More than Just Chasing INRs: Patient-Centred Care in an Anticoagulation Clinic

INTRODUCTION The Canadian Society of Hospital Pharmacy’s 2015 initiative, targeting excellence in pharmacy practice, sets forth a vision for pharmacists to practice to their full scope and to optimize patients’ medication-related outcomes by providing patientcentred care.1 Patient-centred care “is a professional obligation to take responsibility for, and provide care targeted to, the individual patient’s needs”.2 Fundamental elements of patientcentred care encompass respecting individual patients, appreciating their care goals and values, delivering education, enabling patients to participate in treatment decisions, and providing continuity of care.3 Within the Anticoagulation Clinic at the University of Alberta Hospital, the team’s seemingly narrow focus of anticoagulation management often evolves into care issues that go beyond simply “chasing” a specific laboratory value. The purpose of this paper is to model the delivery of patient-centred care through the lens of a specialty anticoagulation clinic, where assessment of the international normalized ratio (INR) is often used as an opportunity to discover, investigate, and treat the whole patient, not just his or her lab values. Established in 2001 with pilot project funding, the Anti coagulation Clinic is directed and staffed by 3.1 full-time equivalent clinical pharmacists, along with secretarial support, and as of spring of 2015 was managing about 750 patients. The clinic receives referrals from across Alberta for patients requiring anticoagulation therapy. Since its inception, the acceptance criteria have changed to target a more complex patient population, thus ensuring optimal resource use.4 Specifically, patients accepted are those with high thromboembolic risk, high risk for major hemorrhage, complex comorbidities, or medications that affect anticoagulation control. This higher-risk patient population requires that pharmacists collaborate with other practitioners across the health care continuum and use their additional prescribing authority to proactively change warfarin dosing and anticoagulant therapy to ensure safe and effective care delivery. Despite practising in a very specialized setting, pharmacists in the Anticoagulation Clinic use comprehensive patient assessment and investigational skills to manage these complex cases, often making interventions in areas not directly related to anticoagulation therapy. This paper presents several case vignettes to describe the scope of pharmacists’ practice at the Anticoagulation Clinic.* In particular, we reflect on the evolution of skill sets that now extend beyond the narrow, misperceived goal of simply “chasing an INR between 2.0 and 3.0”, in alignment with the provision of patient-centred care.