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Needs assessment

Then, we move on to the next topic.
Starting a clinic: step 1-Needs Assessment. Before you start up a pharmacy clinic, you need to do the needs assessment, find out what is your focus on your clinics. Otherwise, if you don’t do this, you will get no patient in your clinics, or you cannot target to the major population of the needed patients. So, there is some strategies for you to do the needs assessment. One is to analyze the condition that lead to frequent hospitalization or emergency care. For example, you can analyze and categorize the patient who go to emergency department and try to know the top 5 reasons for them to go to ER for help.
Then, you will choose the interesting focus and interesting topic for setting up a pharmacist clinics. The second way, you can analyze the prescription from the emergency department. For example, you can categorize the top 5 most frequent prescript prescriptions in emergency department, then you will know probably the one of the top 5 prescription is for asthma instant relief prescription. Then you will know it will be a focus for you to set up your pharmacist clinics. The third way is to evaluating compliance with standard care. You can use it as a guidelines. For example, the stable heart failure patient, if there is no contraindication, you should have diuretics, ACEI or ARB, and beta-blocker as a standard treatment.
And, you can evaluate the patient in ambulatory care and find out patient with stable heart failure, do they have the stable combo treatment. If the standard combo treatment rate is very low, then this is a good entry point for you to set up a pharmacist clinics. There is another way that if there is a new marketing drug. It is a very good way, a very good entry point for you to set up a pharmacist clinics because the physician and the nurse are not very familiar with the new drug.
And as a pharmacist, it is your good chance to co-operate with other medical staff to provide the patient a better medication care, and if you cannot find an interesting focus for you to set up pharmacist clinics, you can use the ICD-9 code. It is a International Classification of Diseases. And in this code, it has E codes. It’s E930-E949. It’s the code for the adverse effects of drugs. So, you can go through all the ICD-9 code in your hospital and find out if they have the E code and you will know that the patient in your hospital they have the top 5 adverse drug effect of a specific drug.
For example, the ICD-9 code, E934.2 is anticoagulant causing adverse effect in therapeutic use, then if you have a lot of patients have the ICD-9 code, you will know that if you set up a clinics focusing on anticoagulation management. You will have a lot of targets in your hospital, then you don’t have to worry about the patient number in your clinics. This is another example, ICD-9 code, E942.0. It’s for antiarrhythmic drug causing adverse effect in therapeutic use. If you have a lot of patients have this code when they admitted to the hospital, then you have a very good target for setting up your pharmacist clinics.
However, you have to know that it is not 100 corresponding to ICD-10 code because ICD-10 code is more disease classification. So, if your hospital already apply ICD-10 code completely, then you have to go to another way to do the analysis.
You have to search the ICD-10 code in disease basis. For example, in ICD-9 code, 250.02, it’s a diabetes without mention of complication. It’s a Type II and it is uncontrol. However, if it is in ICD-10 code, it will be very clear, it’s a Type 2 diabetes with hyperglycemia. So, you can search for E11.65 code, then you will know that how much patient in your hospital have hyperglycemia event, then you will know if you set up a clinics focusing on Type II DM management, the preliminary patient number you can guess according to these ICD-10 code searching. And, this is another example for heart failure. If you use ICD-9 code, 428.0, it is for congestive heart failure.
It cannot specified the disease condition, but if you use ICD-10 code, it will have I50.31, it’s acute diastolic heart failure, which imply that the patient with heart failure are not in a good control, that will be a target for you to set up a pharmacist clinic.
After we go through the therapeutic needs assessment, we can go back to Taipei Veterans General Hospital. In our anticoagulation clinics, we already know that patient in our hospital has poor oral anticoagulant management, and it lead to frequent hospitalization and emergency care, and you cannot saying this just by wild guess. So, the doctor in emergency department collect the patient who go to our emergency department for help between 2009 and 2010, and they found out that there is 452 patients with adverse drug events.
And, in these almost 500 patients, warfarin related emergency department visiting and warfarin related hospitalization is in the second place, so, it is a very good reason for us to set up an anticoagulation clinic to help those people have a better control of anticoagulation treatment, and it will also help the hospital to reduce the cost for managing anticoagulation. And, this is another case, it’s a transplant clinic. The intention of this clinic is to increase graft survival time and survival rate. Patient after organ transplant need to take immunosuppressant agents, and the similar level of immunosuppressant agents need to in a very narrow therapeutic range. So, it require pharmacists to do the management.
So, it’s an interdisciplinary teamwork, and it also need individualized pharmacotherapy. So, for the patient after organ transplant, it require a teamwork. it require physician, it require nurse and nutritionist and pharmacist to help the patient to increase the graft survival time And, this is our third clinic, which is medication therapy clinic, and it’s focusing on patients with Hepatitis C infection. And it is because
there is a new drug: Direct-Acting Antivirals, I will say it in DAA in the following. It launched in Taiwan marketing in 2017, which is couples months ago. The DAA has its own drug-drug interaction. So, before the patient initiate their treatment, they need a comprehensive evaluation of their drug list. So, if the doctor want to initiate the DAA treatment for 12 or 12 to 24 weeks, the doctor will referral this patient to the medication therapy clinics to do the drug evaluation. For example, DAA have sever interaction with amiodarone. So, if the patients have antiarrhythmic problem…… I have to correct it.
If the patient has arrhythmia, and it is taking amiodarone, then he has to be aware that using amiodarone with DAA together may cause vessel bradycardia. Then medication therapy clinics have to contact doctors in cardiovascular department. And, ask them to monitor the heart rate and EKG. Once they initiate DAA treatment in the first two days. That is how medication therapy clinic do.

Wung goes through the first step of setting up a pharmacist clinic in detail, explaining how to access needs of the population.

Key concepts

Needs assessment is the process of finding out the needs of the population to determine the focus of the clinic.

Needs assessment strategies:

  • Analyze the most frequent health conditions that lead to hospitalization or ER admissions.

  • Analyze the prescription record from the emergency department. Find out, for example, the top 5 most frequent prescript.

  • Evaluating compliance with standard care. Find out if patients have received standard care, if they have not, it is a possible area to focus on.

  • Newly marketed drugs. Pharmacists are usually the most up to date with new medication.

  • ICD-9 codes ICD-10 codes. These codes record adverse drug effects and medical conditions. Searching the hospital system for the most common ICD-10/9 codes can identify potential target patient group.

The TVGH model:

The anticoagulation clinic was established because there was poor oral anticoagulant management and TVGH. This led to frequent hospitalization and ER admissions. Between 2009 and 2010, 452 patients reported to the ER due to adverse drug events, and warfarin related cases was the second most frequent.

The transplant clinic was set up because immunosuppressants prescribed for transplant patients require very specific dosage. Pharmacists are best trained to manage this.

The medication therapy clinic targets patients taking new drugs like direct-acting-antivirals (DAA) which have multiple drug-drug interactions. Thus, physicians would refer patients taking these types of drugs or patients on multiple prescriptions to the medication therapy clinic.

Share and learn:

  • How else can you determine the needs of patients?

  • Besides targeting patient needs, are there other ways to determine the focus of pharmacist clinics?

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Good Pharmacy Practice: Introduction to Clinical Pharmacy Services

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