Course Content
What is Self-Care?
The World Health Organization’s (WHO) definition of self-care is:
“The ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health-care provider”.
The benefits of self-care are three-fold:
Better choice: Self-care saves the individuals time and effort by allowing them to manage many health conditions conveniently and successfully by themselves without seeking outside health care providers.
Better care: Self-care empowers people to take control of their health by giving them the incentive to improve their quality of life and enhances well-being at all stages of life.
Better value: Self-care leads to demonstrable long-term savings for healthcare industries by easing the workload of a strained healthcare systems and enabling them to allocate resources more efficiently and effectively.
Expanding Definition of Self-Care
Health care providers (doctors, pharmacists, nurses, etc.) typically consider self-care to include the management of self-care conditions and the related self-care products available to patients without a prescription.
This definition should include the pharmacist assistance in determining whether a patient’s condition is appropriate for self-care. A pharmacist can help a patient improve a condition by recommending the best non-prescription product and/or recommending non-pharmacologic measures to improve certain conditions (e.g., lifestyle changes).
Consumers generally have a different definition of self-care. As above, their responses typically extend beyond the use of non-prescription medications and will include many different things such as healthy lifestyle habits (eg. diet and exercise). Other important aspects of self-care in the consumers’ definition include screenings and wellness check-ups, preventive care, consults with physicians or other health care professionals and their own participation in deciding how to deal with a health problem. All of these considerations represent the consumers’ increasing interest in and expectation to be accountable for their own health and wellness.
Pharmacist Assisted Self-Care
Since pharmacists are accessible to patients when most self-care decisions are being made and are considered valuable experts in this field their role in the self-care process is extremely crucial to assure a positive outcome for the consumer.
To consider the pharmacist role in self-care we must ask valuable questions:
- When does a pharmacist-assisted self-care transition to primary care in a more contemporary health care system?
- Is the pharmacist serving as the first point of contact for on-going patient care in this setting as related to self-care?
- What is the pharmacist’s role in providing patient care services as part of a Medication Therapy Management (MTM) program? Does self-care come into play as part of an integral part of the MTM process?
Federal legislation to secure pharmacists’ recognition as “providers” in the Medicare program (HR592 and S109 introduced in the 2017–18 congressional session) is further advancing this belief. Continued delivery of patient care services, such as immunizations and point-of-care testing, will also advance the public’s recognition of pharmacists as primary care providers and as valuable assets in self-care.
Full Spectrum of Self-Care
Self-care involves a full spectrum of care including prevention and wellness, diagnosis, and treatment of symptoms.
Preventive self-care involves not only maintaining well-being through a healthy lifestyle but also diagnosing conditions for those who are ill and then recommending products for the goal of mitigating illness and relieving symptoms. This would include such things as:
- Controlling diet
- Taking vitamins and minerals
- Taking herbal supplements
- Participating in a regular exercise program
- Maintaining physical appearance by using appropriate oral, dermatological and hair care products
Self-care in illness includes the use of dietary options (e.g., warm soup for a cold or fish high in omega-three fatty acids to lower triglyceride levels); use of devices for disease assessment (e.g., home blood glucose meters and blood pressure monitors); treatment recommendations (e.g., ice packs, first-aid supplies or humidifiers/vaporizers) and use of nonprescription medications.
Seven Pillars of Self-Care
Even at the global level self-care is significant to maintain wellness and preventative care.
The International Self-Care Foundation has developed a framework for self-care around seven pillars or domains:
- Knowledge and health literacy
- Mental wellbeing, self-awareness, and agency
- Physical activity
- Healthy eating
- Risk avoidance or risk mitigation
- Good hygiene
- Rational and responsible use of self-care products and other appropriate services
Pillar One: Health Literacy
The World Health Organization (WHO) defines health literacy as representing, “The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways to promote and maintain good health”.
People with strong health literacy skills enjoy better health and well-being, while those with weaker skills tend to engage in riskier behavior and have poor health outcomes.
Good health literacy also enables people to understand how the benefits of certain types of self-care behaviors are inter-related. For example, good oral hygiene will not only prevent periodontal disease, but has also been shown to reduce cardiovascular disease. Exercise has been shown not only good for overall fitness wellness but has also been shown to reduce the risk of developing Alzheimer’s disease. Putting all of these pieces together will help the consumer see the big picture in the overall health goal of wellness.
Health literacy has been shown to be a stronger predictor of an individual’s health as compared to income, educational level, employment status, racial or ethnic group. Therefore, health literacy is crucial when it comes to appropriate self-care. Being able to assess the health literacy of the consumer is a very valuable tool for the pharmacist.
Pillar Two: Mental Wellbeing, Self-awareness & Agency
The World Health Organization defines mental wellbeing as a state of wellbeing in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to her or his community. This includes areas such as:
- Optimism
- Self-esteem
- Feeling in control
- Having a purpose in life
- Sense of belonging and support
Self-awareness is the personal and practical application of an individual’s health knowledge to their own health situation.
Agency is the capacity and the intention of an individual to take action based on their knowledge and awareness of their particular situation and condition – physical and mental. In other words, a combination of knowledge, health literacy and self-awareness.
Pillar Three: Physical Activity
These recommendations for adult exercise are based on the Physical Activity Guidelines for Americans, 2nd Edition, published by the U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion.
These guidelines state that adults should do at least 150 minutes (2 hours and 30 minutes) to 300 minutes (5 hours) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) to 150 minutes (2 hours and 30 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity.
Preferably, aerobic activity should be spread throughout the week and should include muscle-strengthening activities of moderate or greater intensity that involve all major muscle groups on 2 or more days a week.
As part of their weekly physical activity, older adults (65 years of age and older) should do multicomponent physical activity that includes balance training as well as aerobic and muscle strengthening activities.
Pillar Four: Healthy Eating
Poor nutrition and over-eating has been shown to cause obesity, cardiovascular disease, diabetes, several forms of cancer and a host of other non-communicable diseases.
Mortality rates directly increase with increasing degrees of overweight, as measured by body mass index.
For a healthy diet, recommendations for individuals include the following:
- Increase consumption of fruits, vegetables, legumes, whole grains and nuts
- Limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids.
- Limit the intake of simple sugars
- Limit salt (sodium) consumption from all sources and ensure that the majority of salt consumed is in iodized form.
Pillar Five: Risk Mitigation
As related to health, risk mitigation refers to the avoidance or reduction of behaviors that directly increase the risk of disease or death. Behaviors that reduce health risks are often some of the most achievable self-care practices.
