Students as Pharmacists Extenders Make Precepting a Win Win: Review of Literature Lisa J. Killam Worrall, Pharm.D., BCPS Assistant Dean for Experiential Education Associate Professor in Pharmacotherapy University of North Texas System College of Pharmacy Objectives Define the term pharmacist extender Discuss the benefits and barriers to utilizing students as pharmacist extenders Summarize the literature regarding utilizing students as pharmacist extenders The presenter has no disclosures nor conflicts of interest. Pharmacist Extender Personnel who completes duties that are delegated and overseen by a pharmacist that allows the pharmacist to broaden his or her scope of practice or responsibilities Clerks Technicians Paid Pharmacy Interns Pharmacy Students Introductory Pharmacy Practice Experience (IPPE) Advanced Pharmacy Practice Experience (APPE) Pharmacist Extender Duties Performs data gathering, collating and entry functions May prioritize problems Assist with documentation & scheduling or follow up Assist with medication use process Why needed? Increased duties/responsibilities of pharmacists despite limited resources and budgets Emphasize direct patient care by pharmacists Pharmacist Extenders Review of Literature Benefits Allows focus on direct patient care For pharmacist and extenders Improve patient safety Improve patient outcomes Improve core measures Increase satisfaction Barriers Training required Process Use of systems Reinforcement of training Keeping up with documentation Maintaining motivation Scheduling and coverage issues Search of International Pharmaceutical Abstracts (IPA) and PubMed Keywords and Controlled Vocabulary Utilized Pharmacy students, experiential, rotations, clerkships Clinical pharmacy services, pharmaceutical services Outcomes, value, interventions Limits Publication date 2005 to present 1
Review of Literature Inclusion Criteria Articles that detail utilizing experiential pharmacy students in roles as pharmacist extenders Articles that pertain to pharmacy practice within the United States Exclusion Criteria Articles that measure student and/or preceptor perceptions of experiential rotations instead of capturing actual duties or roles Abstracts of posters or presentations at conference meetings Initial searches returned between 340 to 400 articles on each database Many were duplicates Many on IPA were posters at various meetings 49 articles selected after reviewing titles 36 articles remaining after review of abstracts One Review Article Identified Search of literature to determine clinical services provided by pharmacy students and the economic implications associated with those services Included 29 studies and 6 abstracts Compared number of students, rotation length, length of study, interventions, acceptance rate and cost savings Mersfelder TL, Bouthillier MJ. Value of the Student Pharmacist to Experiential Practice Sites: A Review of the Literature. The Annals of Pharmacotherapy. 2012,46:541 8. One Review Article Identified There were 7 in combined practice experiences, 7 in ambulatory care and 15 in acute care Students made 1.2 to 16 recommendations/week Acceptance rate varied from 32% to 98% 9 of the studies addressed cost savings or cost avoidance of student interventions Generally offset costs of training or orientation for students and student supervision Mersfelder TL, Bouthillier MJ. Value of the Student Pharmacist to Experiential Practice Sites: A Review of the Literature. The Annals of Pharmacotherapy. 2012,46:541 8. Description of Type of Pharmacist Student Extender Utilized 13 articles pertained to APPE Hospital or Acute Care 6 articles were about interventions in general 2 articles were about antimicrobial stewardship 5 articles were about medication reconciliation or discharge medication counseling 1 article was about inpatient anticoagulation service 1 article was about ADR reporting Description of Type of Pharmacist Student Extender Utilized 7 articles pertained to APPE Ambulatory care All of which reported interventions Some reported acceptance rate of student interventions One reported that student verbal interventions were accepted more often than written interventions by medical residents 3 articles pertained to APPE Community 2 articles reported self care recommendations 1 article reported medication therapy management 2
