Pharmacist in

Primary and
Community
Care
July Lee
Pharmacy Practice

Learning Objectives
1.

To understand the various roles of a pharmacist in primary and

community care

2.

To understand the importance of communication skills in

improving patient adherence and reducing medication errors

3.

To understand the responsibility of a pharmacist as a drug

supplier

4.

To understand the opportunity for a pharmacist to be a health

promoter and areas for health promotion

5.

To understand the role of pharmacist collaborating with other

healthcare professionals

6.

To understand the various model of partnerships for primary

care pharmacists

Pharmacists
Communicator
Drug Supplier
Trainer and
Supervisor
Collaborator
Health Promoter

Why is it important for a

pharmacist to be a
communicator?

Drugs Dont Work In

Patients Who Dont
Take Them

Consider the following scenario

A 36-year-old man was prescribed a fentanyl
patch to treat pain resulting from a back injury. He

was not informed that heat could make the patch

unsafe to use.
He fell asleep with a heating pad and died. The
level of fentanyl in his bloodstream was found to
be 100 times the level it should have been.
(Falik 2006)

Pharmacist as a

COMMUNICATOR
Pharmacists have become more

patient-centered in their
provision of pharmaceutical care

Pharmacist can contribute to patient care by

Reducing medication errors

Improving the use of medications by patients through
pharmaceutical care

Using effective communication skills is essential in the

provision of patient care

Providing Patient-Centered Care

The pharmacist must be able to:
Understand the illness experience of the patient
Perceive each patients experience as

unique

Foster a more egalitarian relationship with patients

Build a therapeutic alliance with patients to meet

mutually understood goals of therapy

Develop

self-awareness of personal effects on patients

Mead and Bower (2000)

Importance of Communication
Communication process between a pharmacist and their
patients serves two primary functions:
Establishes the ongoing relationship between the

pharmacist and their patients (formation of a trusting

relationship)
Provides

the exchange of information necessary to assess

the patients health conditions, reach decisions on
treatment plans, implement the plans, and evaluate the
effects of treatment on patients quality of life

Potential Pharmacist-Related Personal

Barriers
Low self-confidence
Shyness
Dysfunctional internal monologue

Lack of objectivity
Cultural differences
Discomfort in sensitive situations
Negative perceptions about the value

of patient interaction

Reasons to Encourage Patient Sharing of

Experiences
They have unanswered

questions regarding their therapy

They have misunderstandings

They experience problems not related to therapy

They monitor their own response

They make their

to treatment

own decisions regarding therapy

AND
They

may not reveal this information unless you initiate a

dialogue

Medication Safety and Communication Skills

Effective communication skills essential in assuring that

patients understand how to take their medicines correctly

Instrumental in assuring patient safety
Research reveal that preventable medication errors still

occur at unacceptable rates (Cohen, 1999)

Medication errors not only cause physical harm to

patients but also undermine patient confidence in

healthcare system

May not trust information by health care providers

Affects patient adherence with prescribed therapy

Common issues in verbal communication

Distractions and noise that interfere with clear transmission

and receipt of the message

Heavy accents and language differences
Use of terminology that other health care providers do not

understand
Speaking too rapidly for the listener to clearly comprehend
Medications that sound alike when spoken (Zantac vs

Zyrtec)
Numbers that sound alike (15 vs

50; 19 vs 90)

Potential Strategies

Fortunately, many errors are discovered during pharmacist-patient

counseling interaction and are corrected before patients leave the
pharmacy (Ukens, 1997)

For this to occur, patients need to be actively involved in their drug

therapy and pharmacist readily available to communicate

Strategies
1.

2.
3.

