PURDUE STEPPED APPROACH MODEL: APPLICATION TOPHARMACY PRACTICE David R. Black, 'leri A. Loughead, and Ronald S. Hadsall
ABSTRACT: The Purdue Stepped Approach Model (PSAM) of service deliveryis applied to pharmacy practice. The PSAM offers a method to organizeinterventions in a systematic and sequential manner according to the amount and type of resources required to achieveoptimal patient healthstatus. The model also provides an approach to integratingthe expertiseof other healthcareprofessionalsinto the provisionof pharmacyservices (e.g., health educators, psychologists, nurse practitioners, exercise physiologists), addresseseconomic costs and differentialmodes of reimbursement,and provides suggestionsfor future research. Examples are includedto facilitateapplicationof the PSAM in pharmacy and implicationsfor holistic healthcareor health promotionin pharmacy practice are discussed. DICPAnn Pharmacother 1991;25:164-8.
THEDEPARTMENT OF HEALTH ANDHUMANSERVICES Office of
the Inspector General has stated that pharmacy services add value to patient care and reduce healthcare costs. 1 Its report further recommended that the federal government develop strategies to enhance clinical pharmacy services. Pharmacy services for product distribution have developed over time but no formulated model of service delivery has been developed for pharmacy practice. Lack of a formalized model is not peculiar to pharmacy but consistent with the current development within other service-oriented health professions.r" A response to the Inspector General's call for strategies to enhance pharmacy services is provided in this article through the application of the Purdue Stepped Approach Model (PSAM) to pharmacy practice. The PSAM is a framework of service delivery that organizes interventions in a systematic and sequential manner. The PSAM has not been empirically evaluated in pharmacy and, accordingly, is a conceptual paradigm. Over 100 empirical studies, however, provide support for its efficacy in other disciplines. These studies are summarized in articles that describe the model's application to health counseling," public health and large-scale community interventions," career development," and leisure counselingt-s-disciplines that are committed to patient services. Pharmacy, also a service-oriented profession, may benefit by applying the principles of the PSAM to pharmacy practice. Presented below are philosophical and clinical reasons for the need for a service delivery model in pharmacy. DAVIDR. BLACK, Ph.D., is an AssociereProfessor, Health Promotion,305 Lambert Bldg., PurdueUniversity, WeslLafayelle,IN 47907;TERI A. LOUGHEAD, Ph.D., is an AssistanlProfessor, Counselingand Development,PurdueUniversity;and RONALD S. HADSALL, Ph.D., is an AssociateProfessor,PharmacyPractice,Universityof Minnesota. Reprints: David R. Black, Ph.D. Supportedin part by grantsfrom The UpjohnCompany,the Purdue UniversityResearch Foundation (#511-1446-0696, #690-1362-1409), and a Purdue University Library ScholarsGrant (#010-1446-0000).
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Service Delivery Pharmacy services "result in improvements in clinical outcomes, enhanced patient compliance, and reductions in health care costs."! Patients, to attain these benefits, want and are willing to pay for expanded pharmacy services. 6-8 One concern in providing expanded services, however, is the lack of a formalized delivery model or implementation strategy for pharmacy practice.v" PATIENTNEEDS
Each patient is unique and requires different amounts of intervention. Some patients progress with minimal professional assistance, others with periodic or sporadic support, and some require a series of interventions to achieve therapeutic benefits. 2-5 Powerful interventions that rely on maximal human and economic resources have often been used as a first line of defense to produce dramatic and homogenous effects." Such interventions, however, may needlessly overcommit human and economic resources, be overly intensive for some patients and clinical problems, and preempt the use of less resource-intensive options. 2-5 ECONOMICS
Healthcare expenditures have risen dramatically in past years, and public and private sectors continue to seek effective ways to provide cost-effective services.'>" It is apparent that pharmacists, as well as other healthcare providers, need to identify methods to effectively deliver services at reasonable economic costs yet still meet patient needs.v"
Purdue SteppedApplYHlCh ModelApplied to PharmacyPractice The PSAM's application to pharmacy practice, in part, embraces Hepler's underlying philosophy that the purpose of pharmacy is to achieve definite outcomes that improve a patient's quality of life. 14 ,18,19 Pharmacy practice "involves the process through which a pharmacist cooperates with a patient and other professionals in designing, implementing, and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient.t'" The PSAM integrates both a pharmaceutical and a modification of lifestyle approach to pharmacy practice. From this perspective, the model is used to enhance drug therapeutic efficacy and is a part ofthe emerging trend to provide holistic healthcare or health promotion within pharmacy practice. 20 •21
1991 February, Volume 25
PURDUE STEPPED APPROACH MODEL
The PSAM of service delivery is designed to provide each patient with the appropriate type and level of intervention needed. It is intended for use with a reasonably stable patient population in which there is continuity of care. Interventions in the model are sequenced in five graduated steps of intensity according to the degree of economic and human resources committed (Figure I). Patients are assessed before any intervention is initiated, as shown by the mat in the figure, and routinely, as shown by the handrail in the figure. Intervention always begins with Step I and an intervention remains unchanged so long as a patient continues to make progress. If progress is inadequate, however, a change in intervention may be indicated and can occur within a given step or by enrollment in a subsequent step. Only one or a few interventions may be necessary to help patients reach a predetermined goal. Interventions within the PSAM are designed to be costeffective. Costs are reduced because patients may need only a single, low-intensity intervention to achieve their health status goals. A variety of minimally intensive interventions are also contained in the model. Finally, the model offers a framework to organize existing pharmacy interventions and to develop new ones. The following discussion details each of the five steps of the PSAM and includes examples from the pharmacy literature relevant to patient care. The examples are not meant to be exhaustive but to serve as illustrations of how interventions can be systematically organized. A single classification system was adopted for economy and to enhance understanding, although some interventions may be categorized under more than one step of the model depending on the application. It should also be noted that it is not the purpose of this article to provide a full range of programs for all health problems and all pharmacy settings. STEPS OF THE MODEL
Step 1. The first step of the PSAM is minimal intervention (MI). The purpose of MI is to provide a modicum of assistance to achieve patient health goals. It consists of brief education and instruction," and involves strategies that are simple, direct, and self-applied. The use of new strategies as well as those that have been successful in the past are encouraged. Existing Mis in pharmacy include instruction in terms of proper use, dosage, and potential adverse effects of medication at the time of dispensing by pharmacy personnel. 23 Another sample is the dissemination and distribution of brief written instructions to patients in conjunction with verbal communication.P'f" Health education information related to diet and exercise made available to pharmacy patrons through the mail or by means of other media is also considered MI. 29.30 Step 2. The second step of the PSAM is media-assisted instruction (MAl). The purpose of MAl is to build upon strategies used during MI, and to introduce more detailed content information and additional techniques. MAl provides self-instructional materials through print, videotape, computer, and audiotape media. Pharmacy examples that involve MAl include home study programs and health assessment devices such as "Managing Your Medications as You Grow Older," "Health Check
ReQularly scheou\ed individual counseling sessions Regular1y scheduled groupcounseling
Step 5 Individual
Caunaeling
Step 4 Group
Counseling
sessions Brief,infrequent contacts
witha service provider to clarifyandsupplement previously provided information
Step 3 Mlnlmll
Contact
Counseling
Step 2
........ MIdi.·
lnanellon
Figure I. Purdue Stepped Approach Model.