Description of Type of Pharmacist Student Extender Utilized 5 articles pertained to IPPE 3 involved Medication Education and/or MTM for elders 2 involved immunizations 2 articles pertained to all APPE interventions Students documented interventions throughout the year during all rotations Description of Type of Pharmacist Student Extender Utilized 2 articles described duties of paid interns Facilitating IV to PO switch Facilitating medication history Facilitating with core measures 1 article pertained to volunteer interns that assisted with medication reconciliation Limitations Articles varied widely in outcome measures reported and length to which they were described Articles varied widely in number of students participating in experience Areas for Future Study Blocked scheduling of APPE Few studies describe allowing students the ability to complete a number of rotations at a single institution Did not address interventions or value of student to institution Could present opportunity to provide more of an impact on practice Conclusions Literature shows promise for utilizing pharmacy students as practice extenders Need more study on the training and logistics as well as time in these activities in addition to more consistent intervention tracking to further expand impact on outcomes and cost savings Questions? All articles reviewed are listed in another document. It has been submitted for posting on TPA website along with slides. 3
Students as Pharmacist Extenders In Medication Therapy Management VAIDEHI (VEE) BHATT, PHARM. D. Disclosure I have no actual or potential conflict of interest in relation to this program. Objectives Provide an overview of Medication Therapy Management (MTM) Discuss primary barrier to providing MTM and its solution Discuss the impact of students as pharmacist extender on the following: Student Administration Patient Discuss tips for successfully precepting MTM rotation Medication Therapy Management (MTM) Term coined by Center for Medicare and Medicaid Services (CMS) under the Medicare Modernization Act of 2003 1 Aim is to optimize drug therapy and improve therapeutic outcomes for patients 1 Core elements of MTM 1 Medication therapy review (MTR) Personal medication record (PMR) Medication related action plan (MAP) Intervention and/or referral Documentation and follow up Pharmacists are #1 providers for delivery of MTM services. 2 Impact of MTM 3 : Improves health outcomes Improves medication adherence rates Reduces adverse drug events Barriers to providing MTM services 2 V2Inadequate time Inadequate support staff Solution: Utilizing pharmacy students as pharmacist extenders! V5 Medication Therapy Management Services Provided by Student Pharmacists 3 Authors: Hata M, Klotz R, Sylvies R, et al. Objective: To evaluate the impact of these MTM services delivered by student pharmacists during their advanced pharmacy practice experience (APPE) on student perception of value and preparation for provision of MTM; and on patient response to the recommendations. APPE Sites: Community pharmacy or independent pharmacy ownership V6 Duration: 12 weeks for 2 years (mid February to the first week of May during 2009 and 2010.) Training: The concept of MTM introduced first year of pharmacy school. V7 How to perform MTM services Spent a full day of class in their third year. Student pharmacists were trained by the CORE faculty members V8for a day on how to implement MTM services at a practice site and how to document the process on MTM forms Prior to starting the APPE. An MTM protocol, created by the CORE faculty members, was incorporated into the course syllabus for added guidance. 1
Slide 5 V2 In 2014,the American Pharmacists Association (APhA) found that one of the greatest barriers to pharmacists providing MTM services was not having adequate time and adequate support staff. Vaidehi, 6/30/2015 Slide 6 V5 V6 V7 V8 This study was done by Micah Hata and colleagues at the Western University of health sciences in California. students were P4 and had completed seven 6 week rotation prior At this point had all therapeutic classes These forms were developed by the CORE faculty members based on APhA suggested standards and are available upon request.
