End of Unit 3 and Unit 4 Longitudinal

Potential for disparities in health care

chaining US demographics by 2050 being more hispanic/latino from 14.8% to 24.3% and more african american from 12.8 to 13.2 and less caucasion from 66.4 to 52.7; pharmacists right now compared to population are more white=66.4 of population and 90.4 of pharmacists and less black=12.8 population and 4.1 pharmacists and less asian=4.6 population and less than 0.1 pharmacists and less native american=1.o population and 0.4 pharmacists and less hispanic=14.8 population and 5.1 of pharmacists; race makes big cultural impact, ex: chinese=western medicine too strong and not complete course of treatment and cut medicine in half or stop taking it and negative medical news shielded form patient by family in believing that telling patient would make condition worse

Culture

complex systems of knowledge, beliefs, attitudes, values, rules, art that undergirds our sense of social reality; allows for shared understanding and coordinated action; we all exist in culture and are all enculturated=even primitive people have complex cultures; we all exist in a web of cultures: mainstream culture vs. sub-cultures; biomedical culture: profession can be a major source of cultural influence that can shape beliefs and values and behaviors, cultural medicine shapes how providers talk and think about patients and their disease, with its own beliefs and language and customs and biomedical=practitioner centered, info giving, save the patient, dictate behavior, persuade and manipulate; CC/psychosocial is patient centered, info exchange, patient saves self, negotiate behavior, understanding/acceptance

Dispensing and Distribution technology to prevent errors

counting systems, medication carousels=increase efficiency in hospital and fill days worth of meds for each patient and as filling=drawers rotate to bring you the right drug, automated dispensing machines=ADM (in hospital) so select patient and wherever drug located the door pops open, dispensing robots=order filled by machine and come out labeled, IV automation=to make IVs and totally sterile environment and can do for syringes too, bar code medication administration=BCMA: nurse barcode scans name tag, scans patient ID bracelet, patient MAR appears on bedside laptop, scheduled and PRN meds are scanned, warning/alerts are issued when indicated and in pharmacy label prints with bar code, scan bottle and label, scan at checkout, "smart" pumps=library inside and will not let nurse run IV bag faster or with more volume than should have, eMAR=color coding to see if the drug was given on time or not and when scanning interact with this

Intercultural competence

culture=life seems elf evident and straight forward within a culture and is taken for granted but uncertain and interaction awkward across cultures and we fear when we don't know so we create stories to rationalize or ease our fears; competence=ability to interact with people from other cultures, mutual understanding and shared decision making, mutual respect, patient-centered, equal and unbiased respect and care/concern; ex: physician counseling native american to lose weight and have to consider native american understanding of and value of weight, understanding of severity of disease/risks; different views of disease and medicine can lead to=misunderstanding or non understanding and resistance and conflict, difficult to understand and honor differences, self-awareness important first step

Humanistic Outcomes

definition of outcomes=change in a patient's current and future health status that can be attributed to antecedent health care: includes social and psychological function and physical and physiological performance; Categories of outcomes: ECHO: Economic outcomes, clinical outcomes, humanistic outcomes=health related quality of life and patient satisfaction make this up; patient reported outcomes: any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else; can include symptom severity, health-related quality of life, treatment adherence, treatment satisfaction

Cultural competence and the pharmacist's oath

devote my professional life to service of all local and global communities=cultural competent pharmacists can understand disparities and discrimination faced by some patients and work toward earning their trust; consider the welfare of humanity and relief of human suffering my primary concenrns=CCP recognize patients have different needs based on health status and language proficiency and socioeconomic status and race and ethnicity and culture and CCP embraces needs of each patient and provides tailored care; embrace and advocate changes that improve patient care=CCP should become an advocate for change when health care disparities occur