Test," and "National Medication Awareness Test." These assessment devices are also available in slide-tape and video format. 31 Other examples of media interventions include reference booklets concerning medication, nutrition, and exercise information that might be read by patients waiting for their prescriptions.W" In the future, additional programs should be developed for existing technology, such as computers, portable audiotape recorders, compact disk players, interactive videos, facsimile machines, and robotics as well as emerging technologic inno-
various." Step 3. The purpose of step 3, minimal contact counseling (MCC), is to briefly address specific barriers to the application of interventions previously introduced during MI and MAL MCC involves individualized and problem-focused interaction with the healthcare provider, although contact is kept to a minimum. Communication with the healthcare provider may consist of a single or periodic consultation either in person, over the telephone, or through the mail. There are several examples ofMCC in pharmacy. Examples include telephone triage , 34-37 mail reminders.P-" and brief educational meetings with follow-up sessions. 39-42 Step 4. This step, group counseling (GC), is designed to specifically address individual patient health needs through a group format. GC consists of regular group meetings for a scheduled period of time, and includes personal contact with a healthcare provider and peers. Counseling groups may have different health-related foci including educational, skill acquisition, and/or psychological. An educational group provides in-depth information didactically and/or through discussion. Skill acquisition groups emphasize learning behaviors or skills specific to individual health needs. Psychological groups seek to eliminate emotional cognitive, and behavioral barriers that impede the effective use of intervention strategies. 4
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GC is sporadically used in pharmacy as a mode of service delivery" and needs to be further explored as a treatment modality in pharmacy practice. For example, pharmacists could provide an acne or skin care program for young adults. Step 5. The purpose of step 5, individual counseling (Ie), is to capitalize on the provider's training and skills in order to maximize patient benefits. IC involves regular meetings with a healthcare provider for a scheduled period of time. Contact with the service provider is intensified, and assistance is provided to identify and address salient patient needs. The foci described in GC are continued in IC on an individual basis. This step is the most resource-intensive and costly; however, benefits cumulated in all prior steps may enhance the efficacy of IC. 43 Examples of the IC application in pharmacy include individual professional care by a pharmacist to residents in a halfway house" and home sessions to patients with specific diseases." Intensive individual programs that promote self-medication have also been developed for renal transplant patients following surgery. 46 Procedures ofthe Purdue Model ASSESSMENT
Both routine and formal assessments are used in the PSAM to evaluate patients. Routine assessments are quick and simple measurements of health status (e.g., blood pressure, body weight), and occur as a part of each patient visit. Formal assessments are time-consuming and thorough, and involve multiple measures on multiple dimensions." Dimensions most often assessed are physiological, educational, behavioral, and psychological. Assessments may vary in complexity and comprehensiveness contingent upon the purpose, problem, and population. Formal assessments in the PSAM are used for three reasons. First, patient screening identifies people for whom the model is inappropriate, such as an acute health crisis that may require the attention of a physician. Second, goals are established for patients for whom the model is deemed appropriate. Patient goals are conceptualized as disease-free (no disease/condition present), symptom-free (disease/condition present but no symptoms), and controlled (disease/condition present but manageable symptoms). Finally, lack of patient progress and the need for an alternative intervention is verified. Alternative interventions and the process of changing therapeutic regimens is described below. CHANGING INTERVENTIONS
Three treatment alternatives are available if previously applied interventions are deemed ineffective. First, additional interventions at the same level of intensity can be introduced and may include reiteration of the same material, introduction of different forms of the same intervention, or selection of another intervention. Second, a change to a subsequent step of intervention that increases treatment intensity can be considered. A change in steps always requires agreement between the pharmacist and patient that a more intensive intervention will provide therapeutic benefit. Third, referral to a service provider outside the pharmacy may be appropriate. Depending on the problem and the remedy, the patient may receive an alternative treatment and/or reenter the PSAM at the first step. 166 •
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OTHER SERVICE PROVIDERS
Pharmacists are involved and participate in the provision of services in all steps of the PSAM. The pharmacist may also be assisted by support staff to perform specific tasks in steps I, 2, and 3. In addition, the pharmacist may contract with a variety of other professionals and function as a service coordinator in steps 3, 4, and 5. Examples of alternate service providers who have interacted with pharmacists are podiatrists," nurses,19.48 and nutritionists." Additional contract service providers might also include health educators, psychologists, nurse practitioners, and exercise physiologists.
Implementation REVENUE
The PSAM for pharmacy suggests several ways to maintain or increase revenue. 50 First, pharmacists might contract with third-party vendors or local employers for reimbursement, over and above normal reimbursement schedules, for services provided. The justification for such contracts is to reduce illness, absenteeism, overuse of health services, and, consequently, the overall cost of medical care to the organization. 51-54 Second, pharmacists could develop a fee-for-service-rendered system. 7,s,u This system ideally is based upon the type of service offered, length of service provided, and healthcare provider status. For example, steps lor 2 may be provided at a minimum charge or included in the product cost; charges for steps 3, 4, and 5 could be based on the specific service rendered. A third possibility is for the pharmacist to create a market niche targeted at a specific patient group. Examples of targeted populations might include the elderly, physically disabled, and culturally unique. 17,19,34,55,56 The cost for this type of service would be included in operating expenses and distributed across revenue centers of the enterprise.
ILLUSTRATIONS
Table 1 presents two examples of the possible implementation of the PSAM in pharmacy practice that illustrate the combination of current and holistic approaches to pharmacy care, and describe the use of pharmacologic and nonpharmacologic interventions. The first example is designed for essential hypertension patients. This example illustrates how both pharmacists and other service providers can work together to optimize patient health status. The second example presents a program for the elderly. 14 This example is directed at a specific population and uses the pharmacists' expertise solely to address patients' specific medicationrelated needs. Examples in Table 1 present an organized sequence of interventions. A feature of the table that is important to recognize is the similarity among the steps. Responsibility for interventions that ameliorate health status is primarily the patient's in step 1 and gradually shifts to the service provider by step 5. All steps, however, encourage patient participation and personal responsibility for health care. It should also be noted that the model might be applied to any number of health-related problems (e.g. arthritis, colitis, diabetes mellitus, obesity) or to a variety of areas of pharmacy practice (e.g., community, hospital, or other practice venues).
