10/16/2014

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Jane Bowen, PharmD, BCPS

Gladys Dueñas, PharmD, BCACP

Valerie Ganetsky, PharmD, BCPS

Anisha Grover, PharmD, BCACP

Karleen Melody, PharmD, BCACP

Sanchita Sen, PharmD, BCPS

Student and Resident Integration into Innovative Collaborative Pharmacy

Practice Models

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Pharmacist Learning Objectives

1. Describe resident and student involvement in the medication reconciliation and discharge processes at an urban, teaching medical center.

2. Identify opportunities for student and resident research involvement associated with the medication reconciliation and discharge processes.

3. Discuss how interprofessional education (IPE) learning experiences prepare graduates to develop meaningful partnerships and add value to your institution.

4. Describe opportunities for student and resident involvement in an interprofessional group medical visit practice model.

5. Identify three opportunities to integrate student pharmacists and residents into a transitions of care (TOC) model that incorporates a community hospital and pharmacy.

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Pharmacy Technician Learning Objectives

1. Describe the role of the pharmacy technician within the Pharmacy Practice Model Initiative.

1. Describe pharmacy technician involvement in the medication reconciliation and discharge processes at an urban, teaching medical center.

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Institute for Healthcare Improvement (IHI) Triple Aim

• Improve outcomes

• Improve patient

satisfaction

• Reduce cost of careTriple Aim

Better Care

Better Health

Lower Costs

Berwick, DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Affairs. 2008 May;27(3):759-69.

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How Can Pharmacists Contribute to Achieving the Triple Aim?

Care Team Integration

Team-based approach to care.

Positions pharmacists as providers.

Leveraging Pharmacy Technicians

Urges technicians to handle non-traditional/advanced responsibilities.

Pharmacist Credentialing & Training

Ensures pharmacists, residents, and students have training and credentials

for activities performed now and in the future.

Leadership in Medication Use

Pharmacists are integral in helping achieve the best outcomes.

Pharmacy Practice Model Initiative

(PPMI)

American Society of Health-System Pharmacists. Pharmacy Practice Model Initiative [Internet]; c2014. Available from: www.ashpmedia.org/ppmi/overview.html.

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Developing Qualities and

Traits

Process Improvement

Research

Patient Care Roles

Building Partnerships

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Jane Bowen, PharmD, BCPS

Assistant Professor of Clinical Pharmacy

Philadelphia College of Pharmacy

Sanchita Sen, PharmD, BCPS

Assistant Professor of Clinical Pharmacy

Philadelphia College of Pharmacy

Student Pharmacist and Pharmacy Resident Involvement in the

Hospital Inpatient Setting

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Objectives

• Describe resident and student involvement in the medication reconciliation and discharge processes at an urban, teaching medical center.

• Identify opportunities for student and resident research involvement associated with the medication reconciliation and discharge processes.

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Developing

Qualities

and Traits

Process

Improvement

Research

Patient Care

Roles

Building

Partnerships

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Partnerships

Philadelphia College of Pharmacy

Cooper University Hospital

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Overview of Process Improvement

Reflect on your current

process

Identify goals and

resources to assess the

process

Assess the process through research

Share research

with stake-holders

Identify, design,

implement improved process

Include students and residents

Utilize partnerships to provide more services

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Medication Reconciliation Process

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Medication Reconciliation Process

Before

•Nurse/physician driven

•Lack of follow-up with objective resources (e.g., retail pharmacy, physicians’ offices)

•Inconsistent medication reconciliation

After

• Pharmacy-technician centered medication reconciliation program developed and implemented in January 2011

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Medication Reconciliation Research

• With resident– Siemianowski L, Sen S, George J. Impact of Pharmacy Technician-Centered

Medication Reconciliation on Optimization of Antiretroviral Therapy and Opportunistic Infection Prophylaxis in Hospitalized Patients With HIV/AIDS. Journalof Pharmacy Practice. January 22, 2013. doi:10.1177/0897190012468451.

