- Email: [email protected]
Civilian pharmacy involvement in Department of Defense Innovative Readiness Training
SCIENCE AND PRACTICE Journal of the American Pharmacists Association 59 (2019) 722e726
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Civilian pharmacy involvement in Department of Defense Innovative Readiness Training Anne Misher*, Misha Thomason Watts, Abigail Hamlin a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 January 2019 Accepted 12 May 2019 Available online 24 June 2019
Objectives: Innovative Readiness Training (IRT) is a United States military exercise that provides training for military personnel while providing services for communities. The objective of this paper was to describe civilian pharmacy services provided during an IRT, Operation Empower Health. Setting: Operation Empower Health took place on May 10 to 18, 2018, in Savannah and Garden City, Georgia. Pharmacy operations included a limited formulary of medications. Civilian pharmacy volunteers were paired with military persons at 2 of 4 locations. Practice description: Student pharmacists, residents, preceptors, and faculty provided disease state education to patients during triage. After receiving medical or dental services, patients were provided prescription and over-the-counter medications at the dispensing and counseling station. Civilian pharmacy personnel worked with military personnel to dispense and counsel on medications. Many patients required additional health services or postclinic care. University of Georgia College of Pharmacy faculty members were able to meet with patients for follow-up. An in-service to military personnel was provided by the pharmacists regarding common medication errors. Evaluation: Within Operation Empower Health, 7942 patients were provided health care services at no cost. A total of 11 students, 5 residents, 2 University of Georgia College of Pharmacy faculty, and 1 preceptor provided pharmacy services during the event. Civilian pharmacy personnel were able to educate 566 patients for a total of 2700 minutes. In addition to medications, patients were counseled on lifestyle interventions. Conclusion: Overall, IRT builds mutually beneficial civilianemilitary partnerships between communities and the Department of Defense. Civilian pharmacy personnel were able to offer medication and lifestyle counseling in addition to managing medication dispensing. Student pharmacists, in particular, were given a unique interprofessional learning opportunity in addition to having a culturally competent experience. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Innovative Readiness Training (IRT) is a United States military exercise that provides real-life deployment training and readiness for military personnel while providing services for communities in select areas of the country.1 The trainings help to prepare service members for missions such as natural disasters and national emergencies. The program is led by the Director of Civil-Military Training policy in the Office of the Deputy Assistant Secretary of Defense for Reserve Integration.
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. * Correspondence: Anne Misher, PharmD, BCACP, BC-ADM, CDE, College of Pharmacy, University of Georgia, 5354 Reynolds St., POB Suite 225, Savannah, GA 31405. E-mail address: [email protected] (A. Misher).
Operations are completed in 3 different areas. These areas include education and job training, civil engineering, and health and medical services. Education and job training services, along with civil engineering projects, have provided resources and met domestic needs across the country. Medical services help to address public and civil-society needs for the underserved. Members from all areas of the military are involved in the training, including those who are in Active, Guard, and Reserve service. The program is beneficial to both the military and the communities they serve. Military members are able to gain experience necessary to fulfill training requirements, prepare for disaster situations, and build relationships with the community. Civilian communities benefit by receiving necessary services and building partnerships. During trainings, civilians leverage community resources for
https://doi.org/10.1016/j.japh.2019.05.009 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE Civilian pharmacy in innovative readiness training
Key Points Background: Innovative Readiness Training (IRT) is a United States military exercise that provides real-life deployment training and readiness for military personnel while providing services for communities in selected areas of the country. During trainings, civilians leverage community resources for use, including facilities, security, and community planning. No available literature describes civilian pharmacy involvement in IRT. Findings: Civilian pharmacists can play several roles in IRT to ultimately improve care for patients. IRT provides a unique opportunity for pharmacy trainees. Civilian pharmacist involvement in IRT can enhance military operations.
