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Clinical Aspects of Pharmacy Education: Focus on Advanced Pharmacy Practice Experience Mort Goldman, Pharm.D., BCPS Director, Pharmacotherapy Services.

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Presentation on theme: "Clinical Aspects of Pharmacy Education: Focus on Advanced Pharmacy Practice Experience Mort Goldman, Pharm.D., BCPS Director, Pharmacotherapy Services."— Presentation transcript:

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 ObjectivesObjectives Cleveland Clinic and Department of Pharmacy overviewCleveland Clinic and Department of Pharmacy overview Standards for clinical education and for Advanced Pharmacy Practice Experiences (APPEs)Standards for clinical education and for Advanced Pharmacy Practice Experiences (APPEs) Community and ambulatory care APPEsCommunity and ambulatory care APPEs Evidence that pharmacists make a differenceEvidence that pharmacists make a difference Future directions for community pharmacyFuture directions for community pharmacy

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11 Established Feb 21, 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 Admits52,561 Surgical Cases73,986 Total OP Visits>3.2M

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14 Education ->1,000 Residents and Fellows in Training 59 accredited residency programs59 accredited residency programs -Lerner College of Medicine Research - >$144.3 M Grants Awarded Federal, State, PrivateFederal, State, Private 3 rd highest NIH funding3 rd highest NIH funding

15 FHC Elyria Family Health Center Westlake Family Health Center FHC Lorain Family Health And Surgery Center FHC Lakewood Family Health Center FHC Strongsville Family Health and Surgery Center FHC Brunswick Family Health Center FHC Wooster Family Health Center FHC Independence Family Health Center FHC Solon Family Health Center FHC Chagrin Falls Family Health Center FHC Beachwood Family Health and Surgery Center FHC Willoughby Hills Family Health Center FHC H H Fairview Hospital Lakewood Hospital H H Lutheran Hospital H H Ashtabula County Medical Center H H Euclid Hospital H H Huron Hospital H H Hillcrest Hospital H H South Pointe Hospital H H Marymount Hospital H H Cleveland Clinic Integrated Health System serving 5.1 million patients

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

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

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

20 Department of Pharmacy FY full time employees (FTEs);319 full time employees (FTEs); $22 million salary expense$22 million salary expense $127 million drug expense$127 million drug expense

21 Department of Pharmacy Inpatient Services (2008) -238 FTEs budgeted million medication orders annually million doses prepared & dispensed annually Hospital Outpatient Clinics, FHCs & ASCs (2008) -40 FTE budgeted -633K main campus clinic doses annually

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 INRs monitored

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25 Department of Pharmacy Research Section -5 dedicated FTEs Investigational Drug Service 350 total protocols350 total protocols Manuf, NIH, SWOG, CCGManuf, NIH, SWOG, CCG -Drug Outcomes Research collaboration and publication with multiple medical departmentscollaboration and publication with multiple medical departments -Clinical and Practice Model outcome evaluation studiesoutcome evaluation studies

26 Pharmacotherapy Section Acute Care Clinical SpecialistsAcute Care Clinical Specialists Pharmaceutical Care ClinicPharmaceutical Care Clinic Drug InformationDrug Information Research/Investigational DrugsResearch/Investigational Drugs EducationEducation 45+ employees including Pharm.D., R.Ph., RN, technical, clerical, and magnificent secretary45+ employees including Pharm.D., R.Ph., RN, technical, clerical, and magnificent secretary

27 Acute Care Clinical Specialists Cardiology X2Cardiology X2 Cardiothoracic ICUCardiothoracic ICU SICUSICU MICU X2MICU X2 NeuroICUNeuroICU Hematology/ OncologyX2Hematology/ OncologyX2 Infectious Diseases X2Infectious Diseases X2 Internal MedicineInternal Medicine Nutrition SupportNutrition Support Pediatrics X3Pediatrics X3 Transplantation X4Transplantation X4

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

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

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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 educationPharmacists 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 dispensingAutomation 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 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 expertsPharmacists 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 patientsPharmacy 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 goalPharmacists 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 processPharmacy is a life-long learning process

35 Clinical Education ACPE Standards Provide patient careProvide patient care Promote health improvement, wellness, and disease preventionPromote health improvement, wellness, and disease prevention Design, implement, monitor, evaluate, and adjust pharmacy care plans that are patient-specificDesign, implement, monitor, evaluate, and adjust pharmacy care plans that are patient-specific Provide population-based careProvide population-based care

36 ACPE Guidelines for Pharmacotherapy Curriculum Begins to translate the basic sciences to patientsBegins 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

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

38 ACPE Guidelines Advanced Pharmacy Practice Experience (APPE) The true application of the pharmaco- therapy and basic science curriculumThe true application of the pharmaco- therapy and basic science curriculum From book to bedsideFrom book to bedside Practicing as a member of an inter- professional teamPracticing as a member of an inter- professional team Providing pharmacist-delivered patient careProviding pharmacist-delivered patient care