– Sen S, Siemianowski L, McAllister S, Murphy M. Implementation of a Pharmacy Technician-Centered Medication Reconciliation Program at an Urban Teaching Medical Center. American Journal of Health-System Pharmacy. January 2014; 71:51-6.

• With student– Kraus S, Pontiggia L, Sen S. Medication Errors and Pharmacy Interventions Post

Pharmacy Technician-Centered Medication Reconciliation Program in the Internal Medicine Services. {Under review}.

• Helped with expansion of program

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Medication Reconciliation Program Progress

• Implemented program throughout more services beyond internal medicine

– Administration requests for program implementation throughout all disciplines (e.g., surgery, intensive care unit)

Internal medicineOncology and post-ED

observational unit addedCardiology added

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Medication Reconciliation Program Improvement Plans

• In-services to health care providers– Intention to increase quantity of medication reconciliation

recommendations to be implemented before discharge

• Requires close involvement of pharmacists and physicians

• Improvement of documentation– Standardization and consistency of pharmacist medication

reconciliation notes

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Discharge Process

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Current Discharge Process

Physician NursePharmacist, Pharmacy

Student/Resident

• Enters discharge orders

• Completes discharge summary and medication reconciliation

• Educates patients on medications (hospital and discharge)

• Counsels patients on medication regimens― Creates medication cards― Teaches device use (e.g.,

insulin, inhalers)

• Completes discharge medication reconciliation

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Discharge Process Current Research

• Residents and research students

– Nurses’ attitudes and perspectives of discharge medication education and counseling

– Patients’ attitudes and understanding of discharge medication education and counseling

Reflect on your

current process

Identify goals and

resources to assess the

process

Assess the process through research

Share research

with stake-holders

Identify, design,

implement improved process

Include students and resident

Utilize partnerships to provide more

services

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• Research

– Focus groups

– Identification of an “intervention”

– Generalizability to the other disciplines

– Grants to implement, study the intervention?

– Assessment of modified discharge medication counseling program

• Ensure APPE and IPPE students, residents more consistently involved in discharge medication counseling

Discharge Process Future Plans

Reflect on your

current process

Identify goals and

resources to assess the

process

Assess the process through research

Share research

with stake-holders

Identify, design,

implement improved process

Include students and resident

Utilize partnerships to provide more

services

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APPE = Advanced Pharmacy Practice Experience; IPPE = Introductory Pharmacy Practice Experience

Active Learning Question

A. True

B. False

All levels of pharmacy residents and students can be involved in the medication reconciliation and discharge process at any hospital with pharmacist supervision.

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Active Learning Question

A. Perform a literature search to identify the information that has been published on this topic

B. Prepare a protocol and help submit it to the institutional review board

C. Survey patients and nurses about their experiences with the medication education on discharge process and suggestions for improvement

D. All of the above

Which of the following is an opportunity for a resident or student to be involved in evaluating and improving the process by which patients are educated about their medications prior to discharge?

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Interprofessional Education (IPE) Student-Run Clinic Experience

Linking Education with Practice

Gladys Dueñas, PharmD, BCACP

Assistant Professor of Clinical Pharmacy

Philadelphia College of Pharmacy

Anisha Grover, PharmD, BCACP

Assistant Professor of Clinical Pharmacy

Philadelphia College of Pharmacy

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Learning Objective

• Discuss how interprofessional learning experiences prepare graduates to develop meaningful partnerships and add value to your institution.

