Chapter 5 Chapter 5 -- Care PlansCare Plans

Care Plans Care Plans -- definitiondefinition

A care plan is the method by which A care plan is the method by which the pharmacist helps the patient the pharmacist helps the patient achieve a preachieve a pre--determined health care determined health care goalgoalCare plans MUST be developed Care plans MUST be developed cooperatively between the cooperatively between the pharmacist and patient.pharmacist and patient.Physicians should always be Physicians should always be informed, and usually be involvedinformed, and usually be involved

Prioritizing ProblemsPrioritizing Problems

If a patient has If a patient has ≥≥ 1 DTP, it is usually 1 DTP, it is usually preferable to solve them one at a preferable to solve them one at a time, not all at once.time, not all at once.Acute problems versus serious Acute problems versus serious problemsproblems#1 priority #1 priority -- DTP is acute DTP is acute andand seriousserious#2 priority #2 priority -- DTP is acute, but not DTP is acute, but not seriousserious#3 priority #3 priority -- DTP is serious, but not DTP is serious, but not acuteacute

Acute & Serious DefinitionsAcute & Serious Definitions

Acute Acute andand serious serious -- problem could problem could possibly be life threatening and there possibly be life threatening and there is no time to waste in solving itis no time to waste in solving itAcute Acute but notbut not serious serious -- problem may problem may or may not be life threatening, but or may not be life threatening, but there is no time to waste in solving itthere is no time to waste in solving itSerious Serious but notbut not acute acute -- problem may problem may or may not be life threatening, but or may not be life threatening, but you have timeyou have time

ExamplesExamples

Priority 1 Priority 1 -- acute acute and and serious serious -- diabetic diabetic ketoacidosisketoacidosis, serious infection, stroke. , serious infection, stroke. These could be fatal, no time to loseThese could be fatal, no time to losePriority 2 Priority 2 -- acute acute notnot serious serious -- pain, pain, diarrhea. Not fatal, but patient hurts diarrhea. Not fatal, but patient hurts nownowPriority 3 Priority 3 -- serious serious notnot acute acute --hypertension, diabetes. May be fatal in hypertension, diabetes. May be fatal in the long run, but you have time to spare the long run, but you have time to spare solving it.solving it.

MinicaseMinicase

A patient comes to the pharmacy A patient comes to the pharmacy seeking therapy for a sunburn. He is seeking therapy for a sunburn. He is also diabetic and takes also diabetic and takes GlucophageGlucophage500 mg bid which upsets his 500 mg bid which upsets his stomach. His am sugars run 140stomach. His am sugars run 140--160mg/dL.160mg/dL.Identify and prioritize his DTPIdentify and prioritize his DTP’’s.s.

Goals for pharmacotherapyGoals for pharmacotherapy

Before you can develop a care plan, Before you can develop a care plan, you must develop a goalyou must develop a goalA goal is simply the outcome you A goal is simply the outcome you want the patient to achievewant the patient to achieveWho has goals for therapy?Who has goals for therapy?How are they stated?How are they stated?

Goals areGoals are

MeasurableMeasurableAchievableAchievableConsistent with the pharmacistConsistent with the pharmacist’’s s responsibilitiesresponsibilitiesE.g., a patient requires radiation for pain E.g., a patient requires radiation for pain for bone for bone metsmets. What goal should the . What goal should the pharmacist set?pharmacist set?•• Trick question Trick question -- radiation is outside our scope radiation is outside our scope

of practiceof practice

Goals are notGoals are not

Vague or ill definedVague or ill definedE.g., a patient with hypertension is poorly E.g., a patient with hypertension is poorly compliant with her compliant with her VasotecVasotec 5 mg 5 mg popo bid. bid. BP is 150/105BP is 150/105Consider goals like Consider goals like ““improve complianceimprove compliance””or or ““control blood pressure.control blood pressure.””Is compliance from 50% to 70% Is compliance from 50% to 70% ““improvedimproved””? Is BP decreased to 140/86 ? Is BP decreased to 140/86 ““controlledcontrolled””??

Other problems Other problems -- 11

A patient needs help to relieve a A patient needs help to relieve a headache or diarrheaheadache or diarrheaHow would your goal be How would your goal be ““measurablemeasurable””??In these cases, the measurement is In these cases, the measurement is qualitative, not quantitativequalitative, not quantitativeE.g., E.g., ““patient no longer complains of patient no longer complains of intolerable pain.intolerable pain.””

