PAIN MANAGEMENT AND PALLIATIVE CARE TRAINEESHIP, LEVEL 3

PAIN MANAGEMENT AND PALLIATIVE CARE TRAINEESHIP, LEVEL 3 Application Policies and Guidelines The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This application-based CPE activity (#0204-9999-14-002-L01-P) offers 40.0 contact hours (4.0CEU) with no partial credit allowed. Copyright 2014 American Society of Health-System Pharmacists Research and Education Foundation All rights reserved

Page 2 of 11 Table of Contents ASHP Research and Education Foundation... 3 Program Overview... 4 Target Audience... 4 Program Description... 4 Post Traineeship Requirements... 6 Application Process... 7 Proposed Timeline... 9 ASHP Foundation Responsibilities... 9 Qualifications of the Applicant... 9 Qualifications of the Applicant s Health-System... 10 Important Traineeship Policies... 10 Traineeship Administration... 11

Page 3 of 11 ASHP Research and Education Foundation Our Vision As the philanthropic arm of the American Society of Health-System Pharmacists, our vision is that patient outcomes improve because of the leadership and clinical skills of pharmacists, as vital members of the health care team, who are accountable for safe and effective medication use. Our Mission The mission of the ASHP Foundation is to improve the health and well-being of patients in health systems through appropriate, safe and effective medication use. The ASHP Foundation accomplishes this by: Sponsoring high-impact practice research leading to advances in patient outcomes; Educating and developing pharmacists and pharmacy staff as leaders and clinicians; Providing funding and programs that optimize the medication-use system and advance the direct and accountable patient care role of pharmacists; Encouraging innovation and adoption of best practices and new patient safety and quality initiatives; Providing recognition and support to diffuse best practices in research, education and practice; and Establishing partnerships, collaborations and strategic alliances to inform our mission and advance common goals. ASHP Foundation Strategic Priorities 1. Facilitate and strongly support the pharmacy profession in advancing pharmacy practice models that foster pharmacists leadership and accountability for patient outcomes. 2. Create demand for new models of pharmacy practice that leverage the expertise and unique abilities of pharmacists. 3. Drive the advancement of the technical, human and leadership competencies of pharmacists and pharmacy staff in complex and rapidly changing organizations. 4. Ensure the long-term financial sustainability of the ASHP Foundation. The ASHP Foundation pursues its mission and strategic priorities through provision of awards, research grants, educational programs, and practice tools. The ASHP Foundation has a long track record of administering research grant, education and practitioner recognition programs that use stringent external review processes to select program recipients. The strategic priorities of the ASHP Foundation are closely aligned with the ASHP strategic plan. As the national professional society of pharmacists who work in health systems, the mission of ASHP is to advance and support the professional practice of these pharmacists and serve as their collective voice on issues related to medication use and public health. ASHP has been in existence for 60 years and currently has a membership of over 40,000. ASHP members practice in a variety of health-system settings such as hospitals, home care, ambulatory care, managed care organizations, and long-term care.

Page 4 of 11 Program Overview The ASHP Research and Education Foundation s Program was developed for pharmacists who provide specialized services for patients in pain and those with palliative care needs. The traineeship prepares participants to design patient-specific pharmacotherapy; solve drug therapy problems; and develop protocols, policies and procedures for the treatment of these patients. Target Audience This program is designed for pharmacists who currently are or will be involved in the provision of pain management/palliative care services. Program Description The curriculum, consisting of Levels 1 and 2 and Level 3, a 5-day experiential program, provides intensive didactic and clinical training for selected pharmacists. Completion of knowledge-based Levels 1 and 2 is a requirement for applying to the skills-based Level 3 experiential program. The experiential program offers 40 continuing education hours (40 CUEs) and allows participants to observe and participate in the care of patients with an established pain management/palliative service. Following the experiential program, participants are required to complete applicationbased activities to demonstrate that they have applied the obtained knowledge and skills in practice. The ASHP Research and Education Foundation s Program is accredited by the Accreditation Council for Pharmacy Education. Tuition Information The tuition for the 5-day Level 3 program is $3,200. Applicants who are accepted into the program can elect to pay their tuition payment in full or participate in a payment plan. For Individuals who select a payment plan, upon acceptance into the Pain Management and Palliative Care Traineeship Level 3 program, trainees will be sent a declaration of payment form with the option of entering into a payment plan with the ASHP Foundation. Four monthly payments of $800 a month can be made from February through May 2015. Payments will be due on February 28, 2015; March 31, 2015; April 30, 2015 and May 30, 2015. Experiential Program During the 5-day experiential program, participants will observe experienced clinicians and, under direct supervision, design, monitor and evaluate patient-specific pain management/palliative care pharmacotherapy. This program focuses on critical thinking, decision-making and communication skills. The 5-day experimental program will take place during April and May 2015.

