© Geriatric Times. All rights reserved.
Care Teams Provide Model for Community Care
by Maura Conry, Pharm.D., M.S.W.
Geriatric Times January/February 2001 Vol. II Issue 1
Pharmacist and social worker care-teams provide community-based support that is alert and adaptive to the needs of elderly and chronically ill individuals who live in communities surrounding neighborhood pharmacies. In spite of high visibility and easy accessibility in most cities, pharmacies are underutilized as the active community health centers they could be. One innovative care model creates an interprofessional team of pharmacists and social workers who collaborate to mobilize communities, families and individuals for the best use of medical treatments of all kinds.This team model consists of a pharmacist and a social worker who work out of neighborhood pharmacies and sometimes even in the homes of high-risk clients who need regular monitoring and observation to maintain optimal health outcomes. The model utilizes the strongest attributes of both professions to address two major causes for concern in these populations: 1) the inability of many patients to take their medications regularly as prescribed, and 2) the accidental misuse of prescription medications and non-prescription drugs that causes dangerous medication misadventures.
Each discipline is particularly effective in a specific professional activity. Pharmacists' strengths are in clinical, client-centered pharmacy practice. Social workers' strengths are in effective communication, problem-solving abilities, human interaction and mobilization of community resources. Zuckerman (1996) noted, "Twelve percent of the elderly are confined to home or need help, and 20% to 30% need some kind of in-home services." Risk factors for these clients include noncompliance, multiple drug use and inability to swallow.
The patient is the focus of all team efforts. A dynamic triad is formed between patient, pharmacist and social worker. The patient is always a functioning member of the team because it is the patient's health and body that are in question. A care plan consistent with the pharmaceutical-care model of contemporary pharmacy practice and specific to the needs of the client is developed. The patient agrees with the plan because the patient has participated in its development. The team creates medication-management interventions from two professional perspectives to assist people who must learn to take lifesaving medications safely and regularly. The care model is dynamic and interactive, with a heavy social services case-management component. Slack et al. (1996) indicated, "Pharmacists are in an advantageous position for providing case management because they frequently practice close to where people live, they enjoy trusting relationships with patients, and they are experts in drug therapy."
The program is cost-effective because it utilizes resources that are already available in most communities and realigns them in a unique way. The concept of using social workers in pharmacy is not new. In 1991, Kilwein posed the question, is there a place for social workers in community pharmacy? He believes there is. Previous attempts to integrate the two professions simply stationed social workers in pharmacies and did not use them for medication-management strategies. McCorkle (1997) suggested that social workers could be used in pharmacies to help indigent patients acquire medications. The new model is unique in that it uses a pharmacist/social worker care team to provide a comprehensive pharmaceutical care program with a heavy social services component.
The thrust of contemporary pharmacy has been, for some time, toward enhanced pharmacist involvement in the more global psychosocial aspects of patient care. Lamsam (1997) described a moral dilemma for the pharmacist who must practice "in the current health care market in which high-volume practice environments have become standard, the reality of practice is far from the ideal of pharmaceutical care, and potentially serious drug-related problems go undetected." The pharmacist is caught between "the patient's interests and the corporation's demands." Collaboration with the social worker frees the pharmacist to focus on the clinical aspects of pharmaceutical care, while the social worker concentrates on the psychosocial issues of adaptation of lifestyle to medical treatments, consistent with social work practice.
Illness creates problems requiring interventions on physical, psychological and social levels. Kilwein (1991) stated, "Social workers are trained to view a patient's problem in its environmental context and therefore are likely to attempt to resolve that problem from several perspectives, by employing diverse strategies." Social workers are ideally suited as a psychosocial resource in community pharmacy; indeed, social work interventions have long been used to help clients achieve health management goals.
The team social worker always works in very close collaboration with the clinical pharmacist who provides all direction in medication-management issues. The pharmacist interacts with the physician in the traditional manner. The model creates a new professional specialty, the "pharmaceutical social worker," who will work in conjunction with a registered pharmacist to provide services to individuals and communities surrounding the pharmacy.
Both the pharmacist and the social worker collaborate on medication adherence strategies, polypharmacy management, adaptation of lifestyle to medical treatment and other issues of medication case management in the home or in the pharmacy. The pharmaceutical social worker can do home visits, possibly at the same time the medications are delivered. Complex medication case management issues can be resolved on an ongoing basis to keep the patient living in the community as long as possible.
