NOTES Pharmacy practice model
ar Layar
Advancing the pharmacy practice model in a community teaching hospital by expanding student rotations Osmel Delgado, William P. Kernan, and Scott J. Knoer
P
harmacy has historically been altruistic in its approach to teaching pharmacy students. While organizations benefit from having a properly trained work force, students are many times hosted out of a sense of professional obligation. In today’s world of declining reimbursement, accountability for outcomes, and the constant pressure of doing more with less, it is imperative for pharmacy to significantly change its paradigm related to teaching. Any extra activities that pharmacy takes on, such as preceptorship of student rotations, must be associated with a measurable improvement in patient outcomes. By fostering deep partnerships with colleges of pharmacy, the colleges, students, and health systems directly benefit in tangible ways from these enhanced relationships. Pharmacy schools need strategic partners that offer high-quality rotations where students learn from providing direct patient care, gaining real-world experience as opposed to merely engaging in academic shadowing and discussions. Health systems benefit from pharmacist extenders who perform patient care services such as medication histories,
Purpose. The implementation, benefits, and outcomes of a layered learner model (LLM) using pharmacy students as pharmacist extenders are described. Summary. In 2011, Cleveland Clinic Florida (CCF) implemented a pharmacy practice model change with the goal of providing all inpatients quality pharmaceutical care while still providing key specialty clinical pharmacy services. An LLM was initiated in which pharmacists supervise pharmacy residents and students in a team format in which students are used as pharmacist extenders. CCF partnered with local and regional colleges of pharmacy to increase the number of advanced pharmacy practice experience student rotations at CCF. Students are given accountability for a specific number of patient beds based on their rotation. They are required to perform medication histories, education on drug indication and adverse effects, discharge counseling, targeted disease counseling, and profile
discharge education, and in-depth patient counseling. This article describes a community teaching hospital’s implementation of a layered learner model (LLM) that optimizes the use of advanced pharmacy practice experience (APPE) students as
Osmel Delgado, Pharm.D., M.B.A., BCPS, FASHP, is Chief Operating Officer; and William P. Kernan, Pharm.D., BCPS, is Assistant Director of Pharmacy, Cleveland Clinic Florida, Weston, FL. Scott J. Knoer, Pharm.D., M.S., FASHP, is Chief Pharmacy Officer, Cleveland Clinic, Cleveland, OH. Address correspondence to Dr. Delgado ([email protected]).
review for drug-related problems for their patients. After the implementation of this model, improvements were observed in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores (58% versus 70%, respectively), pharmacy interventions per patient per day (0.9 versus 1.4, respectively), and bedside medication delivery capture rate (48% versus 65%, respectively). Conclusion. The implementation of an LLM and partnering with local colleges of pharmacy have improved pharmacy practice at CCF by allowing pharmacy students to work as pharmacist extenders in providing comprehensive pharmacy services to many patients who would not otherwise be reached. This approach has improved HCAHPS scores within the “communication of medication” domain, increased overall patient interventions, and allowed expansion of CCF’s discharge prescription program. Am J Health-Syst Pharm. 2014; 71:1871-6
pharmacist extenders to expand direct patient care while improving the overall student learning experience. Background In November 2010, ASHP embarked on the Pharmacy Practice
The authors have declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/1101-1871. DOI 10.2146/ajhp130624
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NOTES Pharmacy practice model
Model Initiative (PPMI) in order to initiate and develop new practice models that will optimize the effective use of pharmacists and other pharmacy personnel.1 The ultimate goal of the PPMI is to improve outcomes of patients in health systems by identifying core pharmacyprovided patient care services and using all available resources (e.g., technology and human resources) to provide such services. Three key recommendations from the ASHP Pharmacy Practice Model Summit included the following: (1) all patients should receive care from their pharmacists, (2) pharmacists must be responsible for patients’ medication-related outcomes, and (3) pharmacy departments should reallocate resources to devote more effort toward managing medicationrelated services. While the ASHP Pharmacy Practice Model Summit did not specifically call for the use of students in the provision of patient care, ASHP has officially recognized the importance of students as pharmacist extenders. In 2009, ASHP passed a policy position calling for practice leaders to incorporate students into more active and meaningful ways as they reengineer their practice models.2 In 2013, ASHP expounded this position by approving a new policy stating that ASHP will promote pharmacy practice training models that use students in teams and recognize student pharmacists in providing direct patient care when overseen by a supervising pharmacist.3 In July 2011, the Cleveland Clinic hosted its own pharmacy practice model summit to launch its practice model initiative throughout its 10 hospitals and 17 family health centers/ambulatory surgery centers.4 The summit highlighted various pharmacy practices at other institutions where pharmacy services had changed to achieve the goals of the PPMI. In particular, the presentations by James Stevenson 1872
at the University of Michigan and Rowell Daniels at the University of North Carolina highlighted the use of students in new roles that foster the ability of pharmacy departments to provide more direct patient care activities. At the University of Michigan, introductory pharmacy practice experience students collect medication histories and improve medication reconciliation. Preceptors for APPE students include specialized pharmacists as well as a generalist pharmacist. The University of North Carolina increased its annual student capacity from 120 to 350 where students serve as clinician extenders. An LLM was initiated in which pharmacists supervise pharmacy residents and students in a team format.5 This model allows pharmacy to reach all patients in the hospital in contrast to the specialty pharmacist model, in which only patients within the specialty are reached. The LLM consists of a team of pharmacists, pharmacy residents, and pharmacy students responsible for the pharmaceutical care of the patient, similar to the medical training model in which care is provided to patients through an attending physician, residents, and students.5 The attending pharmacist is ultimately responsible for each patient on the team and supervises all activities by other pharmacists, residents, and students. This model allows for a greater number of patients to receive comprehensive pharmaceutical care and for all aspects of care to be reviewed. Cleveland Clinic Florida (CCF), located in Weston, Florida, is 1 of 10 hospitals in the Cleveland Clinic Health System. It is a 155-bed teaching hospital that has medical and surgical residency and fellowship programs, along with medical students and students from other allied health professions. CCF has adjoining clinics with 215 physicians representing 40 different adult clinical specialties, making it the largest group practice in the south Florida
