1. Clinical Aspects of Pharmacy Education: Focus on Advanced Pharmacy Practice Experience
Mort Goldman, Pharm.D., BCPS
Director, Pharmacotherapy Services
Department of Pharmacy
Cleveland Clinic, Cleveland, Ohio USA

2. Objectives Cleveland Clinic and Department of Pharmacy overview
Standards for clinical education and for Advanced Pharmacy Practice Experiences (APPEs)
Community and ambulatory care APPEs
Evidence that pharmacists make a difference
Future directions for community pharmacy

11. Established Feb 21, 1921
- Four Physicians
- MD Group Practice
Physician Led
Non-Profit Organization
Group Practice
Hospital / Clinics
- Bring together diverse specialists to “think and act as a unit”
Mission: “…care of the sick, investigation of their problems, and further education of those who serve.”

12. Staff
1,799 physicians and researchers
17,000 employees (main campus)
(36,000 CCHS total)
120 specialties and sub-specialties
1,388 available beds; 94 operating rooms
Patient Care
Total Admits 52,561
Surgical Cases 73,986
Total OP Visits >3.2M

14. Education
>1,000 Residents and Fellows in Training
59 accredited residency programs
Lerner College of Medicine
Research
>$144.3 M Grants Awarded
Federal, State, Private
3rd highest NIH funding

15. H Integrated Health System serving 5.1 million patients FHC
Fairview Hospital
Lakewood Hospital
Lutheran Hospital
Ashtabula County Medical Center
Euclid Hospital
Huron Hospital
Hillcrest Hospital
South Pointe Hospital
Marymount Hospital
FHC
Elyria Family Health Center
Westlake Family Health Center
Lorain Family Health
And Surgery Center
Lakewood Family Health Center
Strongsville Family Health and Surgery Center
Brunswick Family Health Center
Wooster Family Health Center
Independence Family Health Center
Solon Family Health Center
Chagrin Falls Family Health Center
Beachwood Family Health and Surgery Center
Willoughby Hills Family Health Center
Integrated Health System
serving 5.1 million patients
Cleveland Clinic
9 owned community hospitals
2 affiliate community hospitals
13 FHCs / 4 ASCs
EPIC; My Chart

17. Toronto Health & Wellness Center
-Sheikh Khalifa Medical City
(Abu Dhabi, UAE)
Toronto Health & Wellness Center
Cleveland Clinic Abu Dhabi, UAE

18. Department of Pharmacy Mission
The Department of Pharmacy is a clinical care department whose mission is to:
ensure the provision of safe and optimal drug therapy outcomes in patients
educate patients, healthcare practitioners and students about optimal drug therapy
conduct and support drug-related research

19. Department of Pharmacy Vision
The vision of the Department of Pharmacy is to:
be a valued member of the CC patient care team
make a unique contribution to high quality, cost-effective patient care, teaching and research
be known for our service excellence to all of our customer groups
have a local, state, and national reputation and leadership role resulting from the outstanding quality of our services and programs

20. Department of Pharmacy
FY 2008
319 full time employees (FTEs);
$22 million salary expense
$127 million drug expense
FTEs
154 exempt
165 technical / clerical
Salary Expense
16.2M exempt
5.7M non-exempt
Other expense
$7.1M
$420 GR
$206 NR
$55M CM
$17 NI

21. Department of Pharmacy
Inpatient Services (2008)
238 FTEs budgeted
2.23 million medication orders annually
6.94 million doses prepared & dispensed annually
Hospital Outpatient
Clinics, FHCs & ASCs (2008)
40 FTE budgeted
633K main campus clinic
doses annually IP
$225 GR
$74.4 NR
$43M Drug Expense
$5.7M CM
$-25M NI
HOP
$267 GR
98 NR
56 Drug Expense
43 CM
36 NI
Chemo
$169 GR (63%)
63 NR (66%)
33 Drug Expesne (59%)
28 CM (65%)
28 NI (78%)
(12 FTEs)

22. Department of Pharmacy
Ambulatory Pharmacies (2008)
57 FTE budgeted
386K prescriptions
10 locations including Florida
Pharmaceutical Care Clinic (2008)
13 FTE budgeted
>2,100 Active Patients
>40,000 INR’s monitored
OP Rx
CC 296,380
Regional 89,970
Total 386,350
FTEs
- CC
13 - Regional

