Pharmacy Practice Settings

Community Pharmacies

The community pharmacist procures and dispenses prescription drugs, provides advice about OTC drugs, and communicates information between the patient and physician as appropriate. The amount of contact a community pharmacist has with a patient varies greatly. The community pharmacist also screens for drug-drug and drug-disease interactions, therapeutic duplication, and adherence to drug regimens (by examining the pattern of drug refills or directly questioning the patient). Patients should be encouraged to fill all of their prescriptions at the same pharmacy and, when possible, to get to know their pharmacist; this approach enables the pharmacist to oversee their drug therapy comprehensively.

Many community pharmacists are available for face-to-face patient counseling and usually provide take-home printed material. Some community pharmacists participate in disease management programs, with emphasis on preventive medicine. In this role, the pharmacist must complete a certificate program in one or several disease states that are widely prevalent in the elderly (eg, diabetes mellitus, heart failure, hypertension, incontinence, osteoporosis) and, electively, in areas such as immunization awareness (eg, counseling susceptible patients to obtain vaccination against influenza and pneumococcal pneumonia). In several states, pharmacists can administer influenza vaccines. Community pharmacists may also offer screening and monitoring programs (eg, for BP or plasma glucose).

Medicare

Starting January 1, 2006, Medicare Part D provides Medicare beneficiaries with coverage for prescription drug expenses via private insurance companies. The program is formulary-driven, and formularies differ with each insurance provider. Most plans have adopted open formularies, but even these formularies restrict access through differential pricing. Thus, substitution of a drug may be advisable when affordability is an issue for patients. Costs (eg, monthly premiums) and type of coverage also vary.

Many community pharmacists have been trained to explain Medicare Part D to patients. These pharmacists can help patients sort through the many plans available and the options within plans. For example, they help patients choose a plan that covers the needed drugs; if no plan covers all the drugs, pharmacists call the patient's physician to see if other drugs may be substituted. Community pharmacists may also help low-income patients fill out the complex form for financial assistance from the Social Security Administration.

Insurance companies who provide Part D benefits have hired pharmacists to design drug management (medication therapy management, or MTM) programs. The government requires that these programs be offered as part of Part D to patients who have several chronic disorders (eg, cardiovascular disorders, diabetes, asthma, COPD, chronic renal failure, cerebrovascular disease, RA), who take multiple drugs, or who do both. Insurance companies identify such patients. Then in some companies, pharmacists call to advise patients about optimal therapy. In other companies, an appointment may be set up with a local pharmacist, who will review the drugs patients take, provide information, make recommendations to their physician about possible changes in drug therapy, and monitor the patients. Pharmacists who work for insurance companies also analyze the costs and benefits of certain drugs.

Mail Service and Online Pharmacies

Mail service and online pharmacies typically employ relatively few pharmacists because they use automated technology to dispense drugs. Most of these companies have pharmacists whom patients can consult by telephone. A concern about this type of consultation is loss of continuity of care and personal contact.

Other functions of pharmacists in these companies include reviewing and validating prescription orders, being involved in drug utilization review and formulary management, ensuring quality control, and developing education materials for patients and health care practitioners.

Hospitals

Pharmacists in hospital-based practices have long been involved in geriatric interdisciplinary care teams. When a patient is admitted, a pharmacist is typically involved in obtaining a detailed drug history from the patient or caregiver; the history focuses on currently prescribed drugs, current or recent OTC drug use, perceived drug effectiveness and adverse drug reactions, and adherence to drug regimens. Hospital pharmacists usually attend patient rounds with physicians and other team members, making drug recommendations and providing drug information when appropriate. When discharge is imminent, a hospital pharmacist provides oral and written drug-related information to the patient or caregiver.

Hospital pharmacists often participate in collaborative practice agreements, which involve outpatient clinics (eg, anticoagulation, asthma, diabetes, lipids, osteoporosis, or pain clinics). Many of these clinics are managed by pharmacists, who, in collaboration with physicians and other team members, assess, monitor, and adjust drug therapy to optimize therapeutic outcomes and ensure cost-effective care.

Long-Term Care Facilities

Consultant pharmacists have adopted a much more proactive approach to the care of the institutionalized elderly patient. They may participate in clinical rounds with physicians and other team members, participate in facility quality-improvement committees, and assess and interview patients. Such activities by pharmacists have been credited with meaningfully lowering the costs of drug-related problems and improving therapeutic outcomes in long-term care facilities. Consultant pharmacists also procure and dispense drugs. They monitor patients for drug effectiveness; drug-drug, drug-disease, and drug-dietary supplement interactions; adverse drug reactions; and therapeutic failures. If they identify a problem or a high risk of drug-related problems, they contact the patient's nurse or physician directly.

As required by federal law, consultant pharmacists conduct a monthly drug regimen review for all patients. The review is conducted on-site to maximize the pharmacist's access to interdisciplinary team members, patients, and patients' medical records (eg, physician's progress notes, nurse's notes, social service notes, dietary progress notes, the Minimum Data Set). The review monitors adherence to federal indicators: that all drug orders have a supporting diagnosis, that the regimen (dosage strength, frequency of use, and route of administration) is appropriate, and that psychoactive drug use is justified and properly monitored. Additional services of these pharmacists include formulary and disease management as well as procedural and technical reviews such as inspection of all drugs and biologicals for proper storage, review of drug administration policies and procedures, and assessment of all documentation related to drugs. Pertinent findings from patient drug regimen reviews are reported to the patient's attending physician and the facility's director of nursing. Findings from procedural and technical reviews are generally reported to the administrator, director of nursing, and medical director.

Other Settings

Pharmacists who practice in a home health care or hospice setting procure, dispense, and deliver drugs and related devices (eg, spacers for inhalers, IV therapy supplies) as well as provide clinical services to patients being cared for at home, especially to those receiving parenteral therapy. Clinical services may include patient assessment, monitoring of drug therapy, and communication with physicians about pharmacokinetics-based drug dosing, analgesic dosage adjustments, and other drug-related issues.

Assisted living facilities represent a rapidly growing segment of institutionalized care and are becoming a niche for pharmacists with a particular interest in geriatrics. Many assisted living facilities use nonlicensed personnel to assist with drug-related issues; these personnel benefit from frequent staff-education programs by pharmacists. Also, many residents in assisted living facilities have multiple comorbidities and thus are candidates for disease management interventions.

The influx of elderly patients into organized health systems (eg, integrated delivery systems, managed care organizations, group practices) and the changes in Medicare Part D have provided pharmacists with new opportunities outside the realm of individual patient care. Pharmacists in organized health systems develop, implement, and manage formularies; participate in the design and implementation of disease-specific critical pathways or therapeutic guidelines; perform pharmacoeconomic evaluations of new or competitive drug products; design, implement, and manage computer-based adverse event tracking systems; design and monitor performance measurement indicators as part of continuous quality improvement initiatives; and establish and manage drug utilization review programs.

This topic was last updated July 2006.