Integrating a Patient Care Development Model to Enhance Community Pharmacy Residency Programs

Purpose: The purpose of this paper is to describe integration of a community-based patient care service development model, Partner for Promotion (PFP), within five community pharmacy residency programs (CPRPs) across the United States and provide insights and examples of methods for optimizing community pharmacy resident experiences, developing new patient care services, and achieving residency accreditation standards. Summary: Five community pharmacy residency programs have integrated PFP that affiliated with Midwestern University – Glendale, Northeast Ohio Medical University, Ohio State University, University of Utah, and West Virginia University. Each college and residency program has identified different strategies through which PFP enhances their residency training and service development including completion of training modules, reflections and discussion on application of the PFP service development model to practice, research, and teaching, use of assignments to guide service creation, and mentoring of PFP student-pharmacist teams. All five sites directly link these activities to objectives required in PGY1 CPRP accreditation standards. PFP has resulted in resident-facilitated service development of a variety of patient care programs. Conclusion: PFP applied to CPRPs enhances training on service development, builds new services within residency training sites, and assists programs with meeting residency accreditation standards. The experiences of five community pharmacy residency programs across the U.S. that have adopted the program has been positive, with creation of new services and residency sites, integration of novel teaching, practice, research, and learning opportunities for residents, and direct links from the PFP experience to achievement of residency objectives. Introduction Community pharmacy residency programs (CPRPs) provide unique post-graduate training experiences similar to inpatient pharmacy practice residency programs with key differences being the setting in which the residents train, the longitudinal nature of the practice experience, and a distinct set of accreditation standards focused in development of new patient care services. Thus, in addition to providing the resident with a quality experience in direct patient care, a well-structured approach to resident participation in the development of sustainable patient care services is key to meeting required accreditation goals and objectives. Table 1 highlights these goals and objectives for PGY1 CPRPs that directly relate to the development of patient care services. Principle 6 (minimum requirements of the organization Corresponding author : Jennifer L. Rodis, PharmD, BCPS, FAPhA, Associate Professor of Clinical Pharmacy and Assistant Dean for Outreach and Engagement, College of Pharmacy, The Ohio State University, Columbus, OH Parks Hall Room 129B, 500 W. 12th Ave., Columbus, OH 43210; Phone: 614247-8391; Fax: 614-292-1335; E-mail: [email protected] conducting the residency program) and Principle 7 (qualifications of the pharmacy) of the accreditation standards for PGY1 CPRPs highlight the need for establishing and maintaining high quality patient care services beyond the dispensing of medications. An article in the spring 2014 edition of The Communiqué highlights the need for developing patient care services at a community pharmacy residency practice site. In this publication, forty-five percent of programs were marked as partially compliant (PC) on a critical factor where services were not of a scope and quality commensurate with identified patient needs. As community pharmacy residency programs develop activities to enrich resident experiences and meet accreditation standards in the areas of service development, connecting with external programs that guide this process may assist with streamlining and enhancing these experiences. Models developed to enhance other aspects of residency training have been described to augment research and precepting skills as well as preceptor development. These models have been implemented locally within general pharmacy practice residency programs at the institutions Idea Paper PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2015, Vol. 6, No. 4, Article 224 INNOVATIONS in pharmacy 2 where they originated. No evidence exists of any formalized programs to improve service development skills for PGY1 CPRPs being used locally or shared with external programs. Partner for Promotion (PFP) originated in 2005 as a studentled experience to advance pharmacist-provided care in community-based practices in Ohio. PFP was created as a longitudinal, elective Advanced Pharmacy Practice Experience (APPE) that guides students and community pharmacy preceptors through a stepwise approach to developing patient-centered services via a series of online training modules and faculty mentoring. Through PFP, students conduct a needs