25. Department of Pharmacy
Research Section
5 dedicated FTEs Investigational Drug Service
350 total protocols
Manuf, NIH, SWOG, CCG
Drug Outcomes Research
collaboration and publication with multiple medical departments
Clinical and Practice Model
outcome evaluation studies

26. Pharmacotherapy Section
Acute Care Clinical Specialists
Pharmaceutical Care Clinic
Drug Information
Research/Investigational Drugs
Education
45+ employees including Pharm.D., R.Ph., RN, technical, clerical, and magnificent secretary

27. Acute Care Clinical Specialists
Cardiology X2
Cardiothoracic ICU
SICU
MICU X2
NeuroICU
Hematology/ OncologyX2
Infectious Diseases X2
Internal Medicine
Nutrition Support
Pediatrics X3
Transplantation X4

28. Department of Pharmacy
Education (2008)
2 dedicated FTEs
>350 CCF presentations/ inservices per year
College Curriculum Faculty
Lerner College of Medicine
School of Podiatry
ASHP Accredited Residencies
Pharmacy Student Rotations
Univ of Toledo, Ohio Northern, NEOUCOP
High School Students

29. Residencies at Cleveland Clinic
Pharmacy Practice (PGY1)
Pharmacotherapy (PGY1/PGY2)
Infectious Diseases (PGY2)
Critical Care (PGY2)
Hematology/Oncology (PGY2)
Drug Information (PGY2)
????Community Pharmacy Residency (PGY1)

32. Pharmacists should be the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes; and the key element required to move the toward this goal is clinical education

33. Automation and pharmacy technicians should be performing most if not all technical functions of drug dispensing
Pharmacists contributions to patient care have been shown to be essential in hospitals and in the community and are cost effective (even profitable)
Pharmacists are the drug experts

34. Pharmacy colleges must provide a robust clinical curriculum to assure that pharmacists have the skill necessary to take care of patients
Pharmacists must take personal responsibility to enhance their clinical skills; Pharmacy organizations and colleges should provide continuing education to support this goal
Pharmacy is a life-long learning process

35. Clinical Education ACPE Standards
Provide patient care
Promote health improvement, wellness, and disease prevention
Design, implement, monitor, evaluate, and adjust pharmacy care plans that are patient-specific
Provide population-based care
in cooperation with patients, prescribers, and other members of an interprofessional health care team based upon sound therapeutic principles and evidence-based data, taking into account relevant legal, ethical, social, cultural, economic, and professional issues, emerging technologies, and evolving biomedical, pharmaceutical, social/behavioral/ administrative, and clinical sciences that may impact therapeutic outcomes
Promote health improvement, wellness, and disease prevention in cooperation with patients, communities, at-risk populations, and other members of an interprofessional team of health care providers.
Provide population-based care through the ability to develop and implement population-specific, evidence-based disease management programs and protocols based upon analysis of epidemiologic and pharmacoeconomic data, medication-use criteria, medication use review, and risk-reduction strategies

36. ACPE Guidelines for Pharmacotherapy Curriculum
Begins to translate the basic sciences to patients
Principles of clinical practice guidelines
Integration of scientific knowledge in patient care decisions
Application of evidence-based decision making to patient care
Pain management and palliative care
principles of clinical practice guidelines
Interpretation in the clinical setting
Used to reinforce basic science principles

37. ACPE Guidelines for Pharmacotherapy Curriculum
Wellness and disease prevention
Drug monitoring for positive and negative outcomes and disease monitoring
Nonprescription drugs and dietary supplements
Design of patient-centered treatment plans
Identification of drug-induced diseases
diagnostic tests in the diagnosis, staging, and monitoring of various disease states
concepts of pain management and palliative care
promotion of wellness and nonpharmacologic therapies
disease prevention and monitoring
nonprescription drug therapies
dietary supplements
design of patient-centered, culturally relevant treatment plans
drug-induced disease

38. ACPE Guidelines Advanced Pharmacy Practice Experience (APPE)
The true application of the pharmaco- therapy and basic science curriculum
From book to bedside
Practicing as a member of an inter-professional team
Providing pharmacist-delivered patient care
diagnostic tests in the diagnosis, staging, and monitoring of various disease states
concepts of pain management and palliative care
promotion of wellness and nonpharmacologic therapies
disease prevention and monitoring
nonprescription drug therapies
dietary supplements
design of patient-centered, culturally relevant treatment plans
drug-induced disease