Disabilities and healthcare

disability=condition or function judged to be significantly impaired relative to usual standard for individual or group; term used to refer to individual functioning: physical, sensory, cognitive, intellectual, mental illness, and various chronic diseases; barriers: physical characteristics of practice site, lack of awareness among practice personnel, communication barriers; for hearing impaired: prevalent disability, highly impacts outcomes: receiving appropriate info, being honest in understanding, are you a asking, what resources available, be aware and ready to refer

Guide for provider spirituality conversations

faith/belief: how do your beliefs help you cope? Give you meaning?; importance/influence: how important is spirituality to you in general? enough to affect health decisions?; community: are you part of a spiritual community?; address and action: take FIC to make a plan of action. is a chaplain needed?; what resources do you draw on for decision making? what religious or faith practices would you want us to know about as we approach treatment decision?; what specific beliefs do you hold that we should be aware of?

Cultural competence challenges

health care providers may: val to consider differing responses to medication, lack knowledge about traditional remedies, which could lead to harmful drug interactions, make diagnostic errors resulting from miscommunication; patients may not adhere to medical advice due to lack of understanding or due to mistrust of the provider; important to ask patient what cultural considerations important to him/her before recommending treatments=clinical component of readiness question

Determinants of patient satisfaction with healthcare

healthcare provider-related: technical care, interpersonal care, provider's egalitarian role vs. authoritarian role, physical environment, access (accessibility, availability, affordability), organizational characteristics (reputation and image, size and type or services, provider satisfaction, demographics of provider), continuity of care, efficacy/outcome of care; patient-related: age, gender, education, socioeconomic status, geographic factors (rural vs urban residence), visit regularity, health status and HRQL, expectations

The Green Article (bias)

in Atlanta and Bosotn; physician (resident) self report/explicit of racial bias was measured; physician implicit racial preferences were measured; explicit: reported no preference for white versus black patients, no difference in perceptions of cooperativeness; implicit measures=contradicted; physicians showed bias in evidence based treatment decisions in acute coronary syndrome

Financial resource

indigent clinics; charitable pharmacies; patient assistance programs; drug discount cards; manufacturers coupons/rebates

Information and technology resources

information: electronic health record; primary literature; secondary literature; tertiary literature; technology: mobile device apps, wearables, access to notes from office visits

Clinical informatics

is the application of informatics to specific health care disciplines (pharmacy, nursing, medicine, dental); often used interchangeably with medical informatics (the application of informatics in health care settings to the care of individual patients); pharmacy informatics=use and integrating of date, info, knowledge, technology, and automation in the medication use process for the purpose of improving health outcomes; medication use process: prescribing(evaluate patient, establish need for medicine, select med, determine interactions and allergies, prescribe), transcribing documentation(transcribe prescription/order, transmit to pharmacy), dispensing (review order, confirm transcription, contact prescriber for discrepancies, prescribe medicine, distribute medicine), administering(review order, confirm transcription, review writing and interactions and allergies, evaluate patient, administer medicine), monitoring (assess patient's response to medicine, report end document results); in ambulatory med use process has counseling the patient as well

Electronic health records

many different types; with interoperability can all be combined; ambulatory EMR: physician practice have electronic medical record; inpatient EMR and clinical data repository: hospital or IDN have hospital information system; Payer EMR and medical clinical summary and Rx Claims History: payer and pharmacy PBM have managed information system; PACS archive and diagnostic image repository: imaging have image management system; Patient lab history and blood donor repository and genetic profiles: lab have clinical lab information system; prescription history: pharmacy have pharmacy management system; PHR and Clipboard and PMR: current meds: patient have personal health record

