PHARMACEUTICAL

CARE
(CARE PLAN APPROACH)
PERTEMUAN KE 5-6

Rita Suhadi SEM I

2016/2017

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Safety first: for patients &
pharmacists.

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Efficacy vs effectiveness
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Pharmaceutical Care Plan:

Tujuan Kuliah Materi
mahasiswa 1.Teori
mampu menjelaskan Pharmaceutical
proses PCP; Care Plan
mengidentifikasi drug 2.DRP Latihan
related problems DRP
(DRP/DTP); 3.Latihan SOAP
merekomendasi
(kasus)
pencegahan/ solusi
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DRP. (simulasi)
 SOAP
Medical Problems:
Urgency:
Setting:
Subjective Assessment Plan
Objective (Recommendation
+ Monitoring)
Assessment:
1. Were the sign and + evaluation of PCP
symptoms normal?
Indicate of what
condition?
2. What is the goal of the
therapy for the subject?
3. Which class of drug(s)/
drug(s) would be
appropriate to treat the
septicemia according to
guideline?
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Pharmaceutical care practice

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Pharmacist’s care Process

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Pasien bukan satu foto melainkan rangkaian adegan
spt suatu scenario film: pasien perlu di---: visit-ases-
intervensi-monitoring-follow-up.
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Tujuan Penyusunan PCP

 Mengidentifikasi
 Mengatasi
(to resolve)
 Mencegah (to prevent)

Potensial dan aktual DRP

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Elemen PCP:
1. Orientasi pada pasien
2. Fokus penyakit akut dan kronis
3. Penekanan pada pencegahan DRP
4. Dokumentasi kebutuhan pasien dan pelayanan
yang diberikan.
5.Pelayanan berkelanjutan secara sistematik
6.Kerjasama tenaga kesehatan lainnya +
pasien
7.Tanggung jawab tinggi
8.Optimasi HRQoL
9.Tekankan edukasi kesehatan.
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Patient Care Process

1. Gathering information (pengumpulan
informasi pasien)
2. Perform a Patient Assessment
3. Perform a Pharmacotherapy Workup
(Assess Drug Therapy or DRP)
4. Develop a pharmacy care plan –
Pharmacy care Plan Worksheet

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Peran Tugas Farmasis in PCP

1. Mengumpulkan data
2. Mengidentifikasi masalah
3. Menetapkan outcome  perencanaan
manajemen terapi yang baik
4. Mengevaluasi perawatan (monitoring
dan modifikasi PCP)
5. Individualisasi aturan pemakaian
6. Monitoring outcome terapi
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 LATIHAN
PSI-CURB65
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a. Profil pasien,
:
b. Informasi diet,
contoh:
c. Riwayat
Pengobatan:
OTR, jamu,
alergi, ADR
d. Diagnosis:
e. Peresepan, proses pharmaceutical care
dll.
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ROS = review of system

 ROS merangkum semua keluhan pasien
saat pemantauan yg rinci per
sistem/organ yang mungkin terlewatkan
saat keluhan utama.
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*Metode Pengumpulan Data

1. Catatan Medis (Rekam Medis)
2. Observasi Langsung
3. Wawancara

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2. Patient Assessment
Bersamaan dg pengumpulan data pasien

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3. Assess Drug Therapy

(Drug Related Problems)
Sistematik; reproducible
Bandingkan: problem pasien dgn obat/terapi

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Identifikasi Drug therapy problems (DRP/DTP)

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 NEED ASSESSMENT DRP/DTP
During a pharmaceutical care encounter, the patient,
medical conditions, and all drug therapies are assessed
to determine if the following drug-related needs are
being met:
Appropriate indication Need additional
1. There is a clinical indication for each medication being drug therapy
taken.
2. All the medication that is needed to treat each of the Unnecessary
drug therapy
patient’s medical conditions is being taken.
Effectiveness Wrong drug
1. The most effective product is being used.
2. The dose of the medication is achieving the intended Dose too low
goals of therapy.
Safety ADR, DI
1. There are no adverse reactions being experienced.
Dose too high
2. There are no signs of toxicity.
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Appropiate compliance Compliance
The patient is able and willing to take the medications that
have been determined to be appropriate, effective, and safe
 Drug Therapy Problem Drug Therapy Problem
Unnecessary drug therapy Dosage too low Effectiveness
Needs additional drug therapy Dosage too high