When patients quit smoking, the benefit is significant, immediate and there are a range of over-the-counter options to aid people. These helpful tools to assist the patient can be recommended by a pharmacist as well as behavioral strategies to increase success.
Applying sunscreen products when outdoors is simple, cost-effective and has a tangible, immediate benefit in that it prevents painful sunburn or other dangerous skin disorders.
Other risk mitigation behaviors include safe sex, driving safely, and drinking in moderation.
Vaccination has less immediate and apparent personal benefits. However, at a population level, the diseases that we vaccinate against no longer circulate, reducing risk to all.
Pillar Six: Good Hygiene
Regular hand washing reduces the incidence of diarrhea and respiratory illnesses and reduces the development of bacterial resistance by reducing bacterial spread.
Regular washing of hands with soap and water, for twenty seconds, followed by thorough drying, is universally recommended.
Proper food handling refers to care when cooking uncooked food and proper washing of food before consumption.
Regular oral healthcare, particularly brushing twice daily and flossing at least once daily is part of good hygiene and limits dental caries.
When unwell, good self-care hygiene practices include covering the face or mouth when coughing or sneezing.
Pillar Seven: Rational and responsible use of self-care products and services
The World Health Organization defines the rational use of medicines as patients receiving medications appropriate to their clinical needs, in doses that meet their individual requirements, for an adequate period of time and at the lowest cost.
Rational and responsible use of self-care products and services can delay or prevent the development of many conditions, save health care system funding and encourages greater independence in managing any illness that may develop.
Recommendations for rational use include the following:
- Recommend patients read all information provided to them including all instructions on self-care products or any other materials provided by the pharmacist.
- Verify patient understanding by asking if they have any questions.
- Encourage patients to call their physician if symptoms persist or if there is no improvement in symptoms.
Today’s Self-Care Consumers
A survey by the Consumer Healthcare Products Association (CHPA) asked consumers for their perspectives on the role of nonprescription medications in their self-care. Some of the key study results include the following:
- OTC medicine increases treatment access to over 27 million consumers and reduces losses in productivity. On average, each dollar spent on OTC medicines saves the American healthcare system approximately $7.20.
- Medical devices (both for treatment and testing purposes) available over-the-counter create an additional $8 billion in potential savings by reducing the need to see a physician.
- Approximately 90 percent of consumers who treat a condition with OTC medicine would seek professional medical treatment if OTC medicines were not a\readily available.
- Cost savings by avoiding clinical visits were equal to $95 billion.
- Physicians also widely support over-the-counter recommendations by the pharmacist. It was determined that 93% of physicians believe it is important that medications for minor ailments be available over-the-counter.
- 93% of adults prefer to treat minor ailments with non-prescription medications before seeking professional care.
- In support of this, 88% of physicians recommend patients address minor ailments with self-care, including the use of nonprescription medications, before seeking professional care.
Today’s consumer is much more knowledgeable about health care products and health care in general. Consumers are also more motivated to focus on their health and wellness. Today many employers are offering incentives for employees who work toward improving their wellness.
Based on the CHPA survey, one in four respondents self-identified as a “family health influencer”. These influencers report they are knowledgeable about different non-prescription medications, avoid going to the doctor unless they absolutely have to and choose a medication based on the symptoms it will treat. The “family health influencer” is more likely to be female and many are mothers in the family unit. It is important for the pharmacist to identify and partner with this health influencer to help improve overall self-care of the family unit.
The changing demographics of our country’s population are altering the profile of the self-care consumer. The number of people ages 65 years or older is expected to more than double in 2050. The average life expectancy for Americans has increased, with individuals who reach age 65 years expected to live an additional 16–22 years. The racial and ethnic diversity of the older population will also change as the population of Hispanic and non-Caucasian groups increases. These individuals will have a significant impact on the health care system as they deal with illness and disability related to aging.
Pharmacist Evolving Role in Self-Care
As pharmacists’ roles have changed over the past few decades, considerable change has occurred in the profession. Pharmacists have moved from a product-dispensing role to one of a patient care providers who helps patients improve their medication use and advances their health and wellness. This evolution is well stated by the Joint Commission of Pharmacy Practitioners (JCPP) vision for the profession. A combination of factors, including advanced education, pharmacy layout and financial models are supporting this practice change.
In addition, self-care recommendations play an integral role in the Medication Therapy Management (MTM) process. This includes assessment of all over-the-counter related products as well as lifestyle modification recommendations.
The Marketplace of Self-Care
Three general categories of products are available for self-medication:
- Non-prescription medications
- Dietary supplements
- Complementary and integrative therapies
Factors such as high out-of-pocket health care costs and restricted access to conventional health care providers leads some patients to seek care from complementary and integrative health providers. The National Center for Complementary and Integrative Health (formerly, the National Center for Complementary and Alternative Medicine) defines the complementary approach as combining a non-mainstream practice with conventional medicine. The most commonly used complementary supplements include non-vitamin and non-mineral dietary supplements. The mind and body approaches most commonly used by adults include yoga, chiropractic or osteopathic manipulation, meditation, and massage therapy.
Wellness is the primary reason reported by individuals for using natural product supplements or practicing approaches like yoga. The pharmacist is ideally situated to advise patients on appropriate choices of complementary and integrative health options. Advising patients on the best approaches requires integrating an understanding of pharmaceutical and natural product ingredients, physiology, pharmacology, and potential interactions.
Critical Role of the Pharmacist
Some of the subjects that a pharmacist will be involved in when counseling on self-care include the following:
- Product selection for specific symptoms
- Potential drug interactions with other medications (prescription and non-prescription)
- Dosing and administration information
- Signs and/or symptoms that indicate when to seek medical advice
- Side effects and safety considerations
The following lists the therapeutic areas a pharmacist will likely be asked for when consumers are seeking assistance as related to self-care:
- Cough and cold
- Seasonal and environmental allergies
- Gastrointestinal complaints
- Dermatologic conditions
- Dietary supplements
- Nicotine replacement therapy
Medication Efficacy
The pharmacist must ensure that the medication selected for use is the most efficacious, taking into consideration the patient’s unique needs and factors such as diseases, current medication use, lifestyle, daily routine, personal priorities and preferences, and desired outcome.