Medical care and harm

medical care should not lead to harm; (drug knowledge, dose and identity check, patient info, order transaction, allergy, medication order tracking, interstice communication) 78% of errors are from limited information; information should be available to physicians, nurses, and pharmacists when and how it is needed; to avoid mistakes: 6 Rights: right patient, drug, dose, route, time, result; preventable ADEs and potential ADEs: ordering is 49% possible and 48% caught down the line, transcribing is 11% possible and 23% caught, dispensing is 14% possible and 37% caught, and administering is 26% possible and 0% caught because no one else is down the line; to prevent: in ordering=CPOE with CDSS or EHR, transcribing: CPOE with CDSS or eMAR, dispensing: CPOE or Bar code or Robotics or ADM, administering: Bar code or eMAR or smart pumps or ADM

health related quality of life

not health status=current health state, physical and mental wellness as affected by underlying diseases or medical conditions and not quality of life=general well being; the subjective assessment of the impact of health status on quality of life; various aspects of a persons life that are strongly affected by changes in health status and are important to the person; the value assigned to duration of life; goal not only to prolong life but to improve its quality; why assess: part of patient centered care, helps determine burden of disease to patient, can serve as indicator of disease progression, enables treatment decisions by determining the most appropriate therapy based on considerations of cost and health utility

Tools to help support patients in healthy behaviors

open notes=physicians and wiling patients had access to notes after see doctor and remember care plan better and understood what was going on better and could take their meds more appropriately; wearables=like a fit bit, letting patient create own health related information and can help make decisions tin patients; watson: diabetes=personalized diabetes management tools, real-time focus, data from EMRs, insurers, and population sources, cognitive predictive smart phone app that can predict BG drop; Scanadu scout: measures BP, heart rate, O2 saturation, RR, temperature; insideables=goes inside and can be camera that looks for pills or be a patch that monitors chemical release from drugs or contact lens that measure BG or sensor on skin and smartphone that gives you readings on your body

types of information needed

patient specific: created and applied in process of caring for individual patients, can include medication and medical histories, lab test results, and other information that is unique to the specific patient, scattered across locations and episodes of care; knowledge base: forms the scientific basis of health care, includes understanding of how the drugs work in the body, referential information (about meds, disease processes, procedures, etc), clinical practice guidelines, and many other domains of health/medical knowledge found in health profession textbooks and journals, it is growing; knowledge based + patient specific information=/make up patient care decisions

AHRQ health literacy tools/resources

pharmacy setting evaluation guide; available free on line at AHRQ web site; workbook/assessment tools for analyzing pharmacy staff awareness, analyzing pharmacy setting; universal precautions toolkit: can't tell by looking, assume every patient has literacy limitations, communicate clearly with everyone, confirming understanding with everyone; use a universal precautions approach with everyone; other resources: CDC's health literacy web site, culture and language and health literacy at US department of health and human services health resources, health literacy and america's health insurance plans at AHIP web site, national action plan to improve health literacy, plain language.gov, universal health literacy precautions toolkit at AHRQ, key publications: health literacy: a prescription to end confusion, ten attributes of he alt literate health care organizations

Dimensions of health related quality of life

physical/functional well-being: disease and treatment-related symptoms, strength and fatigue, activities of daily life/self care behaviors, mobility, role performance, infections, sleep, appetite; psychological well-being: emotional sate/mood=depression anger anxiety, cognitive functioning=memory concentration confusion recall, perceptions of well-being=outlook life-satisfaction happiness morale; social well-being: ability to engage in social interactions, interpersonal relationships, work relationships, family functioning, sexual functioning and intimacy

The literacy problem

poor vs Skilled readers: literal interpretation, may read/decode one word at a time, not perceiving classes of information or categories, skipping over uncommon words, missing the context of text, may not make inferences; readability difficulties: print size, type style, color contrast between ink and paper, concept density, unfamiliar context, low self efficacy; expensive=low health knowledge, higher incidence of chronic diseases, higher incidence of hospitalizations, limited use of preventative health services, reduction in keeping appointments, misunderstanding medication instructions, unable to read prescription labels, less informed treatment decisions, incur higher health care costs, don't know how to talk with provider, poor health behaviors/lifestyle; low literacy=low self care, esp with HIV, Diabetes, Hypertension, Asthma; goal: 1) to assess/detect literacy limitations, 2) to help patient feel comfortable finding the most effective way of receiving information