use including facilities, security, and community planning. Projects are funded by both government budgets and private contributions, with military funds being used for manpower, travel, freight, expendable items, and rental equipment. Private contributions contribute to facilities and security as needed for the event.1 Both public and private nonprofit entities are eligible to host an IRT through an application process. To receive a viable IRT partnership, the civilian entity must provide an application form, assurance of noncompetition with the private sector, designs, blueprints, property access, additional partners or volunteers, and medical credentialing and privileging. Nonprofit organizations may be designated as eligible by the Office of the Secretary of Defense on request. Civilian entities must submit project applications in the fall 1 year before the fiscal year when the partnership will take place, which allows time for the military to find a project that meets their normal training requirements and readiness planning cycles. Once the project is selected, military leaders work with community partners for several months to prepare for the event. Meetings are held on a regular basis to ensure that steady progress is made toward implementing the event. Input from both military and civilian members is needed to ensure success for the event. It is the responsibility of community partners to ensure that the event is advertised to citizens in need of the services. In addition, at these planning meetings, community partners have the opportunity to offer services that fill needs to expand the services provided during the event.1 In the example provided, we describe the University of Georgia (UGA) College of Pharmacy’s contribution to expand pharmacy services during an IRT held in the greater Savannah area. Chatham County, Georgia, was recently chosen as a training site for a medical IRT. The event was titled Operation Empower Health. According to Data USA, Chatham County has a population of 289,082 people and a 15.7% poverty rate.2 Also, Open
Network’s 2014 statistics report that 22.6% of Chatham County residents aged 18 to 64 years were uninsured and did not possess health insurance.3 These statistics helped to demonstrate the need within the community for medical services. Community partners who submitted the application included St. Joseph’s/Candler Health System (SJCHS) and Georgia Southern University. Key partners included the City of Savannah, the City of Garden City, and Savannah State University. Faculty from the UGA College of Pharmacy have practice sites within SJCHS, including an underserved primary care clinic. The UGA College of Pharmacy faculty members were invited to be involved with the IRT through their practice site.4 Although the overall purpose of IRT is to provide a training opportunity for military personnel, we describe the specific role of civilian pharmacists’ (including pharmacy students, residents, preceptors, and faculty) services during the Department of Defense IRT Operation Empower Health. Specifically, we describe civilian pharmacist involvement before, during, and after the event to illustrate these services. Previous literature has provided brief descriptions of dental students, physician assistant students, and their faculty members’ involvement in IRT; however, to our knowledge pharmacy services have not been previously described in the literature.5 Before the event, civilian pharmacy services included evaluation of facilities and supplies to ensure successful pharmacy operations. In addition, pharmacists were responsible for soliciting and coordination of volunteers. During the event, civilian pharmacy services included medication counseling, dispensing, and disease state education. These services were requested by military personnel before the event based on discussions between pharmacy faculty and event organizers. In addition, a request was made by military organizers for civilian pharmacists to provide a medication in-service to other health professionals for training purposes. Setting Operation Empower Health took place on May 10 to 18, 2018. To execute the event, the military deployed about 400 personnel from all branches of the military. The event provided health care services at no cost to patients at 4 locations within Savannah and Garden City, Georgia. Medical services provided included medical, vision, dental, and veterinary. Workflow stations were used to organize patients and volunteers. These stations consisted of registration, medical services, financial support, medication dispensing and counseling, and community services (e.g., mental health, voter registration, etc.; Figure 1). Stations including registration and medical services were run exclusively by military personnel. Stations including financial support and community services were run exclusively by community partners. Medication dispensing and counseling services were run through a collaboration of military personnel and civilian pharmacists. Pharmacy operations included a limited formulary of medications. Military personnel assigned to pharmacy operations included nurses and pharmacy technicians. Further description of the civilian pharmacists’ roles is provided in the practice description below. To prepare for the event, 2 UGA College of Pharmacy faculty members volunteered to attend several Operation Empower
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regarding use of patient home medications. Patients were also provided disease state education during medication counseling. Medication dispensing and counseling After receiving medical and dental services, patients were provided prescription and over-the-counter medications at the dispensing and counseling station before discharge. Civilian student pharmacists, residents, preceptors, and faculty worked with military personnel to dispense medications. Civilians were responsible for counting tablets and preparing labels for all prescriptions. Counseling included drug, dose, frequency, indication, and adverse effects on each medication dispensed. In addition, when appropriate, lifestyle interventions were recommended. Educational materials, including pamphlets, were used to enhance verbal communication with patients. Figure 1. Workflow stations at each Operation Empower Health Site.
