- Email: [email protected]
Development, implementation and perceived benefits of student pharmacist learning experiences in transitions of care
Currents in Pharmacy Teaching and Learning 11 (2019) 1041–1048
Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Teaching and Learning Matters (Case Report)
Development, implementation and perceived benefits of student pharmacist learning experiences in transitions of care
T
Heather Taylora, Elizabeth F. Englina,b, , Paul O. Gubbinsa ⁎
a b
University of Missouri – Kansas City School of Pharmacy, United States University of Missouri – Kansas City School of Pharmacy, 327 W. Mill St, 4th Floor, Springfield, MO 65806, United States
ARTICLE INFO
ABSTRACT
Keywords: Transitions of care Learning experience development Interprofessional collaboration Experiential education Student learning
Background: Experiential education designed around transitions of care (TOC) offers student pharmacists a variety of educational activities to build their skills and confidence related to direct patient care, communication, and practice management. The purpose of this paper is to describe the development, implementation, and student perceptions of introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs) that emphasize TOC. Educational activity: Sixty students (22 IPPE and 38 APPE) completed the learning experience with the oversight of two faculty members in two, separate, large community hospitals providing pharmacy led TOC services. Each educational activity was mapped to the Pharmacists' Patient Care Process, which includes guided electronic medical record review, patient case discussions, and direct patient care (i.e. medication history collection, patient education). Other aspects of the learning experience include the use of layered learning, intention/reflection dialogues, and topic discussions. Evaluation of the learning experience occurred through review of student performance data and feedback. Critical analysis of the educational activity: Student performance data demonstrated an increase in the mean score between midpoint and final evaluation of all TOC specific competencies. Students expressed a positive learning experience as demonstrated by an approximately 3.8 overall rating of the learning experience on a 4-point scale for both IPPEs and APPEs. Analysis of open comments from students demonstrated the most beneficial aspects of the learning experience as interprofessional communication, patient communication, and a variety of patient care opportunities.
Background The Centers for Medicare and Medicaid (CMS) define transitions of care (TOC) as “the movement of a patient from one care setting to another.”1 The importance of TOC grew following CMS implementation of the Hospital Readmissions Reduction Program that aimed to decrease costs associated with 30-day readmission rates.2 As a result, institutions and clinics focus on TOC as a quality standard for cost and patient safety purposes. During TOC, patients are more vulnerable to preventable adverse drug events, and the majority of medication errors occur during this time. The Joint Commission National Patient Safety Goal 03.06.01 focuses on medication safety during TOC within hospitals,3 and many national organizations support this goal. Studies suggest an estimated 60% of medication errors take place during
⁎
Corresponding author. E-mail address: [email protected] (E.F. Englin).
https://doi.org/10.1016/j.cptl.2019.06.011
1877-1297/ © 2019 Elsevier Inc. All rights reserved.
Currents in Pharmacy Teaching and Learning 11 (2019) 1041–1048
H. Taylor, et al.
transition points.4,5 Moreover, nearly 20% of patients experience an adverse event post-discharge, approximately 70% of which are adverse drug events.4,6,7 Pharmacist involvement in the TOC process substantially reduces the number of medication related errors.8 The Medications at Transitions and Clinical Handoffs (MATCH) study evaluated the effectiveness of pharmacist-provided admission medication history and reconciliation at a large academic medical center.9 The MATCH study demonstrated that a complete and accurate medication reconciliation process throughout the continuum of care is crucial to optimizing patient outcomes and preventing medication errors.9 Project Re-Engineered Discharge demonstrated the value that a clinical pharmacist provides in educating patients and reconciling medications at discharge.10 This study found that patients with pharmacist involvement at discharge had lower rates of emergency department visits and hospital readmissions.10 Pharmacists, along with student pharmacists, are appropriately trained and ideally positioned to deliver effective TOC services to improve patient care during transitions. Under pharmacist supervision, student pharmacists can enhance TOC services and reach more patients by serving as practice extenders at no additional cost to the institution.11 Data demonstrate student pharmacist involvement increased the number of patients receiving pharmacy-led TOC services from 10 patients per day to 15 to 20 patients per day.12 Pharmacy-led TOC services can provide valuable learning opportunities for student pharmacists while also benefitting the institution, school of pharmacy, and patients.13 Such learning opportunities align with contemporary Accreditation Council for Pharmacy Education Standards and the Pharmacists' Patient Care Process (PPCP) by exposing student learners to a standardized approach to patient-centered and team-based care to optimize patient outcomes.14,15 Experiential education designed around TOC offer student pharmacists a variety of educational activities to build their skills and confidence