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region. The pharmacy department consists of 36 staff members, including 2 postgraduate year 1 pharmacy practice residents. Inpatient clinical services are provided in critical care, nutrition, internal medicine, infectious diseases, anticoagulation, and oncology. Ambulatory care services are provided in the CCF outpatient community pharmacy and in the outpatient infusion therapy center. After the Cleveland Clinic Practice Model Summit in July 2011, CCF sought to change its practice model in order to provide comprehensive pharmacy services to all patients while still providing key specialty clinical pharmacy services. A new focus was placed on medication discharge counseling, medication history review, and an improved understanding of medications by all patients. Implementation of the LLM A major restructuring of the workload was needed to facilitate the goal of obtaining pharmacygenerated medication histories and discharge counseling for all patients in a cost-neutral manner. Direct patient care activities were prioritized over non–patient care services, such as pharmacy and therapeutics committee-related activities and other teaching priorities that were previously provided by the clinical specialist. Patients who had historically received only distributive pharmacy services were added to clinical pharmacists’ patient assignments (e.g., the critical care specialist reviewed patients on the medical and surgical units in addition to the intensive care units patients routinely seen). However, even with the reduction in nonclinical services, the pharmacists found it difficult to reach all patients on a routine basis. Department leadership decided to take cues from speakers at the Cleveland Clinic Practice Model Summit and implement an LLM that relied heavily on students to perform medication histories under the direction of a
NOTES Pharmacy practice model
pharmacist. APPE students were then tasked with providing direct patient care activities as part of their learning experience. Each APPE student was assigned a set number of patient beds daily for which he or she was accountable. The students now counsel their patients daily, obtain medication histories, screen for drug-related problems, identify medication-related interventions, and provide discharge counseling. Students document these activities in the electronic health record with either an inpatient note or an electronic intervention. The supervising pharmacist reviews this documentation, cosigns any inpatient notes, and discusses any relevant drug-related problems that need to be addressed, as the pharmacists are ultimately responsible for each patient. The pharmacists have found that this team approach allows more students to reach more patients while maintaining an appropriate ratio of patients to students. In order to implement an LLM in which students provide direct patient care, the pharmacy department needed to significantly expand its number of APPE student rotations. Rotations range from core offerings such as internal medicine to elective rotation offerings such as anticoagulation. The dramatic increase in the number of APPE student rotations required an expansion of affiliations and partnerships with key colleges of pharmacy. Previously, CCF had student affiliation agreements with the colleges of pharmacy from Nova Southeastern University and Palm Beach Atlantic University. New affiliation agreements were signed with the colleges of pharmacy from Lake Erie College of Medicine, Philadelphia College of Osteopathic Medicine, and Florida A&M University between 2011 and 2013, during which time the number of students at CCF rose considerably. In 2011, clinical pharmacists had a baseline of 1 or 2 students per rotation block,
with approximately 98 total students annually. In 2012, the number of students increased to 3 or 4 students per rotation block, with over 146 total students annually. In 2013, this ratio increased to 5 or 6 students per rotation block, with over 226 total students annually. The infrastructure associated with successfully organizing 226 students in a 150-bed hospital and training students for direct patient care roles is substantial. It was essential to work closely with the college of pharmacy partners to facilitate this expansion. Two faculty members from Nova Southeastern University College of Pharmacy and one faculty member from Florida A&M University College of Pharmacy were assigned to CCF as part of their practice location. Part of their role was to work closely with the clinical pharmacists to develop and coordinate a standard student orientation and student group topic discussions and journal clubs so that clinical pharmacists could focus more on direct patient care activities. The faculty also facilitated pharmacy resident research and other preceptor development activities. A standard orientation for all students entering CCF was developed and initiated. All students receive one day of initial instruction that covers general topics, such as how to take medication histories and perform discharge counseling. This minimizes the orientation time each individual preceptor spends with his or her students so that time is dedicated to direct patient care and removes redundancy by the preceptors. The orientation begins with a review of the electronic health record, covering how to navigate the system, review medication profiles, review laboratory and microbiology test results, and document inpatient notes and other intradepartmental pharmacy communication. Students receive education from pharmacy leadership on professionalism, expectations of student behavior, and Hospital
Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Finally, college of pharmacy faculty review key aspects of patient counseling, such as obtaining an effective medication history and using teach-back principles. The implementation of an LLM presented challenges on how preceptors interact with students. In the traditional preceptor–student relationship, preceptors had more direct oversight of the students in their interactions with patients, particularly with only one or two students per preceptor. However, in the LLM, with up to five or six students per preceptor, students have more independence. They are assigned a greater number of patients to review and counsel, and then report back to preceptors. Preceptors observed that significant variability existed in how well students completed medication histories, profile review, and discharge counseling. After discussion among pharmacy leadership, clinical pharmacists, and college of pharmacy faculty, the decision was made to use the teaching model of instruction, modeling, coaching, and facilitating to better ensure student learning under the LLM.6 The use of this teaching model was reviewed and discussed at various clinical meetings to familiarize preceptors with its methods. In particular, the benefits of modeling students for obtaining medication histories and providing discharge counseling was stressed, since many students have little experience performing such tasks. After initial instruction from the standardized orientation, preceptors assess the baseline performance of each student. The preceptor models how to correctly perform these tasks and coaches each student closely until a satisfactory level of competency is achieved. Students must demonstrate their competency under direct observation of the preceptor before they are able to perform these activities on