The dosage form of the product is an important factor to consider and must meet the needs of the patient. For example, pharmacists can work to enhance adherence and improve outcomes by selecting an extended-release formulation that requires fewer daily doses for a patient with a busy schedule. For patients with difficulty swallowing a tablet, a liquid may be the preferable route.
Cultural considerations must always be evaluated to ensure patients’ needs are met. Culture can influence all aspects of human behavior. Of particular importance is the role of culture in health-seeking and health maintenance behaviors.
The pharmacist must also address other ways to improve the patient’s health or condition and may include lifestyle, dietary and behavioral changes that will improve the patient’s symptoms or help to prevent future illnesses. Sometimes these recommendations become more important in ensuring the patient’s wellness than the medication treatment itself. For example, advising a patient on how to avoid allergens can help prevent allergy related symptoms in the future and perhaps even eliminate the need for treatment.
Medication Safety
Pharmacists must ensure that their patients understand all aspects of the self-care intervention which includes the medication dosage and administration instructions. A critical counseling point is ensuring that the patient knows the time limit for symptom improvement or, alternatively, if symptoms worsen, at what point to seek medical care.
When recommending self-care keep in mind that the following may be barriers to safe recommendations:
- Patients who are seeking recommendations when medical care is indicated.
- Patients who are in a hurry to leave the pharmacy and are not interested in any counsel from the pharmacist.
- Patients who erroneously consider nonprescription products overly safe.
Pharmacists must also consider which patients may fall into the category of special populations, including children and the elderly, patients who are pregnant or breastfeeding, and those with chronic conditions (eg. renal or hepatic complications). In these cases, it is especially paramount that the pharmacist plays a key role in helping the patient understand safety parameters for self-care of his or her condition. These special populations will be given consideration in later slides to aid the pharmacist in counseling.
Pharmacist Patient Care Process (PPCP)
The five core components of the PPCP revolve around patient-centered care and the pharmacists’ continual collaboration, documentation, and communication with physicians, other pharmacists and other health care professionals
Recognizing the need for a consistent process in the delivery of patient care across the profession, the Joint Commission of Pharmacy Practitioners (JCPP) released the Pharmacists’ Patient Care Process.
The process is applicable to any practice setting where pharmacists provide patient care and for any patient care service provided by pharmacists. The five components are:
- Collect
- Assess
- Plan
- Implement
- Follow-up: Monitor and Evaluate
PPCP in Self-Care
The foundation for the pharmacist’s patient care process is embedded within the pharmaceutical care model developed by Hepler and Strand in the 1990’s.
An essential first step is the establishment of a patient–pharmacist relationship that supports engagement and effective communication with patients, families, and caregivers throughout the process.
As noted earlier the number of consumers seeking out self-care and the changing marketplace for self-care puts pharmacists in a unique position to use the PPCP in self-care when consulting with consumers to optimize medication outcomes and safety considerations.
Step One: Collect
Self-care encounters in community pharmacies are generally initiated in one of two ways: either the patient or caregiver approaches or contacts the pharmacist, or the pharmacist observes the patient or caregiver in the nonprescription aisle and offers assistance. The pharmacist must then engage the patient in this first step of the process by collecting essential information to begin resolving the self-care complaint.
Collection of information from the patient or caregiver can be accomplished through the patient interview (subjective data) and from medical and pharmacy records, direct observation, laboratory test results and physical assessment (objective data).
A comprehensive patient interview would include the following components of the patient’s health history:
- Chief complaint (CC)
- History of present illness (HPI)
- Past medical history (PMH)
- Health maintenance and immunizations
- Family history (FH)
- Social history (SH)
- Review of systems (ROS)
- Medication history
The amount and type of information collected for a self-care encounter will be different from other patient care services that involve a greater breadth and depth of care and likely will not require all areas of the health history or full physical assessment.
For example, a family history or social history is rarely done if a patient is presenting with a poison ivy rash. However, the chief complaint, history of present illness and past medical history would be necessary in addition to observing the patient’s skin where the rash is present.
There are some situations where it would be pertinent to obtain a family history. For example, if a patient is presenting with a complaint of blood in the stool, a family history of colon cancer would be pertinent. If a patient is presenting with signs and symptoms of asthma or allergies it would be helpful to know if these disorders are present in other family members as there is quite often a genetic link to this type of disease.
Although most information in a self-care encounter will be subjective data obtained through the patient interview, objective data may need to be collected. This type of objective data may take many forms including the following:
- Measuring a blood pressure
- Measuring pulse
- Measuring respirations
- Taking a temperature
- Physical examination of the skin if a dermatologic disorder is present (eg. rash or sunburn)
- Listening to lung sounds
Conducting an efficient patient interview is a skill that develops with practice over time and involves asking appropriate questions and actively listening to the patient. Good communication skills are the foundation of many parts of the PPCP.
Step Two: Assess
The second step involves the assessment and analysis of information collected during the patient interview to identify and prioritize the patient’s problem.
The assess step can be categorized into three areas:
- Medication assessment
- Patient history and risk assessment
- Preventive care assessment
Similar to the collect step, assessing the patient’s information may be more or less focused during a self-care encounter depending on the situation. Additionally, it may or may not involve all three of these categories of assessment.
Step Two: Medication Assessment
Comprehensive medication assessment involves the analysis of each medication for appropriateness, effectiveness, safety, and adherence. In addition to assessing each medication a pharmacist must also include identification and prioritization of medication related problems. This include all of the following: unnecessary drug therapy, needs additional drug therapy, ineffective drug, dosage too low, adverse drug reaction, dosage too high, and adherence.
In the self-care process the most common medication related problem is needs additional drug therapy. This is because most likely the patient is presenting with the intent to purchase a self-care medication to treat a disorder and may require a non-prescription medication for resolution of symptoms.
Other medication-related problems in self-care may include ineffective drug or adverse drug reaction. If an ineffective drug is present a patient may be using a self-care medication that is not producing the desired response. An adverse drug reaction may occur if the patient is attempting to provide self-care for a disorder or symptom that is the result of another medication. For example, a patient who is drowsy due to taking pain medication and may be trying to purchase a caffeine related product to help with wakefulness.
The pharmacist’s role in the medication assessment step in self-care is to use the information collected to make appropriate medication recommendations or changes to the self- care plan if necessary.
Be efficient! Typically, self-care encounters require quick assessments because of the nature of their initiation. They may be taking place in a pharmacy aisle, over the telephone with a patient or caregiver, or at the point-of-sale where the pharmacist and perhaps the patient have limited time to spare.