related to direct patient care, communication, and practice management, yet there are few descriptions of how to develop and implement introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs) focused on the pharmacist role in TOC. The purpose of this paper is to describe the development, implementation, and student perceptions of IPPEs and APPEs that emphasize TOC. Two faculty members, each providing TOC services at large private community hospitals, collaborated to develop and implement an experiential learning opportunity focusing on the pharmacist role in TOC. The pharmacy-led TOC services at these institutions were developed in an acute care setting focused on internal medicine patients. These services involve direct patient care activities, including but not limited to comprehensive medication review, medication reconciliation, and face-to-face TOC encounters at admission and prior to discharge that include services such as medication history collection and patient education. The faculty members recognized an opportunity to involve student pharmacists in their pharmacy-led TOC services at both institutions and developed the learning experience described in this paper. Educational activity Goal The overall goal of the TOC specific IPPE and APPE is to equip students with the unique knowledge and skills required to implement pharmacy-led TOC services in their future careers. To this end, the IPPE and APPE student learning experiences are designed to train students in the pharmacists' role in TOC. The IPPE and APPE student pharmacists learn to provide the same pharmacy-led TOC services. The primary difference between the two learning experiences is the level of autonomy and number of daily patient encounters. The specific learning objectives of a longitudinal IPPE occurring in the third professional year and a month long APPE occurring in the fourth professional year are listed in Table 1. Structure The learning experiences are structured to align with the PPCP to ensure student pharmacists are mastering all skills necessary for their future pharmacy practice. Each educational activity is mapped to the PPCP (Table 2).15,16 The activities are assessed through formative midpoint and summative final evaluations of student performance and their perception of the experience. Prior to the learning experience, all student pharmacists are assigned to read literature regarding TOC to highlight the importance of this pharmacy practice area. For IPPE students, a joint orientation to the learning experience between both institutional sites is conducted, introducing the students to the pharmacists' role in TOC. At the beginning of the IPPE and APPE, the preceptors provide direct instruction to the students regarding their role in providing TOC services such as medication history, medication reconciliation, patient education, and interprofessional communication. The students are provided with standardized processes developed by the preceptors, including checklists to guide them when performing pharmacy-led TOC services (Appendices A–C).17,18 These resources align with recently published guidance documents.16 At each site, the preceptor then models the direct patient care activities for their students until the student pharmacist feels comfortable performing the service. Following preceptor modeling of TOC services, the students perform the activities with coaching from their preceptor. The student's performance is evaluated by the preceptor using an institution specific rubric. Once the student demonstrates competency via this preceptor observed performance, the student pharmacist autonomously delivers TOC services under supervision of the preceptor. Required resources The required resources to develop the educational activity included two faculty members practicing at two large private 1042
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H. Taylor, et al.
Table 1 Learning objectives. IPPE
APPE
Collect and organize accurate and comprehensive subjective and objective patient-specific information.
X
X
Assess information collected and analyze clinical effects of drug therapy.
X
X
Review and assess medication orders.
X
X
Select and recommend appropriate drug and non-drug therapy as part of an individualized patient-centered care plan.
X
Select and recommend appropriate drug and non-drug therapy with defined therapeutic goals and measurable outcomes.
X
Monitor and evaluate the effectiveness of the care plan.
X
X
Develop a complete medical and drug therapy problem list.
X
X
Document patient care activity.
X
X
Demonstrate utilization of appropriate drug information resources to answer clinical questions, support patient care recommendations, and respond to drug information inquiries.
X
Engage in activities that promote to patients the importance of health, wellness, disease prevention, and management of their diseases and medication therapies to optimize outcomes.
X
Demonstrate effective communication skills at appropriate levels for patients, caregivers, and the public.
X
X
Demonstrate effective communication skills at appropriate levels for health care professionals and providers.
X
X
Demonstrate effective communication skills during professional presentations (e.g., case presentation, journal club, in-service, community health education). Demonstrate and maintain an appropriate level of professional behavior displaying habits, attitudes, and values consistent with a respected member of the pharmacy profession. Retrieve, analyze, and interpret the professional, lay, and scientific literature to make informed, rational, and evidence-based decisions. Demonstrate an understanding of practice management issues.