1991 February, Volume 25
Purdue Stepped Approach Model
Evaluation Different modes of service delivery need to be evaluated and compared to each other as well as to the PSAM. Areas for comparison and evaluation might include economics, efficacy, acceptance, and utility of programs. The economics of different clinical approaches could be evaluated in terms of costs to the pharmacy, costs to the consumer, and willingness to pay for services by patients and third-party providers (e.g., insurance companies, corporations). Efficacy of clinical approaches might be contrasted in terms of changes in patient health status and might include the degree of health status amelioration, resource allocation, time efficiency, and impact on quality of life. Acceptance of an approach or a mode of service delivery, by both patients and professionals, could also be evaluated in terms of use of and preference for the different programs. Finally, utility of various programs or their application to pharmacy practice settings might also be evaluated.
Implications An emphasis on health to enhance quality of life and to reduce morbidity and mortality is implicit in this article. Pharmacists are conveniently dispersed throughout communities and are in a central position to playa key role in this process. The pharmacist can continue to be an educator and promoter of health and wellness, and provide information, programs, and interventions for existing and preventable health problems. Pharmacists' focus on holistic care and health promotion can have a powerful and direct impact on the health of the nation. Regardless of the ultimate bene-
fit of applying the PSAM to pharmacy, it is hoped that this article will stimulate discussion and empirical investigation into the value of a formalized model of service delivery for pharmacy practice. ~ JaniceL. DeLuciaisacknowledged forcontributions to a preliminary draft ofthisarticle. The authorsalsothankTimothyGilbertforhisimaginativeness, dedication, andpatience in developing the figure. Orderofauthorship wasdetermined randomly becausecontributionswereequal.Eachpersoncan beconsideredasfirstauthorand it iscorrect,therefore, to cite authorsin anyorder.
References I. KUSSEROW RP. The clinical role of the community pharmacists. Washington, DC: Office of the Inspector General, 1990; publication no. OAI-OI-89-89160. 2. BLACKDR, HULTSMAN IT.The Purdue stepped approach model: a heuristic application to health counseling. Couns Psycho/1988;16:647-67. 3. BLACK DR, HULTSMANIT. The Purdue stepped approach model: sequencing community and clinical interventions to reduce cardiovascular risk factors. /nt Q Community Health Educ 1989-90;10:19-37. 4. DELUCIA JL, BLACK DR, LOUGHEAD TL, HULTSMAN JT. Purdue stepped approach model: groups as a symbiosis of a career development and mental health counseling. J Career Dev 1989;/6:21-36. 5. HULTSMAN JT, BLACK DR, SEEHAFER RW,HOVELL ME The Purdue stepped approach model: application to leisure counseling service delivery. Ther Recreat J 1987;2/(4):9-22. 6. SMITHDL. APhA national survey: willingness of consumers to pay for pharmacists' clinical services. Am Pharm 1983;NS23(6):58-64. 7. SCHOLDELMEYER SW, TRINCA CEo Consumer demand for a pharmacist-conducted prescription counseling service. Am Pharm 1983;NS23 (6):65-8. 8. BROWN GH, KlRKINGDM, ASCIONEFJ. Patient willingness to pay for a community pharmacy based medication reminder service. Am Pharm 1983;NS23(6):69-71.
Table I. Two Examples of the Purdue Stepped Approach Model Applied to Pharmaceutical Care STEP
INTERVENTION
Minimal Intervention
2
Media-Assisted Instruction
3
Minimal Contact Counseling
4
Group Counseling
5
Individual Counseling
COMPONENTS/HEALTHCARE PROVIDER ACTIONS ESSENTIAL HYPERTENSION COMPLIANCE IN THE ELDERLY
provide brief information about normal blood pressure range and the disease process provide brief verbal instruction and written materials about proper drug consumption, dietary intake, and exercise and activity level supply more detailed educational materials for use at home or in the pharmacy (e.g., printed books, audio- or videotapes) regarding drug therapy, diet, and exercise provide materials to assist patients in assessing current levels of drug usage, diet, and exercise discuss with patient the individual application of step 2 components identify and solve problems related to medication and compliance for individuals provide in-house drop-in sessions with a nutritionist or exercise specialist establish hotline for problems related to hypertension referral to hypertension education classes, nutrition education classes, organized exercise programs, or group counseling for noncompliant patients
referral to alternative healthcare providers (e.g., nutritionist, weight-loss specialist) to specifically address an individual's hypertension-related needs and concerns
provide brief verbal instructions and written materials about proper drug use (e.g., frequency, dose timing, vehicle, delivery mechanism) provide treatment regimen and compliance strategies specific to the elderly supply more detailed materials (e.g., printed, audio-, or videotape, electronic) for use at home or in the pharmacy about drug usage and compliance strategies for the elderly (e.g., large-print labels, wrist alarms, compliance calendars) problem identification and resolution related to medication and compliance for individual patients at the pharmacy, over the phone, or at home
offer an education/support group that addresses the following: • pertinent information on high-use medications for the elderly • more intensive compliance strategies • group discussion and problem solving to devise individually tailored compliance strategies • social support systems to aid compliance offer individual counseling over the phone or in person to address medication and compliance issues referral to appropriate community agencies (e.g., visiting nurse, home health agency)
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9. ZELNlO RN, NELSON AA Jr, BENO CEo Clinicalpharmaceutical services in retail practice. I. Pharmacists' willingness and abilities to provide services. Drug Intell Clin Pharm 1984;18:917-22. 10. SCHOLDELMEYER sw. Evolving health care system:economicand organizational patterns. Am J Pharm Educ 1987;51:388-95. II. O'LEARY KD, WILSON GT. Behaviortherapy: application and outcome. Englewood Cliffs, NJ: Prentice-Hall, 1975:450-72. 12. CULBERTSON VL, ARTHUR TG, RHODES PJ, RHODES RS. Consumer preferences for verbaland writtenmedication information. Drug Intell Clin Pharm 1988;22:390-6. 13. HUGHES EFX. Trendsin healthcare systemsdelivery. Am J Pharm Educ 1989;53(suppl):49S-54S. 14. HEPLER CD. Unresolved issues in the future of pharmacy. Am J Hosp Pharm 1988;45:1071-81. 15. HYNERGC, MELBY CL,PETOSA R, SEEHAFER RW, BLACK DR. A preferred target population for comprehensivehealth promotion. Int Q Community Health Educ 1987-88;8:249-61. 16. BUSH GHW. Stateof the union. CongrQ Wk/yRep 1990;48:349-50. 17. HELMS RB. Healthpolicyand the economy: guessingabout the future. AmJ Pharm Educ 1989;53(suppl):4IS-8S. 18. HEPLER CD.The third wavein pharmaceuticaleducation: the clinical movement. Am J Pharm Educ 1987;5/:369-85. 