Other problems Other problems -- 22

If your care plan is educational in If your care plan is educational in nature, how do you measure if you nature, how do you measure if you have achieved your goal?have achieved your goal?E.g., E.g., ““Patient demonstrates Patient demonstrates understanding ofunderstanding of……”……”

Other problems Other problems -- 33The wording of a goal may depend on The wording of a goal may depend on your practice setting.your practice setting.E.g., a patient has a HgBA1c of 8.6% due E.g., a patient has a HgBA1c of 8.6% due to nonto non--compliancecomplianceHow would the goals of pharmacists How would the goals of pharmacists working in a diabetes clinic differ from working in a diabetes clinic differ from those working in a chain store setting?those working in a chain store setting?•• Clinic pharmacist can set goal HgBA1cClinic pharmacist can set goal HgBA1c•• Chain pharmacist can set goal of patient Chain pharmacist can set goal of patient

understanding of need for complianceunderstanding of need for compliance

Other problems Other problems -- 44

Be sure not to confuse a goal with a Be sure not to confuse a goal with a plan.plan.If a patient is not compliant with If a patient is not compliant with therapy, the goal is NOT to educate therapy, the goal is NOT to educate the patient the patient -- thatthat’’s the plans the planIn general, if your goal is worded so In general, if your goal is worded so that the pharmacist must ACT, then that the pharmacist must ACT, then it is usually a plan, not a goal, i.e., it is usually a plan, not a goal, i.e., see to whom the verb applies & it see to whom the verb applies & it shouldnshouldn’’t be you!t be you!

Developing a care plan Developing a care plan -- 11

Considering everything I know about Considering everything I know about this patient, her disease states and this patient, her disease states and drug therapy, what are all the drug therapy, what are all the possible things I could do to correct possible things I could do to correct her DTP?her DTP?Of all these choices, which is the best Of all these choices, which is the best choice (or at least which is the least choice (or at least which is the least bad choice)?bad choice)?

Developing a care plan Developing a care plan -- 22

The best care plan is rarely the first one The best care plan is rarely the first one that comes to mind, i.e., THINK before that comes to mind, i.e., THINK before you act.you act.•• E.g.,ifE.g.,if IndocinIndocin upsets the stomach, saying upsets the stomach, saying

““take it with foodtake it with food”” is not very useful if the is not very useful if the better option is to discontinue the drugbetter option is to discontinue the drug

What do you want to do?What do you want to do?•• Before answering, what are all your choices Before answering, what are all your choices

and which is best/least bad?and which is best/least bad?

You may need to do additional researchYou may need to do additional research

Three kinds of care plansThree kinds of care plans

PatientPatient--focused care plansfocused care plansDrugDrug--focused care plansfocused care plans““Do nothingDo nothing”” care planscare plans

PatientPatient--focused care plansfocused care plans

Usually do not require the physicianUsually do not require the physician’’s s cooperation, so they are popular with cooperation, so they are popular with beginnersbeginnersInclude compliance training, patient Include compliance training, patient education, intensive monitoring, noneducation, intensive monitoring, non--drug therapies, referral to other drug therapies, referral to other providersprovidersLend themselves well to disease Lend themselves well to disease management programsmanagement programs

DrugDrug--focused care plans focused care plans -- 11

Require a change in a patientRequire a change in a patient’’s drug s drug therapytherapyUsually require physicianUsually require physician’’s s cooperation (unless OTC)cooperation (unless OTC)Add a drug, d/c a drug, change a Add a drug, d/c a drug, change a dose, dosing interval or dosage formdose, dosing interval or dosage formBE SPECIFIC BE SPECIFIC -- ““LetLet’’s start him on a s start him on a beta blockerbeta blocker”” is NOT a care planis NOT a care planStart Start metoprololmetoprolol 100 mg 100 mg popo qdqd IS a IS a care plancare plan