Be aware! Time limitations are never an excuse for the pharmacist to be lax on responsibilities when assessing medications, particularly for safety and efficacy. However, the assess step in the PPCP can be modified to a more focused approach in self-care scenarios.
Although the self-care encounter may not include a comprehensive medication review, the pharmacist may have compelling reasons to consider all current medications before making a recommendation. For example, if a patient presents with musculoskeletal pain and the pharmacist is considering a recommendation for a nonsteroidal anti-inflammatory drug (NSAID), the pharmacist should collect information from the patient’s profile and interview regarding current NSAID use to assess for duplicate therapy as well as any medications that may potentially cause a drug–drug interaction or drug–disease interaction. This may present as the patient taking medication for hypertension, GI ulcer related therapy, or current warfarin therapy which would all rule out using an NSAID to treat musculoskeletal complaints.
Step Two: Patient History and Risk Assessment
The patient history and risk assessment includes health and functional status, risk factors, health data, cultural factors, health literacy, and access to medications or other aspects of care that would influence decisions on optimal medication regimens for the patient.
The collection of key information in the patient’s health history, such as health and functional status, could lead the pharmacist to a completely different assessment. The pharmacist should determine whether a patient’s disease state could be causing or contributing to the presenting self-care symptom or disorder. For example, if a patient has asthma and is seeking self-care for the relief of a cough, this disease state with the presenting symptoms would be an exclusion from self-care necessitating a visit to the physician to rule out on asthma exacerbation.
To properly counsel a patient and provide recommendations, a patient’s health literacy should be taken into account to ensure the patient will properly follow the pharmacist’s directions and guidance to self-care. It is safest to assume that all patients may have difficulty comprehending health information and therefore pharmacists should communicate clearly with everyone involved in the care of the patient and confirm that the patient understands the recommendations.
Step Two: Preventive Care Assessment
In a self-care encounter, the pharmacist may focus the preventive care assessment on only the presenting disorder or problem but in certain situations it may be appropriate to make broader recommendations.
For example, if a patient presents seeking relief from the pain of sunburn, the pharmacist may assess the need for future sunburn prevention and recommend a preventive plan that includes a sunscreen with appropriate SPF factor related products.
Other opportunities in preventive care assessment should be used, when appropriate, that may extend beyond immediate symptoms relief. For example, if a patient presents seeking seasonal allergy relief the pharmacist should focus on ways to help the patient avoid allergens in a way that would mitigate medication related strategies. For cough or cold encounters, when patients present during influenza season this gives the pharmacist an opportunity to assess the patient’s immunization status and make recommendations to avoid influenza in the future by providing recommendations for appropriate immunizations.
Step Two: Exclusions for Self-Treatment
A unique component of self-care is the assessment of appropriateness for self-treatment. Within the process, pharmacists should collect the pertinent information for the disorder or problem that would lead to an assessment of the patient as inappropriate for self-care.
If the pharmacist determines the patient is not a candidate for self-care, the medication-related problem may be that the patient needs additional drug therapy. In this case, the therapy requires an assessment from another health care provider which will likely result in treatment with a prescription medication.
Another medication-related problem that may result from an exclusion for self-care is no drug therapy problem exists. If a patient presents with a disorder or injury that requires medical treatment or a procedure from another health care provider as opposed to medication therapy, the patient may not have a medication-related problem to resolve. For example, a patient presenting with tooth pain may not need a pain reliever but in actuality an assessment and procedure required by appropriate dental care.
Exclusions for self-treatment may include but are not limited to the following situations:
Symptom characteristics or other disorder factors are beyond the scope of self-treatment.
- Example: Patient presents with symptoms of headache that have persisted for 10 days.
Patient-specific factors preclude treatment with nonprescription medications.
- Example: A six-year-old child with coughing and wheezing. In this case, non-prescription pharmacologic therapy is not indicated because he or she is younger than 12 years.
The patient’s health status or history precludes self-treatment, even if a nonprescription medication is indicated for the disorder.
- Example: A pregnant patient presents with heartburn symptoms that have not been previously assessed and diagnosed by another health care provider.
Nonprescription medications are not indicated for the disorder.
- Example: A female patient presents with urinary complaints of a fishy odor in the vaginal area and lower back pain. This would require a prescription therapy.
Previous treatment with a non-prescription medication was ineffective after an adequate trial.
- Example: Constipation symptoms persist after 1 week of treatment with a nonprescription laxative agent.
Step Three: Plan
Once the pharmacist has collected and assessed the patient the next step in the self-care process is to make one of three general recommendations:
- Recommend self-care with pharmacologic, non-pharmacologic, and/or complementary/alternative products.
- Refer the patient to another health care provider for treatment.
- Recommend self-care until another health care provider can be consulted
When an appropriate plan is made the pharmacist should address all of the following components:
- All medication-related problems
- Goals of therapy
- Patient engagement
- Care continuity in collaboration with other health care professionals and including the patient or caregiver
Step Three: Medication Related Problems
In this step, the pharmacist usually recommends a therapeutic product such as a non-prescription medication to resolve the needs additional drug therapy problem. Pharmacists should use their knowledge of the medication properties and determine the safest and most cost-effective option while considering all the factors collected from the patient in the first step.
Factors to take into consideration include:
- Age and gender of the patient
- Medication history
- Medical conditions
- Allergies
- Adverse effects
- Potential drug interactions
- Efficacy
- Dosage form preference
- Dosage form regimen
- Cost
- Previous medication experience
Step Three: Goals of Therapy
Goals of therapy serve as endpoints to measure outcomes and include both practitioner and patient contributions. Whenever setting goals they should always conform to the SMART criteria. In other words, the goals should be specific, measurable, achievable, realistic and timely.
The goals need to contain clinical parameters (signs, symptoms, lab values) and the desired goal for the parameter change. The time frame which the goal can be met is a critical piece of information for the patient. Not only knowing when they can expect relief from symptoms but also the time frame for when to contact a physician if relief is not achieved. For example, in relation to a fever a pharmacist recommending acetaminophen should counsel a patient that relief can be achieved within 2 hours. Setting this time frame establishes clear expectations and should include the expected time to onset of relief and degree of relief that can be reasonably expected.
Step Three: Patient Engagement
Every self-care encounter in which the pharmacist provides care should include educating the patient on the presenting disorder, non-pharmacologic measures, non-prescription medications, and when to seek medical attention.