19. HEPLER CD, STRAND LM. Opportunities andresponsibilities in pharmaceuticalcare. Am J Pharm Educ 1989;53(suppl):7S-15S. 20. BARKER KN, Sw.ENSSON E, ALLAN EL. Effectof technological changes in information transfer on the delivery of pharmacy services. Am J Pharm Educ 1989;53(suppl):27S-40S. 21. CARLSON RL. Societaland public policy trends taking us into the 21st century. Am J Pharm Educ I989;53(suppl): 16S-20S. 22. IVEY M,TSO Y, STAMM K. Communicationtechniques for patient instruction.Am J Hosp Pharm 1975;32:828-31. 23. HALPERIN JA. Equityfor the pharmacist: recognition withresponsibility. Drug Intell Clin Pharm 1980;14:489-92. 24. BAKER DM. A studycontrasting differentmodalities of medication dischargecounseling. Hosp Pharm 1984;/9:545-8,551-4. 25. CARDINALE V. The new urgency for counseling. Drug Top 1987;131 (11):30-2,34,36,38. 26. ROBINSON B. Needed: patient information in managed care settings. Drug Top 1988;132(2):14. 27. MCGINTY MK, CHASE SL,MERCER ME. Pharmacy-nursingdischarge counseling program for cardiac patients. Am J Hosp Pharm 1988; 45:1545-8. 28. REGNER MJ, HERMANN F, REID LD. Effectiveness of a printedleaflet for enabling patients to use digoxin side-effect information. Drug Intell ClinPharm 1987;2/:200-4. 29. ROGERS PO. How pharmacists can boost patientcompliance regarding prescription drugs. Pharm Times 1984;54(6):89-94. 30. Washington campaign on "hiddendangers"of medication. Aust J Pharm 1986;67:870. 31. STARprogram rewardspharmacist-educators.Am Pharm 1986;NS26 (11):10-1. 32. KIMBERLIN CL, BERARDO DH. A comparison ofpatienteducationmethods used in community pharmacies. J Pharm Mark Manage 1987; 1(4):75-94. 33. SELFTH, BROOKS JB. Pharmacist's role when dispensing pressurized aerosols for asthma. HospFormuI1984;19:1059,1062-4,1069. 34. BALLAD R. Is thereanythinga pharmacist won't do for a patient?Drug Top 1987;/3/(20):19,20,22. 35. MCKABA J. Pharmacist involvement in poisonprevention activities. Am J HospPharm 1988;45:1496. 36. TAYLOR B,BARBER L. Developing roleof thecommunity healthservice pharmacist. PharmJ 1986;236(5):276-7. 37. w.ILLIAMS DM. "Ask YourPharmacist"consumerphone-in programin North Carolina.AmJ HospPharm 1987;44:1631-2. 38. PIETRUSKA RG,SORENO F. Patient education project advises people whatto ask pharmacists. Pharm Times 1982;48(12):23-6. 39. OGBUOKIRI JE. Self-monitoring of bloodpressures in hypertensive subjects and its effects on patient compliance. Drug Intell Clin Pharm 1980;/4:424-7. 40. DETUWO PL, CORSON ME. Effectof pharmacist counseling on ambulatory patients' use of aerosolized bronchodilators. Am J Hosp Pharm 1987;44:1802-6.
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41. O'DEA P. Glaucoma therapy: the pharmacist's role in compliance. Am Pharm 1988;NS28(9):38-42. 42. BROWN JM, HELLING DK, ALEXANDER MM, BURMEISTER LF. Comparative evaluation of clinicalpharmacists and physicians in the managementof medication-relatedtelephonecalls in family practice offices. Am J Hosp Pharm 1982;39:437-43. 43. SCHACHTER S. Recidivism and self-cure of smokingand obesity. Can J Public Health 1982;72:401-6. 44. SARK MS. Headinghome, prepared. Am Drug 1987;/96(9):52-4. 45. BURRELLE TN. Evaluation of an interdisciplinary compliance servicefor elderlyhypertensives. J Geriatr Drug Ther 1986;/(2):23-51. 46. THOMAS SG, DIETHELM AG, KEITH TO, SIMMONS SM. Evaluating the quality of patient education in a self-medication teaching program. Hosp FormuI1983;18:871-4,877-8,881-2,885-6,891. 47. COATES TJ, JEFFERY RW, SLINKART LA. Heart healthyeating and exercise: introducing and maintaining changes in health behaviors. Am J Public Health 1981;7/:15-23. 48. DAVIDHIZAR R,POWELL MJ. Patientmedication education groups.Hosp Top 1987;65(1):21-4. 49. ENRIQUEN N.Taking the high-tension out of high-tech: howdo you prevent high-tech equipment from interfering with the advantages of the homesetting?Nutr Support Serv 1987;4(8):26-7. 50. VIVIAN JC.Reasoned analysis: thevalueof hesitation. MichPharm 1987; 23(3):26-7. 51. BLY JL, JONES RC, RJCHARDSON JE. Impactof worksite healthpromotion of healthcare cost utilization: evaluation of Johnson & Johnson's Livefor Life Program. .lAMA 1986;256:3235-40. 52. SCIACCA JP, BLACK DR, SEEHAFER RW. Worksite healthpromotion and healthcare cost utilization. .lAMA 1987;258:2379. 53. SCIACCA JP,SEEHAFER RW, REED R,BERRY C,MULVANEY B. Effectof a worksite smokingcessation program on payments forlifestyle-related disease. Fitness Bus 1988;3(10):64-8. 54. SCIACCA JP, SEEHAFER RW, REED R, BERRY C. Evaluating worksite healthand fitness programs. Health Educ 1990;2/(3):17-22. 55. PORTNOY E. Enhancing communication with elderly patients. Am Pharm 1985;NS25(8):50-5. 56. E1GEN BN. Improving communication with the physically disabled. Am Pharm 1982;NS22(10):37-40.
EXTRACTO Los autores aplican el Modelo Purdue de entrega de servicios al ejercicio de la farmacia. Este modelo sirve para organizar las intervencionesfarmaceuticas de acuerdo al tipo y a la cantidad de recursos necesarios para obtener el estado de salud optimo para el paciente. EI modelo tarnbien estipula integrar la pericia de otros profesionales de la salud (ej. educadores, psicologos,enfermeras, y fisiologos), a la provision de servicios farmacetiticos. Se discuten los gastos economicos y diferentes modos de indemnizacion asociados con la implementacion de estos servicios y se proponen ideas para futuros estudios. Los autores incluyen ejemplos para fomentar y facilitar la aplicacion de este modelo al ejercicio de la farmacia. CHRISTINA DALMADY·ISRAEL RESUME
Le modele de distribution de l'Universite de Purdue, deja utilise dans plusieurs disciplines, est applique a la pratique de la pharmacie. Le modele de l'Universite de Purdue permet d'organiser les interventions de maniere systematique et sequentielle en fonction des ressources necessaires a l'optimisation de l'etat de sante du patient. Le modele fournis une rnethodologied'integration de l'expertise d'autres professionnelsde la sante (e.g., educateurs, psychologues, infirmieres, rnedecins) pour la realisation des differents services pharrnaceutiques, etablit les couts et les differents modes de remboursernent,et finalement suggere des champs de recherche. Des exemples sont inclus afin d'encourager l'utilisation de ce modele et d'en faciliter l'application en pharmacie. La promotion de la sante dans la pratique de la pharmacie, par l'utilisation de ce modele, est aussi discute,
1991 February, Volume 25
CELINE flSET
ABSTRACT: The Purdue Stepped Approach Model (PSAM) of service deliveryis applied to pharmacy practice. The PSAM offers a method to organizeinterventions in a systematic and sequential manner according to the amount and type of resources required to achieveoptimal patient healthstatus. The model also provides an approach to integratingthe expertiseof other healthcareprofessionalsinto the provisionof pharmacyservices (e.g., health educators, psychologists, nurse practitioners, exercise physiologists), addresseseconomic costs and differentialmodes of reimbursement,and provides suggestionsfor future research. Examples are includedto facilitateapplicationof the PSAM in pharmacy and implicationsfor holistic healthcareor health promotionin pharmacy practice are discussed. DICPAnn Pharmacother 1991;25:164-8.