Indication Drug product Dosage regimen Outcomes

Safety
Drug Therapy Problem Drug Therapy Problem
Ineffective drug Adverse Noncompliance
drug reaction

Figure 7-1
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4. Develop a pharmacy care plan – Pharmacy care

Plan Worksheet (susun rencana perawatan)

a. List Patient Need; Identifying and Prioritizing Problems

b. Setting Therapeutic Goal
c. Compare alternatives of drug and non-drug therapy
d. Rekomendasi untuk mencegah/ memecahkan DRPs 1). Materi:
a). pemilihan obat: bentuk sediaan, dosis, dan rute.
b). penanganan ADR dan interaksi IO c). uji lab untuk monitoring
2).Penyampaian: tertulis, lisan, pertelpon, presentasi.
e. Monitoring untuk menilai outcome terapi obat, rujukan, dan follow-up.
*Konseling: Nama obat, dosis, cara pakai/ minum, ADR, IO termasuk dg
OTR/CAM.

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 5. DOKUMENTASI
Types of Phar. Care Doc.
1) Guideline: FIP-WHO
2) SOAP Analysis (UMUM)
3) FARM (Findings, assessment, R =???, monitoring
4) CORE Pharmacotherapy Plan
5) PRIME Pharmacotherapy plan
6) PARM/PAM
7) DAP (Data, assessment, plan)
8) DRP (“drp”, recommendation, plan)
9) DDAP (“drp”, data, assessment, plan)
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Penyelesaian dengan metode:

SOAP, FARM, PARM, dll.
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CONTOH
36 1) FIP- WHO
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2) SOAP
S = subjective findings (keluhan, durasi sakit,
keseriusan gejala)
O = objective findings (data lab, BMI, TD, Nadi)
A = assessment(diagnosis atau penjelasan yang
mungkin utk permasalahan medis pasien;
penjelasan DRP subyek; tujuan
penanganan/goals; petunjuk dari guideline)
P= plan pemberian obat (prosedur operasi, dll)
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SOAP VS. FARM VS. PARM

P

A
R
M

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 3) FARM = Findings Assessment
Resolution/Recommendation
Monitoring
 FINDINGs include subjective and objective
info; the patient-specific information of the
patients leads to the recognition of a
pharmacotherapy problem/indication for
pharmacist intervention
 A=assessment (any additional information
that is needed to best access the problem to
make recommendations; the severity priority
or urgency; short-long term goal
R= M=
resolution/recommendation Monitoring/ follow-up
(incl. prevention)  Parameter to be followed
(pain, mood, K+ etc)
Intervention plan includes
proposed action by  The intent of
pharmacist incl. observing- monitoring (efficacy;
reassessing; counseling;  toxicity,
How theADR)
parameter will be
making recommendation; monitored; pt interview; lab
informing prescriber;  Frequency of monitoring;
making recommendation duration monitoring and
to prescriber; withholding until resolved
medication or advising  Anticipated/desired finding
against use. (no pain; euglycemia)
 Decision poin to alter
therapy when or if outcome
is not achieved
4) CORE: Condition - Outcome -
Regimen - Evaluation
C=condition or patient need; it may include
nonmedical conditions or need and not a
reiteration of the current medical problem
O=outcome, desired for the condition or needs
1.patient outcomes; a.mortality;
b.morbidity(related to disease & medication
plan); c. behavior; d. economic; e. QoL. (POEMS:
patient-oriented evidence that matters)
2.therapeutic end point (surrogate markers;
DOES= disease oriented evidence); a:
pharmacology/ expected effects, ultimately to
achieve desired outcome; b: >1end point e.g. BP
& glycemic control for ESRD.
 4) CORE
R=regimen Evaluation
To achieve desired To assess outcome
outcome
achievement
1.Therapeutic regimens:
existing+initial therapy 1.Efficacy parameter
2.Goal setting and
behavior regimens (e.g. 2.Toxicity parameter
exercise; stop smoking etc. ADR allergic reaction
3.State the behavior goal in
terms that are clear, or toxicity is not
specific and reasonable; occurring.
e.g. increase the
frequency
of…..
5) PRIME Pharmacotherapy Plan
 I-Interactions: Drug-Drug; Food-Drug
 M-Mismatch: Medication vs.
conditions/patient needs.
 E-Efficacy: too much/little correct drug;
wrong drug; more efficacious choice
possible
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Ringkasan Data Pasien

(kalau informasinya banyak sekali):
Pemeriksaan Lab Pemeriksaan/ kondisi Riwayat pengobatan Riwayat penyakit
awal: non lab awal:
(nilai normal)

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 Worksheet 2.Metode SOAP
*Setting: RS/komunitas
Sifat: regular/urgent.

