Guidelines for Development of an Individualized Learning Plan for Pharmacists Working In

Guidelines for the Development of an Individualized Learning Plan for Pharmacists Working in Primary Care Practice

These Guidelines outline important knowledge, skills, and values for pharmacists working in a family practice site. The guidelines are similar to the standards of practice used by the Ontario College of Pharmacists and the Leslie Dan Faculty of Pharmacy at the University of Toronto but have been modified to take into consideration the unique needs of family practice.

The Guidelines are based on feedback about common practice and therapeutic issues encountered by pharmacists in a previous pharmacist primary care intervention study (Seniors Medication Assessment Research Trial – SMART). Designed with SMART physicians and pharmacists input, they reflect areas that pharmacists could target for improvement as they strive to work collaboratively in family practice with the goal of improving drug-related outcomes in elderly patients with complex medication regimens.

Goal of guidelines:  To help pharmacists identify general learning needs and/or specific knowledge/ skills for improvement

How to use these Guidelines:

 For each category, assess your learning needs using the scale provided.  Identify a few priority areas to start with using the right-hand column.  Develop an action plan for these learning objectives (with mentor if available). May use OCP learning portfolio as a sample.  Periodically revisit checklist to monitor how well learning needs are being met. This may be done with a mentor’s help.

IMPACT project 2006 Guidelines for Development of an Individualized Learning Plan for Pharmacists Working in Family Practice

Knowledge – Clinical

In order to help pharmacists identify and solve a patient’s drug-related issues, it is helpful to ask the following questions to direct our thinking (therapeutic thought process):

1. What are the medical conditions/ signs and symptoms of the patient? 2. Are the medical conditions/ signs and symptoms under control? 3. How urgent is the situation? 4. Is the problem(s) being caused by drug therapy? 5. Is drug therapy needed for the problem? 6. What are the alternatives to treat the problem? 7. What is the best drug for this patient?

***************** In order to know whether the medical conditions/ signs and symptoms are under control and the urgency of the situation (i.e. the first three questions), the pharmacist should have an understanding of disease conditions (e.g. pathophysiology, signs and symptoms). To know if the problem is being caused by drug therapy and/or if drug therapy is required (i.e. the remaining questions), the pharmacist should have therapeutic and drug knowledge.

IMPACT project 2006 For the following medical conditions, please indicate the number that best represents your current skill level using the following scale:

1 2 3 4 5 needs complete needs some no review review review needed

Prioritize your learning needs in the right hand column. This does not have to follow the same scale as above, you can decide on a few particular areas that are high priorities for your learning needs so that you can get started with your learning plan. Come back to this document often to reassess your learning plan.

Signs & Symptoms Pathophysiology/ Efficacy: Guideline Side Drug/ Cost/ Issues for use in Priority (incl. interpretation of lab & Etiology/ recommendations/Main effects Disease formulary elderly (incl. precaution, areas diagnostic tests, physical Risk factors/ renal dose adjustment, (pick top findings) evidence supporting each interactions coverage Natural drug choice dosage forms) choices to progression start (complications, learning sequelae) plan) Hypertension Dyslipidemia Diabetes Pain Constipation Osteoporosis CHF Coronary artery disease Sleep disorders Depression/ anxiety Falls GERD/ PUD BPH/ urinary incontinence Osteoarthritis

IMPACT project 2006 For each of the knowledge and skill areas below, please indicate the number that best represents your current skill level using the following scale:

Prioritize your learning needs in the right hand column.