DrugDrug--focused care plans focused care plans -- 22

Try to make 1 intervention at a time when Try to make 1 intervention at a time when possiblepossibleIf you do 3 things at once, and something If you do 3 things at once, and something happens, how can you tell which happens, how can you tell which intervention was responsible for which intervention was responsible for which change?change?Work with your local doctors before Work with your local doctors before starting to use these care plans starting to use these care plans -- let them let them know what you are planning to doknow what you are planning to do

““Do nothingDo nothing”” care planscare plans

Historically, Historically, ““do nothingdo nothing”” was pretty was pretty much the pharmacistmuch the pharmacist’’s default s default option.option.““Do nothingDo nothing”” is rarely appropriate is rarely appropriate but needs to be at least consideredbut needs to be at least considered““Do nothingDo nothing”” is appropriate when is appropriate when actively doing anything else is likely actively doing anything else is likely just to make things worsejust to make things worseRule this out deliberately, not Rule this out deliberately, not accidentallyaccidentally

PharmacistPharmacist’’s fearss fears

Many (most?) pharmacists feel OK Many (most?) pharmacists feel OK with patientwith patient--focused care plans but focused care plans but are terrified of drugare terrified of drug--focused care focused care plansplans•• ““If I act here, maybe IIf I act here, maybe I’’ll make it better, ll make it better,

but maybe Ibut maybe I’’ll make it worse. I think I ll make it worse. I think I will just will just ““monitormonitor”” the patient.the patient.””

Drug therapy problems result in Drug therapy problems result in deaths and excess costs each year deaths and excess costs each year --do you really think you will make do you really think you will make things things worseworse? ?

Implementing care plans Implementing care plans -- 11

Care plans require pharmacistCare plans require pharmacist’’s s action to implement themaction to implement themYou need to make sure that all You need to make sure that all parties:parties:•• Agree with the care planAgree with the care plan•• Understand who is responsible for what Understand who is responsible for what

& when& when•• Are capable of complying with the care Are capable of complying with the care

planplan

Implementing patient care plansImplementing patient care plans

Does the patient agree with it and Does the patient agree with it and understand it?understand it?Does the patient have everything Does the patient have everything necessary to put the care plan into necessary to put the care plan into action?action?Does the patient know when to Does the patient know when to follow up and with whom?follow up and with whom?Does the patient agree to follow up if Does the patient agree to follow up if needed?needed?

LifestyleLifestyle--related care plansrelated care plans

Stop smoking, lose weight, start Stop smoking, lose weight, start exercising etc.exercising etc.LifestyleLifestyle--related care plans are related care plans are absolutely the most difficult to absolutely the most difficult to implement and are generally best implement and are generally best handled as part of a formal disease handled as part of a formal disease management program, not a routine management program, not a routine intervention. intervention. Leave them to the experts.Leave them to the experts.

Drug focused care plans Drug focused care plans -- 11

Very difficult if you have not Very difficult if you have not developed a relationship with the developed a relationship with the doctordoctorPhysicians will often be initially Physicians will often be initially skeptical with pharmacistskeptical with pharmacist’’s s interventions so be patient, develop interventions so be patient, develop collegial relationships and market, collegial relationships and market, market, market what you do.market, market what you do.

DrugDrug--focused care plans focused care plans -- 22

Consider the advantages and Consider the advantages and disadvantages of:disadvantages of:•• Calling the MD officeCalling the MD office•• Writing the MD officeWriting the MD office•• Having the patient carry the message to the Having the patient carry the message to the

MDMD

Writing physicians is an art. Written Writing physicians is an art. Written words can be misunderstood and give words can be misunderstood and give accidental offense. Write, read, wait, reaccidental offense. Write, read, wait, re--read, reread, re--write, then printwrite, then print

Patient monitoringPatient monitoring

How else will you know if your goal How else will you know if your goal has been achieved?has been achieved?Make sure the patient knows you will Make sure the patient knows you will be following upbe following upConsider when you will follow up, Consider when you will follow up, where, and how (by phone, in where, and how (by phone, in person, by email, by appointment, person, by email, by appointment, etc.)etc.)

Patient monitoringPatient monitoring

Is a narrowlyIs a narrowly--focused interview.focused interview.What therapeutic effects would you What therapeutic effects would you expect and how would you recognize expect and how would you recognize them?them?What adverse effects would you What adverse effects would you expect and how would you recognize expect and how would you recognize them?them?Make sure no new problems have Make sure no new problems have developed.developed.