When giving information to patients, allow patients the opportunity to

repeat back key information in order to detect possible errors and
misunderstandings
Difficult drug names should be spelled out for patients when giving
verbal instructions
Encourage patients to keep a list of all their medications and other
critical health information like drug allergies

Pharmacist as a

Drug Supplier
In Malaysia, general practitioners (GPS) and community

pharmacists are normally the first point of contact for

patients requiring medical assistance
For patients who wishes to self-medicate, there is no

shortage of health-related information all of which

provides self-care advice

from the internet, self-help books, tv advertisement,

magazine and radio programs, well-meaning friends and
relatives

The

vast number of competing non-prescription products

makes selection difficult

16

Pharmacists play a crucial role in assisting patients who are

seeking self-care products

Pharmacists have the

expertise to screen patient health

information and apply their knowledge and training to select
products according to individual health care needs

In Malaysia, pharmacists are legally allowed to dispense NP and

Group C medications without a prescription

Access to a pharmacist for assistance should be readily

available for patients who request it

Pharmacist as a

Trainer /Supervisor (Manager)

In the community pharmacy, the duties of the manager

depends on the size and requirement of the pharmacy and

professional organisation
At the store level,

the pharmacy manager is in charge of the

Staff
Clinical services
Inventory management
Recruitment
Training and development
General business management

18

In training and development, community pharmacists are

involved in training or supervising student pharmacists or

pharmacists undergoing their pupillage training
Community pharmacists are also involved

in training

pharmacy staff in the following areas:

Product knowledge for common minor ailments

Training the pharmacy staff to act as a filter for information and
referring customers to the pharmacist where the customer
requires further advice on medications, treatments or medical
conditions
Training the pharmacy staff to refer the sale of Group C
medicines (Pharmacist Only Medicines), Group B medicines
(Prescription Only Medicines) and customers with health
conditions to the pharmacist for further advice

Pharmacist as a

Health Promoter

Why should health promotion

be part of pharmacists roles?

Trustable and well-recognised as health consultant

Easy accessible
Beliefs to hold most of the latest knowledge about medication
Patient confidentiality

Pharmacist as primary care provider

Consulted more than 200,000 customers in practice
Opportunity to deliver information

Pharmacist as drug expert & health care product expert

Good knowledge about disease- drug relationship, correct use of
product
Wide knowledge about disease prevention & promotion of good
health

Pharmacist as good communicator

Well trained in communication skills - allows open discussion and
acceptance of information

Roles of Pharmacist in Health Promotion

Health screening and information
Disease prevention
Product information
Risk reduction information

Referral to other health professionals

Drug Abuse/Misuse

(OTC/Medicine/Dangerous drugs)

Areas of Health Promotion

Disease

/Risk Prevention

Smoking cessation
Alcohol use
Healthy lifestyle

Prevention of

drug misuse including OTC misuse

Sexual Health
Prevention of

Pregnancy

Harm/Risk reduction

Methadone supervision
Needle exchange scheme

Are customers willing to discuss health topics

with the pharmacist?

Users experience of advice and services in the

pharmacy setting

23% came into the pharmacy to ask for advice

>3/4 were satisfied with the advice and has learned from it
Nearly all of them - would use pharmacy again as source of
advice on health matters

2/3 respondents - like to talk to the pharmacist in private; only

5% had such facilities

41% of 224 respondents - most important to consider when

using a pharmacy on contraception and safer sex issues is the
availability of quiet area

17.6% of 336 users reported being embarrassed to speak about

head lice.

How do public perceive the pharmacists

role in giving health advice?
Of 592 community pharmacy service user,

the preferred
source of advice for staying healthy was the GP for 77%
and the pharmacist 8%.

15% claimed had ever sought such advice

90% had noticed information leaflets of health topics, 30%

had taken one or more than one and read

Case 1: Osteoporosis
Study

Objectives

To investigate the effectiveness of an osteoporosis

screening and awareness programme by pharmacist in
community setting
Method

Level of awareness were tested pre & post screening and

educational interventions
Result

26% increase in awareness about steps to prevent or delay

fractures post-intervention
Law AV, Shapiron K. Impact of a community pharmacist-directed clinic in improving screening
andawareness of osteoporosis. 2004 Journal of Evaluation in Clinical Practice ,11, 3, :247-255

Case 2: Cholesterol Reduction

Study Objectives

To assess the effect of a multidisciplinary program on

attempts to lower total cholesterol levels

Method

Cholesterol reduction in two arms - standard medical care vs

interventions e.g. diet, behavioural, pharmacological with close
interaction between physician and pharmacist
Result

Lower cholesterol with combined program that include physician

and pharmacist interaction
Bogden PE, Koontz L, Williamson P, Abbott RD, The physician and pharmacist team :
an effective approach to cholesterol reduction. JGIM, 1997, 12 : 158-164

How can pharmacists promote health or

educate patient?
1.