These professionals bring social work skills and values to pharmacy, and they open pharmacy services to active participation in the community through social work community interventions. The profession of pharmacy is moving toward integration of human values into professional curricula. Mrtek and Mrtek (1991) stated, "[It is] crucial that pharmacy integrate education for human values, high order thinking, and problem solving skills." Likewise, Bentley and Reeves (1992) suggested changing social work education to include medication management, so social workers can better help patients and their families adhere to recommended therapeutic regimens. The licensed social worker already possesses case-management and motivational skills that are used in patient care. The issue becomes how to apply these skills to a wide variety of techniques to improve patient compliance and widening their applicability to medication management in the pharmacy setting.
Chronically ill patients or their caregivers have direct contact with pharmacy personnel on a regular basis when they refill prescriptions. This gives the team an opportunity to observe changes in the patient's status and level of functioning, do quick psychosocial evaluations and monitor a number of high-risk factors. For clients who have their prescriptions delivered, psychosocial evaluations can be done by the social worker on a monthly basis at delivery time.
Medication adherence and compliance strategies can be evaluated frequently by the pharmacist and social worker, who are both knowledgeable of the individual patient's needs and life goals. Opportunities for improved monitoring for geriatric clients living at home and in the community have only just begun to be discovered in this model.
The team model represents a significant contribution to patient care because it allows major problems in medication management to be addressed from a new perspective, closer to the patient. Medication problems occur in the home, not in the doctor's office or pharmacy.
Social workers are also trained to mobilize communities to make the best use of their neighborhood pharmacy as a center for health services. The social work practice incorporated into pharmacy allows pharmacy to expand into the community in a manner new to traditional practice. Social workers can also link patients with other community resources. Social workers can run community support groups with the pharmacist for disease-state management and improved health outcomes. Because social workers are adept at working with divergent populations, they are uniquely suited to evaluating community demographics and, with the pharmacist, tailoring programs to specific community needs. Social workers are already trained to interact with assisted-living and retirement communities, hospitals, nursing homes, and home health agencies. They function professionally to keep these systems working collaboratively. Their added value to pharmacy will enable a single pharmacist to provide enhanced care with a strong psychosocial and case-management component. Pharmacies can move out of the dispensing/merchant model of practice and become part of the community support system in a new way. The result of this professional team model is pharmacies whose patient populations take and refill their prescriptions regularly to achieve the best possible health outcomes and remain devoted to the pharmacy community health center.
Merging the social work and pharmacy professions offers the promise of improved community health and help to all patients-especially the elderly, the mentally ill and the disabled-in using their medications safely and regularly. Both professions work collaboratively using their skill sets. Pharmacy will benefit from the integration of the practice strategies of the client-centered interventions of social work and their application to medication adherence and compliance. Pharmacy can begin to form new permanent connections to the aging population and the chronically ill in the communities that surround them. The two professions will learn much from each other's practice skills. The literature of pharmacy strongly suggests the need for an alliance with other professions to improve patient compliance. Health care is moving toward improved patient care utilizing integrated delivery systems built by teams that make use of professionals from all disciplines. Pharmacy can only benefit from a strong alignment with a profession that has high visibility and a long history of client-centered service.
Dr. Conry is both a clinical pharmacist and a clinical social worker practicing in the greater Kansas City area. She is believed to be the only person in the United States who holds both a master's degree in social work and a doctorate in pharmacy.
References
Bentley KJ, Reeves J (1992), Integrating psychopharmacology into social work curriculum: suggested content and resources. Journal of Teaching in Social Work 6(2):41-58.
Kilwein JH (1991), Social workers in the community pharmacy: why not? Am Pharm NS31(7):60-61.
Lamsam GD (1997), Human dignity and pharmaceutical care. Am J Health Syst Pharm 54(23):2733-2735.
Mrtek RG, Mrtek MB (1991), Parsing the paradigms: the case for human values in the pharmacy curriculum. Presented at the 91st American Association of Colleges of Pharmacy Annual meeting. July 10; Salt Lake City.
McCorkle K (1997), Pharmaceutical assistance programs: a social worker's guide. Newsletter of the Council of Nephrology Social Workers 23(2):15.
Slack MK, McEwen MM, Carter JT, Brueckner RL (1996), Case management delivery model for pharmacy. Am J Health Syst Pharm 53(23):2860-2867.
Zuckerman IH (1996), Providing care to homebound patients. U.S. Pharmacist Supplement. April:3-7.