Page 5 of 11 The experiential component of the Pain Management/Palliative Care Traineeship will be offered at the following sites: Southern Illinois University Edwardsville Belleville, IL Preceptor: Chris Herndon, Pharm.D. The University of Iowa Hospitals and Clinics Iowa City, IA Preceptor: Lee Kral, Pharm.D. BCPS, CPE University of Maryland School of Pharmacy Baltimore, MD Preceptor: Mary Lynn McPherson, Pharm.D. University of Virginia Health System Charlottesville, VA Preceptor: James B. Ray, Pharm.D., CPE ASHP Foundation staff and traineeship faculty will strive to align trainees individual educational needs and geographic location when determining site assignments. Alignment of trainees educational needs and training site capabilities will be prioritized. The ASHP Foundation cannot guarantee that trainees will be assigned to the site that is closest in geographic proximity to the trainee s home. At least two weeks in advance of the experiential component, the trainee should provide the site preceptor with a list of topics/questions that the trainee would like to focus on during the experiential week. Experiential Program Objectives Upon completion of this traineeship, applicants will be able to: 1. Establish a collaborative working relationship with all health care providers involved in a pain management/palliative care service. 2. Develop an effective collaborative pharmacist-patient relationship required to elicit information, undertake the development of a pain management/palliative care plan and establish a monitoring process. 3. Design, recommend, administer (when applicable), monitor and evaluate patient-specific pain management/palliative care regimens that incorporate the principles of evidence-based practice to make conscientious, explicit and judicious decisions about the care of individual patients and specifically to: Build the information base needed to design a medication therapy regimen for a patient with pain/ palliative care needs by collecting, organizing and generating patient-specific problem lists using all information needed by the pain management/palliative care pharmacist to prevent, detect and resolve medication-related problems and to make therapeutic medication therapy recommendations. Design a regimen, including modifications to existing medication therapy, that meets the therapeutic goals established for a patient in pain/palliative care needs; integrates patient-specific information, disease and drug information, ethical issues and quality-of-life issues; and considers pharmacoeconomic principles.

Page 6 of 11 Design a monitoring plan for a therapeutic regimen that effectively evaluates achievement of the patient-specific therapeutic goals. Implement the pharmacotherapeutic regimen and/or corresponding monitoring plan. Design an educational program plan that will enable successful implementation of the therapeutic regimen and monitoring plan. 4. Design and deliver education to health care professionals and patients on therapies used in pain management/ provision of palliative care. 5. Demonstrate a caring attitude toward patients with pain/palliative care needs in all aspects of care. 6. Develop effective written and verbal pain management/palliative care consults. 7. Appropriately document all activities related to pain management/palliative care in the appropriate locations (e.g., The Joint Commission documentation requirements). 8. Develop policies and procedures for multidisciplinary pain management/palliative care practice. Post-Training Requirements Four months after completing the experiential component of the traineeship, trainees will be required to provide the ASHP Foundation with the following documentation, demonstrating application of the obtained knowledge and skills, before a certificate of completion will be issued: A copy of the proposed policies and procedures that they have submitted to their health system as part of their proposal for a new or enhanced pain management/palliative care service. Applicants should plan to take a draft of the policy/procedure to the experiential component of the traineeship to obtain feedback from the site preceptor. A letter from the physician colleague that describes how the program participant has become actively involved in the pain management/palliative care service at his or her health system site. An outline of a presentation on pain management/palliative care that he or she has made to associated health care providers. Trainees should plan to take a draft of their slides to the experiential component of the traineeship to obtain feedback from the site preceptor. Five (5) case vignettes that illustrate the trainee s post-traineeship application of the knowledge and skills obtained through the traineeship. Trainee Evaluation Form Evaluation The ASHP Foundation will evaluate program administration, program polices and the impact of training immediately after the experiential training and at 6 and 12 months. In addition, the faculty will participate in a structured discussion that evaluates the strengths and weaknesses of the overall program and opportunities for improvement.