The pharmacist should identify any medication-specific information and any other medication-related instruction for successful use and clinical outcomes.
To ensure pharmacist and patients expectations align, the patient should be included as part of the plan. This includes collaborating with the patient to set appropriate goals. A key part of an effective plan is clear communication by the pharmacist and empowering the patient by including him or her in patient-centered goal setting.
Non-pharmacologic recommendations should always be part of the plan. These recommendations should include non-drug measures, lifestyle recommendations, and preventive measures. If a non-pharmacologic therapy is the only recommendation, the patient should be counseled on why that was preferable to a non-prescription medication. One example may be a patient who is experiencing insomnia caused by inappropriate sleep hygiene habits. This may include things such as eating too close to bedtime, smoking, or exercising to close to bedtime or using too much caffeine. In this case, the best recommendation is to eliminate the stimulant rather than prescribing a hypnotic to alleviate the problem. This along with other good sleep hygiene measures should be communicated to the patient.
Step Three: Care Continuity
Care continuity, involves follow-up, referral, and transitions of care.
The initial follow-up plan is based on the goal of therapy and advises the patient of what to do once that goal is met, what should occur if the goal is not met, and what steps to take if the patient’s condition worsens or the patient experiences an adverse effect.
Here are a series of questions provided that should help guide the part of this encounter:
- When should the patient expect results (i.e., clinical outcomes)?
- What should the patient do if the goal of therapy is not met? Options include the following:
- A return visit to the pharmacist
- Selection of a different nonprescription medication
- Referral to a primary care provider
- How long should the disorder be treated by self-care before further assessment is warranted by another health care provider (i.e., referral)?
- What should the patient do if he or she experiences an adverse drug reaction?
- What should the patient do if he or she experiences a worsening of his or her condition during the treatment?
Another unique component of self-care encounter is to recommend self-care until another health care provider can be consulted. The pharmacist may realize referral to another health care provider is warranted. If the situation is not urgent, however, the pharmacist may consider recommending self-care while simultaneously referring the patient.
The pharmacist must be precise about the referral to ensure the patient understands it (the referral) is the primary recommendation.
An example of this may be a patient presenting with a muscle strain or sprain. If the pharmacist determines that the patient may need an X-ray the pharmacist could recommend a temporary over-the-counter pain reliever but stress that the main recommendation is to see a primary care provider as soon as possible for further evaluation.
The risk in making a recommendation while waiting for another health care provider consultation is that the patient may ignore the referral and take only the self-care recommendation. The pharmacist must be precise about the referral to ensure the patient understands it (the referral) is the primary recommendation.
Step Four: Implement
Several steps for implementing the plan are important to take into consideration:
Step one: Proceed to the appropriate aisle and select the correct product for the patient. A well-executed plan does not include referring the patient to the appropriate aisle and having them make their own product selection. This should be done with the pharmacist assistance in the OTC aisle.
Step two: Communicating the goals of therapy that were established in the plan.
Step three: Relaying all of the pharmacologic and non-pharmacologic educational points to the patient and caregiver.
Step four: Using the teach-back method involves asking the patient to repeat key points and actively listening to ensure understanding. Asking patients to repeat back the treatment information provided and giving them easy-to-read patient-centered printed instructions have been shown to improve patient understanding and medication use.
Step five: Communicating all follow-up plans is the next essential step. If the patient needs to return to see the pharmacist a specific date should be set. Considering busy schedules, a telephone or other technological forms of follow-up may be more appropriate.
Step six: If a referral to another health care provider is necessary the pharmacist may choose to communicate information to that provider to help with continuity of care by communicating patient-specific information obtained during the self-care encounter to facilitate the reason for referral.
Step Five: Monitor and Evaluate
Follow-up may not routinely occur in self-care encounters because of the self-limiting nature of most presenting disorders.
If a follow-up plan does include a return visit, the pharmacist should begin the PPCP again by collecting new information and reassessing the patient’s condition. The goal of therapy should be reviewed for achievement, as well as an assessment of any new medication-related problem related to the recommended non-prescription medication. Adherence to the recommended therapy should specifically be addressed in the follow-up to determine its contribution to the success of the intended goal.
Being Efficient
Efficiency in the PPCP is imperative in a community pharmacy. Since a pharmacy will only generate money on the actual product sale the efficient use of the pharmacists’ time is critical in these situations.
Pharmacists may feel that excessive questioning during the clinical interaction associated with OTC product purchases may be considered to be intrusive by patients. This may occur especially if a patient asks for a product by name in this case the pharmacist may assume that the patient has already made the decision and is not willing to be counseled. Obviously this needs to be balanced with the need for pharmacists to provide care to these patients (whether they expect it or not). Studies have shown that patients are willing to spend time with the pharmacist when selecting an OTC product. One report found that about 75% were prepared to spend 1–5 minutes with the pharmacists during such an encounter.
A large national survey of community pharmacists found that pharmacists felt patients’ expectations for clinical interaction associated with first-time OTC use would be about 2 minutes. It has been noted that most patients expect to spend about 1-5 minutes with the pharmacist when discussing self-care concerns. This can serve as the basis for the development of pharmacist interventions to provide self-care and at the same time balancing patient expectations for the duration of the interaction with what would be clinically important to cover during that interaction.
QuEST/SCHOLAR-MAC
One tool designed specifically for self-care encounters, the QuEST/SCHOLAR method, was first presented by Leibowitz and Ginsburg and is supported by the American Pharmacists Association as an accurate and efficient tool for pharmacists to use in the self-care process.
This interviewing framework guides the clinician to ask a series of questions with
subsequent analysis in order to assess the patient’s problem, establish that the patient is a self-care candidate appropriate for recommendations, select the most appropriate non- prescription product, advise on general care measures and counsel the patient on five aspects of their non-prescription medication.
The easy-to-remember acronyms may expedite completion of the problem-solving
process relative to more structured models that contain no such prompts in helping the pharmacist to remember all relevant pieces of the self-care assessment process.
We will soon see that this method of assessing the patient fits in nicely with the PPCP process we have already discussed.
QuEST stands for the following:
- Quickly and accurately assess the patient
- Establish that a patient is an appropriate self-care candidate
- Suggest appropriate self-care strategies
- Talk with the patient
The SCHOLAR stands for the following:
S- What are the associated symptoms?
C- What are the characteristics? Is the situation changing?
H- Has this ever happened before? What has been done so far?
O- When did the symptoms start?
L- What are the location of symptoms?