X X
X X X
IPPE = introductory pharmacy practice experience; APPE = advanced pharmacy practice experience.
community hospitals and associated tools to guide students. The faculty spent approximately one month of dedicated time to develop these learning experiences. Peer-to-peer and layered learning The student learning experiences overlap for IPPE and APPE student pharmacists, allowing for peer-to-peer and layered learning. All student pharmacists are educated on the concept of layered learning and their roles in this method of experiential learning. Student pharmacists can be paired up with their peers of an equal (i.e. IPPE student with another IPPE student) or different level (i.e. IPPE student with an APPE student) when performing patient encounters. In these scenarios, one student takes the lead and the other student serves as a collaborator. Such pairing allows students to receive reinforcement from their collaborating peer if they require assistance or miss a critical piece of the encounter. Additionally, the pairing allows students to learn from and with each other. Students provide constructive feedback to their peer after each encounter, which benefits each student. Additionally, when student pharmacists are paired with a different level peer, the APPE student pharmacist serves as a collaborator and supervisor for the encounter. As a peer supervisor, the constructive feedback provided by the APPE student focuses on providing performance strengths and areas of improvement for the IPPE student. Intention/reflection Students are required to complete a three-part intention and reflection activity throughout the learning experience. The intention portion occurs prior to the start of the learning experience and allows students to set individual goals to achieve during the learning experience that will benefit their future career. The reflection portions of the activity occur at the midpoint and end of the learning experience. At midpoint, student pharmacists reflect on their progress and set goals for the remainder of the learning experience. The final reflection at the end of the learning experience allows the student to determine achievement of goals and to identify areas of focus for future learning experiences. This activity allows students to set individual goals and approach the learning activities intentionally in order to meet their self-identified goals. 1043
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Table 2 Learning experience educational activities mapped to Pharmacists' Patient Care Process.15,16 Pharmacists' Patient Care Process step Collect
Assess
Plan
Implement Follow-up: monitor and evaluate
Tasks completed on TOC focused learning experience
of electronic medical record for vital signs, laboratory values and information from health care • Review professional notes patient interview for medication history and identify barriers to medication adherence • Conduct • Contact outpatient pharmacy for medication fill history verbal patient presentation to preceptor and fellow students regarding information collected and analysis • Provide of information comprehensive medication review • Perform prioritized medical and drug related problem list • Develop control of disease states • Discuss • Identify pertinent discrepancies through completion of admission or discharge medication reconciliation goals of therapy • Identify evidenced – based recommendations to achieve therapeutic outcomes taking into account patient – specific • Develop factors with other healthcare professionals to achieve goals and reconcile discrepancies • Collaborate • Identify transitions of care needs and work collaboratively with healthcare professionals to overcome the barriers therapeutic recommendations to providers to help improve achievement of therapeutic outcomes • Deliver • Provide counseling to patients and/or caregivers regarding medications and disease states patient adherence to medication therapy regimen • Assess achievement of therapeutic goals and patient tolerance through review of: • Assess o Vital signs o Laboratory values o Patient tolerance
TOC = transitions of care.
