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A pharmacist-managed immunotherapy program for ambulatory atopic patients is described. Pharmacists in a network of three health centers recommended that they assume management of the allergy desensitization program when they recognized problems with the existing program. Guidelines for the immunotherapy service were developed and approved by the pharmacy, therapeutics, and standing orders committee. Patients, already tested by an allergist, are referred to the pharmacists for the administration of their immunotherapy. Under the guidelines for the program, pharmacists collect and record the patients' history, assess the patients' knowledge of allergy desensitization, administer the allergens, examine the injection site, question the patients about symptoms, and initiate treatment of local and systemic reactions. A physician is available for consultation and for treatment of life-threatened adverse reactions. Following any reaction, the pharmacist adjusts the next antigen dose accordingly. Typical charges for these services are $10-15 for the first visit, and $3.50 for subsequent visits. The pharmacists spend about 30 minutes of their time for the initial visits, and 10 minutes for subsequent visits. The time spent by physicians is negligible, and there is no charge for their consultations. Patients under the care of the pharmacists rarely wait more than 15 minutes for an appointment. This service has been well accepted by patients, physicians, and mid-level practitioners. Pharmacists are using their knowledge and skills to provide a direct patient-care service, and they are being reimbursed for a nondispensing activity.

Hospices were surveyed to identify the types of pharmaceutical services provided. The directors of 75 hospice organizations were sent questionnaires regarding: (1) the type and scope of pharmaceutical services and (2) their conception of the future of the hospice movement. Of the 48 usable responses, 37 reported pharmacist affiliation. Of the 11 organizations that did not have a pharmacist affiliated, 10 reported they anticipated using a pharmacist's services in the future. Most (68%) pharmacists who worked in hospices were consultants. Pharmaceutical services included the development of policies and procedures regarding drug storage and handling, inservice education, drug information, and patient education. Of the organizations without a pharmacist, 91% provided only outpatient care; of hospices with pharmacists, 51% provided outpatient, 14% inpatient, and 36% outpatient and inpatient care. Forty-six percent of the hospice directors considered the pharmacist affiliated with their organization to be a member of the interdisciplinary team; 55% of such pharmacists worked full-time with the hospice. Hospice directors expressed a need for greater pharmacist involvement in inservice education, staff consultation, and research on pain.

The development and maintenance of an organized system of emergency care in isolated ambulatory health-care centers are described. A system of three community health centers, staffed chiefly by midlevel practitioners (i.e., physician's associates and nurse practitioners), had a need to provide occasional emergency care to patients. Emergency care needed to be provided (for up to one hour) until an ambulance arrived to transport the patient to a hospital. A system of emergency care, consisting of treatment protocols, a drug manual, equipment and medications, and a program for periodic inservice education was developed by physicians, midlevel practitioners, and pharmacists. Weekly checks of the supplies and medications are conducted. Lists of supplies and medications stocked, and a sample drug monograph, are included in the paper. The program has resulted in more efficient emergency care, including less confusion in executing and documenting treatment.