Medication Therapy Management Services Provided by Student Pharmacists 3 Process: Interested patients completed a medical and medication history form. Form reviewed by student pharmacists. Within 3 days, the student pharmacists conducted a face to face interview with the patient and V9 performed a medication therapy review to address the appropriateness, safety, and cost, and any compliance issues associated with the patient s medications. Students documented the drug related problems they found, specifically in the following areas: Drug use without indication, or duplication of therapy; untreated indication; improper drug selection; sub therapeutic dosage; overdosage; inappropriate administration schedule; adverse drug reaction; drug interaction; and cost effectiveness. The students provided their patients with a written report addressed to the patient s physician with suggested changes and/or safety concerns, which were approved by the student s preceptor. The patient was also provided with a typed personal medication record that was prepared by the student and approved by the preceptor. Medication Therapy Management Services Provided by Student Pharmacists 3 Follow up: Students followed up with the patient, either by phone or in person, in 1 to 2 weeks after the MTM session. The follow up questions were designed to track patient reported outcomes including whether the patient took the student s advice, whether the patient gave the recommendations to their physician, whether the physician accepted the recommendations, and whether the patient felt better about their medication therapy as a result of the service. Student perception survey: To determine their perceived value of the MTM project, the role of the curriculum in adequately preparing them for providing MTM, and whether they intended to continue these services in practice. Data analysis: Students transferred relevant de identified data per Health Insurance Portability and Accountability Act regulations, into a database that listed interventions and outcomes per patient. A unique identifier code was used to link patient data to the patient s personal medication record. The record was stored securely in the pharmacy and only the Excel file was sent to the study investigators for analysis. Students only sent data for those patients who were reached for follow up. Analysis was primarily descriptive in nature, and included summarizing information from student reports and course surveys and comparing data between years using Student t tests at a 95% significance level. Medication Therapy Management Services Provided by Student Pharmacists 3 : Year Students, No. Patient, No. Interventions, No. Average of 10 patients per student Average of 1.4 drug related problem per patient Each student identified 15 drug related problems Students surveyed 2009 28 288 432 21 2010 19 221 272 19 Total 47 509 704 40 V11 Medication Therapy Management Services Provided by Student Pharmacists 3 continued: Type of MTM Interventions No. (%) Drug use without indication/duplication 54 (7.6) of therapy Untreated indication 50 (7.0) Improper drug selection 62 (8.7) Subtherapeutic dosage 39 (5.5) Overdosage 40 (5.6) Inappropriate administration schedule 102 (14.4) Adverse drug reaction 108 (18.2) Drug interaction 105 (14.8) Cost effectiveness 147 (20.7) V12 Medication Therapy Management Services Provided by Student Pharmacists 3 continued: Response to recommendations: Patient acceptance of recommendation 80% Presentation of recommendation to physician 53% Physician acceptance of recommendation 75% Patient perception 88% of the patients felt better about their medications after receiving MTM services. Student perception MTM services they provided were valuable to their patients 2009 100%; 2010 79% (p < 0.05) Pharmacy school curriculum had prepared them to effectively deliver MTM services 2009 96%; 2010 79% (p = 0.14) Whether they would provide MTM services as licensed pharmacists in the future 2009 67%; 2010 63% (p = 0.82) Improvements from this model: Provide point of care testing Directly communicate recommendations to physicians Advantages of utilizing students in MTM 3 Students Patient Administration Enhanced V13 learning experience Improved patient outcomes V15 Improved efficiency in terms of time Improved student confidence in clinical V14 skills Improved patient satisfaction Improved preceptor participation in MTMV16 Students recognized the value of MTM servicesv17 2
Slide 7 V9 While the preceptor was not required to interview the patient with the student, the preceptor did need to review and sign off on every recommendation before it was presented to the patient. Slide 9 V11 FivehundredninepatientsreceivedMTM services, or an average of 10 patients per student. Among the509patients,704drug-relatedproblemswereidentified (anaverageof1.4drug-relatedproblemsperpatient).each student identified an average of 15 drug-related problems for their MTM patients. There were no significant differences between data for 2009 and 2010 in terms of the averagenumberofmtmservicesprovided(p50.09)or follow-up interviews conducted (p 5 0.18). Slide 10 V12 the most common drug-related problems identified by the students: cost effectiveness (n5 146), adverse drug reactions (n 5 116), druginteractions(n5106),andinappropriateadministrationschedule (n5 102). The least common drug-related problems identifiedwereoverdosage(n540)andsubtherapeuticdosage (n 5 39). Slide 12 V13 V14 V15 V16 V17 ACCP requirement, real life experience example of glyburide Even if communitypharmacypreceptorsarenotfamiliarwiththeprocess ofconductingmtm,theyhavetheknowledgetoapprove clinical recommendations that are identified by student pharmacists. This may address both the efficiency of the process in terms of time, as well as improve preceptor confidence in participation in MTM. impt because healtcare need to provide MTM survey results