THEDEPARTMENT OF HEALTH ANDHUMANSERVICES Office of
the Inspector General has stated that pharmacy services add value to patient care and reduce healthcare costs. 1 Its report further recommended that the federal government develop strategies to enhance clinical pharmacy services. Pharmacy services for product distribution have developed over time but no formulated model of service delivery has been developed for pharmacy practice. Lack of a formalized model is not peculiar to pharmacy but consistent with the current development within other service-oriented health professions.r" A response to the Inspector General's call for strategies to enhance pharmacy services is provided in this article through the application of the Purdue Stepped Approach Model (PSAM) to pharmacy practice. The PSAM is a framework of service delivery that organizes interventions in a systematic and sequential manner. The PSAM has not been empirically evaluated in pharmacy and, accordingly, is a conceptual paradigm. Over 100 empirical studies, however, provide support for its efficacy in other disciplines. These studies are summarized in articles that describe the model's application to health counseling," public health and large-scale community interventions," career development," and leisure counselingt-s-disciplines that are committed to patient services. Pharmacy, also a service-oriented profession, may benefit by applying the principles of the PSAM to pharmacy practice. Presented below are philosophical and clinical reasons for the need for a service delivery model in pharmacy. DAVIDR. BLACK, Ph.D., is an AssociereProfessor, Health Promotion,305 Lambert Bldg., PurdueUniversity, WeslLafayelle,IN 47907;TERI A. LOUGHEAD, Ph.D., is an AssistanlProfessor, Counselingand Development,PurdueUniversity;and RONALD S. HADSALL, Ph.D., is an AssociateProfessor,PharmacyPractice,Universityof Minnesota. Reprints: David R. Black, Ph.D. Supportedin part by grantsfrom The UpjohnCompany,the Purdue UniversityResearch Foundation (#511-1446-0696, #690-1362-1409), and a Purdue University Library ScholarsGrant (#010-1446-0000).
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Service Delivery Pharmacy services "result in improvements in clinical outcomes, enhanced patient compliance, and reductions in health care costs."! Patients, to attain these benefits, want and are willing to pay for expanded pharmacy services. 6-8 One concern in providing expanded services, however, is the lack of a formalized delivery model or implementation strategy for pharmacy practice.v" PATIENTNEEDS
Each patient is unique and requires different amounts of intervention. Some patients progress with minimal professional assistance, others with periodic or sporadic support, and some require a series of interventions to achieve therapeutic benefits. 2-5 Powerful interventions that rely on maximal human and economic resources have often been used as a first line of defense to produce dramatic and homogenous effects." Such interventions, however, may needlessly overcommit human and economic resources, be overly intensive for some patients and clinical problems, and preempt the use of less resource-intensive options. 2-5 ECONOMICS
Healthcare expenditures have risen dramatically in past years, and public and private sectors continue to seek effective ways to provide cost-effective services.'>" It is apparent that pharmacists, as well as other healthcare providers, need to identify methods to effectively deliver services at reasonable economic costs yet still meet patient needs.v"
Purdue SteppedApplYHlCh ModelApplied to PharmacyPractice The PSAM's application to pharmacy practice, in part, embraces Hepler's underlying philosophy that the purpose of pharmacy is to achieve definite outcomes that improve a patient's quality of life. 14 ,18,19 Pharmacy practice "involves the process through which a pharmacist cooperates with a patient and other professionals in designing, implementing, and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient.t'" The PSAM integrates both a pharmaceutical and a modification of lifestyle approach to pharmacy practice. From this perspective, the model is used to enhance drug therapeutic efficacy and is a part ofthe emerging trend to provide holistic healthcare or health promotion within pharmacy practice. 20 •21
1991 February, Volume 25
PURDUE STEPPED APPROACH MODEL
The PSAM of service delivery is designed to provide each patient with the appropriate type and level of intervention needed. It is intended for use with a reasonably stable patient population in which there is continuity of care. Interventions in the model are sequenced in five graduated steps of intensity according to the degree of economic and human resources committed (Figure I). Patients are assessed before any intervention is initiated, as shown by the mat in the figure, and routinely, as shown by the handrail in the figure. Intervention always begins with Step I and an intervention remains unchanged so long as a patient continues to make progress. If progress is inadequate, however, a change in intervention may be indicated and can occur within a given step or by enrollment in a subsequent step. Only one or a few interventions may be necessary to help patients reach a predetermined goal. Interventions within the PSAM are designed to be costeffective. Costs are reduced because patients may need only a single, low-intensity intervention to achieve their health status goals. A variety of minimally intensive interventions are also contained in the model. Finally, the model offers a framework to organize existing pharmacy interventions and to develop new ones. The following discussion details each of the five steps of the PSAM and includes examples from the pharmacy literature relevant to patient care. The examples are not meant to be exhaustive but to serve as illustrations of how interventions can be systematically organized. A single classification system was adopted for economy and to enhance understanding, although some interventions may be categorized under more than one step of the model depending on the application. It should also be noted that it is not the purpose of this article to provide a full range of programs for all health problems and all pharmacy settings. STEPS OF THE MODEL
Step 1. The first step of the PSAM is minimal intervention (MI). The purpose of MI is to provide a modicum of assistance to achieve patient health goals. It consists of brief education and instruction," and involves strategies that are simple, direct, and self-applied. The use of new strategies as well as those that have been successful in the past are encouraged. Existing Mis in pharmacy include instruction in terms of proper use, dosage, and potential adverse effects of medication at the time of dispensing by pharmacy personnel. 23 Another sample is the dissemination and distribution of brief written instructions to patients in conjunction with verbal communication.P'f" Health education information related to diet and exercise made available to pharmacy patrons through the mail or by means of other media is also considered MI. 29.30 Step 2. The second step of the PSAM is media-assisted instruction (MAl). The purpose of MAl is to build upon strategies used during MI, and to introduce more detailed content information and additional techniques. MAl provides self-instructional materials through print, videotape, computer, and audiotape media. Pharmacy examples that involve MAl include home study programs and health assessment devices such as "Managing Your Medications as You Grow Older," "Health Check
ReQularly scheou\ed individual counseling sessions Regular1y scheduled groupcounseling
Step 5 Individual
Caunaeling
Step 4 Group
Counseling
sessions Brief,infrequent contacts
witha service provider to clarifyandsupplement previously provided information
Step 3 Mlnlmll
Contact
Counseling
Step 2
........ MIdi.·
lnanellon
Figure I. Purdue Stepped Approach Model.