Health planning meetings. Meetings included both military and civilian leaders who coordinated resources and planned for the event. In addition, the faculty coordinated volunteer registration of students, residents, and preceptors. Owing to the timing of the event, student volunteers were those who were completing their advanced pharmacy practice experiences for the Doctorate of Pharmacy program in the Savannah area, as well as prepharmacy program students from Georgia Southern University. Resident volunteers included those from SJCHS and University of Georgia. Faculty coordinated student and resident volunteers through their preceptors because the event overlapped with experience responsibilities. Pharmacy volunteers were paired with military personnel at 2 of the 4 locations of the IRT: Georgia Southern University and the Savannah Civic Center. Owing to differences in facilities, operations differed slightly between locations. On the Georgia Southern campus, the pharmacy volunteers were physically located in the pharmacy dispensing room. At the Civic Center, one group of volunteers was located in the pharmacy dispensing area and another group provided services in a medication counseling area. Practice description In addition to working collaboratively with military personnel in the medication dispensing and counseling station, civilian pharmacists were actively engaged in disease state education as patients waited for services, referral, and follow-up care after the event and in education of military personnel through a pharmacy in-service as described below. Disease state education At the start of each day, patients were triaged to determine which services were needed. While patients waited to be seen by providers, patients remained in a holding area. Student pharmacists, residents, preceptors, and faculty provided disease state education. Educational materials, including pamphlets, were provided to patients to reinforce counseling points. In addition, questions were answered 724
Referral and follow-up evaluation After their clinic visit, many patients required additional health services or postclinic care. Therefore, several medical clinics within the area worked with IRT and provided no- or low-cost services to these patients in the outpatient setting. Among these clinics was St. Joseph’s/Candler Good Samaritan Clinic and St. Mary’s Health Center, where UGA College of Pharmacy faculty members who volunteered for Operation Empower Health were able to meet with patients for their follow-up care. Pharmacy in-service Military personnel are required to complete continuing education as a component of training.1 Several continuing education sessions were provided by civilian partners, including an in-service by UGA College of Pharmacy faculty. The in-service was a 1-hour education session on common medication errors. Twenty military personnel attended and participated in the session. Topics covered included caveat drug facts and methods to prevent medication errors. Specifically, common medication errors, drug interactions, drug abbreviations, and drug dosage errors were discussed, along with methods to prevent them from occurring. Evaluation (impact of innovation) Before the event it was unclear how many patients would participate in the event, but it was estimated that 6000 patients would be served. Likewise, it was not known how many patients would need pharmacy services and an estimate before the event was not made. However, to provide feedback on the impact of the event, tally sheets were created to track the number of patients served and the time spent by event personnel. Within Operation Empower Health, 7942 patients were provided health care services at no cost. A total of 11 students, 5 residents, 2 UGA College of Pharmacy faculty, and 1 preceptor provided pharmacy services during the event. Pharmacy personnel worked together interprofessionally with military personnel at the dispensing and counseling station to provide adequate health care services. In just 9 days, civilian
SCIENCE AND PRACTICE Civilian pharmacy in innovative readiness training
pharmacy personnel were able to educate 566 patients. A total of 2700 minutes was spent counseling patients on both medication and lifestyle interventions. Counseling and medication education primarily focused on nonsteroidal anti-inflammatory drugs (54%), acetaminophen (20%), oral antibiotics (10%), antihistamines (10%), fluticasone (3%), and hydrochlorothiazide (3%; Figure 2). Other medications that were dispensed and discussed included steroidal creams, gabapentin, stool softeners, and proton pump inhibitors, among others. In addition to medications, patients were counseled on lifestyle interventions, such as diabetes, hypertension, smoking cessation, nutrition, stress management, and exercise. Pharmacy personnel distributed educational pamphlets discussing each of these lifestyle interventions and offered tactics to make these lifestyle changes. Supplemental counseling with the pamphlet information was offered to increase medication adherence and ensure these lifestyle interventions. For example, for patients seeking education on smoking cessation, pharmacy personnel counseled on over-the-counter cessation options, such as nicotine patches, gums, and lozenges; for patients that were receptive, further detail was discussed on the recommended strength of nicotine dosage replacement based on the quantity of cigarettes he or she smoked per day. Pharmacy personnel in Operation Empower Health used motivational interviewing techniques in their counseling to determine patient confidence and commitment to their new therapies and lifestyle changes. Practice implications This service demonstrates the impact that civilian pharmacy personnel can have on the community and other IRT operations. Chatham County and other low-income areas would benefit most from free or low-cost health care
services. In addition to the initial health care visit during Operation Empower Health, these patients are given an opportunity for continuum of care through local resources and clinics. More IRT operations, similar to this one, could provide health care services to large populations of underserved patients in a relatively short amount of time. As a part of these operations, civilian pharmacy personnel can greatly affect and increase the services provided. By including pharmacists in these operations, medical and dental providers are able to spend more time offering services in diagnosis and surgical operations while pharmacists can provide medication and lifestyle counseling. In addition, working directly with military personnel with limited medication dispensing experience (e.g., nurses and pharmacy technicians) provides valuable knowledge to military personnel. As demonstrated by the pharmacist-provided education training for military personnel, pharmacists are proficient in pharmacotherapy knowledge and can provide services to patients and other health professionals within these operations. Pharmacy faculty provided recommendations to military personnel for possible improvements to training operations, such as medication dispensing practices. At the start of the training, medications were dispensed in small bags without labels. It was advised that patients receive medications in prescription bottles with labels containing all necessary information. Faculty were able to obtain prescription bottles from SJCHS for the remainder of the training. In addition, a prescription label was created and provided. This recommendation was provided to military organizers for incorporation into future events. Pharmacists were consulted for advice on formulary options for this operation. Given the patient population, uncontrolled hypertension and respiratory conditions were prevalent. The addition of hydrochlorothiazide and albuterol were
Figure 2. Medication counseling provided at Operation Empower Health by civilians.
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recommended for the formulary. After this pharmacist advice, military personnel were able to obtain these medications and provide them to patients for the training. The additional of hydrochlorothiazide to the formulary allowed patients to lower blood pressure and receive dental procedures.