Tips to make your rotation a success Define expectations Set weekly goals Provide adequate resources Weekly disease state discussion led by students Training videos provided by documentation and billing portals Example: OutcomesMTM, Mirixa, Medmonitor etc. Reading material on MTM Utilizing preset forms or worksheets V4 Assessment questions Q1. Which of the following is NOT effective precepting behavior? A. Setting expectation on the first day B. Setting achievable goals C. Providing no feedback D. Providing adequate resources Provide weekly follow up to discuss progress and challenges Assessment questions Q2. Which of the following healthcare professionals are the most common providers of MTM services? A. Physicians B. Nurses C. Pharmacists D. None of the above Assessment questions Q3. Which of the following is NOT a result of utilizing students as pharmacist extender? A. Better learning experience for the students B. More time consuming for the preceptor C. Better patient outcomes and satisfaction D. All of the above are correct References 1. Medication therapy Management in Pharmacy Practice. Core Elements of an MTM Service Model. Version 2.0. American Pharmacists Association and National Association of Chain Drug Stores Foundation. March 2008. https://www.accp.com/docs/positions/misc/coreelements.pdf 2. American Pharmacists Association. Medication Therapy Management Digest The Pursuit of Provider Status to Support the Growth and Expansion of Pharmacists Patient Care Services http://www.pharmacist.com/sites/default/files/mtm%20digest_2014%20final.pdf 3. Hata, Micah et al. Medication Therapy Management Services Provided by Student Pharmacists. American Journal of Pharmaceutical Education 76.3 (2012): 51. PMC. Web. 1 July 2015. 3
Slide 13 V4 available in reference 1
JOB TITLE: Pharmacy Manager (2) Supervises: Indirectly: Staff Pharmacist, Technicians, Senior Technicians, Pharmacy Cashiers, and Pharmacy Interns (3) Other Major Relationships: Will work closely with pharmacy employees, store management and store employees, as well as cooperate with and maintain good working relationships with store, district, and market management, pharmacy services, and other company and outside associates to ensure that the objectives of the pharmacy and company are met. JOB OBJECTIVES: To manage all aspects of the pharmacy department operations to accurately fill prescriptions and provide high quality patient care through the efficient use of the pharmacy staff and technology. To ensure compliance with all federal and state regulations, as well as all company policies and procedures, applicable to both pharmacy and business operations, including documentation requirements. To provide customer service by counseling patients, resolving complaints, and enhancing satisfaction. To select, train, evaluate, develop, schedule, coordinate, and supervise pharmacy department personnel. To control inventory costs by ordering stock, maintaining proper levels, leveraging company resources, etc. To increase pharmacy sales and profitability by identifying and promoting higher profit pharmacy business. To provide preventative health care services such as immunizations, diabetes awareness, and others as needed. To maintain knowledge and skill in the field of pharmacy and seek self development. JOB RESPONSIBILITIES/TASKS: Manages the workflow of the pharmacy, to include assigning roles, staffing and scheduling, coordinating activities, promoting teamwork, assigning special tasks, prioritizing and scheduling tasks, soliciting employee suggestions, preventing backups, ensuring efficiency, and performing opening, closing, and shift change duties. Reviews and verifies prescriptions to include fully utilizing pharmacy systems, ensuring information is entered correctly, verifying medicine is correct, weighing and counting pills, and checking for possible interactions. Fills prescriptions if no technician or when necessitated by workload by retrieving prescriptions, entering into Intercom Plus, counting or measuring amount, putting medicine into vial, printing and affixing label, printing receipt, putting correct information in computer, taking and giving transfers, etc. Greets customers at pharmacy counter and on the phone to answer pharmacy and store questions, offer services, and provide customer service. Counsels patients and answers their questions on usage of medicine, side effects, interactions, contraindications, patient information privacy, generics, less expensive medicines, over the counter products, and refers to medical provider as needed to ensure medicine taken correctly, health needs addressed, and satisfaction with service. Responds