ASHP InterSections ASHP InterSections

March 25, 2013

With Students’ Help, Pharmacists Reach Every Patient at Cleveland Clinic Florida

Front row, Diana Pinto Perez, Pharm.D., pharmacist, is joined by (from left) Lori Milicevic, Pharm.D., BCPS, pharmacist, and Eniko Balasso, Pharm.D., graduate intern.

ON THE HEELS of ASHP’s Pharmacy Practice Model Initiative Summit in 2010, Cleveland Clinic Florida (CCF) set the goal of giving all patients at the 155-bed academic institution the opportunity to interact with pharmacists as part of their care.

It was a lofty goal, one that would stretch the pharmacy department’s staff and resources.

In addition to the responsibilities they already had for conducting profile reviews, reviewing medication dosing, attending patient care rounds, and providing drug information, pharmacists would also take on conducting medication histories, performing medication reconciliation, and offering disease-state or discharge medication counseling on all patients.

They were clearly going to need help, and that help would come from pharmacy students.

Layered Learning Models for Students

Six months after the Summit, Osmel Delgado, Pharm.D., BCPS, cPH, administrative director of clinical operations and director of pharmacy services, and William Kernan, Pharm.D., BCPS, assistant director and PGY1 residency program director, traveled to Cleveland Clinic’s main campus in Cleveland.

At the Cleveland Clinic Pharmacy Practice Model Summit, they met with pharmacy thought leaders from prominent health systems and learned how other systems were incorporating PPMI recommendations into their practice models.

Osmel Delgado, Pharm.D., BCPS, cPH

Delgado and Kernan were particularly impressed with the layered learning models involving students at the University of Michigan and the University of North Carolina–Chapel Hill.

“We took their examples as lessons learned, and began to engage the colleges of pharmacies that we had affiliations with to see how we could accept more students,” Delgado said. “It took a good six to 12 months to refine and retool the ways we could create a valuable learning experience for the students, but also have them apply what they know in practice.”

Building On a Solid Foundation

CCF already had a progressive pharmacy program in which four clinical pharmacists would take on at least one student per month for introductory and advanced pharmacy practice experiences.

Under the new model, each preceptor would offer at least four rotations per month, and students would work as pharmacist extenders. The process begins with an orientation that covers the health system’s electronic medical records system, documentation practices, medication history and reconciliation processes, and disease-state and discharge education.

From left, student pharmacists Yesenia Fike and Pamela Silva (Nova Southeastern University College of Pharmacy, Class of 2013) consult about a patient’s medications.

After orientation, students provide hands-on care in rotation blocks up to three months long. The preceptors act as coaches, and they review and sign off on the students’ activities and patient notes.

“When students come to orientation, we tell them that they are crucial to the process and that we expect them to do what the pharmacists do and ask questions if they need help,” said Kernan. He added that the block rotations offer consistency across areas of care such as internal medicine, infectious disease, critical care, and anticoagulation.

“In each area, the students have to do medication reconciliation, provide discharge counseling, and answer patient questions about medications.”

Accessing Patient Charts

Under the old system, pharmacy students lacked individual computer access to the health system’s electronic medical records (EMR) and documentation system, which limited their ability to participate fully in recording care and tracking patients. That has since changed, according to Antonia Zapantis, Pharm.D., M.S., BCPS, preceptor in the program and associate professor at Nova Southeastern University College of Pharmacy, Fort Lauderdale, Fla.

“We felt it was crucial that students have access to the records and use the same systems and forms as the pharmacists, so that they could learn how to use these resources as part of providing pharmacy services,” she said.

The pharmacy informatics team reworked several aspects of the EMR and documentations systems so that students could put progress notes into patient charts. Pharmacists cosign the student notes.

Happier Patients, Better Outcomes

Thanks to student involvement in the hands-on provision of care, the pharmacy department has met its goal of providing every patient at CCF with pharmacist interaction. As a result, patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) have risen steadily over the last four quarters.

“The feedback we get from patients is that they’re happy to know and learn about their medications,” said Martha Espinoza-Friedman, Pharm.D., BCPS, clinical pharmacist and preceptor in the program. “Those who were in other hospitals before coming to CCF were impressed. They haven’t seen this kind of care before.”