Problem:1. (medis…………………………………..)

Subjectives Objectives Assessment Plan

 Penyusunan Database
Pasien (Versi Pak Heru)
Metode SOAP
Dimulai dari Subyektif dan Obyektif
Subyektif = data yang bersumber dari pasien atau
keluarga yang tidak dapat dikonfirmasi secara
independen
Data Subyektif bs berupa keluhan pasien terhadap
pengobatannya
Obyektif = data yang bersumber dari hasil
observasi, pengukuran yang dilakukan oleh profesi
kesehatan lain
 Penyusunan Database Pasien
(Obyektif)
Hari ke-1 (awal): data yang mendukung problem
medik (Diagnosa, underlying diseases, co-morbid)
Hari selanjutnya: data hasil monitoring, data yang
mendukung problem medik baru
 Penyusunan Database Pasien
(Asesmen)
Problem medik Data Subyektif dan Terapi Analisa
Obyektif
(berisi diagnosa atau (wawancara (berisi pengobatan (tepat atau tidak tepat
comorbid yang terjadi pasien/keluarga dan yang diterapkan pada problem medik diatasi
pada pasien) data yang mendukung pasien sesuai problem dengan terapi/DRP)
problem medik) medik) (dapat juga berisi ESO
potensial)

Diabetes Melitus Gejala klasik (3P) Glimepiride 1-1-0 Glimipiride tidak

Lemas mampu
GDS 240 mg/dL mengendalikan kadar
RO= glimepiride 1-1-0 gula (Bahasa jangan
judge)
 Penyusunan Database
Pasien (Plan)
Berisi rencana kedepan
Rekomendasi Terapi obat untuk setiap DRP lengkap
dengan dosisnya, missal pengantian terapi,
pengaturan dosis, penambahan terapi dll
Rencana Monitoring Terapi Obat (MTO)
Rencana Konseling
Kadang-kadang juga edukasi mengenai
pemeriksaan rutin yang harus dilakukan mengenai
prognosis penyakit
 Penyusunan Database
Pasien (Plan)
Misal dalam kasus DM dengan glimepiride contoh
plannya
disarankan kombinasi dengan metformin/ganti
dengan insulin karena glimepiride tidak dapat
mengendalikan gula darah pasien
 Worksheet 3.Metode FARM
*Setting: RS/komunitas
Sifat: regular/urgent.

Findings Assessment Resolution Plan

 Worksheet 4.Metode PARM
≈ metode DRP dan DDAP

* Problem Obat: (…………………………………..)

Problems ASSESSMENT RECOMMENDATION MONITORING

(DRP)
 KASUS KLINIS 1
Bapak F 45 thn menikah dg 2 anak; tidak merokok tapi
kegemukan. Pekerjaan: manajer sebuah show room mobil
terkenal dan sibuk, sering bekerja sampai larut malam.
Sering makan di kantor fast food dg jasa delivery
service. Ia bapak yang baik selalu menyempatkan diri
bemain dengan anaknya, setelah anaknya tidur beliau
menikmati acara televisi di atas tempat tidur.

Worksheet model 1. Setting Ra-Jal

Faktor risiko:

Hal baiknya:

Rekomendasi:
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Kasus 2
Pak De. 74 y.o. Veteran Tekanan darah 135/70mmHg
perang, tinggal seorg diri. GDP dan Kolesterol DBN.
Merokok dan minum alkohol Obat yg diperoleh:
waktu muda, sekarang tdk.
Bapak tsb mengatakan saat R/Amiodaron 1x100mg
ini sulit berjalan ke toko utk Enalapril 1x5mg Furosemid
belanja kebutuhan tanpa 2X80 ISDN 2x10mg Nife SR
berhenti, sesak nafas. Ia 2x10mg
mengalami hipertensi >15
Amitriptilin 25mg hs Piroxicam
tahun lalu, dan angina 5 thn,
Diagnosis lain: HF, ventricular 20 prn 1
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aritmia; artritis lutut; depresi
dan sulit tidur.
 FORMAT PCP (ujian)
1. (Ringkasan Data Pasien)
2. Standar Terapi
3. Penatalaksanaan Terapi
Outcome/target, tujuan, sasaran, strategi terapi
4. Penyelesaian Masalah Terapi (DRP)
a. Metode SOAP (mulai dari problem medis)
b. Metode FARM
5. Konseling pasien
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Latihan Penyelesaian Kasus