Guided chart review Students utilize a guided chart review worksheet developed by the faculty to assist with collecting and organizing patient specific subjective and objective information from the electronic medical record. The guided chart review worksheet serves as a standardized approach for collection of the following patient specific information: demographics, chief complaint, history of present illness, past medical history, medication history, allergies/intolerances, immunizations, family history, social history, review of systems, vital signs, lab results, physical exam, and diagnostic tests. It also includes a section for the prioritized medical and drug problem list and associated assessment and plan. This activity is designed to increase the student pharmacist's skill and confidence performing thorough and accurate chart reviews. It also instills in the student a consistent practice process aligned with the PPCP for them to draw upon and incorporate into their future practice.19 Patient case discussions Student pharmacists present their patient case(s), including a detailed assessment and plan, to their faculty preceptor and other learners. Student pharmacists may also present the patient interview and/or education points to the preceptor prior to the patient encounter. Similarly, student pharmacists present their recommendations to the preceptor prior to their interaction with other healthcare professionals. The student's presentation(s) provide the opportunity for their preceptor to coach them in order to increase their preparedness and confidence when interacting with patients and healthcare professionals. Topic discussions The faculty members lead joint topic discussions with all APPE students on each learning experience. The topics include common disease states with a focus on those with high readmission rates such as pneumonia, heart failure, and chronic obstructive pulmonary disease. A unique component of these topic discussions is the focus on TOC from the inpatient and outpatient perspective in collaboration with an ambulatory care faculty preceptor. This allows the students to gain perspective and recognize the pharmacist role in medication management throughout the continuum of care. Data supporting student learning and evaluation of strategy Learning experiences with an emphasis in TOC allow students to learn knowledge and skills related to acute care in addition to the unique skills necessary to assist patients across the continuum of care. Mapping experiences to the PPCP ensures students develop a consistent approach to pharmacy practice.16 The perceived benefit of these learning experiences is illustrated through the appraisal of preceptor evaluation of student performance and student evaluation of the learning experience. 1044
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Table 3 Evaluation of student performance for TOC specific competencies. IPPE (Based on 3-point scale) Midpoint (n = 22)
Review and interpret medication orders, including effectively reconciling medications safely and effectively during TOC Demonstrates effective communication with patients, caregivers and the public Demonstrates effective communication with providers and health care professionals
APPE (Based on 5-point scale) Final (n = 22)
Midpoint (n = 38)
Final (n = 38)
Median
Mean
SD
Median
Mean
SD
Median
Mean
SD
Median
Mean
SD
2
2
0
2.5
2.5
0.51
4
3.68
0.47
4
4.39
0.55
2
2.05
0.21
3
2.86
0.47
4
4.16
0.68
5
4.74
0.45
2
2
0
2
2.41
0.50
4
3.68
0.53
4
4.42
0.50
TOC = transitions of care; IPPE = introductory pharmacy practice experience; APPE = advanced pharmacy practice experience; SD = standard deviation.
Evaluation of student performance For every IPPE and APPE learning experience, the preceptor and student complete a midpoint formative and final summative evaluation of student performance. The preceptor and student utilize the same rubric, which assesses core competencies within the overarching elements of patient care, communication, and professionalism. IPPE and APPE students are assessed on a 3-point and 5point scale, respectively. Both rubrics assess student performance in relation to practice expectations. The IPPE rubric is comprised of 12 questions, where 3 = exceeds expectations, 2 = meets expectations, and 1 = needs improvement. The APPE rubric is comprised of 15 questions, where 5 = significantly exceeds expectations, 4 = above expectations, 3 = meets expectations, 2 = below expectations, and 1 = significantly below expectations. Although all competencies are important for experiential learning, three assess the uniqueness of TOC and the associated direct patient care activities. These competencies assess effective medication reconciliation during TOC, communication with patients and/ or caregivers, and communication with health care professionals. In each of the three competencies, both IPPE and APPE students demonstrated improvement in performance between midpoint and final evaluation. The IPPE data represents 22 students who completed the learning experience from August 2016 to June 2018. The APPE data represents 38 students who completed the learning experience from June 2016 to October 2018 (Table 3). Evaluation of learning experience Similar to the evaluation of student performance, for every IPPE and APPE, students complete an evaluation of the learning experience and preceptor following completion of the experience. Student evaluations of learning experiences completed between June 2018 and October 2018 were not yet available when analysis was performed. In general, students had an overwhelmingly positive experience with the TOC focused learning experience as demonstrated by an approximately 3.8 overall rating of the learning experience on a 4-point scale for both IPPE and APPE learning experiences. Moreover, students felt the learning experience provided them with opportunities to master skills necessary to be successful in future practices. Detailed data regarding student perceived benefit of the learning experience are included in Table 4. Students also have the opportunity to provide comments regarding the most beneficial portions of the experience, strengths of the experience, and impact of working with other preceptors. Analysis of these open comments revealed several themes. First, IPPE students felt the most beneficial portions of the learning experience were providing direct patient care, learning about the role of Table 4 Student evaluation of TOC focused learning experience.
