Wednesday, September 22, 2010

Help me help you

Posted by Jim Stevenson at Wednesday, September 22, 2010

My second rotation is in ambulatory care with Dr. Stu Rockafellow. When seeing the day to day services he provides, an outsider probably would not realize he's a pharmacist. That's the beauty of ambulatory care pharmacy - there is no dispensing, just the optimization of the care for the patient.

This is how it works: There are a number of primary care physicians at the two clinics where Dr. Rockafellow staffs. When they have a patient that requires extended management of diabetes, hypertension, hyperlipidemia, or asthma, they refer them for an appointment with Dr. Rockafellow. At their first appointment with the pharmacist, the pharmacist reconciles their medication lists and learns more about their lifestyle choices (diet, exercise, alcohol, etc). At subsequent appointments, the pharmacist interprets updated lab values (A1c, blood pressure, electrolytes, etc) and adjusts medications accordingly. A huge part of the service is also encouraging better lifestyle choices to the patient.

Instead of pushing the patient toward these decisions with paternalistic lecturing, the pharmacist has the patient make specific, achievable self-management goals (eg walk 3x weekly for 30 min) to help the patient meet their disease-state related goal (A1c <7 etc). If a patient is unable to exercise intensely, we'll either focus on diet or have the patient make a small, achievable exercise goal and work from there. In this way, the patient has a big say in his/her preferences for treatment.

Dr. Rockafellow also has a collaborative practice agreement, allowing him to adjust medications related to diabetes, HTN, and hyperlipidemia. If a patient is above his/her blood pressure goal and has reached his/her lifestyle goals, Dr. Rockafellow can increase their lisinopril dose and order a potassium level to be evaluated a week later at follow-up.

There's a ton of one-on-one patient interaction in ambulatory care, and most of the patients seem to really enjoy having a health care provider listen to them for once and individualize their care. The long-term follow-up that many patients require also builds bonds between the patient and pharmacist with all the repeat visits. If you're known for your rapport with patients and your ability to formulate an individualized plan for a patient, you were born for ambulatory care pharmacy.

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