LGBT considerations

preferred terms: lesbian, gay, bisexual, partner, sexual orientation (not preference), transgender; 13-90% of lesbian and gay patients did not report sexual orientation to primary care physician, 20-75% of lesbians or gay men report negative responses or change in demeanor/respect from provider when disclosed sexual orientation; visitation and decision-making rights of partners may be limited if patient is incapacitation; be aware of your own beliefs and values=set them aside without judgment; be knowledgeable about healthcare issues/communication issues facing these patients: sexually transmitted diseases, immunizations, HIV, reproductive health, domestic violence/sexual abuse; stay up to date on prevention and health promotion practices and treatments; use questions that don't assume heterosexuality

other health care professionals as a resource

primary care physician; specialty physician; physician's assistant; nurse practitioner; psychologist; dentist; registered nurse; dietitian; physical therapist; occupational therapist; respiratory therapist; speech therapist; audiologist; social worker; diabetes educator

Informational accuracy for language barriers

recruit an interpreter/informant: brief the interpreter before counseling about goals; the interpreter stands behind and to the side of the patient, address the patient directly as you, use short simple sentences; should the interpreter be a family member or a professional unrelated to the person=unrelated so no bias; language line service from At&T: subscribe to service, initial fee and then service over the phone per minute/episode, must be prearranged for uncommon languages; computer based programs or smart phone apps; use printed material in patient's native language: some pharmacy chains have much or all in translation=instructions and pamphlets, put together simple translations of basic phrases; printed information should reinforce and not replace oral communicational be sensitive to patient's culture in terms of how deferent/polite to be: don't directly tell what to do, describe that patients with this disease use medication in this way, preserve face and ask permission to share info, being hurried=disrespect in some cultures; use teach back; if patient/caregiver is head nodding=avoid assuming that patient is saying yes or he/she understands: in some asian cultures means that he/she is paying attention

Self Awareness Questions

self awareness of one's own cultural identity and attitudes is a significant key to becoming sensitive to the different cultures of others; what is your cultural heritage, how do you identify yourself in terms of race/ethnicity, where did your family come from, socioeconomic status of your family, how was education valued in your family, while growing up, what messages did you receive about age? ability/disability? gender? sexual orientation?, religion/spirituality, communication and language, interests/hobbies/activities, food/celebrations/rituals, health and illness/self diagnose, minor and major health problems who to go to, who makes health care decisions, OTC meds, expectations care of elderly family members

Strategies in pharmacy for health illiterate patients

slow down, be assertive and direct, limit amount of info=main important points per visit, use visual methods, assess pharmacies written material, avoid medical jargon and use plain language, encourage questions, use teach back=summarize instruction in plain language, can use handout with graphics preferable and explain what each medication is for and point out where info is in hand out; body language that invites questions: sit at same level as patient, look at patient when talking and listening, face the patient, use response gestures (nodding), don't appear rushed; use open-ended questions to gage understanding; use plain language; you may need to advocate for patients who have literacy limitations

Detecting literacy limitations

some patients are open and direct: asking for help or repetition of instructions; most likely will be covert: embarrasses, feel powerless, are defensive and expect judgment, are resistant and have skepticism; be sensitive and respectful and non-judgmental to build trust and make an impact; techniques: hand written material to individual upside down: do they turn it around; hand material and watch how they look at it: do eyes move about page as expected; do they make excuses: forgot glasses, later when more time, take home to relative; validated measures; say: several of my patients say difficult, what sections challenging? etc

physical/mobility resources

syringe devices/pens; pillboxes or unit-dose-dispensing=blister packs; magnifying glasses; canes/walkers

Knowledge-based barriers

technical knowledge=how to take meds, how to use blood glucose meter, etc, involves patient/caregiver education; literacy: oral, print, numeracy, functional literacy, health literacy; US adults read 3-5 grades below their years of completed schooling, average US reading level is 8th grade, greater than 20% of adults read at or below 5th grade level; 42 million US citizens functionally illiterate; 90 million US adults have some form of illiteracy; alabama 4th for highest prevalence of adults without high school diploma