Discussion IRT provides opportunities to prepare United States military personnel for future active missions. Additionally, IRT fosters collaboration between military personnel and members of the community to provide care for patients in need. These trainings are conducted throughout the United States and are an interprofessional opportunity for civilian pharmacists and trainees. All military personnel are highly skilled professionals trained and certified in their areas of expertise. IRT not only provides a positive image of the military, but also allows for teaching opportunities between military participants and civilians of various health professions.1 For example, in this IRT event, civilian student pharmacists and residents were given the opportunity to work with military nurses. Overall, as demonstrated in this example, civilian pharmacists can play several roles in IRT to ultimately improve care for patients. IRT also provides a unique opportunity for trainees. For UGA students in particular, this event was both volunteer for some students and part of a required introductory pharmacy practice experience (IPPE) for others. This event enabled students to work with an underserved patient population, allowing them to use their medical knowledge, all while providing culturally competent health care. The population at this event had specific needs, which are often very different from other patient populations that trainees have previously experienced. One student even described this experience as the best IPPE he or she had been a part of to date. As a subpopulation of trainees within this IRT event, students were given a health care experience they would not have received within their pharmacy curriculum. For patients served at this IRT event, seeking care is challenging due to lack of insurance. Furthermore, ancillary services such as dental and vision are not an option. Therefore, low-cost local health care facilities are often how patients find health care. This, in turn, teaches trainees that maximizing resources is a necessary skill that must be utilized to provide these patients with the proper services they require. To our knowledge, no other description of civilian pharmacist involvement in IRT is provided in the literature. The present description of our involvement in IRT is provided as an example to provide awareness to others about the opportunity to engage in similar activities across the United States. The number of prescriptions filled, impact on and perspective of military personnel regarding the pharmacy in-service, number of referrals to outside services made during the event, and follow-up interactions with patients after the event were not recorded; however, these parameters could be considered for evaluation during future events to further assess and describe the impact of civilian pharmacy services. Ultimately, IRT is beneficial for pharmacists to provide patient care by reviewing medications and educating patients who are underserved in the community. Just as pharmacists can build relationships with military personnel, this type of 726
event allows pharmacists to form partnerships and demonstrate what they have to offer the community. As demonstrated in this event, pharmacists are able to offer more than simply dispensing of medications. During Operation Empower Health, pharmacy personnel counseled patients and initiated several patient initiatives, whether it was medication or lifestyle interventions, in addition to managing the medication dispensing process. Through our description of civilian pharmacists’ involvement with IRT, the ability of pharmacists to offer services including medication education, disease state education, health professional training, and referral for followup may be applicable in similar settings that provide services to the underserved at no cost. It is likely that these services could be implemented as described in nonmilitary settings, such as community events or preparedness exercises. Pharmacists should seek these opportunities when possible. Conclusion Overall, IRT builds mutually beneficial civil-military partnerships between United States communities and the Department of Defense. These operations contribute to meeting society’s needs.1 During Operation Empower Health, an underserved population in Chatham County, Georgia, were given an opportunity seek health care services at no cost and then referred for chronic treatment at local facilities if necessary. The military personnel were provided with an opportunity to complete their continuing education while working interprofessionally with civilians. Pharmacy personnel were able to offer medication and lifestyle counseling in addition to managing medication dispensing. Student pharmacists, in particular, were given a unique interprofessional learning opportunity in addition to a culturally competent experience. As a whole, numerous otherwise unobtainable health care opportunities were provided to the community. Operation Empower Health has demonstrated the benefit of pharmacist involvement within these events and the benefits to these pharmacists, military personnel, and communities. References 1. Department of Defense. Innovative readiness training. Available at: https:// irt.defense.gov/. Accessed December 20, 2018. 2. Data USA. Chatham County, GA. Available at: https://datausa.io/profile/ geo/chatham-county-ga/#category_coverage. Accessed November 17, 2018. 3. Open Data Network. Chatham County, GA. Available at: https://www. opendatanetwork.com/entity/0500000US13051/Chatham_County_GA/ health.health_insurance.pctui?year¼2014&age¼18%20to%2064&race¼All %20races&sex¼Both%20sexes&income¼All%20income%20levels. Accessed November 17, 2018. 4. St. Joseph’s Candler/Live Smart. Operation Empower HealthdGreater Savannah. Available at: https://www.sjchs.org/in-the-community/ operation-empower-health-greater-savannah. Accessed November 15, 2018. 5. Lalich RA. The role of state government, local government, and nongovernmental organizations in medical innovative readiness training. Mil Med. 2002;167(5):367e369. Anne Misher, PharmD, BCACP, BC-ADM, CDE, Clinical Assistant Professor, University of Georgia College of Pharmacy, St. Joseph’s/Candler Health System, Savannah, GA Misha Thomason Watts, PharmD, Campus Director for Pharmacy Practice Experiences, Southeast Georgia, University of Georgia College of Pharmacy, St. Joseph’s/Candler Health System, Savannah, GA Abigail Hamlin, PharmD candidate, University of Georgia College of Pharmacy, Savannah, GA