The rotation improved and strengthened my patient care skills such as communication, care planning and problem – solving (5-point scale) The rotation increased my knowledge and abilities in the practices of pharmacy (5-point scale) The rotation prepared me for future practice by providing relevant experiences (5-point scale) The rotation provided a variety of opportunities and experiences to improve my skills and develop professionally (5point scale) Overall, how would you rate this rotation experience (4-point scale)
IPPE (n = 23)
APPE (n = 27)
Mean
SD
Mean
SD
4.74
0.42
4.85
0.45
4.74 4.70 4.35
0.42 0.42 0.97
4.89 4.85 4.82
0.30 0.42 0.40
3.78
0.37
3.91
0.42
TOC = transitions of care; IPPE = introductory pharmacy practice experience; APPE = advanced pharmacy practice experience; SD = standard deviation. 1045
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H. Taylor, et al.
pharmacists within the hospital setting (including TOC services), and participating in interprofessional care. Similarly, they identified the strengths of the learning experience as increased exposure to a variety of clinical activities, participating in interprofessional practice, and communicating with patients. In regards to working with other preceptors, IPPE students felt the greatest benefit was gaining insight as to how similar services are provided at different health systems in addition to increased opportunities to gain knowledge. Analysis of open comments from APPE students reflected their progress through the experiential portion of the pharmacy program. They felt the most beneficial parts of the learning experience were topic discussions, precepting experience, improving interprofessional and patient communication, and participating in direct patient care activities. In addition to providing TOC services, like the IPPE learners, APPE student pharmacists felt the variety of experiences and providing interprofessional care were amongst the learning experience strengths. Finally, APPE students felt additional preceptors contributed most to their learning through delivery of topic discussions, providing additional clinical expertise and additional feedback on formal presentations. Critical analysis of the educational activity Developing IPPEs and APPEs from pharmacy-led TOC services allows student pharmacists to gain valuable knowledge, skills, and confidence performing direct patient care activities as evidenced by the evaluation data. Anchoring the activities to the PPCP helps student learners adopt standardized practices to collect and assess patient information. Students identified that the activities helped them develop their communication and interprofessional practice skills. Lessons learned The use of a consistent approach allows student pharmacists to comprehend the PPCP, which provides them structure for direct patient care. The repetitive use of the standardized process allows students to develop proficiency earlier in the learning experience, increase confidence in patient care skills, and grow as an autonomous practitioner. The confidence gained also facilitates their effective communication with patients and other healthcare professionals. The student pharmacist's participation in TOC related educational activities and patient care increased their awareness of the importance of interprofessional collaboration. The primary challenge experienced was the alignment of patient care opportunities with the times student pharmacists were present in patient care areas. Pharmacy TOC services are focused at admission and discharge and dependent upon patient load and provider workflow. In order to overcome this challenge, it is necessary to redirect students to other activities that support TOC services such as comprehensive medication review and role-play activities between peers and preceptors. A second challenge in developing the education experiences relates to the peer-to-peer learning experiences and is associated with proper pairing of peers and managing student apprehension towards delivering patient care services in front of their peer. Recognizing these issues and being flexible allows preceptors to manage these situations appropriately. Several influences may drive improvements to the learning experiences including changes in institution workflow, emerging technologies, and evolution in pharmacy practice. To identify the need for future improvements, student assessment data and changes in practice must be continuously monitored. The knowledge and skills used in TOC are aligned with the PPCP and can be applied to all practice settings regardless of preceptor affiliation. Therefore TOC experiential opportunities can assist schools of pharmacy in identifying gaps in APPE readiness. Within our curriculum, the benefits of these activities have already been realized through the implementation of a didactic elective in TOC. This elective has increased the awareness for the need to incorporate more TOC experiences in required coursework. The learning experiences developed to date also create opportunities for scholarly work to enhance student learning and advance pharmacy practice. In conclusion, TOC represents an ideal opportunity for faculty to develop and implement learning experiences that provide benefits to a variety of stakeholders (e.g. students, faculty, patients, and institutions). Disclosures None. Conflict of Interest None. Appendix A. Student checklist for medication history17 Category Setting the stage for the encounter18 Introduction and background
Information to collect and/or questions to ask
patient they are a student and what department they represent • Inform an estimate of how long the encounter will last • Give the reasoning for the visit • Describe • Verify patient