Test," and "National Medication Awareness Test." These assessment devices are also available in slide-tape and video format. 31 Other examples of media interventions include reference booklets concerning medication, nutrition, and exercise information that might be read by patients waiting for their prescriptions.W" In the future, additional programs should be developed for existing technology, such as computers, portable audiotape recorders, compact disk players, interactive videos, facsimile machines, and robotics as well as emerging technologic inno-
various." Step 3. The purpose of step 3, minimal contact counseling (MCC), is to briefly address specific barriers to the application of interventions previously introduced during MI and MAL MCC involves individualized and problem-focused interaction with the healthcare provider, although contact is kept to a minimum. Communication with the healthcare provider may consist of a single or periodic consultation either in person, over the telephone, or through the mail. There are several examples ofMCC in pharmacy. Examples include telephone triage , 34-37 mail reminders.P-" and brief educational meetings with follow-up sessions. 39-42 Step 4. This step, group counseling (GC), is designed to specifically address individual patient health needs through a group format. GC consists of regular group meetings for a scheduled period of time, and includes personal contact with a healthcare provider and peers. Counseling groups may have different health-related foci including educational, skill acquisition, and/or psychological. An educational group provides in-depth information didactically and/or through discussion. Skill acquisition groups emphasize learning behaviors or skills specific to individual health needs. Psychological groups seek to eliminate emotional cognitive, and behavioral barriers that impede the effective use of intervention strategies. 4
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GC is sporadically used in pharmacy as a mode of service delivery" and needs to be further explored as a treatment modality in pharmacy practice. For example, pharmacists could provide an acne or skin care program for young adults. Step 5. The purpose of step 5, individual counseling (Ie), is to capitalize on the provider's training and skills in order to maximize patient benefits. IC involves regular meetings with a healthcare provider for a scheduled period of time. Contact with the service provider is intensified, and assistance is provided to identify and address salient patient needs. The foci described in GC are continued in IC on an individual basis. This step is the most resource-intensive and costly; however, benefits cumulated in all prior steps may enhance the efficacy of IC. 43 Examples of the IC application in pharmacy include individual professional care by a pharmacist to residents in a halfway house" and home sessions to patients with specific diseases." Intensive individual programs that promote self-medication have also been developed for renal transplant patients following surgery. 46 Procedures ofthe Purdue Model ASSESSMENT
Both routine and formal assessments are used in the PSAM to evaluate patients. Routine assessments are quick and simple measurements of health status (e.g., blood pressure, body weight), and occur as a part of each patient visit. Formal assessments are time-consuming and thorough, and involve multiple measures on multiple dimensions." Dimensions most often assessed are physiological, educational, behavioral, and psychological. Assessments may vary in complexity and comprehensiveness contingent upon the purpose, problem, and population. Formal assessments in the PSAM are used for three reasons. First, patient screening identifies people for whom the model is inappropriate, such as an acute health crisis that may require the attention of a physician. Second, goals are established for patients for whom the model is deemed appropriate. Patient goals are conceptualized as disease-free (no disease/condition present), symptom-free (disease/condition present but no symptoms), and controlled (disease/condition present but manageable symptoms). Finally, lack of patient progress and the need for an alternative intervention is verified. Alternative interventions and the process of changing therapeutic regimens is described below. CHANGING INTERVENTIONS
Three treatment alternatives are available if previously applied interventions are deemed ineffective. First, additional interventions at the same level of intensity can be introduced and may include reiteration of the same material, introduction of different forms of the same intervention, or selection of another intervention. Second, a change to a subsequent step of intervention that increases treatment intensity can be considered. A change in steps always requires agreement between the pharmacist and patient that a more intensive intervention will provide therapeutic benefit. Third, referral to a service provider outside the pharmacy may be appropriate. Depending on the problem and the remedy, the patient may receive an alternative treatment and/or reenter the PSAM at the first step. 166 •
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OTHER SERVICE PROVIDERS
Pharmacists are involved and participate in the provision of services in all steps of the PSAM. The pharmacist may also be assisted by support staff to perform specific tasks in steps I, 2, and 3. In addition, the pharmacist may contract with a variety of other professionals and function as a service coordinator in steps 3, 4, and 5. Examples of alternate service providers who have interacted with pharmacists are podiatrists," nurses,19.48 and nutritionists." Additional contract service providers might also include health educators, psychologists, nurse practitioners, and exercise physiologists.
Implementation REVENUE
The PSAM for pharmacy suggests several ways to maintain or increase revenue. 50 First, pharmacists might contract with third-party vendors or local employers for reimbursement, over and above normal reimbursement schedules, for services provided. The justification for such contracts is to reduce illness, absenteeism, overuse of health services, and, consequently, the overall cost of medical care to the organization. 51-54 Second, pharmacists could develop a fee-for-service-rendered system. 7,s,u This system ideally is based upon the type of service offered, length of service provided, and healthcare provider status. For example, steps lor 2 may be provided at a minimum charge or included in the product cost; charges for steps 3, 4, and 5 could be based on the specific service rendered. A third possibility is for the pharmacist to create a market niche targeted at a specific patient group. Examples of targeted populations might include the elderly, physically disabled, and culturally unique. 17,19,34,55,56 The cost for this type of service would be included in operating expenses and distributed across revenue centers of the enterprise.
ILLUSTRATIONS
Table 1 presents two examples of the possible implementation of the PSAM in pharmacy practice that illustrate the combination of current and holistic approaches to pharmacy care, and describe the use of pharmacologic and nonpharmacologic interventions. The first example is designed for essential hypertension patients. This example illustrates how both pharmacists and other service providers can work together to optimize patient health status. The second example presents a program for the elderly. 14 This example is directed at a specific population and uses the pharmacists' expertise solely to address patients' specific medicationrelated needs. Examples in Table 1 present an organized sequence of interventions. A feature of the table that is important to recognize is the similarity among the steps. Responsibility for interventions that ameliorate health status is primarily the patient's in step 1 and gradually shifts to the service provider by step 5. All steps, however, encourage patient participation and personal responsibility for health care. It should also be noted that the model might be applied to any number of health-related problems (e.g. arthritis, colitis, diabetes mellitus, obesity) or to a variety of areas of pharmacy practice (e.g., community, hospital, or other practice venues).