A- Does anything aggravate the symptoms?
R- Does anything relieve the symptoms?
The MAC stands for the following assessments:
- Medications: What prescription and nonprescription as well as complementary and alternative products is the patient taking?
- Allergies: Any allergies to medications and other substances? What was the reaction?
- Conditions: Are there any co-existing health conditions?
QuEST/SCHOLAR-MAC and PPCP
The PPCP process we have already discussed aligns quite nicely with the QuEST/SCHOLAR-MAC process for assessing the patient in the self-care arena.
The steps in the QuEST SCHOLAR that state to Quickly and accurately assess the patient and determine if self-care is appropriate is aligned with the steps in the PPCP process that describe the collect (step one) and assess (step two) areas.
Suggest appropriate self-care strategies in the QuEST SCHOLAR is similar to the plan (step three) in the PPCP.
Talk with the patient to provide necessary education in QuEST SCHOLAR aligns with what we learned in implement (step four) and follow-up (step five) in the PPCP.
Applying to Practice
Let’s take a look at a specific patient case to see how the QuEST/SCHOLAR MAC process can be used in practice. Once we examine how the process is used in a specific disease state or set of symptoms the process can be applied to other health conditions in the same way. Therefore, mastering these steps will help the pharmacist be the most efficient and effective practitioner possible in the self-care arena.
The following is a case about a woman presenting in the OTC aisle with vaginal complaints. The case will be outlined in the steps according to the PPCP and in accordance with assessing the patient through the QuEST/SCHOLAR-MAC method. She presents as a twenty-six-year-old female complaining of symptoms similar to vulvovaginal candidiasis (VVC).
As the pharmacist follow the PPCP and QuEST/SCHOLAR-MAC method to accurately gather information to make an appropriate self-care plan for the patient that includes non-pharmacological recommendations as well as a plan for follow-up.
Case 1
Collect
Evaluation Criteria | Scenario/Outcome |
Description of symptoms (characteristics, history, onset, location, aggravating and remitting factors) | Itchy vaginal area with redness, white cottage cheese discharge, no smell associated, started two days ago, nothing has been tried to alleviate the symptoms, swimming seemed to make it worse. She has had one of these similar episodes in the past a few years ago and her physician told her to buy something OTC but she cannot remember the product |
Medications (prescription, OTC, herbal) | Ortho-Cyclen – 1 tablet once daily Calcium 600 mg tablets twice daily |
Allergies | Sulfa – rash as a child |
Medical conditions | None |
Other relevant information (related to exclusion criteria) | She is 26 years old. Has not had this type of infection for a few years and she went to the physician at that time. Denies fever or pain and is not pregnant. |
Assess
Evaluation Criteria | Scenario/Outcome |
Differentiate symptoms to identify primary problem | Patient has itching, vaginal redness, and white discharge without an odor, symptoms consistent with VVC. |
Identify exclusion criteria | None |
Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine whether triage to a medical practitioner is required |
|
Plan
Evaluation Criteria | Scenario/Outcome |
Determine the most appropriate therapeutic alternative | The patient has symptoms associated with an uncomplicated VVC infection. She has had a previous VVC infection and reports no chronic medical problems. She is a candidate for self-treatment. |
Describe the approach to the patient (or caregiver) making sure it is in patient appropriate terminology | “We can choose from several nonprescription vaginal antifungal products. Since you have external vaginal itching, a combination product with a suppository and a cream may be preferred to assist in relieving your symptoms.” |
Explain your rationale for using this approach | “This is appropriate because you have symptoms common with a vaginal fungal infection. If you do not improve within 3 days see your MD and if there is not complete resolution in 1 week see your MD. If your symptoms return in the next 2 months see your MD.” |
Implement
Evaluation Criteria | Scenario/Outcome |
Product description | Appropriate OTC azole antifungal cream |
How the product works | \Will kill the organism causing your infection |
What to expect | Symptoms should improve in 24-48 hours. See MD if no relief after 3 days or symptoms worsen |
Directions for use | Insert the cream vaginally once daily for 3 days; apply externally to the vulva twice daily as needed for itching up to 7 days. Describe appropriate administration procedures for intravaginal use. Use the directions on the box for additional benefit and so the patient will remember. |
Adverse effects | Vulvovaginal burning and itching are common but if the symptoms exist beyond 48 hours see MD or if they become severe. |
Follow-up: Monitor and Evaluate
Evaluation Criteria | Scenario/Outcome |
Assess the patient response to your recommendation | You may ask the patient to follow-up with you in 7 days by setting a designated time to meet or by phone call. After your call you ascertain that the patient’s symptoms are completely relieved. |
Along with a pharmacological recommendation a non-pharmacological recommendation should be suggested to the patient. It is a good idea to try to provide at least 2 recommendations to the patient.
For VVC the following non-pharmacological recommendations can be provided:
- If significant irritation of the vulva is present, consider a sodium bicarbonate sitz bath to provide relief and give the antifungal medication time to become effective. Make sure to give proper instruction on how to make a sitz bath.
- For recurrent infections, try eating yogurt (1 cup per day of live culture yogurt) and decreasing dietary sugar and refined carbohydrates.
Other pertinent counseling points include:
- Continue the therapy for the recommended length of time, even if symptoms are gone. Stopping treatment early is a common reason for recurrence of vaginal symptoms and, possibly, occurrence of difficult-to-treat organisms.
- Vaginal antifungals can be used during a menstrual period.
- Do not use tampons or douche while using a vaginal antifungal and for 3 days after use.
- Refrain from sexual intercourse during treatment with the vaginal antifungal.
Applying to Practice – Case 2
The following is a case focusing on allergic rhinitis.
A twenty-six-year-old male presents for self-care consultation complaining of seasonal allergies. He has just moved to the area as a new college student and is now experiencing symptoms that have brought him to your pharmacy. After a brief discussion with the pharmacy technician it is evident the patient is in need of a self-care consultation with the pharmacist.
As the pharmacist follow the PPCP and QuEST/SCHOLAR-MAC method to accurately gather information to make an appropriate self-care plan for the patient that includes non-pharmacological recommendations as well as a plan for follow-up.