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Developing

Qualities

and Traits

Process

Improvement

Research

Patient Care

Roles

Building

Partnerships

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Partnerships

University of the Sciences

Cooper Medical School of Rowan UniversityWalgreens

Cooper University Hospital

http://www.rowan.edu/open/map/images/cooper_hospital.jpg

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#

Description of Program

P1

Healthcare teams

(Interprofessionalsatellite sites)

P2

Community pharmacy practice

(Walgreens Pharmacy)

P3

Institutional pharmacy practice

(Cooper Hospital)

Direct patient care(Student-Run Clinic: Camden Community Collaborative Practice)

P1: 36M1: 72

P2: 25M2: 64

P3: 24M3: 50 27

Student-Run Clinic: Basic Pharmacy Practice Skills

• Medication dispensing

• Patient assessment

• Medication information

• Identification and assessment of drug-related problems

• Mathematics

• Ethical, professional, and legal standards

• Communication

• Counseling of patients

• Drug information analysis and literature research

• Promotion of health and wellness (public health)

• Familiarization with insurance/prescription drug coverage and patient assistance options

Learning Domains:

Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree: Draft Standards 2016. Chicago, Illinois; 2014. 32 p.

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Meaningful Qualities We Are Shaping

Collaborative behaviors/teamwork skills

Leadership skills

Understanding roles & responsibilities of different team members

Strong communication (written/verbal)

Patient-centeredness

The “Hidden” Curriculum

“…encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient.”

Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine. Washington, DC:

National Academies Press; 2001.

29Kirkpatrick DL, Kirkpatrick JD. Evaluating Training Programs: The Four Levels. Agency for Healthcare Research and Quality Annual Conference; 2009. Bethesda, Maryland.

Meaningful Partnerships We Are Building

Did the participants like the training? What do they plan to do with what they learned?

What skills, knowledge, or attitudes changed after training? By how much?

Did the participants change their behavior on-the-job based on what they learned?

Did the change in behavior positively affect the organization?

Was the training worth the cost?

Level 1 -Reaction

Level 2 –Learning

Level 3 -Behavior/Training

Transfer

Level 4 - Results

Level 5 - Return on Investment

Kirkpatrick’s Model of Training Evaluation

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Additional Outcomes

Student-Reported Changed Behaviors

New Learning of Roles

Values/Attitudes

Skills/Knowledge

“If my mom was the patient…I would want a team of

providers..”

“I have to write legibly because I get frustrated

when I am in the dispensary and receive illegible prescriptions”

“I finally now understand the

‘prior-auth’ process on both sides… ”

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Active Learning Question

Which of the following best describes a method by which interprofessional learning experiences prepare graduates to develop meaningful partnerships?

A. Multidisciplinary didactic lecturers expand students’ exposure to healthcare professions

B. Adoption of multiple roles within a student-run clinic provides hands-on experiences with the responsibilities of all team members

C. Student physicians and student pharmacists complete identical didactic coursework to facilitate teamwork

D. Student physicians serve as team leaders to realistically simulate clinical practice

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Valerie S. Ganetsky, PharmD, BCPS

Assistant Professor of Clinical Pharmacy

Philadelphia College of Pharmacy

Student Pharmacist and Pharmacy Resident Integration into a

Diabetes Group Medical Visit

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Learning Objective

• Describe opportunities for student and resident involvement in an interprofessional group medical visit (GMV) practice model.

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Developing

Qualities

and Traits

Process

Improvement

Research

Patient Care

Roles

Building

Partnerships

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Partnerships

Philadelphia College of Pharmacy

Cooper University Hospital

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What is a GMV?

Improve Outcomes of Chronic Illness

Facilitation and group dynamics

Team-based care

Traditional office visit

+ education

Bronson DL, Maxwell RA. Shared medical appointments: increasing patient access without increasing physician hours. CCJM. 2004 May;71(5):369-77.