assessment, develop a solution to gaps identified in the needs assessment, and implement the solution as an advanced patient care service at a patient care site. The model is available online and created for turn-key integration into an academic setting. In 2009, the PFP model was shared with the University of Utah to enhance student APPEs, foster relationships with community pharmacy partners, and assist with building the infrastructure of preceptors and patient care services to support a new community residency program that was emerging at the University. Building upon the successful integration of the program in Utah and receipt of funding from the Community Pharmacy Foundation, four additional colleges of pharmacy have adopted PFP and integrated it into their curricula and residency programs in varying fashions. Impact of PFP on student skill development has been published previously. The purpose of this paper is to describe adaptation of the PFP model of community-based patient care service development within five community pharmacy residency programs across the United States to provide insights and examples of methods for enhancing community pharmacy resident experience in advancing pharmacist-provided, communitybased patient care and achieving PGY1 CPRP accreditation standards. Integration into Residency Programs The five community pharmacy residency programs that have integrated PFP are affiliated with colleges of pharmacy, including Midwestern University – Glendale, Northeast Ohio Medical University, Ohio State University, University of Utah, and West Virginia University. Each college and residency program has identified different strategies through which PFP enhances their residency training and service development. Each college’s strategy is described below. Ohio State University PGY1 Community and Ambulatory Pharmacy Practice Residencies The Ohio State University College of Pharmacy (OSU COP) offers community and ambulatory care PGY1 and PGY2 residency training programs for a total of up to twelve residents per year. The practice sites include an independent community pharmacy, a grocery chain retail pharmacy, a 501(c)3 non-profit charitable pharmacy, a patient-centered medical home affiliated with an academic medical center, and an interprofessional urgent/primary care clinic and pharmacy associated with university employee health services. Since the faculty creator of PFP is a preceptor within the residency programs, the connectivity between the residency and PFP has been ongoing since the initiation of PFP. At the start of the residency year, the faculty director of PFP presents the program to the incoming residents with opportunities for involvement during their residency year. All PGY1 residents review Partner for Promotion training modules, a series of twelve recorded, online modules that serve as the “toolkit” for service development through PFP. Residents write a reflection and meet one time with the PFP faculty director for an interactive discussion to apply the PFP concepts to their residency and practice site as part of an orientation session focused on project management. Further involvement in PFP can be longitudinal throughout the year or project-based. At what level residents participate in PFP depends upon resident interest and fit with each resident’s individualized plan for the year. Residents at Ohio State may serve as mentors to student-pharmacist teams developing novel community-based services through PFP. In the resident mentorship experience, residents get the opportunity to not only enhance their service development skills, but also teaching skills through providing one-on-one student evaluations as well as providing formative feedback to students longitudinally over the year. Other, more focused projects have allowed residents to enhance research skills through mentoring PFP site-specific research projects. Teaching skill development has also been an experience through developing and/or updating PFP training modules, recording them, and delivering them through the program. Evaluations of the residents regarding their PFP experiences are individualized as quarterly, snapshot, or customized depending upon the experience with both summative and formative feedback mechanisms applied to the assessments. University of Utah PGY1 Community Pharmacy Practice Residency The University of Utah College of Pharmacy began offering PFP in collaboration with The Ohio State University in 2009 with two practice partners. The success of the program and the sustainable addition of clinical services to the community practice sites led to the popularity and continuation of the program in subsequent years for students and ultimately migrated from a student education program to one focused on training PGY1 CPRP residents. Implementing PFP at the University of Utah has allowed College of Pharmacy faculty to impact the level of outpatient clinical pharmacy practice Idea Paper PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2015, Vol. 