Collect
Evaluation Criteria | Scenario/Outcome |
Description of symptoms (characteristics, history, onset, location, aggravating and remitting factors) | Patient has had a runny nose along with itchy eyes and sneezing for approximately 1 week. He states it is worse when he is outside and gets better when he is in the house. Symptoms are usually worse in the morning, lessen in severity during the day, and then get worse again at night. This is his first time with these symptoms and is presenting in the early spring. |
Medications (prescription, OTC, herbal) | None |
Allergies | Penicillin – rash as a child |
Medical conditions | None |
Other relevant information (related to exclusion criteria) | He is a 26-year-old male |
Assess
Evaluation Criteria | Scenario/Outcome |
Differentiate symptoms to identify the primary problem | Symptoms consistent with allergic rhinitis. Non-allergic rhinitis symptoms are typically present the entire day and do not include sneezing or itchy eyes and nose. |
Identify exclusion criteria | None |
Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine whether triage to a medical practitioner is required |
|
Plan
Evaluation Criteria | Scenario/Outcome |
Determine the most appropriate therapeutic alternative | Recommend that the patient try a non-sedating oral antihistamine to relieve his allergic rhinitis. |
Describe the approach to the patient (or caregiver) making sure it is in patient appropriate terminology | “Because allergic rhinitis accounts for all of the present symptoms, therapy with an oral antihistamine is the most appropriate.” |
Explain your rationale for using this approach | “This case of allergic rhinitis seems to be mild and intermittent based on the timing and severity of the symptoms. An oral antihistamine is a reasonable option for treatment, because it should relieve these issues within a few days.” |
Implement
Evaluation Criteria | Scenario/Outcome |
Product description | Oral antihistamine |
How the product works | Will block histamines and relieve the allergy symptoms |
What to expect | Will relieve symptoms within a few days but full effect may not be seen for 2-4 weeks. If symptoms worsen or there is no improvement in 2-4 weeks see an MD. |
Directions for use | Take 1 tablet every morning |
Adverse effects | May include drowsiness, headache, or somnolence |
Follow-up: Monitor and Evaluate
Evaluation Criteria | Scenario/Outcome |
Assess the patient response to your recommendation | Contact patient in 2–4 weeks to see if symptoms have been relieved. It may be helpful to check in with the patient after allergy season has ended to recommend a course of action until the following spring when allergies are at a high once again. This would include pro-active measures to alleviate the symptoms prior to the onset of allergy season. |
Along with a pharmacological recommendation, a non-pharmacological recommendation should be suggested to the patient. It is a good idea to try to provide at least 2 recommendations to the patient.
For allergic rhinitis the following non-pharmacological recommendations can be provided:
- Avoidance of allergens is important regardless of whether allergy medications are being taken.
- Frequently check local pollen counts and air quality index. Only venture outside when the air quality index is safe and pollen counts are low.
- Keep house and car windows shut; avoid yard work and outdoor sports on days with high levels of pollen (spring/summer), mold (late summer/fall), or pollution.
Other pertinent counseling points include:
- Allergy medications are more effective if they are used regularly rather than episodically.
- If you have episodic or intermittent allergies, start allergy medications as soon as possible, before exposure to allergen.
- If you have persistent allergies, take allergy medications on a regular basis.
Tips for Self-Care in Special Populations
Providing appropriate recommendations is the goal in every self-care encounter. Special consideration must be given to certain groups of patients known to be at higher risk for medication-related problems. These populations include pediatric, geriatric, pregnant, and lactating patients. Medication-related problems with non-prescription products in these populations can have serious consequences if they are not counseled on the appropriate use of non-prescription medications.
The four specific populations mentioned above will be given special consideration.
Pediatric Patients
Verify the patient’s age:
- Age can have a significant impact on the exclusion criteria. For instance, a child under 12 years of age presenting with seasonal allergy symptoms should be evaluated by a physician prior to any self-care recommendation.
- Age can help guide dosage form selection. For example, it may be very difficult for a young child to swallow tablets and liquid may be the preferable route of administration.
Obtain the patient’s weight:
- Infants and child dosage guidelines may be recommended according to weight.
Consider caregiver factors:
- Taking into consideration the health literacy of the parent or caregiver is appropriate when making recommendations for a self-care regimen to a pediatric patient.
Watch for unique adverse effects that may only be present in children and not adults. For instance, antihistamines may cause paradoxical excitement in children while causing drowsiness in adults.
Due to unique labelling restrictions more emphasis should be placed on non-pharmacological recommendations versus non-prescription medications.
Geriatric patients
The geriatric population is defined as age 65 years and older. The aging process includes physiologic changes and decline in the function of many organ systems which can affect pharmacokinetic and pharmacodynamic profiles of medications. Absorption, distribution, metabolism and excretion can be altered in older adults and the pharmacist must be educated on how these changes will affect their self-care recommendations.
Without the ability to assess the individual’s specific profile, the pharmacist must assume that the older adult patient has age-related changes in function and then adjust medication and dosage recommendations accordingly. For example, this might mean that a geriatric patient who is requesting a calcium supplement be recommended calcium citrate because a less acidic gastric pH is required for absorption.
Keep in mind the following tips unique to the older population:
- Polypharmacy increases the risk for adverse events and drug interactions
- Multiple chronic disorders are common
- Cognition changes may be present and make assessment and planning difficult for the pharmacist
Specific information to consider during each step of the PPCP for geriatric patients is outlined below:
- Recognize that the collect step may take additional time in older adults because of the amount and complexity of information needed to make an appropriate assessment.
- Ask more in-depth questions regarding symptoms that could be unrecognized or falsely attributed to age.
- Evaluate for potential duplicate therapy or if the dose is too high.
- Because older adults are more likely to have multiple medical conditions, product selection based on chronic disease status is warranted in this population.
- Evaluate for non-adherence to medication regimens and consider adherence assistive devices such as pill boxes or involve other caregivers if deemed appropriate.
Improving Communication in the Geriatric Population
- A patient who is hard of hearing may require the pharmacist to speak slowly in a slightly raised voice. Avoid yelling since it will be deemed disrespectful and consider moving to an area where there is less noise and distractions.
- Written instructions may help the patient remember key take away points of the self-care recommendations and plan. Consider if large print instructions would be helpful if the patients present with low vision or has difficulty understanding audible instructions.
- Physical challenges such as decreased dexterity associated with arthritis may require selection of a medication without child-resistant closures and include counseling to keep the product out of the reach of children.