to special needs of customers or goes out of way to provide customer service, including helping select or use special items (e.g., blood pressure and blood glucose monitoring), contacting patients when there are delays, conducting investigations, ordering special items, knowing patient names, following up, solving problems, etc. Resolves customer complaints and monitors the customer service provided by employees. Contacts medical providers offices to clarify prescriptions, dosages, refills, interactions and allergies, and to suggest alternative medications, and answer medical provider questions. Adheres to government laws and regulations, corporate policies and procedures, ethics and codes of conduct. Prepares, maintains, and submits all records, reports, and other documentation as required by state and federal laws (e.g., copies of prescriptions, regulatory reports, etc.), and all documentation required to run the business (e.g., operating statements, performance indicator reports, supervision notes, deletions, transfers, etc.). Ensures the proper processing of insurance claims including following and instructing staff on procedures, monitoring progress, and calling insurance companies to help resolve insurance problems to lessen payment rejections and charge backs and heighten customer satisfaction. Provides immunizations, diabetes awareness, and other preventative health care services as needed. Performs other pharmacist tasks, such as compounding, flavoring, brown bags, drug therapy reviews, medication therapy managementcases, and other patient services. Develops and maintains good relationships with medical community including physicians, nurses, and other health care providers by medical provider detailing and outreach to health groups, retirement homes, nursing homes, and other forums for enhancing growth opportunities. Maintains knowledge and skill in the fields of pharmacy and healthcare, reads pharmacy related journals, reads company publications and communications, completes People Plus Learning modules and continuing education credits, researches new drugs, attends district meetings, etc. Reviews and analyzes customer service, financial, and inventory information, including pharmacy sales and income reports, inventory reports, payroll and expense reports, and historical reports to understand pharmacy performance, determine trends, discover problems, and to identify opportunities for improvement. Manages inventory by maximizing inventory investment by ordering and returning items, balancing stock between stores, monitoring levels, and anticipating needs to minimize high cost orders, expired and recalled stock, overstock and slow moving items, and reconciling stock exceptions and partial fills, leveraging company resources, etc. Participates in and manages loss prevention activities, including conducting audits, checking security, verifying vendor deliveries, monitoring for employee theft, and implementing policies, procedures and internal controls, etc. Manages the maintenance, housekeeping, and improvement of the pharmacy department, including repairs, cleaning, new equipment, and changes to the layout to ensure a functioning, presentable, and efficient pharmacy. Ensures information technology support (i.e. Intercom Plus, registers, robots, StoreNet), maintains working knowledge, implements new systems, and responds to problems. Conducts or participates in audits (e.g., supervision, state inspector, insurance company, controlled substance, and peer reviews) including prescriptions files, narcotics invoices, inventories, legal documentation, licenses, etc. Trains employees, including new hire orientation, on the job training, cross training, answering questions, determining training needs, following up to ensure training is used, and coaching. Addresses employee job performance issues by giving feedback, conducting performance reviews of pharmacy staff and documenting performance and disciplinary actions according to company policy. Manages employee performance, including assigning responsibilities, setting goals and expectations, observing performance, providing feedback, giving assistance, solving problems, and conducting formal reviews. Identifies and develops employees for promotion, discusses career aspirations, evaluates potential, provides training and development, provides feedback, etc., to meet the talent needs of the company. Addresses employee relations concerns and maintains morale by checking on employee welfare, addressing complaints, conflicts,and concerns, and ensures positive employee management relationships. Manages employee diversity and compliance with all applicable employment laws to ensure equity, consistency, fairness, prevention of discrimination, and harassment and to show that the company values diversity. 