6, No. 4, Article 224 INNOVATIONS in pharmacy 3 within the state, develop and expand PGY1 CPRP sites and mentor current practitioners and residents to establish clinical pharmacy services at community pharmacy sites. One of the first practice partners to collaborate with the College of Pharmacy was an independent pharmacy located within an independent grocery store near a family medicine clinic located about 25 miles north of Salt Lake City. The first set of students to participate in PFP helped the preceptor develop an influenza immunization service. The extra revenue from this service allowed the pharmacy to participate in PFP again the next year and develop a clinical pharmacy service at the nearby family medicine clinic. This collaboration and clinical service progressed over the next couple of years and led to the launch of a PGY1 CPRP in 2011 with one other site within University of Utah Health Care. The PGY1 CPRP has grown to one resident at three different practice sites including the independent pharmacy previously mentioned and two sites with University of Utah Health Care. Each resident participates in PFP during the training year. The residents complete all of the modules of the program, develop a sustainable and needed clinical service at his or her home practice site by following the stepwise approach laid out in the modules, and analyze outcomes regarding impact of the program by the conclusion of the residency experience. Formal evaluations of the residency objectives related to the patient care project are evaluated quarterly. The resident also receives formative feedback throughout the year when he or she completes each module and project associated with PFP. Northeast Ohio Medical University PGY1 Community Pharmacy Practice Residency Northeast Ohio Medical University College of Pharmacy offers a PGY1 CPRP in conjunction with AxessPointe Community Health Center, a section 330 funded federally-qualified health center. In 2010, PFP was adopted as a college-based program partnering student pharmacists with community pharmacies throughout Northeast Ohio. After success with developing innovative and sustainable patient care services, the program was expanded to the PGY1 CPRP in 2013. The intent of the expansion to the PGY1 CPRP was to provide the resident with a more structured experience with developing, implementing, and evaluating patient care services. In addition, the program was implemented to allow for expansion of sustainable patient care services at the practice site, which ultimately increases the depth and breadth of services offered in the residency experience. PFP is a required component of both the orientation and project management learning experiences for residents. Each incoming resident reviews the PFP training modules prior to developing, implementing, and evaluating a patient care project. The resident’s PFP project is evaluated as part of the quarterly summative evaluation of the project management learning experience. West Virginia University PGY1 Community Pharmacy Practice Residency The West Virginia University School of Pharmacy (WVU) offers two, PGY1 CPRP positions each year. The practice sites include an independent community pharmacy and a grocery chain. WVU CPRP residents may complete PFP on a longitudinal basis or can apply aspects of the program to their residency research projects. Both residents complete all modules, as well as assignments as incorporated into their residency training plans related to the stepwise approach to service development laid out in the modules. In addition, residents utilize PFP modules to assist them with their final project of the residency year, creating and implementing a business plan. Evaluations of the residency objectives related to the patient care project are evaluated as part of their summative quarterly assessment. Midwestern-Glendale PGY1 Community Pharmacy Practice Residency Midwestern University College of Pharmacy-Glendale (MWUCPG) currently offers four PGY1 CPRPs in three sites. One is a national retail pharmacy chain, while the other two are regional grocery store chains. Initial planning meetings have been held with the residency program directors to explain PFP and how it could be utilized in community pharmacy residencies. Those who have been involved in early discussions have expressed interest and meetings are ongoing to discuss using PFP in the 2016-2017 residency year. Preliminary plans would utilize the PFP curriculum in order to walk the resident and their preceptor through the initiation of a new service within one of the residency’s pharmacy locations. Going forward, the resident would participate in PFP with their residency preceptor with additional guidance from a faculty member from MWU-CPG. Description of Impact Partner for Promotion learning experiences can be linked directly to the ASHP PGY1 CPRP objectives as is described in Table 2. Concepts covered in the online modules guide those