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Challenges with Traditional Office Visits for Patients with Diabetes

Diabetes Care

Self-Management

Education

Psychosocial Issues

Medication Management

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Benefits of GMV for Patients with Diabetes

Increased time for education and self-

management teaching

Improved clinical outcomes

Improved knowledge of diabetes health

behaviors

Improved patient and provider satisfaction

Increased adherence to American Diabetes Association process-

of-care indicators

Clancy DE, Huang P, Okonofua E, et al. Group visits: promoting adherence to diabetes guidelines. SGIM. 2007 Mar;22(5):620-24; Wagner EH, Grothaus LC, Sandhu N, et al. Chronic care clinics for diabetes in primary care. Diabetes Care. 2001 Apr;25(4):695-700; Trento M, Passera P, Tomalino M, et al. Group visits improve metabolic control in type 2 diabetes. Diabetes Care. 2001 Jun;24(6):995-1000; Trento et al. A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Diabetes Care. 2004 Mar;27(3):670-5.

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Cooper University Hospital Urban Health Institute (UHI) & Cooper Advanced Care Center (CACC)

• UHI focuses on health care delivery to underserved

patients of Camden, New Jersey

• Supported in part by a grant from the Nicholson

Foundation

• GMVs initiated at the CACC in June 2013

• Current GMVs exist for diabetes, sleep apnea,

headache, hand surgery, podiatry

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Image adapted from: www.thenicholsonfoundation-newjersey.org/

Diabetes GMVMultidisciplinary Team Approach

Endocrinologist

Clinical Pharmacist

Behaviorist

Medical Assistant

Licensed Practical Nurse

(LPN)

Advanced Practice Nurse

(APN)

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Diabetes GMV Overview

• Patients referred by endocrinologist and primary care providers

• Morning/afternoon of 3-4 sessions: 1-hour long visits with 8-12 patients/hour

• Patients sign group confidentiality agreement at initial visit

• APN, clinical pharmacist, and LPN serve as patient navigators

Image adapted from: www.cooperhealth.org/departments-programs/cooper-advanced-care-center/group-visits

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Diabetes GMVRole of Patient Navigators

• APN and clinical pharmacist prepare “huddle note” for every scheduled patient (includes past medical history, previous labs, current medications, etc)

• Create educational “toolkits” for use during education sessions

Pre-GMV

• Interview patients based on questionnaire to extract pertinent information related to diabetes, hypertension, and dyslipidemia

• Facilitate patient education sessions based on curriculum

• Create treatment plan in conjunction with endocrinologist

During GMV

• Document patient encounter, order medications and laboratory tests

After GMV

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Diabetes GMVSample Agenda

Activity Time Allotted

Meet with Diabetes Navigator

Medical Review by Endocrinologist

30 minutes

Facilitated Group Session 10 minutes

Review of Medical Plan 5 minutes

Educational Topic Based on Curriculum 10 minutes

Wrap-Up 5 minutes

Image adapted from: www.cooperhealth.org/departments-programs/cooper-advanced-care-center

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• Participate in completing “huddle notes” for upcoming patient visits

• Prepare educational “toolkits”

• Residents participate in creation of GMV protocols for use by navigators (e.g., insulin titration protocol)

Pre-GMV

• Serve as patient navigator under supervision of preceptor

• Create treatment plan in conjunction with preceptor and endocrinologist

• Create and facilitate patient education sessions under supervision of preceptor

During GMV

• Document patient encounter in medical record

• Order medications and laboratory tests (pharmacy resident)

After GMV

Diabetes GMVRole of Student Pharmacists and Pharmacy Residents

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Active Learning Question

Which of the following best describes the role pharmacy students and/or residents can play in a GMV?

A. Serve as patient navigators to facilitate completion of the visit questionnaire

B. Participate in creation and delivery of patient education toolkits

C. Participate in creation of group visit treatment protocols

D. All of the above

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Integrating Student Pharmacists and Pharmacy Residents into a Community Pharmacy-Based Transitions of Care Program

Karleen Melody, PharmD, BCACP

Assistant Professor of Clinical Pharmacy

Philadelphia College of Pharmacy

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Learning Objective

• Identify three opportunities to integrate student pharmacists and residents into a transitions of care (TOC) model that incorporates a community hospital and pharmacy.

