Pharmaceutical care

Pharmaceutical care as reprofessionalization

In the late 1950s and 1960s, astute pharmacists began to conceptualize a new role for pharmacists that would involve the specialized provision of information about these powerful new agents that were beginning to reach the market.

As it came to be known, the clinical pharmacy movement sought to create a role for pharmacists in the provision of patient-specific drug information or advice to physicians and other members of the health care team.

Helper has identified three simultaneous trends that served as the basis for the clinical pharmacy movement:

1. Drug information2. Drug distribution3. Teaching and research programs in pharmacology and

biopharmaceutics  These three currents combined for the first time in the

famous 1966 " Ninth Floor Project" at the university of California-San Francisco, in which the faculty sought to find a way to train students for a role that did not previously exist.

The project began in September 1966 with the following goals:

- To develop a hospital floor-based pharmaceutical service that would provide maximal patient safety in the utilization of drugs.

- To charge the pharmacist with the responsibility for all phases of drug distribution, except the administration of medication to the patient.

- To provide an unbiased and easily available source of reliable drug information ( the pharmacist) and to disseminate information according to the needs of professional personnel.

- To provide clinical experience for interns and residents and other qualified pharmacy students in hospital pharmacy.

- To design and conduct studies in cooperation with the physician and nurse so that a full evaluation may be obtained of institutional pharmacy service within the framework of the team approach to patient care.

The publication of Drug Intelligence and Clinical Pharmacy ( now Annals of Pharmacotherapy) began in 1967, and two pharmacy therapeutics textbooks came out of San Francisco in 1972.

By 1974, the Federal government recognized a clinical role for pharmacists when it began requiring the pharmacist to conduct monthly Drug-regimen reviews of residents in skilled-care nursing homes.

Thus, the clinical pharmacy movement created the opportunity for pharmacy to continue as a profession worthy of the respect and trust of its patients

Clinical pharmacy was involved in the health care of patients, it required specialized knowledge and skills, and it was individualized.

Affirmation of the trend: The Millis Report

In 1975, the American association of colleges of pharmacy commissioned a study of pharmacy by a 12-member group headed by dr. John Millis. Known commonly as the Millis commission, the group issued its finding in a 161-page report called pharmacists for the Future: The Report of the study Commission on Pharmacy.

Among the changes in pharmacy and pharmacy education as a direct result of the Millis Commission were the following :

- Acceleration of development of Clinical sites for pharmacy school faculty.

- Development of a national examination for licensure of pharmacists, now called the NAPLEX ® (North American Pharmacist Licensure Examination®).

- Increased movement toward making pharmacy a knowledge-based clinical profession.

- Creation of a small number of clinical scientist programs in schools of pharmacy at the doctor of philosophy.

- Creation of a Board of Pharmaceutical Specialties within APhA to recognize specialty practices in pharmacy and certify individuals in those specialties.

However, as Helper has noted, the Millis Report failed to produce a real shifting in pharmacy dramatically and irreversibly toward its desired goals.

Unlike some previous similar reports in pharmacy or medicine, the Millis Report did not outline specific changes in pharmacy school curricula or give a plan for the future.

It provided only external recognition for the advances made by pharmacy as a clinical profession.

Helper raises the stakes with pharmaceutical care

The clinical pharmacy movement continued in the 1980s. two new journals were published: pharmacotherapy was founded in 1981 by Miller, and Clinical pharmacy, by the American society of hospital pharmacists from 1982 through 1993.

A third textbook in the clinical pharmacy field, pharmacotherapy: A Pathophysiologic Approach, was first published in 1989.

Hepler began to conclude that the clinical pharmacy and pharmacotherapy movement was not the sole answer to pharmacy's problems. Beginning at the 1985 directions for clinical practice in pharmacy ( called commonly the Hilton Head conference), Hepler explained the notion that pharmacists had to do more than just try to control the use of drugs.

Hepler recommended that they had to take responsibility for the care provided to patients through the clinical use of drugs. In 1987, he first applied the term pharmaceutical care in describing what he and colleague linda strand called these new self-actualization roles for pharmacists.

Definition of Pharmaceutical Care

Pharmaceutical care is the direct responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life. these outcomes are:

1. Cure of disease2. Elimination or reduction of a patient's

symptoms3. Arresting or slowing of a disease process4. Preventing a disease or symptom.

Pharmaceutical care involves the process through which a pharmacist cooperates with a patient and other professionals in designing, implementing, and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient.

This in turn involves three major functions:1. Identifying potential and actual drug-related

problems2. Resolving actual drug-related problems3. Preventing potential drug-related problems.

Pharmaceutical care is a necessary element of health care, and should be integrated with other elements. Pharmaceutical care is, however, provided for the direct benefit of the patient, and the pharmacist is responsible directly to patient for the quality of that care.

The fundamental relationship in pharmaceutical care is a mutually beneficial exchange in which the patient grants authority to the provider, and the provider gives competence and commitment ( accepts responsibility) to the patient.

  The fundamental goals, processes, and relationships of

pharmaceutical care exist regardless of practice setting.

Making a decision about the entry-level degree

pharmacy profession struggled and disccused for 40 years as to what the appropriate entry-level degree for pharmacy should be. Finally, in the early 1990s, the profession settled on the doctor of pharmacy.

An increasing number of student pharmacists had been voluntarily seeking the pharmD degree during the 1980s, but many of them did so after obtaining their baccalaureate degrees and, in many cases, working for a few years.

Most pharmacy graduates, however, finished with B.S. degrees in pharmacy. By 1995, the enrollment in PharmD programs would total 9,346 individuals , compared with 24,069 in B.S. degree programs.

In 1989, the American Council on Pharmaceutical education ( now the Accreditation counsel on pharmacy education), which accredits schools of pharmacy, announced plans to consider revising its accreditation standards such that the B.S Pharmacy degree would be eliminated by 2000.

Since many state boards require pharmacists to be graduates of ACPE-approved programs, this ACPE action essentially eliminated the B.S. Pharmacy as an entry-level degree for pharmacy practice, replacing it with the PharmD credential.

In 1997 ACPE finalized the standards for the Pharm D programs.

The Medicare Modernization Act or MMA Act of 2003 required that MTM services be provided to high-risk patients with the goals of enhancing patients' understanding of appropriate drug use, increasing adherence to medication therapy, and improving the detection of adverse drug events.

The MTM service model in pharmacy practice includes the following five core:

- Medication therapy review- Personal medication record- Medication-related action plan- Intervention and/or referral- Documentation and follow-up

Pharmacy : The future belongs to you

Pharmacists are now positioned well to be the drug-therapy experts on the health care team.

The bold decisions made about the appropriate role for pharmacists and the entry-level degree have produced formal recognition of pharmacists' clinical services, and through MTM, many believe that pharmacists in coming years will spend most of their time in this mode of practice rather than in the drug preparation duties that dominated in the past.

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