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their own with extended supervision by the preceptor. Preceptors then regularly assess student competency throughout the rotation by direct observation or assessment of patients’ understanding after the student has counseled them. The competency assessment is formally documented by the preceptor for each student rotation. The student has the opportunity to evaluate the rotation both at the college of pharmacy and at CCF. Outcomes of the LLM Both direct and indirect markers associated with the practice model change were measured. It was expected that it would likely take time to demonstrate an impact through some of the measurable markers. HCAHPS scores assess patient perspectives over nine key areas, ranging from communication with doctors and nurses to cleanliness of the hospital, and are currently the national standard for assessing patient satisfaction with hospital care.7 CCF assessed the LLM’s impact on HCAHPS scores with a focus on the “communication of medication” domain. For six consecutive quarters beginning in January 2012, CCF achieved improvement in “communication of medication” domain scores, with the proportion of “always” responses increasing from 58% at the start of that period to 70% at the end. This improvement correlated with the implementation of the practice model change. Interacting directly with patients in a proactive manner through bedside prescription delivery and patient education had a positive effect on patients’ perception of medication communication as defined by medication-related HCAHPS scores. Readmission rates for targeted diseases such as pneumonia, acute myocardial infarction, and congestive heart failure (CHF) have not yet demonstrated a reduction resulting from the pharmacy practice model change. However, the amount of counseling completed for these targeted diseases increased substantially 1874
after the practice model change and implementation of the LLM at CCF. From 2011 to 2013, pharmacist interventions per patient increased 55%, with discharge counseling and medication reconciliations accounting for the majority of this increase. Although readmission rates have not yet been affected by the practice model change, pharmacy staff subjectively feel that they are improving patients’ understanding of their medication-related issues, particularly with the subset of patients with a high risk of hospital readmission. The implementation of a practice model change using an LLM has enabled the pharmacy staff to fully reconcile patient medication lists. Students review the medication history with the patient and reconcile any inconsistencies found between the home medication list and the inpatient medication list. The increased number of students serving as pharmacist extenders has decreased the load of patients per pharmacy staff member from 30:1 to 7:1. This low ratio has allowed CCF to thoroughly interview patients about their medications to gain a full understanding of the intricacies of patients’ home medication regimens. The detailed level of information obtained from patients has facilitated a higher number of pharmacy interventions per patient day (0.9 versus 1.4) compared with the previous practice model. In addition to a higher intervention rate, the pharmacy is now fully equipped to meet the intended purpose of medication reconciliation as defined by many organizations focused on patient safety and quality, such as the Joint Commission8 and the Agency for Healthcare Research and Quality.9 These organizations define medication reconciliation as the process of avoiding inadvertent inconsistencies with medication regimens across transitions of care by reviewing the patient’s complete medication regimen at the time of admission, transfer, and discharge.
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The increased presence of pharmacy personnel in all hospital units has facilitated a more involved level of pharmacy practice during transitions of care, particularly during admission and discharge. This is particularly important during the discharge process, when high-risk drugs, such as anticoagulants, are often newly prescribed. Pharmacists at CCF also facilitate coordinated interprofessional care with the medical and nursing staff, ensuring a full understanding of all medications at discharge. The LLM at CCF leverages the comprehensive nature of the pharmacy enterprise by ensuring that inpatient staff work in coordination with the outpatient pharmacy to offer bedside delivery of discharge medication prescriptions before patients leave the hospital. This ensures that potential insurance issues are handled and completes one component of a comprehensive medication adherence program. The other component consists of full comprehension of the new medication regimen at discharge. Other financial benefits to the organization are gained through a discharge delivery program. Filling these prescriptions is not only a patient-centered convenience that facilitates compliance but also results in a significant increase in collateral incremental revenue generated indirectly by our medical staff that would otherwise go to external third-party pharmacies. The number of bedside discharge prescriptions delivered was also measured as a marker of adherence and discharge education, as students and pharmacist counsel most discharged patients. The bedside discharge prescription capture rate increased from 48% to 65% over the 2012 calendar year. The capture rate of potential revenue adequately supports a return on investment which validates providing such a program within a hospital. Many retail pharmacy chains have begun to offer these services to
NOTES Pharmacy practice model
hospitals that have not pursued such pharmacy services. Discussion The expansion of students used as pharmacist extenders in an LLM improved the overall care of our patients. The number of pharmacist extenders was directly correlated with improvements in HCAHPS scores and increased numbers of pharmacy interventions, patient counseling encounters, and prescriptions delivered to the bedside. While not directly measured, the leadership team interpreted these results to indicate that patients have an improved understanding of their medications, have fewer medication-related errors, and are more adherent to their medication regimens. While CCF’s practice model is not a controlled trial, other programs have demonstrated similar results when evaluating the impact of pharmacist-provided discharge counseling. Sarangarm et al.10 performed a randomized controlled trial comparing pharmacist-provided discharge counseling with standard discharge counseling by a nurse. The trial revealed that pharmacist counseling at discharge significantly increased the detection of problems that required corrective medical interventions, improved patient satisfaction, and improved medication adherence. That study, however, did not use APPE students, so a direct correlation to our experience may warrant caution. While drug cost savings and reductions in adverse drug events were not measured, such benefits can be expected since pharmacists and students were able to review and recommend changes to patients’ profiles before discharge. Chinthammit et al.11 evaluated the cost-effectiveness of pharmacistprovided discharge counseling and found that such counseling was associated with cost savings in 48% of the patients counseled. They also found that pharmacist-provided counsel-