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Civilian pharmacy involvement in Department of Defense Innovative Readiness Training Anne Misher*, Misha Thomason Watts, Abigail Hamlin a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 January 2019 Accepted 12 May 2019 Available online 24 June 2019
Objectives: Innovative Readiness Training (IRT) is a United States military exercise that provides training for military personnel while providing services for communities. The objective of this paper was to describe civilian pharmacy services provided during an IRT, Operation Empower Health. Setting: Operation Empower Health took place on May 10 to 18, 2018, in Savannah and Garden City, Georgia. Pharmacy operations included a limited formulary of medications. Civilian pharmacy volunteers were paired with military persons at 2 of 4 locations. Practice description: Student pharmacists, residents, preceptors, and faculty provided disease state education to patients during triage. After receiving medical or dental services, patients were provided prescription and over-the-counter medications at the dispensing and counseling station. Civilian pharmacy personnel worked with military personnel to dispense and counsel on medications. Many patients required additional health services or postclinic care. University of Georgia College of Pharmacy faculty members were able to meet with patients for follow-up. An in-service to military personnel was provided by the pharmacists regarding common medication errors. Evaluation: Within Operation Empower Health, 7942 patients were provided health care services at no cost. A total of 11 students, 5 residents, 2 University of Georgia College of Pharmacy faculty, and 1 preceptor provided pharmacy services during the event. Civilian pharmacy personnel were able to educate 566 patients for a total of 2700 minutes. In addition to medications, patients were counseled on lifestyle interventions. Conclusion: Overall, IRT builds mutually beneficial civilianemilitary partnerships between communities and the Department of Defense. Civilian pharmacy personnel were able to offer medication and lifestyle counseling in addition to managing medication dispensing. Student pharmacists, in particular, were given a unique interprofessional learning opportunity in addition to having a culturally competent experience. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Innovative Readiness Training (IRT) is a United States military exercise that provides real-life deployment training and readiness for military personnel while providing services for communities in select areas of the country.1 The trainings help to prepare service members for missions such as natural disasters and national emergencies. The program is led by the Director of Civil-Military Training policy in the Office of the Deputy Assistant Secretary of Defense for Reserve Integration.
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. * Correspondence: Anne Misher, PharmD, BCACP, BC-ADM, CDE, College of Pharmacy, University of Georgia, 5354 Reynolds St., POB Suite 225, Savannah, GA 31405. E-mail address: [email protected] (A. Misher).
Operations are completed in 3 different areas. These areas include education and job training, civil engineering, and health and medical services. Education and job training services, along with civil engineering projects, have provided resources and met domestic needs across the country. Medical services help to address public and civil-society needs for the underserved. Members from all areas of the military are involved in the training, including those who are in Active, Guard, and Reserve service. The program is beneficial to both the military and the communities they serve. Military members are able to gain experience necessary to fulfill training requirements, prepare for disaster situations, and build relationships with the community. Civilian communities benefit by receiving necessary services and building partnerships. During trainings, civilians leverage community resources for
https://doi.org/10.1016/j.japh.2019.05.009 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE Civilian pharmacy in innovative readiness training
Key Points Background: Innovative Readiness Training (IRT) is a United States military exercise that provides real-life deployment training and readiness for military personnel while providing services for communities in selected areas of the country. During trainings, civilians leverage community resources for use, including facilities, security, and community planning. No available literature describes civilian pharmacy involvement in IRT. Findings: Civilian pharmacists can play several roles in IRT to ultimately improve care for patients. IRT provides a unique opportunity for pharmacy trainees. Civilian pharmacist involvement in IRT can enhance military operations.