Plan your session

2.

Work from the Known to the Unknown

3.

Especially if tit is a new session

Identify the aims, how to introduce and develop the session, how will
you involve in audiences
Building new information or facts on what is already known
Not to waste time for facts that is already known but is sometimes
necessary if you have audiences with varies degree of knowledge
So, spend time to find out what people know : information should be
tailored to needs

Aim for Maximum Involvement (relevance to learners)

People learn best when they are involved in it rather than to work
under direction
Ask yourself - Is what you teach what my clients want to learn?

4.

Devise learning activities

5.

Varying teaching and learning methods

6.

Should be tailored to groups

Should encourage participation

It is important to look from the learners point of view

Identify realistic goals and objectives

Teaching more does not necessary mean they learn more

Teaching should have a clear aims and objectives - deliver
important facts

7.

Organise your materials

8.

Evaluation, Feedback and Assessment

Common Types of Learning Activities

Types of Activity

Example

Diary Records

Analysing and discussing about

diary records for asthma or
tobacco or alcohol consumption

Identify own thoughts, feelings or

behaviour in different scenarios

Discussion of feelings when

smoking in front of non-smokers

Practical skills development

Leaflets, videos of using nicotine

patch or gum

Identifying barriers

Identify and generate list of

barriers to smoking cessation

Learning Methods Involving Clients

Client Involvement

Materials and Methods

Listen

Lectures, audiotapes

Read

Books, leaflets, handouts, posters, flipcharts

Visual aid

Photographs, charts, material from magazines

Look and listen

Film, videotapes, demonstrations

Listen and talk

Q+A session, discussions, informal conversation,

debate

Read, listen and talk

Case studies, discussions based on study questions or

handouts

Read, listen and talk and

actively participate

Drama, role-play, games, simulations, practicing

skills

Read and actively

participate

Programmed learning, computer assisted learning

Make and use

Models, charts , drawing

Important points in health education & promotion

1.

Get your facts right

2.

Say the important points first

3.

Patients are more likely to remember what was said at the

beginning of session, so give the most important advice and
instruction first, whenever possible.

Give specific and precise advice

You should do a 30 minutes brisk walk 3 times a week rather

than You should exercise more

4.

Ensure advice is relevant and realistic

5.

Get feedback from patients or clients

Pharmacist as a

Collaborator
Primary care pharmacist normally work as part of a

interdisciplinary team that provides services to patient

An interdisciplinary team would normally consist of

Doctors, Pharmacists, Nurses

Dietician, Psychologist

Community pharmacists may have

interaction with physician

and nurses in the community but it normally occurs through
telephone conversation

Time spent collaborating with other professionals would depend

on the level of management held by the pharmacist

Model of Partnership in
Primary Care

Model of Partnerships in Primary Care

Monte SV, Clinical and economic impact of a diabetes clinical
pharmacy service program in a university and primary care
based collaboration model.
J Am Pharm Assoc. 2009;49:200-208.
SETTING: Regional primary care group in Buffalo, New York.
CONCLUSION: In this CPS model, there were initial and
sustained reductions in the primary diabetes endpoints and a
high rate of improvement for accompanying metabolic
parameters. Concurrent with clinical improvements, total direct
medical costs were reduced despite an increase in antidiabetic
medication and total medication costs.

Model of Partnerships in Primary Care

Nkanash NT et al, Clinical outcomes of patients with diabetes
mellitus receiving medication management by pharmacists in
an urban private physician practice.
Am J Health-Syst Pharm. 2008; 65:145-9.
SETTING: Johns Hopkins Community Physicians Maryland;
pharmacy clinic located within the physicians practice.
CONCLUSION: Integrating a pharmacist into a private physician
practice significantly improved patients glycaemic control and
maintained patients weight and the number of patients at blood
pressure goal. Clinic adherence with ADA recommendations was
sustained.

Model of Partnerships in Primary Care

Zerumsky K et al, Pharmacist Detection of Peripheral Arterial
Disease Through the Use of a Handheld Doppler.