Tips for Self-Care in Special Populations
Pregnant patients
Patients should never presume that a nonprescription product is safe to use during pregnancy. Pharmacists should be ready to provide guidance to determine when self-care is appropriate and when referral is needed. The pharmacist should ask all female patients of child-bearing age who present with common symptoms of early pregnancy, such as nausea and vomiting, if they are pregnant or could be pregnant. Visual observation is not considerable to be reliable. If pregnancy is confirmed, identify the stage of pregnancy. Some medications include specific information regarding safety based on the trimester of pregnancy.
To minimize medication exposure, the pharmacist might initially recommend non-pharmacologic self-care for pregnant patients.
In many cases, even if a safe non-prescription medication is appropriate, a pregnant patient may still need to be referred before taking the medication. For instance, pregnant patients can use certain medications to treat seasonal allergies but only after being told to do so by a physician.
Lactating Patients
The pharmacist should ask female patients, particularly those who present with an infant or young child, about breastfeeding status. Assumptions are not appropriate and professional communication is essential to collect the appropriate information to make the best assessment.
The Drug Facts label for specific non-prescription medications may advise the lactating patient to consult a health care professional before use. The pharmacist should assess the patient’s symptoms and determine whether self-treatment is appropriate with a safe product or if referral to another health care professional is needed.
Consider non-pharmacological options first in this population and always choose medications with the shortest half-life.
Advantages of Self-Care to Society
- Saves time and money as time off work or childcare to see a healthcare professional is not required.
- Creates a feeling of control and self-reliance in consumers as they gain access and knowledge to various different ways to treat their health ailments.
- Reduces anxiety about their health status due to confidence in self-diagnosis, appropriate self-care advice and knowing when to seek professional help.
- Improves quality of life and feelings of self-worth when consumers feel knowledgeable and are able to take control of the final outcome of their health status.
- People with long-term conditions who are able to recognize when their health issue is worsening and what action to take have fewer risks of serious complications therefore improving disease outcomes.
- Frees up healthcare professional time to see patients who are unable to self-care or who need additional support thereby alleviating the burden on the professional or health care system in general and allowing more time to focus on acute problems that require immediate attention.
Helping Shape the Future
Self-care is frequently mentioned in governmental policy as a way to reduce the overall burden to the health care system. Encouraging individuals to utilize appropriate self-care directly benefits individuals and their families and creates a society engaged and empowered in their own health all leading toward better health outcomes.
In the midst of declining economic activity and resources, governments and other third-party payers and individuals worldwide are grappling with escalating health care costs. Many countries are establishing mechanisms whereby these costs can be contained, and health care can be made more cost-effective. Worldwide, self-medication is being promoted as a means of reducing the health care burden on the public budget.
Self-care is undoubtedly the primary resource of any health care system. People already manage or treat a large proportion of their ailments without consulting a doctor or pharmacist. However, the pharmacist can play a key role in helping people to make informed choices about self-care. By providing and interpreting the information available to consumers, the pharmacist can act as a guide to help the patient make the most informed choices possible and lead to better health outcomes for society as a whole.
Conclusion
Pharmacists play an active role in assisting patients with self-care by using the five key PPCP components: collect, assess, plan, implement, and follow-up which includes monitoring and evaluating for positive outcomes.
The PPCP is the same process for self-care encounters as it is with any other pharmacist-provided patient care service and in any practice setting.
Collecting essential information for the specific presenting medical condition will lead to an appropriate assessment and may lead to unique considerations in self-care, such as exclusions for self-treatment and require referral for the most appropriate treatment.
Efficiency in the PPCP is imperative in a community pharmacy. Tools such as the QuEST/SCHOLAR-MAC serve as a resource to streamline the process and assist the pharmacist in quickly and accurately using the process in this practice setting.
Special populations have increased risk of serious adverse events and may require extra time because of the amount and complexity of information needed for an appropriate assessment.
Active Learning
Self-care involves much more than buying over-the-counter medicines. It starts with preventing ill health, including the actions taken to maintain both physical and mental health. It also includes caring for minor ailments, managing long-term conditions and maintaining health after an acute illness. Supporting self-care leads to improved health and quality of life for patients, with reduced use of both primary care and hospital resources. Pharmacists can be a key player in supporting and advising on efficient and effective self-care for the patient.
The following article was developed to describe the global healthcare trends affecting self-care with a specific focus on the role of the pharmacist in facilitating over-the-counter medication management. The evolving role of the pharmacist is outlined, and recommendations are provided for ways to successfully engage with other health care professionals and consumers to optimize the self-care arena. An example displaying the role of the pharmacist in the management of frequent heartburn with an over-the-counter pharmacological recommendation is outlined to show the role of the pharmacist in this common ailment and how self-care recommendations and guidance by the pharmacist can help to improve health outcomes.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055554/
References
- World Health Organization (WHO) Q+A About Self-Care. Retrieved December 9, 2019, from https://www.who.int/reproductivehealth/self-care-interventions/questions-answers-self-care.pdf?ua=1.
- Global Self-Care Federation (2019). What is self-care? Retrieved December 9, 2019, from https://www.selfcarefederation.org/what-is-self-care.
- International Self-Care Foundation (ISF) 2019. The Seven Pillars of Self-Care. Retrieved December 9, 2019 from https://isfglobal.org/practise-self-care/the-seven-pillars-of-self-care/
- Office of Disease Prevention and Health Promotion (ODPHP) (2019). Executive Summary: Physical Activity Guidelines for Americans: Second Edition. https://health.gov/paguidelines/second-edition/pdf/PAG_ExecutiveSummary.pdf
- Consumer Healthcare Products Association (CHPA) 2019. White Paper: Value of OTC Medicines to the US Healthcare System. Retrieved December 10, 2019 from http://overthecountervalue.org/white-paper/#summary.
- Joint Commission of Pharmacy Practitioners (JCPP) 2019. The Pharmacist Patient Care Process. Retrieved December 12, 2019 from http://jcpp.net/patient-care-process.
- Hong S. Patient valuation of pharmacist services for self care with OTC medications. J Clin Pharm Ther. 2005;3:193–9.
- Ross T Tsuyuki, BSc(Pharm), PharmD, MSc, Eric Landry, BSP, Lyne Lalonde, BPharm, PhD, and Jeff Taylor, BSP, PhD. Results of a national survey on OTC medicines, Part 3: Perceived time expectations for clinical encounters associated with over-the-counter medicines. Can Pharm J (Ott). 2012 May; 145(3): 116–118.e1.
- Krinsky D, Ferreri S, Hemstreet B, Hume A, Newton G, Rollins C and Tietze K.Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. American Pharmacists Association; 19th edition (December 5, 2017).