ing to elderly patients significantly reduced the number of adverse drug reactions and overall healthcare costs. Al Ghamdi et al.12 found that pharmacist discharge counseling led to a 22% reduction in adverse events. These studies demonstrate the value of pharmacist discharge counseling and validate the importance of extending pharmacist counseling to all patients. Such a task may only be practical today with the utilization of an LLM in which students and residents are used to counsel all patients in a hospital setting. Ideally, the impact on 30-day readmissions for targeted diseases such as CHF and chronic obstructive pulmonary disease should be assessed. As part of our practice model, pharmacists, residents, and students perform specialized counseling to all patients with CHF, chronic obstructive pulmonary disease, acute myocardial infarction, or pneumonia; however, there is little evidence that such counseling reduces 30-day readmissions. Szkiladz et al.13 utilized students and residents to perform discharge counseling for patients with CHF but did not find a reduction in 30-day CHF readmission rates when compared with standard discharge counseling. However, the authors did see a reduction in medication errors that resulted in significant cost avoidance for the institution and found that patients demonstrated an improved understanding of their medications. Since that study used students and residents in a similar capacity as in our practice model, it would be reasonable to expect similar outcomes at our institution. While the use of students in an LLM has provided substantial benefits to our patients, some limitations exist. Currently, we do not provide pharmacy services such as discharge counseling, medication reconciliation, and bedside delivery on weekends and evenings. Efforts are ongoing to effectively implement coverage during these times to en-
sure that all patients are reached. The student rotation structure and hours are being evaluated and adjusted to reflect the practical need to provide care while maintaining an adequate learning experience to ensure that students achieve the necessary skills. In addition, pharmacist schedules will require adjustment as preceptor supervision must be provided during these extended hours and weekends. Another challenge involves student availability from the colleges of pharmacy. Many schools limit rotations in May and December due to graduation and the holiday break. This presents a challenge, as the number of APPE students available is significantly reduced during these months, resulting in inadequate coverage. Subsequently, pharmacy management may need to adjust schedules to provide more resources during these months, and pharmacists must adjust work priorities and work collaboratively to reach all patients during this time. Increasing the number of affiliation agreements with colleges of pharmacy may help reduce the likelihood of student reductions during these months. These issues present significant challenges to further expansion of our practice model and full utilization of the LLM. We have also assumed that students are achieving an enhanced learning experience through the LLM. Students must still achieve core objectives for their specific rotation while providing general pharmacy service functions such as medication reconciliation, discharge counseling, and profile review, all under the supervision of a pharmacist. Students gain added skills in communicating important healthcare information that may not be emphasized, taught, or evaluated in the traditional specialized rotation format. Evaluations of the rotations by the students have not reflected a drop in student satisfaction with the learning experience. Preceptors are ultimately responsible for the care students provide
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under their direction. A specific ratio of preceptors to students has not been established as an educational standard, and the state of Florida does not specify a maximum ratio. We believe our ratio provides appropriate supervision of students to obtain medication histories, provide discharge counseling, and perform other monitoring services. By garnering feedback from patients, students, and other caregivers, preceptors effectively monitor the care provided by their students. We have not observed an increase in medication errors or in complaints from patients about the extensive pharmacy student interaction. Although unsubstantiated through hard data, there has been an increase in subjective positive feedback from multiple disciplines on the benefit of having pharmacy students more actively involved in patient care. Conclusion The implementation of an LLM and partnering with local colleges of pharmacy have improved pharmacy practice at CCF by allowing pharmacy students to work as pharmacist ex-
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tenders in providing comprehensive pharmacy services to many patients who would not otherwise be reached. This approach has improved HCAHPS scores within the “communication of medication” domain, increased overall patient interventions, and allowed expansion of CCF’s discharge prescription program. References 1. American Society of Health-System Pharmacists. Pharmacy Practice Model Summit: executive summary. Am J Health-Syst Pharm. 2011; 68:1079-85. 2. American Society of Health-System Pharmacists. ASHP policy positions, 2009–2012 (with rationales): education and training. www.ashp.org/DocLibrary/ BestPractices/EducationPositions.aspx (accessed 2013 Aug 26). 3. American Society of Health-System Pharmacists. ASHP policies approved by the 2013 ASHP House of Delegates. www.ashp.org/DocLibrary/Policy/HOD/ OfficialLang2013Policies.aspx (accessed 2013 Aug 26). 4. Knoer S, Weber RJ, Witmer DR et al. Highlights of the Cleveland Clinic Pharmacy Practice Model Summit. Am J Health-Syst Pharm. 2013; 70:356-65. 5. Buie L. The layered learning practice model and the pharmacy practice model initiative. http://connect.ashp.org/ blogsmain/blogviewer/?BlogKey=1ff0fea1dd0b-46c3-81f6-b5c5ec1e0e95 (accessed 2013 Aug 26).
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6. Weitzel W, Walters EA, Taylor J. Teaching clinical problem solving: a preceptor’s guide. Am J Health-Syst Pharm. 2012; 69:1588-99. 7. Centers for Medicare and Medicaid Services. HCAHPS: patients’ perspectives of care survey. www.cms.gov/medicare/qualityinitiatives-patient-assessment-instruments/ hospitalqualityinits/hospitalhcahps.html (accessed 2013 Sep 2). 8. Joint Commission. Sentinel event alert: using medication reconciliation to prevent errors. www.jointcommission.org/ SentinelEvents/SentinelEventAlertsea_35. htm (accessed 2013 Sep 2). 9. Agency for Healthcare Research and Quality. Patient safety primers: medication reconciliation. http://psnet.ahrq.gov/ primer.aspx?primerID=1 (accessed 2013 Sep 2). 10. Sarangarm P, London MS, Snowden SS et al. Impact of pharmacist discharge medication therapy counseling and disease state education: Pharmacist Assisting at Routine Medical Discharge (project PhARMD). Am J Med Qual. 2013; 28:292-300. 11. Chinthammit C, Armstrong EP, Warholak TL. A cost effectiveness evaluation of hospital discharge counseling by pharmacists. J Pharm Pract. 2011; 25:201-8. 12. Al Ghamdi S, Mahmoud MA, Alammari MA et al. The outcome of pharmacist counseling at the time of hospital discharge: an observational nonrandomized study. Ann Saudi Med. 2012; 32:492-7. 13. Szkiladz A, Carey K, Ackerbauer K et al. Impact of pharmacy student and resident-led discharge counseling on heart failure patients. J Pharm Pract. 2013; 26:574-9.