Jaime Riskin, Pharm.D., BCPS

The patients are safer, too, said preceptor Jaime Riskin, Pharm.D., BCPS, clinical assistant professor at Nova Southeastern University College of Pharmacy.

“The pharmacy caught errors and documented adverse drug events because of all the students out there identifying discrepancies. It shows just how helpful students can be if you give them the right tools,” she said.

Riskin added that having access to the EMR system allows students to follow up and see whether their interventions made a difference in a patient’s care.

According to Kernan, the program at CCF shows how there is nothing to fear by extending the student experience into patient care areas. “We found that when you add more students, it makes your job more efficient. If you train them and use them right, it works in your favor.”

Delgado is optimistic about the future—for the program, the students who participate, and the students’ future patients.

“We’re teaching students to inject themselves into the process at key times for the patient, such as discharge or any transition of care from acute to post-acute settings,” he said. “As pharmacists, they will ultimately understand the importance of their work across an enterprise-wide continuum of care.”

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September 28, 2010

What I Learned: Reaching Patients In Central America

William P. Albanese is a Pharm. D. candidate, class of 2011, University of Maryland School of Pharmacy

When a friend invited University of Maryland pharmacy student William Albanese to travel to Honduras to help run a mobile medical clinic with Global Medical Brigades, a student-run non-governmental service organization, Albanese jumped at the opportunity. He thought it would be a chance to use his pharmacy education to help those with limited access to care, and he looked forward to getting practical experience counseling patients on the finer points of their medications. He didn’t think he would be talking about shampoo.

“It was a rural situation where roads are the exception and not the norm, and over half the population is more than 20 miles away from a medical professional,” Albanese said. “That takes it beyond medicine into basic health, and I did a lot of things that I didn’t expect to do. I wasn’t titrating drugs and getting labs. It was more like, ‘Here’s how to brush your teeth, and here’s how you use shampoo.’”

Facilitating Patient Care

That’s not to say that Albanese didn’t get the practical experience he craved. Quite the opposite. “From a pharmacy perspective, we became facilitators of the whole mission,” he said. “The physicians relied on us for a lot of things—assessments, therapeutic interchanges when drugs ran out, and just thinking on our feet. We had to be quick, yet precise.”

In one case, student input changed a diagnosis. A patient had come to the clinic with what physicians thought was asthma. “But when he described his situation, it sounded more like chronic obstructive pulmonary disease (COPD),” said Albanese. “We spent an extra five minutes going over his symptoms, and we learned that he’d been smoking for 60 years. When we spoke with the physician about it, he changed the prescription on the spot, and the patient walked away with three months of COPD meds.”

Events like that made getting up at 5:30 each morning, trucking for two hours over rough terrain, and getting back to the campsite at 6 or 7 p.m. well worth the effort, he added.

“Here in the U.S., students are often taught how to do physical exams and be more of a primary provider, yet we never get to actually experience it in person,” he said. “My first experience with an actual patient was in Honduras. After just three or four screenings, I felt so much better about being able to do exams properly.”

Realizing One’s Potential

Albanese feels that student opportunities like the one he experienced are all about realizing potential. “In an international setting, physicians wanted to see what we could do,” he said. “It was all under the supervision of a Honduran doctor, but we were given a chance to make things happen.”

%%sidebar%%The interdisciplinary interactions were priceless, he said. “The physicians asked a lot of questions, and allowed us to ask questions in return,” Albanese said. “Our input was an important part of the morning meetings.”

The experience taught Albanese something about himself, as well. “It made me realize that I need to interact with patients to be happy in the profession and in my career,” he said. “That’s what I crave. I can’t be a pharmacist who works from a remote location or behind a counter. It made my career take a different turn.”

Albanese plans to return to Honduras with Global Medical Brigades this winter. He will pack a suitcase of clothes and one of supplies and medications provided by the organization. While many students will be enjoying the holidays with their families, Albanese will be deep in a Central American jungle, keeping formulary records, educating patients about their medications, checking blood pressure—and explaining shampoo.