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Purdue Stepped Approach Model
Evaluation Different modes of service delivery need to be evaluated and compared to each other as well as to the PSAM. Areas for comparison and evaluation might include economics, efficacy, acceptance, and utility of programs. The economics of different clinical approaches could be evaluated in terms of costs to the pharmacy, costs to the consumer, and willingness to pay for services by patients and third-party providers (e.g., insurance companies, corporations). Efficacy of clinical approaches might be contrasted in terms of changes in patient health status and might include the degree of health status amelioration, resource allocation, time efficiency, and impact on quality of life. Acceptance of an approach or a mode of service delivery, by both patients and professionals, could also be evaluated in terms of use of and preference for the different programs. Finally, utility of various programs or their application to pharmacy practice settings might also be evaluated.
Implications An emphasis on health to enhance quality of life and to reduce morbidity and mortality is implicit in this article. Pharmacists are conveniently dispersed throughout communities and are in a central position to playa key role in this process. The pharmacist can continue to be an educator and promoter of health and wellness, and provide information, programs, and interventions for existing and preventable health problems. Pharmacists' focus on holistic care and health promotion can have a powerful and direct impact on the health of the nation. Regardless of the ultimate bene-
fit of applying the PSAM to pharmacy, it is hoped that this article will stimulate discussion and empirical investigation into the value of a formalized model of service delivery for pharmacy practice. ~ JaniceL. DeLuciaisacknowledged forcontributions to a preliminary draft ofthisarticle. The authorsalsothankTimothyGilbertforhisimaginativeness, dedication, andpatience in developing the figure. Orderofauthorship wasdetermined randomly becausecontributionswereequal.Eachpersoncan beconsideredasfirstauthorand it iscorrect,therefore, to cite authorsin anyorder.
References I. KUSSEROW RP. The clinical role of the community pharmacists. Washington, DC: Office of the Inspector General, 1990; publication no. OAI-OI-89-89160. 2. BLACKDR, HULTSMAN IT.The Purdue stepped approach model: a heuristic application to health counseling. Couns Psycho/1988;16:647-67. 3. BLACK DR, HULTSMANIT. The Purdue stepped approach model: sequencing community and clinical interventions to reduce cardiovascular risk factors. /nt Q Community Health Educ 1989-90;10:19-37. 4. DELUCIA JL, BLACK DR, LOUGHEAD TL, HULTSMAN JT. Purdue stepped approach model: groups as a symbiosis of a career development and mental health counseling. J Career Dev 1989;/6:21-36. 5. HULTSMAN JT, BLACK DR, SEEHAFER RW,HOVELL ME The Purdue stepped approach model: application to leisure counseling service delivery. Ther Recreat J 1987;2/(4):9-22. 6. SMITHDL. APhA national survey: willingness of consumers to pay for pharmacists' clinical services. Am Pharm 1983;NS23(6):58-64. 7. SCHOLDELMEYER SW, TRINCA CEo Consumer demand for a pharmacist-conducted prescription counseling service. Am Pharm 1983;NS23 (6):65-8. 8. BROWN GH, KlRKINGDM, ASCIONEFJ. Patient willingness to pay for a community pharmacy based medication reminder service. Am Pharm 1983;NS23(6):69-71.
Table I. Two Examples of the Purdue Stepped Approach Model Applied to Pharmaceutical Care STEP
INTERVENTION
Minimal Intervention
2
Media-Assisted Instruction
3
Minimal Contact Counseling
4
Group Counseling
5
Individual Counseling
COMPONENTS/HEALTHCARE PROVIDER ACTIONS ESSENTIAL HYPERTENSION COMPLIANCE IN THE ELDERLY
provide brief information about normal blood pressure range and the disease process provide brief verbal instruction and written materials about proper drug consumption, dietary intake, and exercise and activity level supply more detailed educational materials for use at home or in the pharmacy (e.g., printed books, audio- or videotapes) regarding drug therapy, diet, and exercise provide materials to assist patients in assessing current levels of drug usage, diet, and exercise discuss with patient the individual application of step 2 components identify and solve problems related to medication and compliance for individuals provide in-house drop-in sessions with a nutritionist or exercise specialist establish hotline for problems related to hypertension referral to hypertension education classes, nutrition education classes, organized exercise programs, or group counseling for noncompliant patients
referral to alternative healthcare providers (e.g., nutritionist, weight-loss specialist) to specifically address an individual's hypertension-related needs and concerns
provide brief verbal instructions and written materials about proper drug use (e.g., frequency, dose timing, vehicle, delivery mechanism) provide treatment regimen and compliance strategies specific to the elderly supply more detailed materials (e.g., printed, audio-, or videotape, electronic) for use at home or in the pharmacy about drug usage and compliance strategies for the elderly (e.g., large-print labels, wrist alarms, compliance calendars) problem identification and resolution related to medication and compliance for individual patients at the pharmacy, over the phone, or at home
offer an education/support group that addresses the following: • pertinent information on high-use medications for the elderly • more intensive compliance strategies • group discussion and problem solving to devise individually tailored compliance strategies • social support systems to aid compliance offer individual counseling over the phone or in person to address medication and compliance issues referral to appropriate community agencies (e.g., visiting nurse, home health agency)