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ar Layar
Advancing the pharmacy practice model in a community teaching hospital by expanding student rotations Osmel Delgado, William P. Kernan, and Scott J. Knoer
P
harmacy has historically been altruistic in its approach to teaching pharmacy students. While organizations benefit from having a properly trained work force, students are many times hosted out of a sense of professional obligation. In today’s world of declining reimbursement, accountability for outcomes, and the constant pressure of doing more with less, it is imperative for pharmacy to significantly change its paradigm related to teaching. Any extra activities that pharmacy takes on, such as preceptorship of student rotations, must be associated with a measurable improvement in patient outcomes. By fostering deep partnerships with colleges of pharmacy, the colleges, students, and health systems directly benefit in tangible ways from these enhanced relationships. Pharmacy schools need strategic partners that offer high-quality rotations where students learn from providing direct patient care, gaining real-world experience as opposed to merely engaging in academic shadowing and discussions. Health systems benefit from pharmacist extenders who perform patient care services such as medication histories,
Purpose. The implementation, benefits, and outcomes of a layered learner model (LLM) using pharmacy students as pharmacist extenders are described. Summary. In 2011, Cleveland Clinic Florida (CCF) implemented a pharmacy practice model change with the goal of providing all inpatients quality pharmaceutical care while still providing key specialty clinical pharmacy services. An LLM was initiated in which pharmacists supervise pharmacy residents and students in a team format in which students are used as pharmacist extenders. CCF partnered with local and regional colleges of pharmacy to increase the number of advanced pharmacy practice experience student rotations at CCF. Students are given accountability for a specific number of patient beds based on their rotation. They are required to perform medication histories, education on drug indication and adverse effects, discharge counseling, targeted disease counseling, and profile
discharge education, and in-depth patient counseling. This article describes a community teaching hospital’s implementation of a layered learner model (LLM) that optimizes the use of advanced pharmacy practice experience (APPE) students as
Osmel Delgado, Pharm.D., M.B.A., BCPS, FASHP, is Chief Operating Officer; and William P. Kernan, Pharm.D., BCPS, is Assistant Director of Pharmacy, Cleveland Clinic Florida, Weston, FL. Scott J. Knoer, Pharm.D., M.S., FASHP, is Chief Pharmacy Officer, Cleveland Clinic, Cleveland, OH. Address correspondence to Dr. Delgado ([email protected]).
review for drug-related problems for their patients. After the implementation of this model, improvements were observed in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores (58% versus 70%, respectively), pharmacy interventions per patient per day (0.9 versus 1.4, respectively), and bedside medication delivery capture rate (48% versus 65%, respectively). Conclusion. The implementation of an LLM and partnering with local colleges of pharmacy have improved pharmacy practice at CCF by allowing pharmacy students to work as pharmacist extenders in providing comprehensive pharmacy services to many patients who would not otherwise be reached. This approach has improved HCAHPS scores within the “communication of medication” domain, increased overall patient interventions, and allowed expansion of CCF’s discharge prescription program. Am J Health-Syst Pharm. 2014; 71:1871-6
pharmacist extenders to expand direct patient care while improving the overall student learning experience. Background In November 2010, ASHP embarked on the Pharmacy Practice
The authors have declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/1101-1871. DOI 10.2146/ajhp130624
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NOTES Pharmacy practice model
Model Initiative (PPMI) in order to initiate and develop new practice models that will optimize the effective use of pharmacists and other pharmacy personnel.1 The ultimate goal of the PPMI is to improve outcomes of patients in health systems by identifying core pharmacyprovided patient care services and using all available resources (e.g., technology and human resources) to provide such services. Three key recommendations from the ASHP Pharmacy Practice Model Summit included the following: (1) all patients should receive care from their pharmacists, (2) pharmacists must be responsible for patients’ medication-related outcomes, and (3) pharmacy departments should reallocate resources to devote more effort toward managing medicationrelated services. While the ASHP Pharmacy Practice Model Summit did not specifically call for the use of students in the provision of patient care, ASHP has officially recognized the importance of students as pharmacist extenders. In 2009, ASHP passed a policy position calling for practice leaders to incorporate students into more active and meaningful ways as they reengineer their practice models.2 In 2013, ASHP expounded this position by approving a new policy stating that ASHP will promote pharmacy practice training models that use students in teams and recognize student pharmacists in providing direct patient care when overseen by a supervising pharmacist.3 In July 2011, the Cleveland Clinic hosted its own pharmacy practice model summit to launch its practice model initiative throughout its 10 hospitals and 17 family health centers/ambulatory surgery centers.4 The summit highlighted various pharmacy practices at other institutions where pharmacy services had changed to achieve the goals of the PPMI. In particular, the presentations by James Stevenson 1872
at the University of Michigan and Rowell Daniels at the University of North Carolina highlighted the use of students in new roles that foster the ability of pharmacy departments to provide more direct patient care activities. At the University of Michigan, introductory pharmacy practice experience students collect medication histories and improve medication reconciliation. Preceptors for APPE students include specialized pharmacists as well as a generalist pharmacist. The University of North Carolina increased its annual student capacity from 120 to 350 where students serve as clinician extenders. An LLM was initiated in which pharmacists supervise pharmacy residents and students in a team format.5 This model allows pharmacy to reach all patients in the hospital in contrast to the specialty pharmacist model, in which only patients within the specialty are reached. The LLM consists of a team of pharmacists, pharmacy residents, and pharmacy students responsible for the pharmaceutical care of the patient, similar to the medical training model in which care is provided to patients through an attending physician, residents, and students.5 The attending pharmacist is ultimately responsible for each patient on the team and supervises all activities by other pharmacists, residents, and students. This model allows for a greater number of patients to receive comprehensive pharmaceutical care and for all aspects of care to be reviewed. Cleveland Clinic Florida (CCF), located in Weston, Florida, is 1 of 10 hospitals in the Cleveland Clinic Health System. It is a 155-bed teaching hospital that has medical and surgical residency and fellowship programs, along with medical students and students from other allied health professions. CCF has adjoining clinics with 215 physicians representing 40 different adult clinical specialties, making it the largest group practice in the south Florida