39 practicing as a member of an interprofessional teampracticing as a member of an interprofessional team appropriateness of patient specific drug therapyappropriateness of patient specific drug therapy recommending prescription and nonprescription medications,recommending prescription and nonprescription medications, identifying and reporting medication errors and adverse drug reactionsidentifying and reporting medication errors and adverse drug reactions managing the drug regimen through monitoring and assessing patient informationmanaging the drug regimen through monitoring and assessing patient information providing pharmacist-delivered patient careproviding pharmacist-delivered patient care educating the public and health care professionalseducating the public and health care professionals ACPE Guidelines for Advanced Pharmacy Practice Experiences (APPE)

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 collegesProvide 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 systemTypically one month rotations with pass/fail grading system

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

42 Student Experiences offered at Cleveland Clinic Advanced CommunityAdvanced Community Advanced HospitalAdvanced Hospital Ambulatory CareAmbulatory Care Internal MedicineInternal Medicine CardiologyCardiology ICUICU -Medical, surgical, cardiothroacic, neurological, cardiac, pediatric, neonatal TransplantTransplant -Liver, lung, heart, kidney Infectious DiseasesInfectious Diseases Nutrition SupportNutrition Support Drug InformationDrug Information Investigational drugsInvestigational drugs Pharmacoeconomics and Outcomes researchPharmacoeconomics 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 educationPharmacists 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 managementCommunity Pharmacy experiences allow significant patient counseling, and some directed disease state management Ambulatory care experiences allow direct patient care in the outpatient clinic settingAmbulatory 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 counselingPatient counseling -OTC consultation Specialized servicesSpecialized services -Immunizations – all Ohio Colleges train students in vaccination technique (they are permitted by law to administer particular agents to adults) -Medication Therapy Management

46 Medication Therapy Management: Definition Continuity of pharmaceutical careContinuity of pharmaceutical care Assessment of health statusAssessment of health status Formulating a medication treatment planFormulating a medication treatment plan Selecting initiating modifying therapySelecting initiating modifying therapy Monitoring and evaluating response to therapy including safety and effectivenessMonitoring and evaluating response to therapy including safety and effectiveness

47 Medication Therapy Management: Definition Performing medication review to identify resolve and prevent drug related problemsPerforming medication review to identify resolve and prevent drug related problems Documenting and communicating to patients other primary care providersDocumenting and communicating to patients other primary care providers Providing patient education and trainingProviding patient education and training Providing support to enhance adherenceProviding support to enhance adherence Coordinating medication therapy management servicesCoordinating medication therapy management services

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

49 Challenges in Community Pharmacy Availability of medical informationAvailability of medical information -Continuity at the time of admission or discharge from the hospital Ability to document interventions or medication changes in the medical recordAbility to document interventions or medication changes in the medical record Marketing – the public and professionals dont know what we can do!Marketing – the public and professionals dont know what we can do!

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 diabetesTo assess the clinical, economic, and humanistic outcomes of pharmaceutical care services provided in community pharmacies for patients with diabetes Pharmacists served as care providersPharmacists served as care providers Patient appointments included initial history, needs assessment and goal setting followed by monitoring, training and goal re-evaluationPatient appointments included initial history, needs assessment and goal setting followed by monitoring, training and goal re-evaluation

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52 What we can do in the Community: The Ashville Project HbA1C in range was 33% at base line and 85% in 14 monthsHbA1C in range was 33% at base line and 85% in 14 months Significant improvement in LDL, HDLSignificant improvement in LDL, HDL 10% decline in total costs10% decline in total costs -33% decline in inpatient costs -20 % increase in outpatient costs Glucometers, pharmacist fees, diabetes center costs, etc.Glucometers, pharmacist fees, diabetes center costs, etc. Improved outcomes at decrease costsImproved outcomes at decrease costs

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

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

55 Community Pharmacy Future Directions Disease screening programs to help identify patients requiring in depth disease state management and MTMDisease 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 processWorking 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 ClinicThe 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 areaPharmacy 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 locationsMore 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)Economic analysis compared to non- pharmacist run anticoagulation services (1998) Cost avoidance of $300,000Cost avoidance of $300,000 -Decrease risk/admissions for thrombosis and bleed Benefit to cost ratio of 1.5:1Benefit to cost ratio of 1.5:1 Revenue producing serviceRevenue producing service -Working toward a budget neutral service

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

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

61 Anticoagulation Clinic Students learn to care for these patientsStudents 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 clinicReferred 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 intervalsPatients 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 diseasePharmacist counsels patients on use of glucometer, medication adherence, diet, and symptoms of their disease Multiple parameters measured including HbA1CMultiple 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 visitsPatient 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 retinopathyPatients 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 problemsReview patient medical record for appropriate therapy, dosing, drug interactions, drug related problems History including compliance and dietHistory including compliance and diet Medication, diet, lifestyle councelingMedication, diet, lifestyle counceling Medication adjustmentMedication adjustment Case presentations, journal club, lectures to health professionalsCase 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: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 outcomesPharmacists 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 outcomesPharmacists will be the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes

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