residents who apply the stepwise approach to creation of a novel service at their community practice site as well as those who consider the concepts in the context of their major research project or another longitudinal, needs-based project such as a quality improvement initiative or teaching opportunity. While achievement of objectives vary by residency program, PFP-related learning experiences consistently link to R3.3.1 through R3.3.8, which are within the goal of “Exercise leadership and practice management Idea Paper PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2015, Vol. 6, No. 4, Article 224 INNOVATIONS in pharmacy 4 skills”, with the most specific being “Goal R3.3:Contribute to the development, implementation, and evaluation of a new pharmacy service or to the enhancement of an existing service”. (Table 1). Table 2 links the activities conducted at each CPRP to learning objectives and showcases the impact PFP has had on service development with each program. Services created at these sites reflect the opportunities of the individual states with regard to their pharmacy practice acts and patient populations served as well as the resources available with each pharmacy site. Common services developed and implemented include medication therapy management (MTM), immunizations, and more specialty services such as compounding and medical nutrition therapy. These services have shown longevity at the pharmacy sites following creation during the residency with PFP, which is notable. Evaluations of resident perceptions of Partner for Promotion have been conducted through written reflections composed by residents engaged in PGY1 community and ambulatory care pharmacy practice residencies at OSU COP for the 20132014 and 2014-2015 classes. A total of 12 residents composed reflections after reviewing the online modules and prior to a group discussion on application of the concepts. Resident journal reflections were downloaded and deidentified and then evaluated for thematic content. Openended journal responses were reviewed by two faculty members at different colleges of pharmacy and assigned to emerging categories after consensus among the faculty. Major themes emerged and are described in Table 3. The major themes included in reflective journals by 75% or more of residents were that residents felt the information included in the PFP modules was new beyond what they had learned in pharmacy school, of high quality and value, and was applicable to their clinical practice. Conclusion Partner for Promotion is a model of practice development that can be applied to PGY1 CPRPs to enhance training on service development, build new services within residency training sites, and assist programs with meeting PGY1 CPRP accreditation standards. The experiences of five community pharmacy residency programs across the U.S. that have adopted the program has been positive, with creation of new services and residency sites, integration of novel teaching, practice, research, and learning opportunities for residents and pharmacy students, and direct links from the PFP experience to required goals and objectives. Comprehensive service development programs similar to Partner for Promotion have not been described in the pharmacy practice or education literature. However, residency programs have shown impact on expanding practice capacity and development of novel services in the areas of osteoporosis and hypertension / stroke screening. A survey conducted by Schommer et al, showed that the types and intensity of services provided at CPRP sites gave residents opportunities for advancing patient care services training, directing patient contact, and creating opportunities to be engaged in practice innovation. Partner for Promotion provides an enhancement of training beyond provision of care, allowing residents to foster development of a novel service through a stepwise approach. For the CPRP, this lends consistency in training year to year and a formal process around which evaluations can be structured as well as an organized approach to practice site development. This structure can address common sources of cited partial compliance for PGY1 residency programs, such as: developed and documented descriptions of learning experiences, linking activities to objectives, and completing evaluations using a set process. Limitations to Partner for Promotion and the application to residency training in a widespread fashion include the current focus the training modules have toward the community practice setting. The program was created to foster community practice service development and advancement; thus, the modules do not directly apply to other practice settings. However, in recent years at Ohio State, students have engaged in PFP with health care systems and ambulatory care clinics to advance pharmacy practice. As the healthcare system evolves to focus on team-based, integrated care, PFP is adapting to support pharmacistprovided direct patient care through