Organizing Patient Visits

LEARNING OBJECTIVES

• INTRODUCTION

One of the topics infrequently taught in health profession schools is how to organize a patient visit. The primary exposure to the topic occurs informally during clerkship rotations and residencies. This informal approach tends to leave large gaps in provider knowledge, and may even teach inappropriate and/or inefficient practices. Because pharmacists are relatively new to providing primary care for patients with chronic diseases, it is an important topic as they increasingly enter roles in chronic disease management.

• PURPOSE OF PATIENT VISTIS FOR CHRONIC DISEASES

There are four broad functions of patient visits (Table 6.1). The first and most obvious is to collect data to assess disease control, patient adherence to all aspects of the therapeutic regimen (drugs, diet, exercise), and assess the presence of unwanted complications due to the disease and the medication used to manage that disease. The second function is to develop and maintain rapport with the patient, which facilitates joint efforts to manage their disease. This includes dealing with patients’ concerns, perspectives, and emotions regarding their chronic diseases. The third function involves assisting the patients in implementing jointly developed plans to optimize disease control and minimize complications. Subfunctions include patient education, assistance to optimize medication adherence, modification of therapeutic regimen, referral to specialists, etc. The last function is to ensure that patients receive appropriate levels of preventive care. Common to all practice areas is the tertiary preventive services whose aim is to prevent complications from the patient’s chronic diseases. Some examples for patients with diabetes include routine diabetic foot examinations, annual dilated ophthalmoscopic examination, and annual microalbuminuria testing. Most of these tertiary prevention services can be found in national organization diagnosis and treatment guidelines. Secondary prevention includes screening for the development of comorbid diseases such as hypertension and hyperlipidemia in patients with diabetes mellitus or colonoscopy in older patients. Last are primary prevention services such as immunizations, weight control, and others recommended by the US Preventive Services Task Force. Depending on the practice site and extent of clinical privileges in preventive health, pharmacists’ responsibilities range from recommendations to the primary care provider, to ordering the tests/procedures and making appointments for those tests and procedures. In the community pharmacy setting, pharmacists may be limited to “coaching” roles. In that situation, the pharmacist’s role in preventive health would be limited to recommendations to the primary care provider and point-of-service laboratory testing. Pharmacists working in organized health care delivery systems, such as health maintenance organizations, the Veterans Administration, or the Indian Health Service, are expected to identify those preventive needs and order appropriate testing in a timely fashion.

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