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Medication regimen
Questions related to medication regimen Important concepts to use during medication histories
what allergy or adverse reactions to medications patients have including details on medication name and • Ask reaction what outpatient pharmacy(ies) patient uses to fill medications • Ask what prescription medications the patient is currently taking • Ask what over-the-counter, herbal, vitamins or supplements the patient is currently taking • Ask what non-oral medications (i.e. topical, injectable, inhalers) the patient is currently taking • Ask how patient is taking each medication with a goal of collecting drug name, strength, dose, route, frequency • Ask and indication if possible if patient has any trouble affording their medications • Ask how often patient misses doses of their medications • Ask about efficacy and tolerance (i.e. safety) of their medications • Ask patient-friendly language • Use open-ended questions as much as possible. If needed can use close-ended questions to obtain specific • Use information • If medication adherence issues identified, ask probing question to determine reason for non-adherence
Appendix B. Student checklist for medication reconciliation Omission Commission Wrong dose or route or frequency Therapeutic duplication Drug-drug interactions Drug-disease state interactions Contraindicated medications Medications without indication Indications without medications Medications requiring dose adjustments (i.e. renal or liver dysfunction, age, weight) New medications Discontinued medications Medications with changes (i.e. change in dose or frequency of same medication)
Appendix C. Student checklist for TOC discharge counseling Areas of education Setting the stage for the encounter18 Transitions of care education
Medication counseling
Ending of encounter
Specific details to educate patients on
patient they are a student and what department they represent • Inform an estimate of how long the encounter will last • Give the reasoning for the visit • Describe started • Medications discontinued • Medications changed • Medications plan regarding next appointments • Follow-up the prime three questions to guide counseling • Utilize lifestyle changes for disease states • Discuss medication counseling per OBRA ‘90 requirements • Provide how to use medication devices (if applicable) • Demonstrate on importance of adherence and methods to improve adherence • Educate • Utilize teach-back method for TOC education and medication counseling to verify patient understanding
TOC = transitions of care; OBRA ‘90 = Omnibus Budget Reconciliation Act of 1990.
References 1. Eligible professional meaningful use menu set measures: measure 6 of 9. Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/downloads/7_Medication_Reconciliation.pdf Updated May 2014. Accessed 20 June 2019. 2. Hospital Readmissions Reduction Program (HRRP). Centers for medicare & medicaid services. https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Updated 27 September 2018. Accessed 20 June 2019. 3. 2019 hospital national patient safety goals. The Joint Commission. https://www.jointcommission.org/assets/1/6/2018_HAP_NPSG_goals_final.pdf. Published 16 October 2018. Accessed 20 June 2019. 4. American Pharmacists Association and American Society of Health – System Pharmacists. Improving care transitions: optimizing medication reconciliation. J Am Pharm Assoc. 2003;52(4):e43–e52. https://doi.org/10.1331/JAPhA.2012.12527 2012. 5. Rozich JD, Resar RK. Medication safety: one organization's approach to the challenge. J Clin Outcomes Manag. 2001;8(10):27–34. 6. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167. https://doi.org/10.7326/0003-4819-138-3-200302040-00007. 7. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345–349. 8. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals. Pharmacotherapy. 2006;26(6):735–747. 9. Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication
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reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441–447. 10. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178–187. https://doi.org/10.7326/0003-4819-150-3-200902030-00007. 11. Eltaki SM, Singh-Franco D, Leon DJ, Nguyen M, Wolowich WR. Allocation of faculty and curricular time to the teaching of transitions of care concepts by colleges of pharmacy. Curr Pharm Teach Learn. 2018;10(6):701–711. 12. Walker PC, Tucker Jones JN, Mason NA. An advanced pharmacy practice experience in transitional care. Am J Pharm Educ. 2010;74(2) https://doi.org/10.5688/ aj740220. 13. Donihi AC, Weber RJ, Sirio CA, Mark SM, Meyer SM. An advanced pharmacy practice experience in inpatient medication education. Am J Pharm Educ. 2009;73(1) https://doi.org/10.5688/aj73011. 14. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Accreditation Council for Pharmacy Education. https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf. Published 2 February 2015. Accessed 20 June 2019. 15. Pharmacists' patient care process. Joint Commission of Pharmacy Practitioners. https://jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-with-supportingorganizations.pdf. Published 29 May 2014. Accessed 20 June 2019. 16. Applying the pharmacists' patient care process to care transitions services. American Pharmacists Association; February 2019 , Accessed: 20 June 2019. 17. Medication reconciliation: a learning guide. Queen's University. https://meds.queensu.ca/central/assets/modules/mr/4.html. Published 2009. Accessed 26 April 2019. 18. AIDET patient communication. The Studer Group. https://www.studergroup.com/aidet. Updated 2019. Accessed 20 June 2019. 19. Boyce EG. The pharmacists' patient care process and more. Am J Pharm Educ. 2017;81(4) https://doi.org/10.5688/ajpe81462.