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9. ZELNlO RN, NELSON AA Jr, BENO CEo Clinicalpharmaceutical services in retail practice. I. Pharmacists' willingness and abilities to provide services. Drug Intell Clin Pharm 1984;18:917-22. 10. SCHOLDELMEYER sw. Evolving health care system:economicand organizational patterns. Am J Pharm Educ 1987;51:388-95. II. O'LEARY KD, WILSON GT. Behaviortherapy: application and outcome. Englewood Cliffs, NJ: Prentice-Hall, 1975:450-72. 12. CULBERTSON VL, ARTHUR TG, RHODES PJ, RHODES RS. Consumer preferences for verbaland writtenmedication information. Drug Intell Clin Pharm 1988;22:390-6. 13. HUGHES EFX. Trendsin healthcare systemsdelivery. Am J Pharm Educ 1989;53(suppl):49S-54S. 14. HEPLER CD. Unresolved issues in the future of pharmacy. Am J Hosp Pharm 1988;45:1071-81. 15. HYNERGC, MELBY CL,PETOSA R, SEEHAFER RW, BLACK DR. A preferred target population for comprehensivehealth promotion. Int Q Community Health Educ 1987-88;8:249-61. 16. BUSH GHW. Stateof the union. CongrQ Wk/yRep 1990;48:349-50. 17. HELMS RB. Healthpolicyand the economy: guessingabout the future. AmJ Pharm Educ 1989;53(suppl):4IS-8S. 18. HEPLER CD.The third wavein pharmaceuticaleducation: the clinical movement. Am J Pharm Educ 1987;5/:369-85. 19. HEPLER CD, STRAND LM. Opportunities andresponsibilities in pharmaceuticalcare. Am J Pharm Educ 1989;53(suppl):7S-15S. 20. BARKER KN, Sw.ENSSON E, ALLAN EL. Effectof technological changes in information transfer on the delivery of pharmacy services. Am J Pharm Educ 1989;53(suppl):27S-40S. 21. CARLSON RL. Societaland public policy trends taking us into the 21st century. Am J Pharm Educ I989;53(suppl): 16S-20S. 22. IVEY M,TSO Y, STAMM K. Communicationtechniques for patient instruction.Am J Hosp Pharm 1975;32:828-31. 23. HALPERIN JA. Equityfor the pharmacist: recognition withresponsibility. Drug Intell Clin Pharm 1980;14:489-92. 24. BAKER DM. A studycontrasting differentmodalities of medication dischargecounseling. Hosp Pharm 1984;/9:545-8,551-4. 25. CARDINALE V. The new urgency for counseling. Drug Top 1987;131 (11):30-2,34,36,38. 26. ROBINSON B. Needed: patient information in managed care settings. Drug Top 1988;132(2):14. 27. MCGINTY MK, CHASE SL,MERCER ME. Pharmacy-nursingdischarge counseling program for cardiac patients. Am J Hosp Pharm 1988; 45:1545-8. 28. REGNER MJ, HERMANN F, REID LD. Effectiveness of a printedleaflet for enabling patients to use digoxin side-effect information. Drug Intell ClinPharm 1987;2/:200-4. 29. ROGERS PO. How pharmacists can boost patientcompliance regarding prescription drugs. Pharm Times 1984;54(6):89-94. 30. Washington campaign on "hiddendangers"of medication. Aust J Pharm 1986;67:870. 31. STARprogram rewardspharmacist-educators.Am Pharm 1986;NS26 (11):10-1. 32. KIMBERLIN CL, BERARDO DH. A comparison ofpatienteducationmethods used in community pharmacies. J Pharm Mark Manage 1987; 1(4):75-94. 33. SELFTH, BROOKS JB. Pharmacist's role when dispensing pressurized aerosols for asthma. HospFormuI1984;19:1059,1062-4,1069. 34. BALLAD R. Is thereanythinga pharmacist won't do for a patient?Drug Top 1987;/3/(20):19,20,22. 35. MCKABA J. Pharmacist involvement in poisonprevention activities. Am J HospPharm 1988;45:1496. 36. TAYLOR B,BARBER L. Developing roleof thecommunity healthservice pharmacist. PharmJ 1986;236(5):276-7. 37. w.ILLIAMS DM. "Ask YourPharmacist"consumerphone-in programin North Carolina.AmJ HospPharm 1987;44:1631-2. 38. PIETRUSKA RG,SORENO F. Patient education project advises people whatto ask pharmacists. Pharm Times 1982;48(12):23-6. 39. OGBUOKIRI JE. Self-monitoring of bloodpressures in hypertensive subjects and its effects on patient compliance. Drug Intell Clin Pharm 1980;/4:424-7. 40. DETUWO PL, CORSON ME. Effectof pharmacist counseling on ambulatory patients' use of aerosolized bronchodilators. Am J Hosp Pharm 1987;44:1802-6.
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41. O'DEA P. Glaucoma therapy: the pharmacist's role in compliance. Am Pharm 1988;NS28(9):38-42. 42. BROWN JM, HELLING DK, ALEXANDER MM, BURMEISTER LF. Comparative evaluation of clinicalpharmacists and physicians in the managementof medication-relatedtelephonecalls in family practice offices. Am J Hosp Pharm 1982;39:437-43. 43. SCHACHTER S. Recidivism and self-cure of smokingand obesity. Can J Public Health 1982;72:401-6. 44. SARK MS. Headinghome, prepared. Am Drug 1987;/96(9):52-4. 45. BURRELLE TN. Evaluation of an interdisciplinary compliance servicefor elderlyhypertensives. J Geriatr Drug Ther 1986;/(2):23-51. 46. THOMAS SG, DIETHELM AG, KEITH TO, SIMMONS SM. Evaluating the quality of patient education in a self-medication teaching program. Hosp FormuI1983;18:871-4,877-8,881-2,885-6,891. 47. COATES TJ, JEFFERY RW, SLINKART LA. Heart healthyeating and exercise: introducing and maintaining changes in health behaviors. Am J Public Health 1981;7/:15-23. 48. DAVIDHIZAR R,POWELL MJ. Patientmedication education groups.Hosp Top 1987;65(1):21-4. 49. ENRIQUEN N.Taking the high-tension out of high-tech: howdo you prevent high-tech equipment from interfering with the advantages of the homesetting?Nutr Support Serv 1987;4(8):26-7. 50. VIVIAN JC.Reasoned analysis: thevalueof hesitation. MichPharm 1987; 23(3):26-7. 51. BLY JL, JONES RC, RJCHARDSON JE. Impactof worksite healthpromotion of healthcare cost utilization: evaluation of Johnson & Johnson's Livefor Life Program. .lAMA 1986;256:3235-40. 52. SCIACCA JP, BLACK DR, SEEHAFER RW. Worksite healthpromotion and healthcare cost utilization. .lAMA 1987;258:2379. 53. SCIACCA JP,SEEHAFER RW, REED R,BERRY C,MULVANEY B. Effectof a worksite smokingcessation program on payments forlifestyle-related disease. Fitness Bus 1988;3(10):64-8. 54. SCIACCA JP, SEEHAFER RW, REED R, BERRY C. Evaluating worksite healthand fitness programs. Health Educ 1990;2/(3):17-22. 55. PORTNOY E. Enhancing communication with elderly patients. Am Pharm 1985;NS25(8):50-5. 56. E1GEN BN. Improving communication with the physically disabled. Am Pharm 1982;NS22(10):37-40.
EXTRACTO Los autores aplican el Modelo Purdue de entrega de servicios al ejercicio de la farmacia. Este modelo sirve para organizar las intervencionesfarmaceuticas de acuerdo al tipo y a la cantidad de recursos necesarios para obtener el estado de salud optimo para el paciente. EI modelo tarnbien estipula integrar la pericia de otros profesionales de la salud (ej. educadores, psicologos,enfermeras, y fisiologos), a la provision de servicios farmacetiticos. Se discuten los gastos economicos y diferentes modos de indemnizacion asociados con la implementacion de estos servicios y se proponen ideas para futuros estudios. Los autores incluyen ejemplos para fomentar y facilitar la aplicacion de este modelo al ejercicio de la farmacia. CHRISTINA DALMADY·ISRAEL RESUME
Le modele de distribution de l'Universite de Purdue, deja utilise dans plusieurs disciplines, est applique a la pratique de la pharmacie. Le modele de l'Universite de Purdue permet d'organiser les interventions de maniere systematique et sequentielle en fonction des ressources necessaires a l'optimisation de l'etat de sante du patient. Le modele fournis une rnethodologied'integration de l'expertise d'autres professionnelsde la sante (e.g., educateurs, psychologues, infirmieres, rnedecins) pour la realisation des differents services pharrnaceutiques, etablit les couts et les differents modes de remboursernent,et finalement suggere des champs de recherche. Des exemples sont inclus afin d'encourager l'utilisation de ce modele et d'en faciliter l'application en pharmacie. La promotion de la sante dans la pratique de la pharmacie, par l'utilisation de ce modele, est aussi discute,
1991 February, Volume 25
CELINE flSET