Page 7 of 11 Application Process To apply to the traineeship, the applicant must complete an online application along with the following items: 1) A cover letter from the applicant that describes how they will use the training obtained through this program; 2) Four page maximum biographical sketch in NIH format; (See grants.nih.gov/grants/funding/phs398/biosketchsample.doc) 3) A letter of support from the chief executive officer of the applicants organization confirming a commitment to the establishment of a pain management/palliative service or other such organized care system for pain management/palliative care or the applicant s involvement in an existing service or care system; 4) A letter of support from the physician, or other individual, responsible for the management of a pain management/palliative care service or other such organized care system for pain management/palliative care indicating support for the applicant s participation on the service; and 5) A letter from the director of pharmacy that provides support for the applicant s participation in the program and post-training participation on the pain management/palliative care service. 6) Certification and Acceptance Form with all required signatures. The director of pharmacy, physician, and chief executive officer letters are critical to the reviewers evaluation of institutional support for the trainee to participate on the pain/palliative care services. These letters are also evaluated closely to assess sustainability of the service. International applicants must also provide: 1. Evidence of English proficiency (TOEFL results) or International English Language Testing System (IELTS) for individuals in countries where English is not the first language; TOFEL Score Scale Reading High (22-30) Listening High (22-30) Speaking Good (26-30) Writing Good (24-30) Band 7 Band 8 Band 9 IELTS Good User Very Good User Expert User

Page 8 of 11 2. If the United States requires that you obtain a visa for entry into the United States, a copy of an existing visa to travel to the U.S. to study or a detailed timeline indicating your ability to obtain a visa to participate in a 1-2 week education program in the United States; 3. A copy of your school/college of pharmacy diploma; and 4. Documentation from your college or school of pharmacy that it is an accredited institution. a. Exceptions: 1) United States citizens living outside of the U.S. do not need to submit English proficiency test results or visa information. 2) International applicants who graduated from a U.S. university do not need to submit English proficiency results or accreditation information. 3) Participants from English-speaking countries do not need to submit English proficiency test results. Selection Criteria All applications will be reviewed by a panel appointed by the ASHP Foundation Board of Directors. The following criteria will be used to review and score applications: Criterion Number Criteria Points 1 Academic Preparation 5 2 Clinical Practice and Academic Experience 5 3 Training Expectations (Along with applicant responses to related application questions, the applicant s cover letter will be used to score under this criterion.) 30 4 Institutional Support for Applicant to Participate in the Traineeship and Service Establishment or Enhancement (Along with applicant responses to related application questions, letters from the Director of Pharmacy, Medical Director and Chief Executive Officer will be used to score under this criterion.) 30 5 Institutional Service Viability (Along with applicant responses to related application questions, letters from the Director of Pharmacy, Medical Director and Chief Executive Officer will be used to score under this criterion.) 30 TOTAL 100

Page 9 of 11 Proposed Timeline for the 2014-2015 Program Offering Applications available June 23, 2014 Application deadline September 19, 2014 Participants announced November 2014 Experiential training April -May 2015 Post training requirements are due Fall 2015 ASHP Foundation Responsibilities The proposed program will be conducted for professional development and improving the quality of care to pain management/palliative care services. The ASHP Foundation will maintain control of all program development, content and administration in coordination with the program faculty. A Foundation staff member will coordinate all faculty activities including selection of preceptors, preceptor meetings and any curriculum material revisions/updates. The Foundation will: Coordinate all selection panel activities; Develop and administer of all aspects of the program promotion, application process, and selection process; Design, produce and distribute all promotional materials associated with the program; Design, produce and distribute all news releases about program participants; Provide communication and program updates to the sponsor representatives at mutually agreed upon intervals; Ensure participants successful completion of the distance education program; Coordinate placement of trainees at experiential sites; and Ensure that trainees submit post-training materials before issuance of certificates of completion. Qualifications of the Applicant To apply to the traineeship, the applicant must be a graduate of an accredited college or school of pharmacy. The applicant must have completed an accredited PGY1 residency or have 2 years experience in clinical practice. Current pharmacy residents are not eligible to apply. Applicants must have successfully completed levels 1 and 2 of the ASHP Foundation Pain Management and Palliative Care Traineeship.

