Adherence with medication regimens is reviewed by the nurse practitioner or physician, and the list of prescribed medications is compared with what the patient is actually taking according the pharmacist. Blood pressure, A1C and cholesterol measurements are taken as a baseline before the consulting session, and compared with readings three months after this session. Using such objective outcomes to measure the success of medication management therapy is pivotal in setting a systems change project. Objective outcomes as markers, such as LDL, A1C, and blood pressure to measure results with outpatient drug therapy is especially important when addressing polypharmacy management in the elderly. 11

  Three months after the counseling session, objective lab values were obtained to determine any improvement in chronic disease management that could be associated with the counseling. After the counseling session, a detailed note was provided by the PharmD to the primary care provider with an overview of the counseling suggestions, such as list of the medications changes or labs that were needed. This note was then filed in the patient's chart. When following up with the primary care provider, the patient and provider review the suggestions provided by the PharmD.

Barriers

  In the beginning stages of implementation, it was noted that the reports from the SafeMed pharmacists included recommendations for the primary care provider that were embedded in the pharmaceutical consult note, and were being overlooked. These recommendations were being overlooked due to the layout of the note from the pharmacist. Because of this, a request was made to SafeMed to separate the recommendations into a separate section on the form. A plan section was then integrated into the form of the pharmaceutical consult note to advise the patients' nurse of recommended changes or follow up in drug therapy.

  During the implementation stage, a decision was made to train the nurses in the importance of placing these pharmaceutical consult notes on the patients' charts and bringing these notes to the provider, advising the nurse practitioner or physician of the new recommendation section on the form. Nurses also notify the patients of the changes that the provider would like to make based on the recommendations provided by the pharmacist. Only after the form has been reviewed by the nursing staff and signed by the nurse practitioner or physician is the form filed away.

Analyses

  Outcomes are analyzed through a random chart review of patients referred to this counseling. Chart reviews have been shown to be an effective means to review outcomes of quality improvement projects in outpatient settings. 12

  Medication review with patients showed improved results with drug adherence and chronic disease markers in Australia. 13 Results were analyzed from charts through comparing A1C, LDL, and blood pressure values with precounseling values.

  The outcomes of this counseling are reviewed with the nurse practitioner or physician three months after pharmacist telephone consultation.

  Survey forms discussed above are filled out by patients at the time of the follow up with the healthcare provider. Survey forms are kept anonymous and are reviewed by the office manager. One hundred percent of the patients filled out the survey forms, and these results are discussed.

Results

  Patient satisfaction was evaluated from the survey forms given by the pharmD and satisfaction rate averaged 95%. Patients' only complaint was the delay in the time of counseling from the time of referral. This apparently was due to language barriers (some patients only speak some Spanish and were unable to find interpreters), and also due to disconnected phone numbers. Patients clearly stated in their survey forms that they were able to understand their medication regimens more clearly, and questions were answered appropriately. Although none of the patients referred to pharmaceutical counseling understood their medication purpose and regimens, ninety percent of the patients confirmed that they understood the indications of their medications after the pharmaceutical counseling.

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