updating of training modules to address a broader scope of practice settings and opportunities. Additional limitations include geography and pharmacy practice laws being variable across the United States; thus, opportunities and potential for service development may be optimized or limited based upon state law. Finally, Partner for Promotion is a licensed product with an associated fee for use. Most schools have funded the license through education and community practice grants. Next steps for this program include fostering a practice based-research network among residents and residency program directors, as well as PFP alumni. These networks provide opportunities to collaborate on practice and research projects locally and nationally as well as to broadly evaluate PFP and other models that enhance residency training. Another opportunity exists in using the training modules in preceptor development, another commonly cited accreditation standard. As the number of accredited community pharmacy residency programs entering the ASHP Residency Matching Program increases (n = 82 in 2010 and 160 in 2014) and the profession Idea Paper PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS2015, Vol. 6, No. 4, Article 224INNOVATIONS in pharmacy5grows in the level of post-graduate training provided topharmacy practitioners in the community setting, there is anopportunity to not only advance clinical skills, but alsoenhance pharmacists’ capabilities and roles in managementand practice development. Partner for Promotion provides amodel that integrates with residency training to fosterpractice growth as well as enhance skills in practiceadvancement. References1. American Society of Health-System Pharmacists(ASHP) and American Pharmacists Association(APhA). Required and elective educationaloutcomes, goals, objectives and instructionalobjectives for postgraduate year one (PGY1)community pharmacy residency programs. Availableathttp://www.ashp.org/menu/Accreditation/ResidencyAccreditation.aspx. Accessed September 29, 2014.2. American Society of Health-System Pharmacists(ASHP) and American Pharmacists Association(APhA). Accreditation standard for postgraduateyear one (PGY1) community pharmacy residencyprograms. Available athttp://www.ashp.org/menu/Accreditation/ResidencyAccreditation.aspx. Accessed September 29, 2014.3. American Society of Health-System Pharmacists(ASHP) Accreditation Services Division. TheCommuniqué. Spring 2014. 17(1):5. Available athttp://www.ashp.org/DocLibrary/Accreditation/Communiqu-Newsletter/Spring-2014.pdf. AccessedSeptember 29, 2014.4. Baker JW, Bean J, Benge C, McFarland MS. Designinga resident research program. Am J Health SystPharm. 2014;71(7):592-8.5. Anderegg SV, Christenson JC, Padgett CP. Anaccelerated, practice-based model for fosteringprecepting skills in pharmacy residents. Hosp Pharm.2014;49(8):713-6.6. Fuller PD, Peters LL, Hoel R, Baldwin JN, Olsen KM.Residency preceptor development and evaluation: anew approach. Am J Health Syst Pharm.2013;70(18):1605-8.7. Rodis JL, Legg JE, Casper KA. Partner for Promotion:an innovative advanced community pharmacypractice experience. Am J Pharm Educ. 2008 Dec15;72(6):134.8. Rodis JL, Jennings BT. Adopting an advancedcommunity pharmacy practice experientialeducational model across colleges of pharmacy.INNOVATIONS. 2011;2(4): Article 56.9. Liu Y, Nevins JC, Carruthers KM, Doucette WR,McDonough RP, Pan X. Osteoporosis risk screeningfor women in a community pharmacy. J Am PharmAssoc. 2007 Jul-Aug;47(4):521-6.10. Mangum SA, Kraenow KR, Narducci WA. Identifyingat-risk patients through community pharmacy-basedhypertension and stroke prevention screeningprojects. J Am Pharm Assoc . 2003 Jan-Feb;43(1):50-5.11. Schommer JC1, Owen JA, Scime GM, Millonig MK.Patient care services provided at primary communitypharmacy residency sites. J Am Pharm Assoc. 2013Mar-Apr;53(2):e125-31. Idea PaperPHARMACY PRACTICE http://z.umn.edu/INNOVATIONS2015, Vol. 6, No. 4, Article 224INNOVATIONS in pharmacy6Table 1: Required (R) goals and objectives for PGY-1 community pharmacy residencyprograms (CPRP) related to patient care service development. OutcomeAssociated Goal(s)Associated Objective(s) R1: Manage andimprove themedication-useprocess.R1.2: Identify, design, and implementquality improvement changes to theorganization’s (e.g., community pharmacy,corporation, health-system) medication-usesystem.R1.2.4:(Synthesis) Participate in the process by which theorganization identifies the need for, develops, implements,and evaluates evidence-based treatmentguidelines/protocols for specific patient populations. R2: Provideevidence-based,patient-centeredcare andcollaborate withother healthcareprofessionals tooptimize patientcare.R2.1: Establish collaborative professionalrelationships with other healthcareprofessionals involved in the care ofpatients.R2.1.1: (Comprehension) Explain the process by whichcollaborative practice agreements are developed andimplemented. R2.1.2: (Synthesis) Develop a collaborative