April 9, 2010

Cultivating a Deep Bench for Pharmacy

Michael Kelly, associate dean of the University of Iowa’s College of Pharmacy, works with a high school student.

MICHAEL KELLY, PHARM.D., is a recruiter for the University of Iowa. Instead of wooing young athletes for Hawkeyes sports teams, Kelly recruits potential clinical pharmacy talent.

In his attempts to pack a deep bench of talent among the student body at University of Iowa’s College of Pharmacy, where he is associate dean, Kelly has become an ambassador for health-system pharmacy in general.

“We are trying to move our recruiting down to middle school and early high school years,” Kelly said, adding that exposing young students to what pharmacists do helps to counter misperceptions about the profession and open the minds of young people to the rewards and challenges of a career in the field.

Attracting the Next Generation

“When you ask a little kid what they want to be, they usually don’t say, ‘I want to be a hospital pharmacist,’ ” noted Marni Lun, Pharm.D., M.B.A., director of ASHP’s Pharmacy Student Forum. Efforts such as those at the University of Iowa to educate students about careers in health-system pharmacy “help to ensure that we won’t miss out on valuable talent,” said Lun.

The College of Pharmacy works in partnership with other health sciences programs and with the university’s admissions office to host students, according to Kelly. Hundreds of middle and high school students from around Iowa and as far away as Chicago have participated in the program over the past several years.

In particular, the college is seeking to engage those students who don’t typically think of a career in pharmacy. “We’re focusing on underrepresented minorities,” Kelly says, including African American, Hispanic, and Native American students.

A “Hands On” Approach

RaShauna Applewhite, Spring 2010 Pharm.D. candidate at the University of Iowa

One young student impressed by a visit to University of Iowa’s College of Pharmacy was RaShauna Applewhite. As a freshman at Waterloo East High School in Waterloo, Iowa, several years ago, Applewhite visited the campus as part of a weeklong camp. The notion of a career in pharmacy intrigued her; this May, she expects to earn her Pharm.D. at University of Iowa.

“During one of the days, we visited the College of Pharmacy, and during that visit we made hand lotion,” Applewhite recalls. “Compounding the lotion was so fascinating, and I felt like pharmacy was a career that intrigued me.”

Hands-on activities seem to especially appeal to the students, according to Kelly. “When we get the glassware and chemicals out, they become engaged,” Kelly said, adding that he and his staff also teach students about how pharmacists work collaboratively with physicians and nurses on medical teams to care for patients.

%%SIDEBAR%%Kelly also takes the opportunity to debunk misperceptions about pharmacy, including the predominant view that pharmacists work only in retail settings dispensing medications.

Applewhite pointed to a black female pharmacist at the college, Lois Garland-Patterson, as someone who opened her eyes to the possibilities of a career in health-system pharmacy.

“She inspired me to pursue this career through her intelligence and passion for the profession,” Applewhite said. “Before meeting Lois, I had never met or talked to a pharmacist before, especially not an African American one. Throughout the rest of my high school career, I kept in touch with Lois. I knew when I prepared to graduate from high school that I definitely wanted to go to the University of Iowa.”

Applewhite first pursued a B.S. in microbiology at Iowa and then applied to the College of Pharmacy. At the time, “pharmacy was truly transitioning into a unique field,” she said, noting the profession’s increased patient-care focus.

“I’ve always known that I am a people person, and I like face-to-face interaction with patients daily,” she said. “I knew that with microbiology, I would probably be faced with isolation in a lab on a daily basis. I ultimately realized that pharmacy encompasses infectious disease as well as other disease states that I find  interesting.”

The University of Iowa’s outreach is important because “we don’t want to lose any good students,” said Kelly. Also, with younger students, Kelly is able to plant the seed they need to take four years of math and science in high school to have a realistic shot of getting into pharmacy school.

“We show them that there is a path, but you have to think about it earlier than later,” said Kelly.

“I am forever grateful to the people and opportunities in my life that encouraged me to go to pharmacy school and showed me that there are so many definitions to being a pharmacist,” Applewhite said.

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