Page 10 of 11 Upon acceptance into the program, the participant will be asked to provide evidence of HIPAA training and current vaccination status. The following vaccine-related information is required: Measles-documentation of administration of TWO measles vaccine doses in your lifetime or one dose if administered after 1980. If first measles vaccination was at 15 months of age or younger, it does not count toward the two lifetime doses. Rubella-proof of immunity to rubella, positive serology for rubella antibodies (copy of lab slip), or documentation of administration of rubella vaccine. Varicella-known past history of disease. A stated history is acceptable, or if there is no known history of disease: serology documenting absence or presence of antibody to VZ is required (copy of lab slip). Tuberculosis-evidence of negative PPD skin test results within the last 12 months or a tuberculosis screening questionnaire completed within the last 12 months. If the participant is PPD Positive, evidence of a chest x-ray within the last 12 months must be provided (symptom interview). Tetanus-documentation of administration of a tetanus vaccine within the last ten years. Hepatitis B-documentation of administration of the entire hepatitis B vaccine series and the booster dose if required. In addition, some sites may require that participants complete a criminal background check before arrival at the site. Qualifications of the Applicant's Healthcare Organization The applicant's employer must be a health care organization with resources for the provision of pain/palliative care patients. The chief executive officer and the physician who is responsible for the care of pain/palliative care patients must provide a letter of support for inclusion of the applicant on the pain management/palliative care service. If the service is already established, the chief executive officer and the physician who is responsible for care of pain management/palliative care must confirm that the pharmacist applying for the traineeship will be or is already involved in the pain management/palliative care team and provides drug therapy management to patients. They must also confirm that the participant s involvement in this patient care service will continue after the traineeship program. The organizational culture for pharmacist provision of direct patient care including drug therapy decision making will be described by each practice setting. A letter from the director of pharmacy that indicates support for the applicant s participation, departmental commitment to the applicant s participation on the pain/palliative care team and an institutional commitment to payment of the program tuition is required. Important Traineeship Polices The Pain Management and Palliative Care Program is administered by the ASHP Research and Education Foundation, 7272 Wisconsin Avenue, Bethesda, MD 20814, and funded by tuition support. Other administrative policies applying to this ASHP Foundation traineeship include the following: The traineeship is awarded to an individual participant. No stipend or honorarium is awarded to the participant.

Page 11 of 11 The participant is responsible for providing his or her transportation to the experiential site and lodging. Upon acceptance into the program, the participant will be asked to provide proof of liability insurance, evidence of current vaccination status, HIPPA training documentation, and other site-specific documentation before traveling to the training site. Some sites may require completion of a criminal background check before commencement of the experiential component. Tuition payments must be completed by May 31, 2015; If the participant must cancel his or her participation, he or she must notify the ASHP Foundation and preceptor at least 8 weeks in advance of the starting date of the experiential portion of the program. The participant will be required to attend all sessions of the program and to complete the post-training requirements and a program evaluation. Traineeship Administration The proposed program will be conducted for experiential professional development and improving the quality of pain and palliative care to patients. The ASHP Foundation will maintain full control of all program development, content and administration in coordination with the program faculty. Continuing education will be offered with this traineeship program. The Program will be conducted in accordance with the U.S. Food and Drug Administration s Guidelines for Industry-Supported Scientific and Educational Activities and the Accreditation Council for Continuing Medical Education (ACCME) Guidelines for Industry Support. The program will be administered according to the Standards and Quality Assurance Procedures for ACPE-Approved Providers of Continuing Pharmaceutical Education Offering Certificate Programs in Pharmacy. As part of its responsibility, the ASHP Research and Education Foundation will assure that these guidelines and standards are followed. The is administered by the ASHP Research and Education Foundation, 7272 Wisconsin Avenue, Bethesda, MD 20814, and is funded by tuition support. Questions regarding this traineeship should be directed to Daniel J. Cobaugh, Pharm.D. at foundation@ashp.org or at 301-664-8612.