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Social Work and Pharmacy 

Social Work and Pharmacy
Chapter:
Social Work and Pharmacy
Source:
Oxford Textbook of Palliative Social Work
Author(s):

Maura Conry

, Christopher M. Herndon

, and Diane R. Jackson

DOI:
10.1093/med/9780199739110.003.0042

My husband says I don't take my medications right. I don't know why I should have to take them because they cause too many side effects.

—Anonymous

Key Concepts

  • Social workers may be unaware of the role pharmacists play in palliative care, and the wide range of services they provide to enhance quality of life for clients.

  • Consulting the readily available pharmacist is a direct, time-saving first step when medication related concerns are observed.

  • This chapter describes a step-by-step process by which social workers may collaborate with pharmacists to streamline and coordinate care.

Introduction

Palliative care is a dynamic process beginning at first diagnosis and proceeding through end-of-life care. The role of the social worker changes with every milestone as the client alternates between home, hospital, institution, and/or hospice. A social worker may initially engage a client at any stage in this process. Many clients refuse home care for long periods of time, seeking to manage independently. When services are requested, the social worker must coordinate a myriad of services focused on medical, emotional, family, community, and social service needs. Since pharmacy has not typically been included in the psychosocial evaluation as a medical resource, many social workers are unaware of the role of pharmacists in palliative care and the wide range of services pharmacists provide.

Nowhere are medication safety issues more urgent than in palliative care, where individuals at the end of life are possibly our most vulnerable client population. The need for medication accuracy and safety in palliative care can only be achieved with coordinated interdisciplinary efforts involving all members of the treatment team, including pharmacists (American Society of Health-Systems Pharmacists, 2002). Understanding medication-related problems, and how to solve them, becomes especially important for the social worker who may be the first professional encountered. Since the use of pharmaceuticals can be intense in palliative care, the imperative exists that social workers be able to interface with and utilize pharmacists as a readily available health care resource. This chapter provides social workers with an overview of the education and practice of pharmacy, models for collaboration, and recommendations for strengthening collaboration with pharmacists within interdisciplinary teams, as well as a step-by-step process by which social workers can help clients through increased collaboration (see Box 42.1).

Barriers and Challenges to Collaboration between Social Workers and Pharmacists in Palliative Care

Professional barriers, for both social workers and pharmacists, include lack of knowledge of the training and expertise of the other profession, not understanding the professional jargon, and basic philosophical differences in their approaches to client care and treatment (Curran, Deacon, & Fleet, 2005). Professional stereotypes exist where social workers are thought of as “food stamp getters” and pharmacists as “pill counter merchants.” These negative connotations can be reduced over time through formal education and interdisciplinary training. Social workers and pharmacists are often isolated from each other with limited opportunities for contact unless they proactively initiate them directly. Both professionals may feel intimidated or limited in their understanding of what the other does. Social workers may feel that it is out of their scope of care to even inquire about medications. Pharmacists may be reluctant to get too involved in the personal lives of clients or even fear opening a “Pandora's box” of emotions and personal issues.

For collaboration to occur, both professionals must agree that helping the client, reducing distress, and improving quality of life is the primary focus of their care. Professionals will need to understand and respect the benefits and treatment approaches of the other discipline. Professionals who embrace interdisciplinary client care will have one less obstacle to effective collaboration.

Social workers are trained to assess the client in his or her environment and intervene according to the assessed needs of the patient and family. They bring specific skills and knowledge in accessing community resources to resolve psychosocial–spiritual challenges to health care. They are trained in communication, paying specific attention to nonverbal communication from the client, and cues from the environment (home, outpatient clinic, hospital) that may indicate barriers to effective palliative care. They often view non-adherence or medication misuse as behaviors that require assessment and inquiry as to the underlying beliefs, history, or fears that may influence patient and family attitudes and worries about medication. These skills are applicable to any palliative care setting, whether the home, long-term care facilities, institutions, or hospice.

Similarly, pharmacists have unique skill sets that lend themselves to the pharmacotherapy and other multidimensional issues frequently encountered by clients receiving palliative care (Thompson, 2008). Pharmacists, like social workers, have numerous different training environments, specialties, and practice settings. Most pharmacists have what is considered an entry-level professional degree. This may be a master of pharmacy (MPharm) degree in the European Union, doctor of pharmacy (PharmD) in the United States, or a diploma in pharmacy (DPharm) in India. It is important for social workers seeking to collaborate with pharmacists in their respective areas and practice settings to become familiar with the skills and knowledge base of the pharmacist available to them. While we might assume a basic skill set in these respective disciplines, a specialist-level skill set ought not to be assumed in either discipline. That said, basic skills all pharmacists should possess include medication record review for adherence assessment, anticipation of common adverse effects of medications, client education on the appropriate use of medications, and administration routes (see Box 42.2). Any pharmacist in any practice setting will likely have these basic minimum competencies. A growing number of pharmacists are becoming more specialized in clinical practice and may additionally possess the ability to diagnose and adjust pharmacotherapy in conjunction with a physician (American Society of Health-Systems Pharmacists, 2002). Pharmacists in these practice roles usually have additional training in the form of residencies, fellowships, apprenticeships, or advanced degrees. Credentialing or board certification in a specialized area may also provide the social worker with background on the pharmacist's abilities.