7/6/2015 Students as Pharmacist Extenders: Make Precepting a Win Win for You and Your Practice Site July 12 th 2015 Texas Pharmacy Association State Conference Carole Hardin Oliver RPh. Health Care Supervisor, Area 5 Walgreens Boots Alliance July 12, 2015 4 Benefits: 1. Define the term "pharmacist extender" 2. Discuss the benefits and barriers to utilizing students as pharmacist extenders 3. Articulate the benefits of integrating learners into administrative or patient care duties 4. Develop new rotation models integrating learners into daily activities The presenter has no disclosures nor conflicts of interest. Allow application of knowledge to create practice ready Pharmacists Fast Track Opportunity Relationship and Inclusion in higher level processes Allows focus on direct patient care for pharmacists and extenders Improve patient safety Improve patient outcomes Improve core measures Increase satisfaction Barriers: Training required Process Use of systems Reinforcement of training Keeping up with documentation Maintaining motivation Scheduling and coverage issues July 12, 2015 5 Personnel who complete duties that are delegated and overseen by a pharmacist that allows the pharmacist to broaden his or her scope of practice or responsibilities Clerks Technicians Paid Pharmacy Interns Pharmacy Students - Introductory Pharmacy Practice Experience (IPPE) - Advanced Pharmacy Practice Experience (APPE) Benefits: Allow application of knowledge to create practice ready Pharmacists and Fast Track Opportunity Mentoring transfers years of applied experience with efficiency Selection of Preceptor/Mentor requires partnership with COP, Site and Student Preceptor/Mentor has ability to recommend and advance Student careers Employers recognize these Students experience July 12, 2015 3 July 12 th 2015 6 1
Benefits: Time: Barrier One: Relationship and Inclusion in higher level processes Advocacy for the Profession and Patient Membership Healthcare Team and Committees Appointments Access to meetings Assignments Bigger picture Thinking Effectiveness Student Training Experience Correction Oversight July 12 th 2015 7 July 12 th 2015 10 Benefits: Allows focus on direct patient care for pharmacists and students, Improve patient safety, Improve patient outcomes, Improve core measures, Increase satisfaction. RTS NTT LTF Routine Patient Counseling Immunization Assessment Med Sync Barrier Two: Resources: Basic Equipment Phones Computers Desk Access Shared Calendar Shared on Day 1 Expectations Assignments Examples Presentation Meeting Visuals White Paper Executive Summary Reports July 12 th 2015 8 July 12 th 2015 11 Barriers: Quiz: Based on a recent study, what were the Top Three Barriers Identified? 1. Time no Spare, Assigned or Free Time to precept 2. Resources I want to.but is do not have 3. Student Attitude Yup! Sometimes.. Barrier Three: Creating a Motivated Student Experience: Preceptor/Mentor Plan Communicate the plan Professionalism positive Dedication you are creating the next leaders of Pharmacy Hold to the APPR standards this is fair to all Adapt every student learns differently July 12 th 2015 9 July 12 th 2015 12 2
Students: Come prepared Ready to Learn Patient Confidentiality Business Confidentiality Strive to leave the Rotation a better person AND Strive to leave the Rotation better than you found it Current Community Rotation Models: Community : Introductory, 300+ hours, Common practice setting Community Pharmaceutical Care: Advanced, 400+ hours, Standards are specific to the setting MTM: Advanced, Specific, measureable, patient care Management: Advanced, Specific, adds management and Administration training and skills July 12 th 2015 13 July 12 th 2015 16 Barriers: From the Employer Perspective Barrier Four: Training 6 week rotation one week training minimum. Decreased effectiveness of Preceptor Decreased effectiveness level at task/service Staffing Annual schedule and Intern placement. Skill variation between students results in workload variation to staff Rotation assignment gaps leave tasks/services unsupported How do we integrate Students into new Rotational Models? Interoperability Interacts with Preceptor/Mentor and full range of contacts Fiscal Proposed fiscal study of annualized financial benefit by rotation Strategic Residency potential Long Term Partnership July 12 th 2015 14 July 12 th 2015 17 The Benefits of Integrating Students into Practice Medication Error 3.6B annually MTM Interventions averaging $700/patient intervention Outcomes/Adherence Interventions Increase Rx and decreased readmissions Pharmacies achieved a nearly 91 percent Proportion of Days Covered (PDC) score for medications of patients enrolled in the program. This compares to a PDC score of 72 percent for patients assigned to a control group. Average Days on Therapy (ADT), a measure of medication persistence, was significantly higher in the intervention group, averaging approximately 20 additional fills per patient per year. Perspectives Ryan Hudson PharmD UHCOP PGY1 Resident Graduate 2015. Amanda Beck PharmD? IUWCOP 2015 Graduate Allison Phuc Nguyen Student Pharmacist UHCOP PharmD Candidate 2016 July 12 th 2015 15 December 17, 2014 18 3
Assessment Question What is the #1 reported barrier to utilization of Students as Pharmacist Extenders? 1. Poor Staffing 2. Lack of knowledge 3. Time December 17, 2014 19 Assessment Question What benefit does the Student Extender bring? 1. Allows focus on direct patient care for pharmacists and extenders 2. Improve patient safety 3. Improve patient outcomes 4. All of the above December 17, 2014 20 Assessment Question From the Employer Perspective, what is a concern? 1. Lack of skills 2. Inconsistent staffing 3. Patient medication errors rate increases December 17, 2014 21 4