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Developing

Qualities

and Traits

Process

Improvement

Research

Patient Care

Roles

Building

Partnerships

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Transitions of Care (TOC)

Increase

Access

Improve

Use

Image adapted from: http://events.r20.constantcontact.com/register/event?llr=pgcxumfab&oeidk=a07e78v5tetf96cd86b

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TOC Partnerships

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Logos obtained from SunRay Drugs, Mercy Philadelphia Hospital and Philadelphia College of Pharmacy

Inpatient Opportunities

• Identifying Patients

– Admission lists

– Interprofessional rounds

– Priority lists from insurers

• Recruiting/Enrolling Patients

• Communicating with Outpatient Pharmacy

– Medication reconciliation

• Data Collection/Reporting

Image adapted from: http://missionbayhospitals.ucsf.edu/our-facilities/childrens-hospital/acute-care-patient-room

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Community Pharmacy Opportunities

• Dispensing

• Making follow-up phone calls

• Data collection

• Scheduling MTM session

• Making refill reminder phone calls

• Creating marketing materials

Image adapted from: http://www.sunraydrugs.com/locations/

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Community Pharmacy Opportunities

Complete medication

review (CMR)

Personal medication

record (PMR)

Medication-related action

plan (MAP)

Intervention and/or referral

Documentation and follow-up

Patient Care-Medication Therapy Management (MTM)

American Pharmacists Association and National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc. 2008 May;48(3):341-53.

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Clinical Pharmacy Opportunities

Complete medication

review (CMR)

• Conduct medication reconciliation• Perform physical assessments• Provide medication and disease state

education• Assess regimen for drug therapy

problems

• Create complete and accurate medication list

Personal medication

record (PMR)

55American Pharmacists Association and National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc. 2008 May;48(3):341-53.

Clinical Pharmacy Opportunities

Intervention and/or referral

Documentation and follow-up

• Document encounter• Communicate with healthcare

professionals• Schedule follow-up appointments • Make appointment reminders

• Develop a collaborative action plan with SMART goals

Medication-related action

plan (MAP)

• Create resource list of referral sources and aid patients with referrals

SMART= Specific, Measurable, Achievable, Realistic, Timely

56American Pharmacists Association and National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc. 2008 May;48(3):341-53.

Active Learning Question

Which of the following tasks can a student pharmacist and/or pharmacy resident complete?

A. Recruiting patients

B. Conducting comprehensive medication reviews

C. Performing physical assessments

D. All of the above

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How Can Pharmacists Contribute to Achieving the Triple Aim?

Care Team Integration

Team-based approach to care.

Positions pharmacists as providers.

Leveraging Pharmacy Technicians

Urges technicians to handle non-traditional/advanced responsibilities.

Pharmacist Credentialing & Training

Ensures pharmacists, residents, and students have training and credentials

for activities performed now and in the future.

Leadership in Medication Use

Pharmacists are integral in helping achieve the best outcomes.

Pharmacy Practice Model Initiative

(PPMI)

American Society of Health-System Pharmacists. Pharmacy Practice Model Initiative [Internet]; c2014. Available from: www.ashpmedia.org/ppmi/overview.html.

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• Increase preceptor time to focus on other clinical tasks.

• Integrate into clinic flow and decrease preceptor administrative time = ability to see more patients.

Patient Care Roles

• Contribute to model of interprofessionalpractice/education.

Building Partnerships

• Evaluate current practice and identify opportunities for improvement.

• Contribute to scholarship endeavors.Research

Added Value of Student Pharmacists and Pharmacy Residents

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Dealing with Challenges

• Younger vs. older students

• Varying level of competence

• Upfront time investment

• Dealing with a difficult student

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Conclusion

• Pharmacists can contribute to achieving the healthcare triple aim through the PPMI.

• Student pharmacists and pharmacy residents can add value to your institution through their participation in collaborative pharmacy practice models.

• Student pharmacists and pharmacy residents can contribute to patient care roles, research, and building partnerships.

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