Practice Settings to Engage Pharmacistsfor Collaboration

Palliative care is provided to clients in a growing number of health care settings. Each of these settings may have a pharmacist responsible for the care of these clients. While not an exhaustive list, pharmacists are frequently available in hospitals, community pharmacies, specialized pharmacies serving hospice programs, and long-term care facilities. Given the setting the social worker's client is in may dictate the most appropriate pharmacist with whom to seek a collaborative relationship. Unfortunately, most pharmacists do not cross practice settings for continuity of care, nor do they frequently communicate with pharmacists in the other areas. Examples of care settings, corresponding pharmacists available, and potential services are outlined in Table 42.1.

Table 42.1. Settings for Collaborating with Pharmacists and Potential Services

Setting of Patient

Setting of Pharmacist

Triggers for Consultation

Services to Be Requested

Ambulatory or home health

  • Community-based pharmacists

  • Clinic-based pharmacists

  • Polypharmacy

  • Multiple physicians

  • Multiple pharmacies

  • Numerous non-prescription items and remedies

  • Suspected non- adherence issues

  • Medication expense

  • Concern regarding accessibility of medications from the pharmacy

  • Review of all medications for potential drug interactions

  • Review of all medications for potential adverse effects

  • Consolidation of all prescriptions to one pharmacy

  • Review and suggestion of lower cost alternatives when necessary

  • Medication education for patient or caregiver

  • Provision of adherence tools and education (pill boxes, refill reminders, etc.)

Hospital

  • Hospital pharmacists

  • Specialist pharmacists

  • Home medication reconciliation

  • Discharge planning

  • Unresolved or unexpected symptoms or side effects

  • Review home medication list for accuracy while inpatient

  • Review of medication list for drug interactions or adverse drug effects

  • Discharge planning for continuation of appropriate medications, discontinuation of unnecessary medications, accessibility in community

  • Recommendations based on cost, efficacy, ease of adherence

Long Term Care Facilities (LTCF)

  • Community-based pharmacists

  • Consultant pharmacists

  • Unresolved or unexpected symptoms

  • Medication expense

  • Transitions: Are medication immediately available in receiving facility?

  • Review of patient chart for medication interactions or adverse effects

  • Recommendations for medication alteration for unresolved symptoms

  • Recommendations for discontinuation for unnecessary medications

Hospice

  • Community-based pharmacists

  • Consultant pharmacists

  • Specialist pharmacists

  • Unresolved or unexpected symptoms

  • Loss of usual administration route

  • Suspected non-adherence issues

  • Recommendations for discontinuation of unnecessary medications

  • Review for potential medication interactions or adverse effects

  • Assistance with adherence / costs

Note: Community-based pharmacists are pharmacists who practice in a community, retail, or drugstore setting. Hospital pharmacists will usually practice as part of the general provision of medications to inpatients. Oftentimes specialist pharmacists will additionally work within the hospital environment in focused care areas such as pain management or palliative care. Consultant pharmacists are generally affiliated with a long-term care facility (LTCF), nursing home, or convalescent center. These pharmacists may be involved with the provision of medications, review of medication reconciliation records, and patient charts for identification of drug–drug or drug–disease interactions. In the United States, consultant pharmacists are required to review each LTCF patient's chart monthly.

Opportunities for Social Work/Pharmacist Collaboration in Palliative Care

Networking with pharmacists is an invaluable resource for social workers who can benefit from their easy access, immediate problem solving, efficient physician interface, and medication counseling (Kilwein, 1991). Pharmacy is, by far, the most accessible of all the medical professions with most pharmacies open and staffed long hours (some 24 hours). Pharmacists interface with physicians throughout the day, and they are trained to evaluate and report medication problems to physicians for their patients as a standard part of daily practice. All clients who use prescription medications obtain them from pharmacists who are bound by law to assist with medication safety and counseling.

Pharmacists are particularly helpful when the social worker discovers a dangerous in-home situation called polypharmacy, which occurs when a client's prescription, non-prescription, over-the-counter drugs, home remedies, and health-store medicinal products are in confusion and disarray. Polypharmacy can, and all too often does, lead to accidental overdoses and medication emergencies which are on the rise. Pharmacists are trained to resolve chaotic polypharmacy situations to create clear, understandable, and safe medication regimens for their patients.

Social workers cannot ethically or legally make medication corrections on their own regardless of their level of perceived knowledge. When social workers call physicians directly with medication problems they can only report concerns from a social work perspective. Pharmacists, on the other hand, can consult physicians for new prescription orders; make changes in existing medications, dosages, and other medication-related issues while providing new medication at the same time. In most cases, calling the pharmacist is a rational, time-saving, first step. Consultation with pharmacists may save time, expense for the client, and potentially prevent further medical misadventures.