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Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Teaching and Learning Matters (Case Report)
Development, implementation and perceived benefits of student pharmacist learning experiences in transitions of care
T
Heather Taylora, Elizabeth F. Englina,b, , Paul O. Gubbinsa ⁎
a b
University of Missouri – Kansas City School of Pharmacy, United States University of Missouri – Kansas City School of Pharmacy, 327 W. Mill St, 4th Floor, Springfield, MO 65806, United States
ARTICLE INFO
ABSTRACT
Keywords: Transitions of care Learning experience development Interprofessional collaboration Experiential education Student learning
Background: Experiential education designed around transitions of care (TOC) offers student pharmacists a variety of educational activities to build their skills and confidence related to direct patient care, communication, and practice management. The purpose of this paper is to describe the development, implementation, and student perceptions of introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs) that emphasize TOC. Educational activity: Sixty students (22 IPPE and 38 APPE) completed the learning experience with the oversight of two faculty members in two, separate, large community hospitals providing pharmacy led TOC services. Each educational activity was mapped to the Pharmacists' Patient Care Process, which includes guided electronic medical record review, patient case discussions, and direct patient care (i.e. medication history collection, patient education). Other aspects of the learning experience include the use of layered learning, intention/reflection dialogues, and topic discussions. Evaluation of the learning experience occurred through review of student performance data and feedback. Critical analysis of the educational activity: Student performance data demonstrated an increase in the mean score between midpoint and final evaluation of all TOC specific competencies. Students expressed a positive learning experience as demonstrated by an approximately 3.8 overall rating of the learning experience on a 4-point scale for both IPPEs and APPEs. Analysis of open comments from students demonstrated the most beneficial aspects of the learning experience as interprofessional communication, patient communication, and a variety of patient care opportunities.
Background The Centers for Medicare and Medicaid (CMS) define transitions of care (TOC) as “the movement of a patient from one care setting to another.”1 The importance of TOC grew following CMS implementation of the Hospital Readmissions Reduction Program that aimed to decrease costs associated with 30-day readmission rates.2 As a result, institutions and clinics focus on TOC as a quality standard for cost and patient safety purposes. During TOC, patients are more vulnerable to preventable adverse drug events, and the majority of medication errors occur during this time. The Joint Commission National Patient Safety Goal 03.06.01 focuses on medication safety during TOC within hospitals,3 and many national organizations support this goal. Studies suggest an estimated 60% of medication errors take place during
⁎
Corresponding author. E-mail address: [email protected] (E.F. Englin).
https://doi.org/10.1016/j.cptl.2019.06.011
1877-1297/ © 2019 Elsevier Inc. All rights reserved.
Currents in Pharmacy Teaching and Learning 11 (2019) 1041–1048
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transition points.4,5 Moreover, nearly 20% of patients experience an adverse event post-discharge, approximately 70% of which are adverse drug events.4,6,7 Pharmacist involvement in the TOC process substantially reduces the number of medication related errors.8 The Medications at Transitions and Clinical Handoffs (MATCH) study evaluated the effectiveness of pharmacist-provided admission medication history and reconciliation at a large academic medical center.9 The MATCH study demonstrated that a complete and accurate medication reconciliation process throughout the continuum of care is crucial to optimizing patient outcomes and preventing medication errors.9 Project Re-Engineered Discharge demonstrated the value that a clinical pharmacist provides in educating patients and reconciling medications at discharge.10 This study found that patients with pharmacist involvement at discharge had lower rates of emergency department visits and hospital readmissions.10 Pharmacists, along with student pharmacists, are appropriately trained and ideally positioned to deliver effective TOC services to improve patient care during transitions. Under pharmacist supervision, student pharmacists can enhance TOC services and reach more patients by serving as practice extenders at no additional cost to the institution.11 Data demonstrate student pharmacist involvement increased the number of patients receiving pharmacy-led TOC services from 10 patients per day to 15 to 20 patients per day.12 Pharmacy-led TOC services can provide valuable learning opportunities for student pharmacists while also benefitting the institution, school of pharmacy, and patients.13 Such learning opportunities align with contemporary Accreditation Council for Pharmacy Education Standards and the Pharmacists' Patient Care Process (PPCP) by exposing student learners to a standardized approach to patient-centered and team-based care to optimize patient outcomes.14,15 Experiential education designed around TOC offer student pharmacists a variety of educational activities to build their skills and confidence related to direct patient care, communication, and practice management, yet