use including facilities, security, and community planning. Projects are funded by both government budgets and private contributions, with military funds being used for manpower, travel, freight, expendable items, and rental equipment. Private contributions contribute to facilities and security as needed for the event.1 Both public and private nonprofit entities are eligible to host an IRT through an application process. To receive a viable IRT partnership, the civilian entity must provide an application form, assurance of noncompetition with the private sector, designs, blueprints, property access, additional partners or volunteers, and medical credentialing and privileging. Nonprofit organizations may be designated as eligible by the Office of the Secretary of Defense on request. Civilian entities must submit project applications in the fall 1 year before the fiscal year when the partnership will take place, which allows time for the military to find a project that meets their normal training requirements and readiness planning cycles. Once the project is selected, military leaders work with community partners for several months to prepare for the event. Meetings are held on a regular basis to ensure that steady progress is made toward implementing the event. Input from both military and civilian members is needed to ensure success for the event. It is the responsibility of community partners to ensure that the event is advertised to citizens in need of the services. In addition, at these planning meetings, community partners have the opportunity to offer services that fill needs to expand the services provided during the event.1 In the example provided, we describe the University of Georgia (UGA) College of Pharmacy’s contribution to expand pharmacy services during an IRT held in the greater Savannah area. Chatham County, Georgia, was recently chosen as a training site for a medical IRT. The event was titled Operation Empower Health. According to Data USA, Chatham County has a population of 289,082 people and a 15.7% poverty rate.2 Also, Open
Network’s 2014 statistics report that 22.6% of Chatham County residents aged 18 to 64 years were uninsured and did not possess health insurance.3 These statistics helped to demonstrate the need within the community for medical services. Community partners who submitted the application included St. Joseph’s/Candler Health System (SJCHS) and Georgia Southern University. Key partners included the City of Savannah, the City of Garden City, and Savannah State University. Faculty from the UGA College of Pharmacy have practice sites within SJCHS, including an underserved primary care clinic. The UGA College of Pharmacy faculty members were invited to be involved with the IRT through their practice site.4 Although the overall purpose of IRT is to provide a training opportunity for military personnel, we describe the specific role of civilian pharmacists’ (including pharmacy students, residents, preceptors, and faculty) services during the Department of Defense IRT Operation Empower Health. Specifically, we describe civilian pharmacist involvement before, during, and after the event to illustrate these services. Previous literature has provided brief descriptions of dental students, physician assistant students, and their faculty members’ involvement in IRT; however, to our knowledge pharmacy services have not been previously described in the literature.5 Before the event, civilian pharmacy services included evaluation of facilities and supplies to ensure successful pharmacy operations. In addition, pharmacists were responsible for soliciting and coordination of volunteers. During the event, civilian pharmacy services included medication counseling, dispensing, and disease state education. These services were requested by military personnel before the event based on discussions between pharmacy faculty and event organizers. In addition, a request was made by military organizers for civilian pharmacists to provide a medication in-service to other health professionals for training purposes. Setting Operation Empower Health took place on May 10 to 18, 2018. To execute the event, the military deployed about 400 personnel from all branches of the military. The event provided health care services at no cost to patients at 4 locations within Savannah and Garden City, Georgia. Medical services provided included medical, vision, dental, and veterinary. Workflow stations were used to organize patients and volunteers. These stations consisted of registration, medical services, financial support, medication dispensing and counseling, and community services (e.g., mental health, voter registration, etc.; Figure 1). Stations including registration and medical services were run exclusively by military personnel. Stations including financial support and community services were run exclusively by community partners. Medication dispensing and counseling services were run through a collaboration of military personnel and civilian pharmacists. Pharmacy operations included a limited formulary of medications. Military personnel assigned to pharmacy operations included nurses and pharmacy technicians. Further description of the civilian pharmacists’ roles is provided in the practice description below. To prepare for the event, 2 UGA College of Pharmacy faculty members volunteered to attend several Operation Empower
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regarding use of patient home medications. Patients were also provided disease state education during medication counseling. Medication dispensing and counseling After receiving medical and dental services, patients were provided prescription and over-the-counter medications at the dispensing and counseling station before discharge. Civilian student pharmacists, residents, preceptors, and faculty worked with military personnel to dispense medications. Civilians were responsible for counting tablets and preparing labels for all prescriptions. Counseling included drug, dose, frequency, indication, and adverse effects on each medication dispensed. In addition, when appropriate, lifestyle interventions were recommended. Educational materials, including pamphlets, were used to enhance verbal communication with patients. Figure 1. Workflow stations at each Operation Empower Health Site.