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region. The pharmacy department consists of 36 staff members, including 2 postgraduate year 1 pharmacy practice residents. Inpatient clinical services are provided in critical care, nutrition, internal medicine, infectious diseases, anticoagulation, and oncology. Ambulatory care services are provided in the CCF outpatient community pharmacy and in the outpatient infusion therapy center. After the Cleveland Clinic Practice Model Summit in July 2011, CCF sought to change its practice model in order to provide comprehensive pharmacy services to all patients while still providing key specialty clinical pharmacy services. A new focus was placed on medication discharge counseling, medication history review, and an improved understanding of medications by all patients. Implementation of the LLM A major restructuring of the workload was needed to facilitate the goal of obtaining pharmacygenerated medication histories and discharge counseling for all patients in a cost-neutral manner. Direct patient care activities were prioritized over non–patient care services, such as pharmacy and therapeutics committee-related activities and other teaching priorities that were previously provided by the clinical specialist. Patients who had historically received only distributive pharmacy services were added to clinical pharmacists’ patient assignments (e.g., the critical care specialist reviewed patients on the medical and surgical units in addition to the intensive care units patients routinely seen). However, even with the reduction in nonclinical services, the pharmacists found it difficult to reach all patients on a routine basis. Department leadership decided to take cues from speakers at the Cleveland Clinic Practice Model Summit and implement an LLM that relied heavily on students to perform medication histories under the direction of a
NOTES Pharmacy practice model
pharmacist. APPE students were then tasked with providing direct patient care activities as part of their learning experience. Each APPE student was assigned a set number of patient beds daily for which he or she was accountable. The students now counsel their patients daily, obtain medication histories, screen for drug-related problems, identify medication-related interventions, and provide discharge counseling. Students document these activities in the electronic health record with either an inpatient note or an electronic intervention. The supervising pharmacist reviews this documentation, cosigns any inpatient notes, and discusses any relevant drug-related problems that need to be addressed, as the pharmacists are ultimately responsible for each patient. The pharmacists have found that this team approach allows more students to reach more patients while maintaining an appropriate ratio of patients to students. In order to implement an LLM in which students provide direct patient care, the pharmacy department needed to significantly expand its number of APPE student rotations. Rotations range from core offerings such as internal medicine to elective rotation offerings such as anticoagulation. The dramatic increase in the number of APPE student rotations required an expansion of affiliations and partnerships with key colleges of pharmacy. Previously, CCF had student affiliation agreements with the colleges of pharmacy from Nova Southeastern University and Palm Beach Atlantic University. New affiliation agreements were signed with the colleges of pharmacy from Lake Erie College of Medicine, Philadelphia College of Osteopathic Medicine, and Florida A&M University between 2011 and 2013, during which time the number of students at CCF rose considerably. In 2011, clinical pharmacists had a baseline of 1 or 2 students per rotation block,
with approximately 98 total students annually. In 2012, the number of students increased to 3 or 4 students per rotation block, with over 146 total students annually. In 2013, this ratio increased to 5 or 6 students per rotation block, with over 226 total students annually. The infrastructure associated with successfully organizing 226 students in a 150-bed hospital and training students for direct patient care roles is substantial. It was essential to work closely with the college of pharmacy partners to facilitate this expansion. Two faculty members from Nova Southeastern University College of Pharmacy and one faculty member from Florida A&M University College of Pharmacy were assigned to CCF as part of their practice location. Part of their role was to work closely with the clinical pharmacists to develop and coordinate a standard student orientation and student group topic discussions and journal clubs so that clinical pharmacists could focus more on direct patient care activities. The faculty also facilitated pharmacy resident research and other preceptor development activities. A standard orientation for all students entering CCF was developed and initiated. All students receive one day of initial instruction that covers general topics, such as how to take medication histories and perform discharge counseling. This minimizes the orientation time each individual preceptor spends with his or her students so that time is dedicated to direct patient care and removes redundancy by the preceptors. The orientation begins with a review of the electronic health record, covering how to navigate the system, review medication profiles, review laboratory and microbiology test results, and document inpatient notes and other intradepartmental pharmacy communication. Students receive education from pharmacy leadership on professionalism, expectations of student behavior, and Hospital
Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Finally, college of pharmacy faculty review key aspects of patient counseling, such as obtaining an effective medication history and using teach-back principles. The implementation of an LLM presented challenges on how preceptors interact with students. In the traditional preceptor–student relationship, preceptors had more direct oversight of the students in their interactions with patients, particularly with only one or two students per preceptor. However, in the LLM, with up to five or six students per preceptor, students have more independence. They are assigned a greater number of patients to review and counsel, and then report back to preceptors. Preceptors observed that significant variability existed in how well students completed medication histories, profile review, and discharge counseling. After discussion among pharmacy leadership, clinical pharmacists, and college of pharmacy faculty, the decision was made to use the teaching model of instruction, modeling, coaching, and facilitating to better ensure student learning under the LLM.6 The use of this teaching model was reviewed and discussed at various clinical meetings to familiarize preceptors with its methods. In particular, the benefits of modeling students for obtaining medication histories and providing discharge counseling was stressed, since many students have little experience performing such tasks. After initial instruction from the standardized orientation, preceptors assess the baseline performance of each student. The preceptor models how to correctly perform these tasks and coaches each student closely until a satisfactory level of competency is achieved. Students must demonstrate their competency under direct observation of the preceptor before they are able to perform these activities on