Pharmacotherapy 2005;25(6):797802.
SETTING: Primary care and consultative outpatient clinic.
CONCLUSION: This pharmacist-initiated screening program increased
recognition of peripheral arterial disease in previously unscreened
patients. A pharmacist can play a role in a clinic where patients at highest
risk are seen. This finding can further assist pharmacists in developing a
role in the primary care clinic setting. The clinical pharmacist at the
Benedum Geriatric Center, University of Pittsburgh, continues to screen
patients without documented peripheral arterial disease. As a result of
this research, the Benedum Geriatric Center will establish a program for a
pharmacist to evaluate patients for peripheral arterial disease and assist in
controlling other cardiovascular risk factors.

Model of Partnerships in Primary Care

Carter BL et al, A Cluster Randomized Trial to Evaluate
Physician/Pharmacist Collaboration to Improve Blood Pressure
Control
J Clin Hypertens. 2008;10:260271.
SETTING: Two family medicine clinics at a major teaching hospital
in the mid-western United States.
CONCLUSION: An intervention involving physician/pharmacist
collaboration that focused on optimizing and intensifying
medications was associated with significant reductions in BP and
improvements in BP control. This study was the first to include 24hour BP monitoring to objectively confirm clinic pressures. [cont]

Model of Partnerships in Primary Care

Carter BL et al, A Cluster Randomized Trial to Evaluate
Physician/Pharmacist Collaboration to Improve Blood Pressure
Control
CONCLUSION: [cont] These improvements were correlated with
increased intensity of medication use, which suggests that the
model had an effect to overcome suboptimal medication
regimens.
The intervention also improved medication adherence in the small
number of patients with poor adherence without increasing
adverse effects. This study suggests that for clinics or health
systems that have clinical pharmacists, their reallocation to
provide more direct patient management may significantly
improve BP control.

Model of Partnerships in Primary Care

Devine EB et al, Strategies to optimize medication use in the
physician group practice: The role of the clinical pharmacist.

J Am Pharm Assoc 2009;49:181191.

SETTING: Community-based, multispecialty, physician group practice
located in the north Puget Sound area between 2003 and 2007.
CONCLUSION: In 20062007, 71% of our hypertensive patients
received generic agents compared with a network average for
receiving generic agents of 43%, while the proportion of patients
with controlled blood pressure increased from 45% to 60%. We
saved $450,000 in inpatient costs for deep venous thrombosis.
Clinical pharmacists employed in a physician group practice can
optimize medication use, improve care, and reduce costs.

Model of Partnerships in Primary Care

Hunt JS et al, A Randomized Controlled Trial of Team-Based
Care: Impact of Physician-Pharmacist Collaboration on
Uncontrolled Hypertension.

J Gen Intern Med 23(12):196672.

SETIING: Providence Primary Care Research Network-Providence
Physician Division, Beaverton, OR, USA.
CONCLUSION: Patients randomized to collaborative primary carepharmacist hypertension management achieved significantly
better blood pressure control compared to usual care with no
difference in quality of life or satisfaction.

Model of Partnerships in Primary Care

Isetts BJ et al, Clinical and Economic Outcomes of medication
therapy management services: the Minnesota experience.
J Am Pharm Assoc January 2009.
SETTING: Six ambulatory clinics in Minnesota.
CONCLUSION: Patients receiving face-to-face MTM services
provided by a pharmacist in collaboration with prescribers
experienced improved clinical outcomes and lower total health
expenditures. Clinical outcomes of MTM services have chronic
care improvement and value-based purchasing implications,
and economic outcomes support inclusion of MTM services in
health plan design.

Model of Partnerships in Primary Care

Michael EE et al, Evaluation of 4 Years of Clinical Pharmacist
Anticoagulation Case Management in a Rural, Private Physician
Office.
J Am Pharm Assoc. 2003; 43:6306.
SETTING: Rural, private physician office in Mt. Vernon, Iowa.
CONCLUSION: A clinical pharmacist can provide anticoagulation
case management services safely and effectively in a private
physician office, and the service is highly valued by both patients
and providers. We believe case management is an optimal
method for systematically monitoring outpatient anticoagulation
therapies and is preferable to usual medical care.

Thank You