39. ACPE Guidelines for Advanced Pharmacy Practice Experiences (APPE)
practicing as a member of an interprofessional team
appropriateness of patient specific drug therapy
recommending prescription and nonprescription medications,
identifying and reporting medication errors and adverse drug reactions
managing the drug regimen through monitoring and assessing patient information
providing pharmacist-delivered patient care
educating the public and health care professionals
practicing as a member of an interprofessional team
identifying, evaluating, and communicating to the patient and other health care professionals the appropriateness of the patient’s specific pharmacotherapeutic agents, dosing regimens, dosage forms, routes of administration, and delivery systems
consulting with patients regarding self-care products
recommending prescription and nonprescription medications, dietary supplements, diet, nutrition, traditional nondrug therapies, and complementary and alternative therapies
identifying and reporting medication errors and adverse drug reactions

40. Clinical Education at Cleveland Clinic
Provide advanced pharmacy practice experiences in hospital pharmacy, acute care clinical services, community pharmacy and ambulatory care for students at several Ohio colleges
Typically one month rotations with pass/fail grading system

41. . . University of Toledo (UT) Ohio Northern University (ONU)
Northeastern Ohio Universities College of Pharmacy (NEOUCOP)

42. Student Experiences offered at Cleveland Clinic
Advanced Community
Advanced Hospital
Ambulatory Care
Internal Medicine
Cardiology
ICU
Medical, surgical, cardiothroacic, neurological, cardiac, pediatric, neonatal
Transplant
Liver, lung, heart, kidney
Infectious Diseases
Nutrition Support
Drug Information
Investigational drugs
Pharmacoeconomics and Outcomes research

43. Community Pharmacy: Why is Clinical Education so Important?
Pharmacists should be the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes; and the key element required to move the toward this goal is clinical education
Too many drugs and data for physicians to keep up with
Pharmacists are the Drug Experts!!
Patients are in the community!

44. Community/Ambulatory Clinical Education at Cleveland Clinic
Community Pharmacy experiences allow significant patient counseling, and some directed disease state management
Ambulatory care experiences allow direct patient care in the outpatient clinic setting
Anticoagulation monitoring
Diabetes care
Hypertension and lipid management
General mediation therapy management

45. Community APPE Experience Practices at Cleveland Clinic (ONU, UT) and NEOUCP sites
Patient counseling
OTC consultation
Specialized services
Immunizations – all Ohio Colleges train students in vaccination technique (they are permitted by law to administer particular agents to adults)
Medication Therapy Management
MTM based on specific criteria… number of meds, diseases, types of diseases.

46. Medication Therapy Management: Definition
Continuity of pharmaceutical care
Assessment of health status
Formulating a medication treatment plan
Selecting initiating modifying therapy
Monitoring and evaluating response to therapy including safety and effectiveness
continuity of pharmaceutical care among health care
assessment of the patients health status
Formulating a medication treatment plan
Selecting initiating modifying therapy
Monitoring and evaluating the patients response to therapy including safety and effectiveness
Performing a medication review to identify resolve and prevent medication related problems

47. Medication Therapy Management: Definition
Performing medication review to identify resolve and prevent drug related problems
Documenting and communicating to patients other primary care providers
Providing patient education and training
Providing support to enhance adherence
Coordinating medication therapy management services
Documenting and communicating the essential information to the patients other primary care providers
Providing patient education and training Providing information support services and resources designed to enhance patient adherence with his/her therapeutic regimens
Coordinating and integrating medication therapy management services within the broader health care management services being provided to the patient

48. Community Pharmacy APPE Experience
Medication histories, independently or part of MTM, OTC consults, etc
Antibiotic call-back program (NEOUCOP)
Drug Use Review
Review dosing, drug interactions, etc. and make recommendations to physicians
Answer drug information questions from patients and physicians

49. Challenges in Community Pharmacy
Availability of medical information
Continuity at the time of admission or discharge from the hospital
Ability to document interventions or medication changes in the medical record
Marketing – the public and professionals don’t know what we can do!
Fill discharge rx’s
Councel patients – hospital pharmacy vs community neither does a particularly good job
E chart vs paper… no access cleve clinic op pharmacies…

