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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10/16/2014
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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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10/16/2014
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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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10/16/2014
9
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.
58
• 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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