For these reasons, social workers will benefit from developing a network of pharmacist colleagues with whom collaboration is possible. Specific opportunities include transitions in care in which patient's medications may not be immediately available. Unfortunately there are numerous reports of pharmacies in specific areas failing to stock adequate supplies of opioids and other essential medications for the palliative care patient. Knowing which pharmacies frequently provide services to hospice organizations in the surrounding area may help avert a crisis due to lack of medication availability. Recommendations for requesting services from pharmacists are presented in Table 42.2 (Conry, 2001).

Table 42.2. Recommendations for Requesting Additional Services from Available Pharmacists

Medication counseling or education. Most pharmacists are willing and eager to educate patients and caregivers on prescription and nonprescription medications. Numerous studies link medication counseling with patient satisfaction and reduced symptom burden. It may take a patient advocate, such as the social worker, to request this service.

Educational materials. Pharmacists have easy-to-understand medication and disease information readily available, oftentimes in multilingual formats. This may be beneficial for the patient, the caregiver, and the social worker.

Adherence aids. Depending on the setting, pharmacists have adherence aids such as pill boxes to assist in the appropriate use of medications. Additionally, more advanced services are commonly available such as automated telephone call reminders for refills, Internet-based cellular phone text message reminders, and automatic refill and mailing. Pharmacies may offer a single-dose option called “blister packing,” which is a form of a disposable pill box upon request.

Request pharmacist to simplify medication regimen. Complicated medication regimens make optimal patient outcomes difficult to achieve. If this is suspected, ask the pharmacist to recommend easier to administer options (i.e., once daily versus three or four times daily administration or once weekly for some medications).

Locate the specialist in your area of practice. Like social workers, oftentimes local pharmacists may gain advanced training in a particular area, such as pain management or palliative care. These individuals may serve as valuable resources when questions arise or more complex patient needs occur.

Conclusion

In summary, the social worker often through assessment, pain and symptom management interventions, and case management may identify problems before or as they arise in the palliative care population. Effective interdisciplinary collaboration is the centrepiece of every strong palliative care program, and pharmacist collaboration is a vital tool for achieving optimal client outcomes. By availing themselves of this resource, social workers may improve the quality of life and decrease the distress and symptom burden of their clients.

Learning exercises

  • Consider how many pharmacists you interact with regularly. How often do you utilize the recommendations from this chapter?

  • Consider your last five to ten clients. Applying the recommendations from this chapter to those clients, list opportunities for each client in which a proactive collaboration with a pharmacist may have improved overall client care.

  • A good learning exercise is to create medication safety in your own home first. Perhaps you have a chronically ill, or elderly, family member you could assist with medication safety?

  • Consider the narrative of Cecilia and her husband. How might some of these problems have been overcome by engaging a pharmacist in this client's care? Using Tables 42.1 and 42.2, develop a plan for collaborating with a pharmacist to address Cecilia's problems.

Additional resources and web sites

American Society of Consultant Pharmacists: http://www.seniorcarepharmacist.com

Offers patients and caregivers tips on safe medication use, information on polypharmacy, and a database to find consultant pharmacists in your area. Note that this searchable database is currently only available in Australia, Canada, Sweden, and the United States.Find this resource:

Case Management Society of America: http://www.cmsa.org

Provides guidelines and tools on assisting case managers on improving adherence to medication therapies.Find this resource:

Growth House: http://www.growthhouse.org

A wonderful resource for all professionals practicing in palliative care, several of the materials may assist the social worker in learning more about medications frequently used in palliative care.Find this resource:

International Association for Hospice and Palliative Care: http://www.hospicecare.com

Provides a list of essential medicines used in palliative care.Find this resource:

National Council on Patient Information and Education: http://www.talkaboutrx.org

Provides both free and fee-based content on safe medication use.Find this resource:

National Network of Libraries of Medicine: http://www.nnlm.gov

Provides health, medical, and medication information for the consumer in over 10 different languages.Find this resource:

Needy Meds: http://www.needymeds.org

Provides consumers and social workers with access to additional prescription assistance programs and printable coupons for various prescription medications.Find this resource:

RX assist: http://www.rxassist.org

A Web site offered by a coalition of pharmaceutical companies to serve as a single source for patient assistance programs for those with difficulties obtaining medications due to financial challenges.Find this resource:

References

American Society of Health-System Pharmacists. (2002). ASHP statement on the pharmacist's role in hospice and palliative care. American Journal of Health-System Pharmacy, 59(18), 1770–1773.Find this resource:

Conry, M. (2001). Your practice: Care teams provide model for community practice. Geriatric Times, 2(1), 21–25.Find this resource:

Curran, V. R., Deacon, D. R., & Fleet, L. (2005). Academic administrators' attitudes towards interprofessional education in Canadian schools of health professional education. Journal of Interprofessional Care, 19(Suppl. 1), 76–86.Find this resource:

Kilwein, J. H. (1991). Social workers in the community pharmacy: Why not? American Pharmacist, NS31(7), 60–61.Find this resource:

Thompson, C. A. (2008). Palliative care pharmacists consider patients' psychosocial issues. American Journal of Health-System Pharmacy, 65(6), 500–502.Find this resource:

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