began to ask myself again.

I held the can of apple juice and began to read the label. Jenna will need fifteen carbohydrates of juice when her sugar drops. But this can has thirty-two.  Immediately I could see my hand begin to tremble. I tried to steady the can and reread the label when I felt tears leave my eyes and make their way down the sides of my face. Not knowing what to do, I grabbed a couple six-packs of apple juice and placed them in my cart. Frustrated by feelings of total inadequacy, I crumpled up my grocery list, covered my face in my hands and cried.

“Honey, are you all right?”  I heard a gentle voice ask.  I had been so engrossed in my own thoughts that I hadn’t even noticed the woman who was shopping along side of me. Suddenly I felt her hand as she reached towards me and rested it upon my shoulder. “Are you all right? Honey, are you a little short of cash? Why don’t you just let me…?”

I slowly dropped my hands from my face and looked into the eyes of the silvery haired woman who waited for my answer. “Oh, no, thank you ma’am.” I said while wiping my tears, trying to gather my composure. “I have enough money.”

“Well, Honey, what is it then?” she persisted.

“It’s just that I’m kind of overwhelmed. I’m here shopping for groceries so that I can bring my children home from the hospital tomorrow.”

“Home from the hospital! What a celebration that shall be. Why, you should have a party!”

Within minutes this stranger had befriended me. She took my crumpled up grocery list, smoothed it out, and became my personal shopper. She stayed by my side until each item on my list was checked off. She even walked me to my car helping me as I placed the groceries in my trunk. Then with a hug and a smile, she sent me on my way.

It was shortly after midnight, while lugging the groceries into my house, that I realized the lesson this woman had taught me. “My kids are coming home from the hospital!” I shouted with joy. “Joel is off life support and functioning on a monitor. Jenna and I can learn how to manage her diabetes and give her shots properly. What a reason to celebrate.” I giggled to myself. “I have a reason to celebrate!” I shouted to my empty house.

“Why you should have a party,” the woman had exclaimed.

And a party there will be!

The human side of patient care cannot be learned in school.  It can only be taught to us by those we care for… our patients.