practiceagreement (may be hypothetical) that could be used in thecommunity pharmacy. R3: Exerciseleadership andpracticemanagementskills.R3.1: Exhibit essential personal skills of apractice leaderR3.1.4: (Characterization) Serve as a role model forpharmacists, pharmacy students, pharmacy technicians, andother healthcare professionals. R3.2: Exhibit practice leadership inorganizational and management activities.R3.2.1: (Synthesis) Participate in the pharmacy's planningprocesses. R3.2.2: (Synthesis) Use knowledge of an organization'spolitical and decision-making structure to influence theaccomplishment of a practice area goal. R3.2.3: (Application) Use group participation skills whenleading or working as a member of a committee or informalwork group. R3.2.4: (Synthesis) Integrate compliance with communitypractice accreditation, legal, regulatory, and safetyrequirements into daily practice. R3.2.5: (Synthesis) Prioritize the work load, organize thework flow, and verify the accuracy of the work of pharmacytechnical and clerical personnel involved in all communitypharmacy services. R3.2.6: (Application) Observe organizational customerservice policies and procedures in the conduct of dailypractice activities. R3.2.7: (Application) Use knowledge of the principles ofchange management to achieve organizational,departmental, and/or team goals. Idea PaperPHARMACY PRACTICE http://z.umn.edu/INNOVATIONS2015, Vol. 6, No. 4, Article 224INNOVATIONS in pharmacy7OutcomeAssociated Goal(s)Associated Objective(s) R3: Exerciseleadership andpracticemanagementskills.R3.3: Contribute to the development,implementation, and evaluation of a newpharmacy service or to the enhancement ofan existing service.R3.3.1: (Synthesis) Generate an idea for a new service orevaluate a current pharmacy service or program todetermine if it meets the stated goals. R3.3.2: (Synthesis) Develop a business plan for a newservice or an enhanced service, if applicable. R3.3.3: (Application) Use presentation and persuasive skillsto secure approval of a plan for a new or enhanced service. R3.3.4: (Synthesis) Contribute to the development of amarketing strategy for a new or enhanced service that isintegrated with the overall marketing plan. R3.3.5: (Comprehension) Explain the various mechanismsby which pharmacists can be paid for the patient careservices they provide. R3.3.6: (Analysis) Employ an effective strategy forobtaining compensation for a new or enhanced service fromappropriate potential sources of compensation. R3.3.7: (Synthesis) Implement a new or enhanced serviceaccording to the business and marketing plans. R3.3.8: (Evaluation) Evaluate the new or enhanced serviceto determine if it meets the stated goals. R4: Demonstrateprojectmanagementskills.R4.1: Conduct a practice-related projectusing effective project management skills.R4.1.1: (Synthesis) Identify a topic for a practice-relatedproject of significance for community pharmacy. R4.1.2: (Synthesis) Formulate a feasible design for apractice-related project. R4.1.3: (Synthesis) Secure any necessary approvals,including IRB and funding, for one’s design of a practice-related project. R4.1.4: (Synthesis) Implement a practice-related project asspecified in its design. R4.1.5: (Synthesis) Effectively present the results of apractice-related project. R4.1.6: (Synthesis) Successfully employ acceptedmanuscript style to prepare a final report of a practice-related project. R4.1.7: (Evaluation) Accurately assess the impact, includingsustainability if applicable, of the residency project. Idea PaperPHARMACY PRACTICE http://z.umn.edu/INNOVATIONS2015, Vol. 6, No. 4, Article 224INNOVATIONS in pharmacy8Table 2: Overview of the utilization of the Partner for Promotion (PFP)program at five PGY-1 community pharmacy residency programs (CPRPs) in the US. Residency Program Residency programareas for inclusion ofPFPObjectives covered bythe PFP programServices developed to date Ohio StateUniversity College ofPharmacy• Orientation toservicedevelopment andprojectmanagement • Mentoring ofstudent PFP groupthrough servicedevelopment andresearch • Creation of PFPonline moduleR3.1.4R3.2.1-7R3.3.1-8R4.1.1-7R5.1.1-4E3.1.1-10Residents mentor student-drivenprojects and have not appliedPFP directly to servicedevelopment at their residencysites. Mentored student projectshave developed: • Immunization screening andmobile clinics • Medication therapymanagement (MTM) services • Point-of-caretesting/screening services Northeast OhioMedical UniversityCollege of Pharmacy• Orientation learningexperience (projectmanagementsection) • Projectmanagementlearning experienceR3.3.1-8• Immunization service • Medication therapymanagement (MTM) services • Anticoagulationmanagement service University of UtahCollege of Pharmacy• Orientation learningexperience (projectmanagementsection) • Projectmanagementlearning experienceR2.1.3R3.1.2R3.1.4R3.1.5R3.2.1R3.2.2R3.2.3R3.2.4R3.2.6R3.2.7R3.3.1-8• Clinical Pharmacy Service atFamily Medicine Clinic • Diabetes Store Tours Program