50. What we can do in the Community: The Ashville Project
To assess the clinical, economic, and humanistic outcomes of pharmaceutical care services provided in community pharmacies for patients with diabetes
Pharmacists served as care providers
Patient appointments included initial history, needs assessment and goal setting followed by monitoring, training and goal re-evaluation

52. What we can do in the Community: The Ashville Project
HbA1C in range was 33% at base line and 85% in 14 months
Significant improvement in LDL, HDL
10% decline in total costs
33% decline in inpatient costs
20 % increase in outpatient costs
Glucometers, pharmacist fees, diabetes center costs, etc.
Improved outcomes at decrease costs

53. What we can do in the Community: The Ashville Project
Follow-up projects
Long-term diabetes care
Asthma care
Hypertension and lipid management
All have shown improvements of patient care at lower costs
All performed by appropriate collaboration and referal in community pharmacies

54. J Am Pharm Assoc 2003;43:173-84
J Am Pharm Assoc 2003;43:185-90
J Am Pharm Assoc 2006;46:133-47
J Am Pharm Assoc 2008;48:23-31
Pharmacy Times 1998, October suppl

55. Community Pharmacy Future Directions
Disease screening programs to help identify patients requiring in depth disease state management and MTM
Blood pressure, Glucose, Lipid profile, HgA1c, Others
Working with local physician groups and medical centers for improved referral process

56. Anticoagulation Clinic
The Pharmacy Managed Anticoagulation Clinic (AC) is the largest single provider of anticoagulation monitoring services for the Cleveland Clinic
Pharmacy AC services are available in 6 distinct locations throughout the Cleveland area
Patient appointments are typically 10 minutes and include a point-of-care blood test during the appointment

57. Anticoagulation Clinic
More than 3,000 anticoagulation patients referred by CC physicians received PCC medication management with ~40,000 INR tests in 2008 for all locations

58. Anticoagulation Clinic
Economic analysis compared to non-pharmacist run anticoagulation services (1998)
Cost avoidance of $300,000
Decrease risk/admissions for thrombosis and bleed
Benefit to cost ratio of 1.5:1
Revenue producing service
Working toward a budget neutral service

59. Anticoagulation Clinic APPE Experience
Patient medication and medical history
Asking specifically about concurrent medications, changes in medications, changes in health status, diet changes
Finger stick for Point of Care Testing
Place blood sample on the test strip

60. Anticoagulation Clinic APPE Experience
Place test strip in the device
Read and interpret results
Adjust medication
If result is unexpected, inquire again about health, drug, diet status changes
Document all information in the electronic medical record

61. Anticoagulation Clinic
Students learn to care for these patients
How to recognize drug-drug interactions
How to recognize food-drug interactions
Dealing with minor bruising and bleeding
Dealing with urgent patient situations
Providing additional disease management to patients with multiple medical problems and multiple drug related problems

62. Patients with difficult-to-treat diabetes: Cleveland Clinic Pharmacy
Referred to pharmacists in an internal medicine clinic
Patients seen in clinic, and requested to return for follow-up with the pharmacist initially in 2-4 week intervals
Pharmacist counsels patients on use of glucometer, medication adherence, diet, and symptoms of their disease
Multiple parameters measured including HbA1C

63. Patients with difficult-to-treat diabetes: Cleveland Clinic Pharmacy
Patient data reviewed for those who were followed by a pharmacist for at least 6 months with at least 3 visits
Patients who were seen by the pharmacist had a significant decline in HbA1C of more than 2% decreasing their risk for cardiovascular disease, nephropathy and retinopathy

64. Patients with difficult-to-treat diabetes: APPE experience
Review patient medical record for appropriate therapy, dosing, drug interactions, drug related problems
History including compliance and diet
Medication, diet, lifestyle counceling
Medication adjustment
Case presentations, “journal club”, lectures to health professionals

65. ACPE: Future Vision of Pharmacy Practice Vision Statement
As experts regarding medication use, pharmacists will be responsible for:
rational use of medications, including the measurement and assurance of medication therapy outcomes
promotion of wellness, health improvement, and disease prevention
design and oversight of safe, accurate, and timely medication distribution systems

66. ACPE: Future Vision of Pharmacy Practice Vision Statement
Pharmacists will have the authority and autonomy to manage medication therapy and will be accountable for patients’ therapeutic outcomes

67. ACPE: Future Vision of Pharmacy Practice Vision Statement
Pharmacists will be the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes