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By N. Rasul. University of Pennsylvania.

Dispense oral oncology medications in an area of the office that is mindful of patient flow and individual2 buy antivert 25mg fast delivery. Plan for point-of-care dispensing and devote the necessary time to successfully train all personnelstate requirements Staff 5 purchase 25 mg antivert overnight delivery. Collect prescription drug benefit information on all patients as a routine part of patient check-in4. Stock all medications generally required by patients as well as be mindful of volumes and averages • Is convenient and is housed inside of oncology officesBenefits1 • Varying levels of physician supervision may Challenges1 In-House Dispensing Pharmacy method of distribution. Case managers know when patients receive their medications and can educate patients at the outsetabout the course of therapy, side effects, and dosing scheduleSpecialty Pharmacy Stafffor Health CareProviders & 3. Physicians receive regular e-mails and phone calls from case managers regarding their patients taking oral2. Medication therapy management service informs case managers when to be on the lookout for specific toxicitiesand other issues that clinical trials and other patient experiences have made apparent oncology medicationsBenefits1 Challenges1 Specialty • Delivers medication to patient at no additional costs• Likely able to custom pack doses • Provides additional patient education by phone or mailto avoid multiple • Potential challenge with communication about patient care between the specialty pharmacy and oncologypractice Pharmacy • Works closely with various insurance plans• Has access to patient assistance programscopayments • Specialty pharmacy may not be local• Patients may have concerns about working with a pharmacy by phone References:1. Adherence to oral therapies for cancer: helping your patients stay on course toolkit. Behind Closed Network Doors: Oral Cancer Drugs and the Rise of Specialty Pharmacy. To assist, this resource provides a general framework of review questions that are in line with a core set of key components for managing patient therapy with oral oncology medications. Specifically, this resource may be helpful to organizations that will need to conduct a readiness assessment toward developing a new oral oncology program, or to organizations that are looking to refine the processes of an existing program. Operations, as a core component of oral oncology management, involves: • Managing flow patterns and operational processes specific to treating a patient who is prescribed oral oncology medications throughout the care continuum, from treatment planning and financial review through medication acquisition and educational training Operations Assessment, as a core component of oral oncology management, involves: • Conducting baseline patient readiness assessments to evaluate if patients are appropriate candidates for therapy with oral oncology medications Assessment Access, as a core component of oral oncology management, involves: • Conducting financial review of patient access to insurance or other assistance programs, including identifying support resources • Understanding the methods of acquiring oral oncology medications, most commonly through an in-house dispensing pharmacy or specialty pharmacy, including the specific considerations for each Access route of access Treatment plan, as a core component of oral oncology management, involves: • Conducting comprehensive review of the patient’s medical care with oral oncology medications, including informed consent, obtaining clinical history, performing clinical evaluations and review, and developing an adherence plan, among other considerations Treatment Plan Communication, as a core component of oral oncology management, involves: • At a practice level, ensuring effective and coordinated communication among all providers who are part of a patient’s health care team • At a patient level, understanding when and how to communicate with the health care team, including issues related to correctly administering the oral oncology medication, monitoring adherence, and Communication managing side effects, among other considerations Education, as a core component of oral oncology management, involves: • At a practice level, establishing an educational program and developing a curriculum as needed • At a patient level, receiving educational training related to therapy with oral oncology medications EducationEducation Operations Questions for the organization to review internally 1. What are your current patterns of patient-flow with intravenous oncology treatments and how do you think the integration of orals will impact these patterns? Where and when along the patient flow of care do you think issues may arise with patients taking oral oncology medications? Specifically, what do you anticipate these issues will be and how will you plan to address them? Who within the organization will be responsible for leading the overall effort to develop new or refine existing processes related to the oral oncology program? How do you anticipate staff roles changing with the implementation of an oral oncology program? Who within the organization will be responsible for leading financial assessments and counseling for patients who are prescribed oral oncology medications? How will patients be able to obtain their oral oncology medications (eg, through specialty pharmacy or in-house dispensing)? If considering dispensing through in-house pharmacy, what will your organization need to review in terms of requirements (eg, stocking specialized items, credentialing with insurers, assessing if payers allow refills, complying with state regulations) and who will be responsible for leading this effort? If considering routing through specialty pharmacy, what coordination of care and communication processes will your organization and specialty pharmacy establish (eg, monitoring and communicating patient adherence, tracking patient refills, notifying dose changes) and who will be responsible for leading this effort? Who within the organization will be responsible for developing the treatment plan specific to oral oncology medications? What type of information will be included in a patient’s oral oncology treatment plan and how may this be different from an intravenous oncology treatment plan? What plans will your organization have in place to update current policies and procedures to integrate oral oncology medications; who will be responsible for leading this effort, and how will this be communicated within your practice? How will patients be able to communicate with your organization and report issues with taking their oral oncology medications should they arise (eg, adherence, side effects, toxicity/safety concerns) 3. How does your organization anticipate that physician communication will change with the patients who are prescribed therapy with oral oncology medications and what type of training can your practice offer to address communication changes? How will your organization communicate with other providers who are part of your patient’s health care team (eg, primary care physicians, specialists, specialty pharmacy)? How will your organization support caregivers during a patient’s course of treatment with oral oncology medications? How will your organization manage patient adherence and monitoring with oral oncology medications and what level of support will be offered? In general, what is the current level of staff education and knowledge base on treatment with oral oncology medications? What competency training will be provided to your organization’s staff to review the integration of oral oncology medications (eg, documentation processes, patient education support)? How will your practice develop a patient-education plan for those who are prescribed treatment with oral oncology medications and who will be responsible for leading this effort? Will your practice be able to attend off-site presentations related to oral oncology management? What are your organization’s main areas of strengths and how can these strengths be leveraged?

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In addition buy antivert 25 mg with mastercard, older adults benefits of long-term intensive diabetes help their patients to reach individual- tend to have higher rates of unidentified management antivert 25mg cheap, who have good cognitive ized glycemic, blood pressure, and lipid cognitive deficits, causing difficulty in and physical function, and who choose targets. These cognitive deficits tions and goals similar to those for ing and adjusting insulin doses. As with hinders their ability to appropriately risk of hypoglycemia, and, conversely, all patients with diabetes, diabetes self- maintain the timing and content of severe hypoglycemia has been linked management education and ongoing diet. There- diabetes self-management support are these types of patients, it is critical to fore, it is important to routinely screen vital components of diabetes care care. Self-management knowledge and skills should be reassessed when regimen changes aremadeoranindividual’s functional abilities diminish. In addition, declining or impaired ability to perform diabetes self-care behaviors may be an indication for referral of older adults with diabetes for cognitive and physical functional as- sessment using age-normalized evalua- tion tools (16,22). Patients With Complications and Reduced Functionality Forpatientswithadvanceddiabetes complications, life-limiting comorbid ill- nesses, or substantial cognitive or func- tional impairments, it is reasonable to set less intensive glycemic goals. These patients are less likely to benefitfrom reducing the risk of microvascular com- plications and more likely to suffer seri- ous adverse effects from hypoglycemia. However, patients with poorly con- trolled diabetes may be subject to acute complications of diabetes, including de- hydration, poor wound healing, and hyperglycemic hyperosmolar coma. Vulnerable Patients at the End of Life For patients receiving palliative care and end-of-life care, the focus should be to avoid symptoms and complications from glycemic management. Thus, when organ failure develops, several agents will have to be titrated or discon- tinued. There is, however, no consensus for the management of type 1 diabetes in this scenario (23,24). Beyond Glycemic Control Although hyperglycemia control may be important in older individuals with dia- betes, greater reductions in morbidity and mortality are likely to result from control of other cardiovascular risk factors rather than from tight glycemic control alone. There is strong evidence from clin- ical trials of the value of treating hyperten- sion in older adults (25,26). There is less evidence for lipid-lowering therapy and aspirin therapy, although the benefits of these interventions for primary preven- tion and secondary intervention are likely to apply to older adults whose life expectancies equal or exceed the time frames of the clinical trials. Insulin therapy relies on the abil- and procedures for prevention and cially as older adults tend to be on ity of the older patient to administer in- management of hypoglycemia. Recent stud- prove the management of older adults Once-daily basal insulin injection ther- ies have indicated that it may be used with diabetes. Treatments for each pa- apy is associated with minimal side ef- safely in patients with estimated glomer- tient should be individualized. Special fects and may be a reasonable option in 2 management considerations include ular filtration rate $30 mL/min/1. However, it is contraindicated in pa- theneedtoavoidbothhypoglycemia jections of insulin may be too complex tients with advancedrenalinsufficiency or and the metabolic complications of di- for the older patient with advanced di- significant heart failure. Other Factors to Consider of Diabetes in Long-term Care and The needs of older adults with diabetes Skilled Nursing Facilities: A Position Thiazolidinediones Statement of the American Diabetes and their caregivers should be evaluated Thiazolidinediones, if used at all, should Association” (32). Social be used very cautiously in those with, difficulties may impair their quality of or at risk for, congestive heart failure and Nutritional Considerations life and increase the risk of functional those at risk for falls or fractures. The patient’s living sit- may have irregular and unpredictable meal Insulin Secretagogues uation must be considered, as it may consumption, undernutrition, anorexia, Sulfonylureas and other insulin secreta- affect diabetes management and sup- and impaired swallowing. Social and instrumental support therapeutic diets may inadvertently mia and should be used with caution. Diets tailored to a pa- ide is a longer-duration sulfonylurea and with diabetes should be included in di- tient’s culture, preferences, and per- contraindicated in older adults (29). Incretin-Based Therapies life, satisfaction with meals, and nutri- Older adults in assisted living facilities Oral dipeptidyl peptidase 4 inhibitors tion status (35). A systematic ing centers) may rely completely on the especially vulnerable to hypoglycemia. Those re- They have a disproportionately high agents do not increase major adverse ceiving palliative care (with or without number of clinical complications and co- cardiovascular events (30). Diabetologia 2005;48:2460–2469 Providers may make adjustments to cause gastrointestinal symptoms such 5. Neurology vided they are given timely notification symptoms progress, some agents may 2014;82:1132–1141 6. Uncontrolled diabetes increases The following alert strategy could be Strata have been proposed for diabe- the risk of Alzheimer’s disease: a population- considered: tes management in those with advanced based cohort study. Intranasal glucose values should be confirmed focus on the prevention of hypogly- insulin therapy for Alzheimer disease and am- by laboratory glucose measurement. There is disease: a review of basic research and clinical men may need to be adjusted), b) glu- very little role for A1C monitoring evidence. Antidiabetic drugs and their potential role in treating mild cognitive glucose values greater than 300 mg/dL venting hypoglycemia is of greater impairment and Alzheimer’sdisease.