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their own with extended supervision by the preceptor. Preceptors then regularly assess student competency throughout the rotation by direct observation or assessment of patients’ understanding after the student has counseled them. The competency assessment is formally documented by the preceptor for each student rotation. The student has the opportunity to evaluate the rotation both at the college of pharmacy and at CCF. Outcomes of the LLM Both direct and indirect markers associated with the practice model change were measured. It was expected that it would likely take time to demonstrate an impact through some of the measurable markers. HCAHPS scores assess patient perspectives over nine key areas, ranging from communication with doctors and nurses to cleanliness of the hospital, and are currently the national standard for assessing patient satisfaction with hospital care.7 CCF assessed the LLM’s impact on HCAHPS scores with a focus on the “communication of medication” domain. For six consecutive quarters beginning in January 2012, CCF achieved improvement in “communication of medication” domain scores, with the proportion of “always” responses increasing from 58% at the start of that period to 70% at the end. This improvement correlated with the implementation of the practice model change. Interacting directly with patients in a proactive manner through bedside prescription delivery and patient education had a positive effect on patients’ perception of medication communication as defined by medication-related HCAHPS scores. Readmission rates for targeted diseases such as pneumonia, acute myocardial infarction, and congestive heart failure (CHF) have not yet demonstrated a reduction resulting from the pharmacy practice model change. However, the amount of counseling completed for these targeted diseases increased substantially 1874
after the practice model change and implementation of the LLM at CCF. From 2011 to 2013, pharmacist interventions per patient increased 55%, with discharge counseling and medication reconciliations accounting for the majority of this increase. Although readmission rates have not yet been affected by the practice model change, pharmacy staff subjectively feel that they are improving patients’ understanding of their medication-related issues, particularly with the subset of patients with a high risk of hospital readmission. The implementation of a practice model change using an LLM has enabled the pharmacy staff to fully reconcile patient medication lists. Students review the medication history with the patient and reconcile any inconsistencies found between the home medication list and the inpatient medication list. The increased number of students serving as pharmacist extenders has decreased the load of patients per pharmacy staff member from 30:1 to 7:1. This low ratio has allowed CCF to thoroughly interview patients about their medications to gain a full understanding of the intricacies of patients’ home medication regimens. The detailed level of information obtained from patients has facilitated a higher number of pharmacy interventions per patient day (0.9 versus 1.4) compared with the previous practice model. In addition to a higher intervention rate, the pharmacy is now fully equipped to meet the intended purpose of medication reconciliation as defined by many organizations focused on patient safety and quality, such as the Joint Commission8 and the Agency for Healthcare Research and Quality.9 These organizations define medication reconciliation as the process of avoiding inadvertent inconsistencies with medication regimens across transitions of care by reviewing the patient’s complete medication regimen at the time of admission, transfer, and discharge.
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The increased presence of pharmacy personnel in all hospital units has facilitated a more involved level of pharmacy practice during transitions of care, particularly during admission and discharge. This is particularly important during the discharge process, when high-risk drugs, such as anticoagulants, are often newly prescribed. Pharmacists at CCF also facilitate coordinated interprofessional care with the medical and nursing staff, ensuring a full understanding of all medications at discharge. The LLM at CCF leverages the comprehensive nature of the pharmacy enterprise by ensuring that inpatient staff work in coordination with the outpatient pharmacy to offer bedside delivery of discharge medication prescriptions before patients leave the hospital. This ensures that potential insurance issues are handled and completes one component of a comprehensive medication adherence program. The other component consists of full comprehension of the new medication regimen at discharge. Other financial benefits to the organization are gained through a discharge delivery program. Filling these prescriptions is not only a patient-centered convenience that facilitates compliance but also results in a significant increase in collateral incremental revenue generated indirectly by our medical staff that would otherwise go to external third-party pharmacies. The number of bedside discharge prescriptions delivered was also measured as a marker of adherence and discharge education, as students and pharmacist counsel most discharged patients. The bedside discharge prescription capture rate increased from 48% to 65% over the 2012 calendar year. The capture rate of potential revenue adequately supports a return on investment which validates providing such a program within a hospital. Many retail pharmacy chains have begun to offer these services to
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hospitals that have not pursued such pharmacy services. Discussion The expansion of students used as pharmacist extenders in an LLM improved the overall care of our patients. The number of pharmacist extenders was directly correlated with improvements in HCAHPS scores and increased numbers of pharmacy interventions, patient counseling encounters, and prescriptions delivered to the bedside. While not directly measured, the leadership team interpreted these results to indicate that patients have an improved understanding of their medications, have fewer medication-related errors, and are more adherent to their medication regimens. While CCF’s practice model is not a controlled trial, other programs have demonstrated similar results when evaluating the impact of pharmacist-provided discharge counseling. Sarangarm et al.10 performed a randomized controlled trial comparing pharmacist-provided discharge counseling with standard discharge counseling by a nurse. The trial revealed that pharmacist counseling at discharge significantly increased the detection of problems that required corrective medical interventions, improved patient satisfaction, and improved medication adherence. That study, however, did not use APPE students, so a direct correlation to our experience may warrant caution. While drug cost savings and reductions in adverse drug events were not measured, such benefits can be expected since pharmacists and students were able to review and recommend changes to patients’ profiles before discharge. Chinthammit et al.11 evaluated the cost-effectiveness of pharmacistprovided discharge counseling and found that such counseling was associated with cost savings in 48% of the patients counseled. They also found that pharmacist-provided counsel-