 Menyelesai Kasus Drug Related Problems
Isikan DRP, berikan assessment DRP,
apakah DRP tersebut bersifat potensial
atau aktual Kasus!

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KESIMPULAN:
Proses pelaksanaan “pharmaceutical care plan”
oleh farmasis dapat membantu pasien dalam
mencapai hasil terapi yang lebih baik, mencegah
dan memecahkan masalah terapi obat.

Pustaka:
Rovers, JP., et.al, A Practical Guide to
Pharmaceutical Care, 2nd, APhA, Washington.
Cipolle & Strand, 2004
Terima kasih
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TERIMA KASIH

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 DISCLAIMER
INFORMATION AND PICTURES IN THESE SLIDES WERE
COLLECTED FROM VARIOUS SOURCES;
THE USAGE WAS LIMITED FOR CLASS ROOM
ACTIVITIES;
SHOULD THERE ANY PARTIES BEING DISTURBED WITH
THIS CONTENT PLEASE
CONTACT ritasuhadi@usd.ac.id
 PERAN FARMASIS
APPEARANCE VS PERSONALITY

66
 Clinical Pharmacist
Competencies
1. Direct patient care (clinical problem solving,
judgment, decision making, specific
recommendation; independently assess)
2. Pharmacotherapy knowledge (medication
information, evaluation, and management): good
looking --- competence
3. System based care and population health
4. Communication (medical terminology) --- go beyond
value
5. Professionalism: effective communication; team work;
effective task management; good decision.
6. Continuing Professional Development
 Pharmacist’s Profession
Development ---
Medication Therapy
Management (MTM)
1. Pharmacist Basic Role
2. Clinical Pharmacist (Patient Directed not Drug Directed)
3. Pharmaceutical Care
4. MTM

https://pharmacy.ucsd.edu/pmt/index.shtml
http://www.pharmacist.com/mtm
https://www.ncbi.nlm.nih.gov/books/NBK294489/pdf/Bookshelf_NBK294489.pdf (558 pages)
https://www.pharmacist.com/site
s/default/files/files/core_element
s_of_an_mtm_practice.pdf
 Medication Therapy
Management (MTM)
Background
The term "Medication Therapy
Management" was defined by the
Medicare Modernization Act of 2003,
which established Medicare Part D (the
Medicare "Drug Coverage Plan" for
seniors). Patients may communicate with
their MTM clinical pharmacists face-to-
face, via telephone, or on the Internet.

Today MTM services are available to

patients of all ages.
 MTM APhA, 2017 Ref:
http://www.pharmacist.co
m/mtm
MTM is a service or group of services that optimize
therapeutic outcomes for individual patients. MTM
services include medication therapy reviews,
pharmacotherapy consults, anticoagulation
management, immunizations, health and wellness
programs and many other clinical services.
Pharmacists provide MTM to help patients get the
best benefits from their medications by actively
managing drug therapy and by identifying,
preventing and resolving medication-related
problems (a consensus definition by the pharmacy
profession in 2004).
 The Importance of Medication Adherence
Research demonstrates that medication nonadherence has a
significant negative impact on patient outcomes and overall
health-care costs.