General Access Resources

telemedicine/telepharmacy; public transportation; mail order prescription delivery; pharmacy-based or community delivery service; meal delivery; food bank

Interoperability

the challenge in healthcare; lots of data in different systems; where can find patient information: skilled nursing facility, public HIE, practice, diagnostic center, hospital, ACOs, outpatient facility, acute care facility, home care team; proposal for connected-care solution is that there is a fourth source that holds all patient information

Health literacy

the degree to which individuals have the capacity to brain, process, and understand basic health information and services needed to make appropriate health decisions; anyone can have this; who is at greater risk: older patients, inner city patients, rural patients, lower socio-economic status, lower education level, racial/ethnic minorities; commonly misinterpret warning labels so explain them thoroughly; resources for help: national institute for literacy: national assessment of adult literacy, national center for education statistics, america's literacy director, ProLiteracy Worldwide, National Center for Family Literacy, Agency for Healthcare Research and Quality (AHRQ); www.askme3.org: partnership for clear health communication (national patient safety foundation) and the three questions are: what is my main problem, what do I need to do, Why is it important for me to do this

biomedical and health informatics

the optimal use of info, often aided by the use of technology to improve individual health, health care, public health, and biomedical research; it is a science; also known as medical informatics, biomedical informatics, health informatics; informatics: connects data and people and systems; biomedical informatics: connects clinical care and research and informatics and between those clinical care and informatics make up medical information, research and informatics make up bio informatics

Patient Satisfaction

theory of disconfirmation of expectations: satisfied when emotions surrounding confirmed or disconfirmed expectations is coupled with the person's prior feelings about the service, more satisfied when meet expectations; factors influencing satisfaction: social norms/past experience, attribution, perceptions of equity; why measure: goal of patient-centered care, marker for patient adherence, indicator of likelihood of malpractice suit, accreditation requirement, financial reimbursement, competition (consumerism): average store loses 20% of patients in any given year due to dissatisfaction, marketing tool

Communication resources

translation services: in-person, phone, written materials; use of caregiver as translator; written materials in large font/plain language; educational/intstructional materials for the hearing or visually impaired: braille, audio materials, video materials, TTY/TDD=teletypewriter or telecommunications display device

Religions and Health

85% of population has some religious/spiritual affiliation; most 78.4% are christian; men more likely than women to have no religious/spiritual affiliation (20% vs 13%); 37% of married couples have different religions; considerations: longstanding traditions that are difficult for outsider to understand, difference commitment levels in family members, great diversity in religions practiced in US: impossible for providers to fully understand all; health care considerations: accepting treatment or surgery: chemotherapy infusion pump/port site, organ donating or receiving, blood transfusions, beliefs about contraceptions and abortion, beliefs about end of life decisions and life like support addition or removal, dietary practice: fasting for ramadan in islam, important=how religion affects decisions may be patient specific

Measurements for HRQL

Dartmouth COOP charts: 9 charts that ask about health during the past 4 weeks; 5=ordinal scales where5 is most unfavorable level of functioning; to measure HRQL; Ex: what was the hardest physical activity you could do for at least 2 minutes very heavy, heavy, moderate, light, very light; medical outcomes study short form 36=SF-36 and is a 36 item health survey that uses eight scales and a brief description and items compromising a scale to measure physical functioning, role limitations physically, bodily pain, general health, social functioning, vitality, role limitations emotionally, mental health; Euroqol=EQ5D: utility assessment that has 5 domains each with 3 levels and uses a visual analog scale of 0-100, scores are 0-100, measures mobility, self-care, usual activities, pain/discomfort, anxiety/depression