ing to elderly patients significantly reduced the number of adverse drug reactions and overall healthcare costs. Al Ghamdi et al.12 found that pharmacist discharge counseling led to a 22% reduction in adverse events. These studies demonstrate the value of pharmacist discharge counseling and validate the importance of extending pharmacist counseling to all patients. Such a task may only be practical today with the utilization of an LLM in which students and residents are used to counsel all patients in a hospital setting. Ideally, the impact on 30-day readmissions for targeted diseases such as CHF and chronic obstructive pulmonary disease should be assessed. As part of our practice model, pharmacists, residents, and students perform specialized counseling to all patients with CHF, chronic obstructive pulmonary disease, acute myocardial infarction, or pneumonia; however, there is little evidence that such counseling reduces 30-day readmissions. Szkiladz et al.13 utilized students and residents to perform discharge counseling for patients with CHF but did not find a reduction in 30-day CHF readmission rates when compared with standard discharge counseling. However, the authors did see a reduction in medication errors that resulted in significant cost avoidance for the institution and found that patients demonstrated an improved understanding of their medications. Since that study used students and residents in a similar capacity as in our practice model, it would be reasonable to expect similar outcomes at our institution. While the use of students in an LLM has provided substantial benefits to our patients, some limitations exist. Currently, we do not provide pharmacy services such as discharge counseling, medication reconciliation, and bedside delivery on weekends and evenings. Efforts are ongoing to effectively implement coverage during these times to en-
sure that all patients are reached. The student rotation structure and hours are being evaluated and adjusted to reflect the practical need to provide care while maintaining an adequate learning experience to ensure that students achieve the necessary skills. In addition, pharmacist schedules will require adjustment as preceptor supervision must be provided during these extended hours and weekends. Another challenge involves student availability from the colleges of pharmacy. Many schools limit rotations in May and December due to graduation and the holiday break. This presents a challenge, as the number of APPE students available is significantly reduced during these months, resulting in inadequate coverage. Subsequently, pharmacy management may need to adjust schedules to provide more resources during these months, and pharmacists must adjust work priorities and work collaboratively to reach all patients during this time. Increasing the number of affiliation agreements with colleges of pharmacy may help reduce the likelihood of student reductions during these months. These issues present significant challenges to further expansion of our practice model and full utilization of the LLM. We have also assumed that students are achieving an enhanced learning experience through the LLM. Students must still achieve core objectives for their specific rotation while providing general pharmacy service functions such as medication reconciliation, discharge counseling, and profile review, all under the supervision of a pharmacist. Students gain added skills in communicating important healthcare information that may not be emphasized, taught, or evaluated in the traditional specialized rotation format. Evaluations of the rotations by the students have not reflected a drop in student satisfaction with the learning experience. Preceptors are ultimately responsible for the care students provide
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under their direction. A specific ratio of preceptors to students has not been established as an educational standard, and the state of Florida does not specify a maximum ratio. We believe our ratio provides appropriate supervision of students to obtain medication histories, provide discharge counseling, and perform other monitoring services. By garnering feedback from patients, students, and other caregivers, preceptors effectively monitor the care provided by their students. We have not observed an increase in medication errors or in complaints from patients about the extensive pharmacy student interaction. Although unsubstantiated through hard data, there has been an increase in subjective positive feedback from multiple disciplines on the benefit of having pharmacy students more actively involved in patient care. Conclusion The implementation of an LLM and partnering with local colleges of pharmacy have improved pharmacy practice at CCF by allowing pharmacy students to work as pharmacist ex-
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tenders in providing comprehensive pharmacy services to many patients who would not otherwise be reached. This approach has improved HCAHPS scores within the “communication of medication” domain, increased overall patient interventions, and allowed expansion of CCF’s discharge prescription program. References 1. American Society of Health-System Pharmacists. Pharmacy Practice Model Summit: executive summary. Am J Health-Syst Pharm. 2011; 68:1079-85. 2. American Society of Health-System Pharmacists. ASHP policy positions, 2009–2012 (with rationales): education and training. www.ashp.org/DocLibrary/ BestPractices/EducationPositions.aspx (accessed 2013 Aug 26). 3. American Society of Health-System Pharmacists. ASHP policies approved by the 2013 ASHP House of Delegates. www.ashp.org/DocLibrary/Policy/HOD/ OfficialLang2013Policies.aspx (accessed 2013 Aug 26). 4. Knoer S, Weber RJ, Witmer DR et al. Highlights of the Cleveland Clinic Pharmacy Practice Model Summit. Am J Health-Syst Pharm. 2013; 70:356-65. 5. Buie L. The layered learning practice model and the pharmacy practice model initiative. http://connect.ashp.org/ blogsmain/blogviewer/?BlogKey=1ff0fea1dd0b-46c3-81f6-b5c5ec1e0e95 (accessed 2013 Aug 26).
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6. Weitzel W, Walters EA, Taylor J. Teaching clinical problem solving: a preceptor’s guide. Am J Health-Syst Pharm. 2012; 69:1588-99. 7. Centers for Medicare and Medicaid Services. HCAHPS: patients’ perspectives of care survey. www.cms.gov/medicare/qualityinitiatives-patient-assessment-instruments/ hospitalqualityinits/hospitalhcahps.html (accessed 2013 Sep 2). 8. Joint Commission. Sentinel event alert: using medication reconciliation to prevent errors. www.jointcommission.org/ SentinelEvents/SentinelEventAlertsea_35. htm (accessed 2013 Sep 2). 9. Agency for Healthcare Research and Quality. Patient safety primers: medication reconciliation. http://psnet.ahrq.gov/ primer.aspx?primerID=1 (accessed 2013 Sep 2). 10. Sarangarm P, London MS, Snowden SS et al. Impact of pharmacist discharge medication therapy counseling and disease state education: Pharmacist Assisting at Routine Medical Discharge (project PhARMD). Am J Med Qual. 2013; 28:292-300. 11. Chinthammit C, Armstrong EP, Warholak TL. A cost effectiveness evaluation of hospital discharge counseling by pharmacists. J Pharm Pract. 2011; 25:201-8. 12. Al Ghamdi S, Mahmoud MA, Alammari MA et al. The outcome of pharmacist counseling at the time of hospital discharge: an observational nonrandomized study. Ann Saudi Med. 2012; 32:492-7. 13. Szkiladz A, Carey K, Ackerbauer K et al. Impact of pharmacy student and resident-led discharge counseling on heart failure patients. J Pharm Pract. 2013; 26:574-9.
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