https://pharmacy.ucsd.edu/pmt/mtm/benefits.shtml
 MTM Services
MTM services are based on comprehensive, personalized
patient encounters that leverage the school's pharmacists'
expertise in assessing complex drug regimens. Services
include:
Conducting comprehensive medication reviews, including all
prescription, over-the-counter, nutritional, and herbal
supplements the patient is taking
Providing education and counseling to patients on their
medications – prescription and nonprescription products
Detecting and solving adherence problems and promoting
appropriate use of medications
Monitoring patient laboratory results and response to therapy
Selecting, initiating, modifying, or administering medication
therapy collaboratively with prescribers (e.g., cost-efficacy
management; resolving drug therapy problems)
 Benefits for MTM Patients
(+Employers)
Patients take medications to improve the QoL, but many are
unsure about whether they are really benefitting from them
the way they should. Many patients also take a combination
of prescribed and OTC, natural and vitamin supplements.
Experts who can help manage these medication regimens
contribute to both the well-being and safety of the patient.
Employers who offer MTM services benefit both in productivity
and in savings. They also create a work environment that
encourages wellness for all. Advantages include:
Improved patient adherence and utilization of medications
Increased % patients meeting their treatment goals (e.g. BP,
BG, cholesterol)
Reduced drug duplication, ADR, or DI medications, vitamins,
& supplements
Greater medication cost savings, and medical resource cost
savings (e.g., fewer ED visits), due to more effective use of
drug therapy
 Medication therapy
management (MTM):
MTM is a term used to describe a broad range of health
care services provided by pharmacists, the medication
experts on the health care team.
MTM services focus on optimizing medication usage to
improve patient outcomes, enhance patient knowledge,
and manage costs for chronic conditions such as diabetes,
asthma, and cardiovascular disease, among others.
Potential candidates for MTM often:

1. Take multiple medications

2. Have multiple health conditions
3. Have more than one physician prescribing
medications
MTM DIAGRAM
MTM DIAGRAM2
 Why is MTM needed?

Medication-related problems and

medication mismanagement are a massive
public health problem in the United States.
Experts estimate that 1.5 million preventable
adverse events occur each year that result in
$177 billion in injury and death.
 Where is MTM provided?

Pharmacists provide MTM services in all care

settings in which patients take medications. While
pharmacists in different settings may provide
different types of MTM services, the goal of all
pharmacists providing medication therapy
management is to make sure that the medication is
right for the patient and his or her health conditions
and that the best possible outcomes from
treatment are achieved.
 Who can benefit from
MTM?
Anyone who uses prescription/ non-prescription
medications, herbals, or other dietary supplements
may potentially benefit from MTM services. People
who may benefit the most include those who: use
several medications, have several health
conditions, have questions or problems with their
medications, are taking medications that require
close monitoring, have been hospitalized, and
obtain their medications from more than one
pharmacy.
 MTM: 5 cores

Medication therapy management

includes five core components:
1. medication therapy review (MTR),
2. personal medication record (PMR),
3. medication-related action plan
(MAP),
4. intervention and/or referral,
5. documentation and follow-up.
 CORE ELEMENT OF MTM SERVICE

Medication Therapy Review: Personal Medication Record:

The medication therapy review (MTR) is a The personal medication record (PMR) is
systematic process of collecting patient-
specific information, assessing medication a comprehensive record of the patient’s
therapies to identify medication-related medications (prescription and
problems, developing a prioritized list of nonprescription medications, herbal
medication-related problems, and creating
a plan to resolve them. products, and other dietary
supplements).
 Continued: Core element

Medication-Related Action Plan: Intervention and/or Referral:

The medication-related action plan The pharmacist provides consultative
(MAP) is a patient-centric document services and intervenes to address
containing a list of actions for the patient medication-related problems; when
to use in tracking progress for self- necessary, the pharmacist refers the
management. patient to a physician or other healthcare
professional.
 Continued: core element

Documentation and Follow-up: Conclusion

MTM services are documented in a The MTM core elements, as presented in this
document, are intended to be applicable to patients
consistent manner, and a follow-up MTM in all care settings where the patients or their
caregivers can be actively involved with managing
visit is scheduled based on the patient’s their medication therapy, taking full advantage of
medication-related needs, or the patient the pharmacist’s
role as the
is transitioned from one care setting to “medication therapy expert.”
another.
 Core Elements of an MTM Service; Model in Pharmacy
Practice
https://www.pharmacist.com/sites/default/files/files/core_elements_of_an
_mtm_practice.pdf
PMR: Personal Medication Review ; MAP: Medication-related Action Plan
 DISCLAIMER

INFORMATION AND PICTURES IN THESE SLIDES WERE

COLLECTED FROM VARIOUS SOURCES;
THE USAGE WAS LIMITED FOR CLASS ROOM ACTIVITIES;
SHOULD THERE ANY PARTIES BEING DISTURBED WITH THIS
CONTENT PLEASE CONTACT ritasuhadi@usd.ac.id
THANK YOU
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