Skill Priority Skill Priority level Areas level Areas Knowledge – Technical/Procedural Skills – determining personal learning needs Locating relevant resources to answer DI question Using therapeutic thought process to identify general and identify/ resolve DRPs (e.g. DIRC, Medline, learning needs Micromedex) Role of pharmacist in family practice site (experience Use of focused clinical questions to identify patient- or shadowing) specific learning needs Roles of family physicians and other practice staff Information retrieval – chart Resources/people to refer patient to for additional Information searching and retrieval – literature (e.g. non-pharmacological advice Medline, Cochrane database, Clinical Evidence) Office procedures, charting system, and medication Information retrieval – team, community pharmacy, management system (addressed during orientation) other Critical appraisal (of articles about therapy, of guidelines) to determine if results should be used in patient care (User’s Guide; JAMA series) Evaluating:  Study methodology  Results interpretation (e.g. p value, confidence interval) Skills – Determining patient needs  How to apply results to patients Comprehensive interviewing (e.g. medication Skills – identifying and prioritizing drug-related assessment) problems Brief, focused interviewing (e.g. addressing specific Using systematic method (e.g. therapeutic thought patient issue, disease-specific?) process) to identify DRPs Interviewing patients with special needs (cognitive, Prioritizing DRPs based on urgency visual, hearing impairment, ESL) Basic physical assessment skills (e.g. BP measurement) General communication skills – active listening, verbal/non-verbal, use of empathy

IMPACT project 2006 For each of the knowledge and skill areas below, please indicate the number that best represents your current skill level using the following scale:

Prioritize your learning needs in the right hand column.

Skill Priority Skill Priority level Areas level Areas Skills – developing therapeutic plans Skills – Documentation Eliciting desired endpoints/outcomes from patient Uses appropriate style of documentation for target and team perspective audience Weighing pros and cons of each therapeutic Uses systematic method to present information, alternative provides support for DRPs identified, and justifies recommendations Determining from MD what s/he expects pharmacist Documents in a clear and concise manner to do for patient Develops a plan that is clear, complete, and Documents relevant information that complements individualized for the patient team’s documentation Skills – implementing therapeutic plans Skills – meeting practice-based needs Educating patients about appropriate medication use Delivering presentations on medication-related topics to family physicians and practice staff Facilitating patient adherence to medications Responding to drug information requests Use of evidence and patient specific information to Prioritizing workload to ensure that patient, practice, justify recommendations and study requirements are met Discussion of therapeutic plan/ recommendations Organizing and coordinating changes to office systems with physician to improve medication management Negotiates with team and patient who will be responsible for implementing which part of the plan Skills – Follow-up/monitoring Use of a monitoring tool to define monitoring parameters and time-frame for follow-up Anticipates what changes are needed to plan in case things do not go as expected Integrates pharmacy monitoring plan in with team’s overall monitoring plan

IMPACT project 2006 We recommend that you review these values and responsibilities when starting a position in family practice. We suggest that you review/ reflect on them again after a couple of months as many of the issues may make more sense after being in the practice for a while and experiencing situations first- hand. As you proceed in your practice, you will likely encounter examples of the values and responsibilities listed. In the columns below, you can write down a brief description of the scenario as you experience it in practice and any thoughts you may wish to discuss with your mentor.

Values and Responsibilities Description of example scenario as Reflections/new insights to be encountered in practice discussed with mentor Taking responsibility for a decision and being prepared to deal with a situation when the plan does not have the intended outcome Following patient through until all DRPs are resolved (or at least ensuring that someone else is able to take over responsibility) Dealing with uncertainty or ambiguity in diagnosis (eg. knowing when and how to discuss diagnosis with the family doctor rather than researching it yourself) Determining when additional research into a problem is not yielding useful results (knowing when to stop researching and develop a plan for discussion with the physician) Ensuring continuity of care/seamless care (b/w FP office, hospital, community pharmacy, home care, etc) Encouraging and reinforcing lifestyle choices that decrease risk and enhance health-related well-being on an individual patient level (health promotion) Negotiating with patient re: use of herbal products for which weak evidence to support/may be harmful Respecting and taking into account both patient’s and FP’s concerns in patient care activities Negotiating with FP how much responsibility is acceptable for pharmacist to have in different family practice activities Maintaining confidentiality for study purposes, negotiating between patient and FP (issues around patient confidentiality) Providing patients with necessary information to enable them to make informed decisions and take responsibility for their health (patient empowerment/supporting shared decision-making) Advocating for patients’ best interests and intervening on their behalf with FPs Promoting evidence-based, rational and cost-effective medication use

Next steps: Develop an action/ learning plan to address your learning needs (may use OCP learning portfolio). Developed by: Elaine Lau, Barb Farrell, Zubin Austin, Lisa Dolovich, IMPACT project 2006 Lisa Kwok, Shelly House, Lisa McCarthy, Connie Sellors