Health planning meetings. Meetings included both military and civilian leaders who coordinated resources and planned for the event. In addition, the faculty coordinated volunteer registration of students, residents, and preceptors. Owing to the timing of the event, student volunteers were those who were completing their advanced pharmacy practice experiences for the Doctorate of Pharmacy program in the Savannah area, as well as prepharmacy program students from Georgia Southern University. Resident volunteers included those from SJCHS and University of Georgia. Faculty coordinated student and resident volunteers through their preceptors because the event overlapped with experience responsibilities. Pharmacy volunteers were paired with military personnel at 2 of the 4 locations of the IRT: Georgia Southern University and the Savannah Civic Center. Owing to differences in facilities, operations differed slightly between locations. On the Georgia Southern campus, the pharmacy volunteers were physically located in the pharmacy dispensing room. At the Civic Center, one group of volunteers was located in the pharmacy dispensing area and another group provided services in a medication counseling area. Practice description In addition to working collaboratively with military personnel in the medication dispensing and counseling station, civilian pharmacists were actively engaged in disease state education as patients waited for services, referral, and follow-up care after the event and in education of military personnel through a pharmacy in-service as described below. Disease state education At the start of each day, patients were triaged to determine which services were needed. While patients waited to be seen by providers, patients remained in a holding area. Student pharmacists, residents, preceptors, and faculty provided disease state education. Educational materials, including pamphlets, were provided to patients to reinforce counseling points. In addition, questions were answered 724
Referral and follow-up evaluation After their clinic visit, many patients required additional health services or postclinic care. Therefore, several medical clinics within the area worked with IRT and provided no- or low-cost services to these patients in the outpatient setting. Among these clinics was St. Joseph’s/Candler Good Samaritan Clinic and St. Mary’s Health Center, where UGA College of Pharmacy faculty members who volunteered for Operation Empower Health were able to meet with patients for their follow-up care. Pharmacy in-service Military personnel are required to complete continuing education as a component of training.1 Several continuing education sessions were provided by civilian partners, including an in-service by UGA College of Pharmacy faculty. The in-service was a 1-hour education session on common medication errors. Twenty military personnel attended and participated in the session. Topics covered included caveat drug facts and methods to prevent medication errors. Specifically, common medication errors, drug interactions, drug abbreviations, and drug dosage errors were discussed, along with methods to prevent them from occurring. Evaluation (impact of innovation) Before the event it was unclear how many patients would participate in the event, but it was estimated that 6000 patients would be served. Likewise, it was not known how many patients would need pharmacy services and an estimate before the event was not made. However, to provide feedback on the impact of the event, tally sheets were created to track the number of patients served and the time spent by event personnel. Within Operation Empower Health, 7942 patients were provided health care services at no cost. A total of 11 students, 5 residents, 2 UGA College of Pharmacy faculty, and 1 preceptor provided pharmacy services during the event. Pharmacy personnel worked together interprofessionally with military personnel at the dispensing and counseling station to provide adequate health care services. In just 9 days, civilian
SCIENCE AND PRACTICE Civilian pharmacy in innovative readiness training
pharmacy personnel were able to educate 566 patients. A total of 2700 minutes was spent counseling patients on both medication and lifestyle interventions. Counseling and medication education primarily focused on nonsteroidal anti-inflammatory drugs (54%), acetaminophen (20%), oral antibiotics (10%), antihistamines (10%), fluticasone (3%), and hydrochlorothiazide (3%; Figure 2). Other medications that were dispensed and discussed included steroidal creams, gabapentin, stool softeners, and proton pump inhibitors, among others. In addition to medications, patients were counseled on lifestyle interventions, such as diabetes, hypertension, smoking cessation, nutrition, stress management, and exercise. Pharmacy personnel distributed educational pamphlets discussing each of these lifestyle interventions and offered tactics to make these lifestyle changes. Supplemental counseling with the pamphlet information was offered to increase medication adherence and ensure these lifestyle interventions. For example, for patients seeking education on smoking cessation, pharmacy personnel counseled on over-the-counter cessation options, such as nicotine patches, gums, and lozenges; for patients that were receptive, further detail was discussed on the recommended strength of nicotine dosage replacement based on the quantity of cigarettes he or she smoked per day. Pharmacy personnel in Operation Empower Health used motivational interviewing techniques in their counseling to determine patient confidence and commitment to their new therapies and lifestyle changes. Practice implications This service demonstrates the impact that civilian pharmacy personnel can have on the community and other IRT operations. Chatham County and other low-income areas would benefit most from free or low-cost health care
services. In addition to the initial health care visit during Operation Empower Health, these patients are given an opportunity for continuum of care through local resources and clinics. More IRT operations, similar to this one, could provide health care services to large populations of underserved patients in a relatively short amount of time. As a part of these operations, civilian pharmacy personnel can greatly affect and increase the services provided. By including pharmacists in these operations, medical and dental providers are able to spend more time offering services in diagnosis and surgical operations while pharmacists can provide medication and lifestyle counseling. In addition, working directly with military personnel with limited medication dispensing experience (e.g., nurses and pharmacy technicians) provides valuable knowledge to military personnel. As demonstrated by the pharmacist-provided education training for military personnel, pharmacists are proficient in pharmacotherapy knowledge and can provide services to patients and other health professionals within these operations. Pharmacy faculty provided recommendations to military personnel for possible improvements to training operations, such as medication dispensing practices. At the start of the training, medications were dispensed in small bags without labels. It was advised that patients receive medications in prescription bottles with labels containing all necessary information. Faculty were able to obtain prescription bottles from SJCHS for the remainder of the training. In addition, a prescription label was created and provided. This recommendation was provided to military organizers for incorporation into future events. Pharmacists were consulted for advice on formulary options for this operation. Given the patient population, uncontrolled hypertension and respiratory conditions were prevalent. The addition of hydrochlorothiazide and albuterol were
Figure 2. Medication counseling provided at Operation Empower Health by civilians.
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recommended for the formulary. After this pharmacist advice, military personnel were able to obtain these medications and provide them to patients for the training. The additional of hydrochlorothiazide to the formulary allowed patients to lower blood pressure and receive dental procedures.