Healthcare quality

Donabedian's quality framework: structure: characteristics of institutions and providers and is made up of accreditation/certification, material resources (facilities and equipment), and human resources; process: what is done to the patient and is made up of technical excellence and availability, access, utilization; outcomes: what happens to the patient and is made up of patient satisfaction, mortality/morbidity, quality of life

foundations/technology to prevent errors

CPOE=computerized prescriber order entry=direct entry of orders for meds, procedures, and radiology or laboratory tests by a licensed prescriber, orders are transmitted to appropriate location; clinical decision support system=CDSS: provides clinicians with clinical knowledge and/or patient related information, intelligently filtered or presented at appropriate times, to enhance patient care: augment decision making, update on change in patient status, prevent negative action, five rights of CDSS=right information, right person, right CDSS intervention format, right channel, right time in workflow

Culturally Competent Patient Counseling=ETHNIC

Explanation: what do you think may be the reason you have these symptoms, what is the nature of the disease, what are the symptoms of the disease and what do they mean to the patient; treatment: what kinds of medicine, homes remedies, or other treatments have you tried, tell me what you eat drink or do to stay healthy what difficulties might there be with the treatment, who makes health decisions; healers: what other healers, friends, or special people have you talked to about this disease, tell me what they said or did; Negotiate: figure out understandings that are mutually acceptable to you and the patient, must not contradict patient's health beliefs, what results do you want to get; intervention: figure out treatments that are compatible with the prescribed treatment regimen, avoid ethnocentric rejections of all other treatments, who would patient know if treatments not working well together; collaborate: with patient and family members, with other healers and community members, learn greetings and departures in their language, respect their cultural understandings and practices: be sensitive to how respect is expressed verbally and nonverbally

Culturally tailored MI

MI emphasized a patient-centered approach; aligning behavior change within the context of personal ideas and goals; contextualize with patient's point of view or cultural beliefs, values, and practices; cultural competence in practice: Halbur and Halbur: essentials of cultural competence in pharmacy practice; learning a new language: medical terminology in that language; be informed about resources, interpreters; decide to be patient-centered by being aware of varying needs of diverse populations, including aging patents, low health literacy, religion in health care decision making, LGBT, etc; golden rule: what would you want

Clinical surveillance rules to prevent errors

boolean logic using patient specific data: meds, laboratory, demographics; generally assess 3 primary conditions: orders for known antidotes, laboratory abnormalities, laboratory abnormalities occurring concurrently with certain drugs; built using conditional statement: IF receiving X medication and serum creatinine>y, THEN activate rule (or alert): IF receiving ranitidine AND platelet count has decreased to <50% previous value, THEN

Pharmacy-specific measures to measure patient satisfaction

can assess satisfaction with dispensing services or with more advanced care services or both; satisfaction with pharmacy services questionnaire=SPSQ: MacKeigan and Larson has one and Larson, Rovers, and MacKeigan has one with 20 items; Pharmacy Encounter Survey=PES: Briesacher and Corey

Cultural competence

ability to interact effectively with people of different cultures; in delivery of healthcare services=process in which healthcare professional continually strives to achieve the ability to effectively work within the cultural context of a client=family, individual, or community; ASKED yourself the right questions to do this=Awareness-aware of biases and prejudices, Skill-skill of conducting a cultural assessment in a sensitive manner, knowledge-knolwedgeable about world views or different cultural and ethnic groups, encounters-seek out or avoid face to face encounters and other types of interactions with individuals different from me, desire-do i want to become culturally competent

Literacy

ability to read and write and speak in english and compute and solve problems at levels of proficiency necessary to function on the job and in society, achieve one's goals and develop one's knowledge and potential; functional literacy: viewed historically in terms of amount of education achieved, historically expressed in terms of grade level equivalents, functional reading level in US was established as being at 8th grade level, among medicaid patients=5th grade or lower is average; levels: illiterate=complete inability to read or write, functional illiterate=below 5th grade level; low/marginal literacy: 5th to 8th grade level; only 10% of pharmacies pro-actively identify and address low literacy; patient education material: 2% readability 7th-8th grade, 69% 9th-12th grade and 29% at higher than 12th grade level