Tuesday, October 8, 2013

Ambulatory Care at the Canton Health Center

Posted by Patrick at Tuesday, October 08, 2013

At its core, ambulatory care pharmacy is about building relationships between a pharmacist and patient and meeting regularly to discuss specific problems and optimize the use of the patient’s medications. Sometimes these meetings are over the phone, and other times they visit the clinic; it’s generally up to the patient as to their preference. In the ambulatory care setting, we listen to the patient’s story, study the objective lab values, optimize dosing, and provide a substantial amount of motivational interviewing to help patients achieve their lifestyle goals (usually diet and exercise counseling for diabetes).
The contours of potential areas of focus are clearly spelled out in the collaborative practice agreement with oversight physicians. At the Canton Health Center, Dr. Rockafellow mostly manages diabetic patients, some hypertension patients, a few hyperlipidemia patients, and an occasional patient who is referred for polypharmacy (on such a large number of medications they their care requires active management).

This particular clinic operates 3 half days per week, from 9 a.m. to 1 p.m. with a full day from 9 a.m. to 5 p.m. on Tuesdays, with an average of six to ten appointments per day, though some days can be much higher (I’m pretty sure my busiest day was 16 patients, though most of these were shorter phone visits). By continuing to work with the same patients every few weeks, we have the chance to work on long-term goals in concert.  We can monitor their home glucose readings every week or every other week and make sure they are taking the optimal dose of insulin. We can also use this same data to help patients make connections between their diet and their diabetes control.

My patient load grew by the day until, by the end of the third week, I was managing all of the clinic visits and upwards of half of the phone visits. Regardless of how the schedule appears in advance, one scheduling change (for example, a patient arrives late, or has additional important topics to discuss that takes a bit longer than the appointed time) has the potential to turn a well-oiled morning into a scramble. After my first full clinic day overflowed all reasonable time constraints, I learned the importance of keeping one eye on the clock as well as a collection of techniques to move the conversation forward efficiently.
The best experiences were when the patients surprised you. One week a patient might not be open to making any lifestyle changes, but after listening to them and beginning to build a trusting relationship, it is amazing what changes one can see. On more than one occasion, I had a reluctant patient open up their lifestyle and independently identify possible changes. One thing I learned from this was that it’s not necessary to make every change at once. It’s largely unfeasible and it is certainly overwhelming for patients. Instead, it’s usually appropriate to work with them to find feasible targets for change build toward a more holistic approach week by week. In my view, this is one of the greatest advantages of ambulatory care pharmacy, an enormous opportunity for the profession to improve patient care in the future, and a possible career path for myself  as I gear up for graduation. It would be hard to imagine a better ambulatory care pharmacy practice experience than the one I had. 

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