Discussion IRT provides opportunities to prepare United States military personnel for future active missions. Additionally, IRT fosters collaboration between military personnel and members of the community to provide care for patients in need. These trainings are conducted throughout the United States and are an interprofessional opportunity for civilian pharmacists and trainees. All military personnel are highly skilled professionals trained and certified in their areas of expertise. IRT not only provides a positive image of the military, but also allows for teaching opportunities between military participants and civilians of various health professions.1 For example, in this IRT event, civilian student pharmacists and residents were given the opportunity to work with military nurses. Overall, as demonstrated in this example, civilian pharmacists can play several roles in IRT to ultimately improve care for patients. IRT also provides a unique opportunity for trainees. For UGA students in particular, this event was both volunteer for some students and part of a required introductory pharmacy practice experience (IPPE) for others. This event enabled students to work with an underserved patient population, allowing them to use their medical knowledge, all while providing culturally competent health care. The population at this event had specific needs, which are often very different from other patient populations that trainees have previously experienced. One student even described this experience as the best IPPE he or she had been a part of to date. As a subpopulation of trainees within this IRT event, students were given a health care experience they would not have received within their pharmacy curriculum. For patients served at this IRT event, seeking care is challenging due to lack of insurance. Furthermore, ancillary services such as dental and vision are not an option. Therefore, low-cost local health care facilities are often how patients find health care. This, in turn, teaches trainees that maximizing resources is a necessary skill that must be utilized to provide these patients with the proper services they require. To our knowledge, no other description of civilian pharmacist involvement in IRT is provided in the literature. The present description of our involvement in IRT is provided as an example to provide awareness to others about the opportunity to engage in similar activities across the United States. The number of prescriptions filled, impact on and perspective of military personnel regarding the pharmacy in-service, number of referrals to outside services made during the event, and follow-up interactions with patients after the event were not recorded; however, these parameters could be considered for evaluation during future events to further assess and describe the impact of civilian pharmacy services. Ultimately, IRT is beneficial for pharmacists to provide patient care by reviewing medications and educating patients who are underserved in the community. Just as pharmacists can build relationships with military personnel, this type of 726
event allows pharmacists to form partnerships and demonstrate what they have to offer the community. As demonstrated in this event, pharmacists are able to offer more than simply dispensing of medications. During Operation Empower Health, pharmacy personnel counseled patients and initiated several patient initiatives, whether it was medication or lifestyle interventions, in addition to managing the medication dispensing process. Through our description of civilian pharmacists’ involvement with IRT, the ability of pharmacists to offer services including medication education, disease state education, health professional training, and referral for followup may be applicable in similar settings that provide services to the underserved at no cost. It is likely that these services could be implemented as described in nonmilitary settings, such as community events or preparedness exercises. Pharmacists should seek these opportunities when possible. Conclusion Overall, IRT builds mutually beneficial civil-military partnerships between United States communities and the Department of Defense. These operations contribute to meeting society’s needs.1 During Operation Empower Health, an underserved population in Chatham County, Georgia, were given an opportunity seek health care services at no cost and then referred for chronic treatment at local facilities if necessary. The military personnel were provided with an opportunity to complete their continuing education while working interprofessionally with civilians. Pharmacy personnel were able to offer medication and lifestyle counseling in addition to managing medication dispensing. Student pharmacists, in particular, were given a unique interprofessional learning opportunity in addition to a culturally competent experience. As a whole, numerous otherwise unobtainable health care opportunities were provided to the community. Operation Empower Health has demonstrated the benefit of pharmacist involvement within these events and the benefits to these pharmacists, military personnel, and communities. References 1. Department of Defense. Innovative readiness training. Available at: https:// irt.defense.gov/. Accessed December 20, 2018. 2. Data USA. Chatham County, GA. Available at: https://datausa.io/profile/ geo/chatham-county-ga/#category_coverage. Accessed November 17, 2018. 3. Open Data Network. Chatham County, GA. Available at: https://www. opendatanetwork.com/entity/0500000US13051/Chatham_County_GA/ health.health_insurance.pctui?year¼2014&age¼18%20to%2064&race¼All %20races&sex¼Both%20sexes&income¼All%20income%20levels. Accessed November 17, 2018. 4. St. Joseph’s Candler/Live Smart. Operation Empower HealthdGreater Savannah. Available at: https://www.sjchs.org/in-the-community/ operation-empower-health-greater-savannah. Accessed November 15, 2018. 5. Lalich RA. The role of state government, local government, and nongovernmental organizations in medical innovative readiness training. Mil Med. 2002;167(5):367e369. Anne Misher, PharmD, BCACP, BC-ADM, CDE, Clinical Assistant Professor, University of Georgia College of Pharmacy, St. Joseph’s/Candler Health System, Savannah, GA Misha Thomason Watts, PharmD, Campus Director for Pharmacy Practice Experiences, Southeast Georgia, University of Georgia College of Pharmacy, St. Joseph’s/Candler Health System, Savannah, GA Abigail Hamlin, PharmD candidate, University of Georgia College of Pharmacy, Savannah, GA