there are few descriptions of how to develop and implement introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs) focused on the pharmacist role in TOC. The purpose of this paper is to describe the development, implementation, and student perceptions of IPPEs and APPEs that emphasize TOC. Two faculty members, each providing TOC services at large private community hospitals, collaborated to develop and implement an experiential learning opportunity focusing on the pharmacist role in TOC. The pharmacy-led TOC services at these institutions were developed in an acute care setting focused on internal medicine patients. These services involve direct patient care activities, including but not limited to comprehensive medication review, medication reconciliation, and face-to-face TOC encounters at admission and prior to discharge that include services such as medication history collection and patient education. The faculty members recognized an opportunity to involve student pharmacists in their pharmacy-led TOC services at both institutions and developed the learning experience described in this paper. Educational activity Goal The overall goal of the TOC specific IPPE and APPE is to equip students with the unique knowledge and skills required to implement pharmacy-led TOC services in their future careers. To this end, the IPPE and APPE student learning experiences are designed to train students in the pharmacists' role in TOC. The IPPE and APPE student pharmacists learn to provide the same pharmacy-led TOC services. The primary difference between the two learning experiences is the level of autonomy and number of daily patient encounters. The specific learning objectives of a longitudinal IPPE occurring in the third professional year and a month long APPE occurring in the fourth professional year are listed in Table 1. Structure The learning experiences are structured to align with the PPCP to ensure student pharmacists are mastering all skills necessary for their future pharmacy practice. Each educational activity is mapped to the PPCP (Table 2).15,16 The activities are assessed through formative midpoint and summative final evaluations of student performance and their perception of the experience. Prior to the learning experience, all student pharmacists are assigned to read literature regarding TOC to highlight the importance of this pharmacy practice area. For IPPE students, a joint orientation to the learning experience between both institutional sites is conducted, introducing the students to the pharmacists' role in TOC. At the beginning of the IPPE and APPE, the preceptors provide direct instruction to the students regarding their role in providing TOC services such as medication history, medication reconciliation, patient education, and interprofessional communication. The students are provided with standardized processes developed by the preceptors, including checklists to guide them when performing pharmacy-led TOC services (Appendices A–C).17,18 These resources align with recently published guidance documents.16 At each site, the preceptor then models the direct patient care activities for their students until the student pharmacist feels comfortable performing the service. Following preceptor modeling of TOC services, the students perform the activities with coaching from their preceptor. The student's performance is evaluated by the preceptor using an institution specific rubric. Once the student demonstrates competency via this preceptor observed performance, the student pharmacist autonomously delivers TOC services under supervision of the preceptor. Required resources The required resources to develop the educational activity included two faculty members practicing at two large private 1042
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Table 1 Learning objectives. IPPE
APPE
Collect and organize accurate and comprehensive subjective and objective patient-specific information.
X
X
Assess information collected and analyze clinical effects of drug therapy.
X
X
Review and assess medication orders.
X
X
Select and recommend appropriate drug and non-drug therapy as part of an individualized patient-centered care plan.
X
Select and recommend appropriate drug and non-drug therapy with defined therapeutic goals and measurable outcomes.
X
Monitor and evaluate the effectiveness of the care plan.
X
X
Develop a complete medical and drug therapy problem list.
X
X
Document patient care activity.
X
X
Demonstrate utilization of appropriate drug information resources to answer clinical questions, support patient care recommendations, and respond to drug information inquiries.
X
Engage in activities that promote to patients the importance of health, wellness, disease prevention, and management of their diseases and medication therapies to optimize outcomes.
X
Demonstrate effective communication skills at appropriate levels for patients, caregivers, and the public.
X
X
Demonstrate effective communication skills at appropriate levels for health care professionals and providers.
X
X
Demonstrate effective communication skills during professional presentations (e.g., case presentation, journal club, in-service, community health education). Demonstrate and maintain an appropriate level of professional behavior displaying habits, attitudes, and values consistent with a respected member of the pharmacy profession. Retrieve, analyze, and interpret the professional, lay, and scientific literature to make informed, rational, and evidence-based decisions. Demonstrate an understanding of practice management issues.
X X
X X X
IPPE = introductory pharmacy practice experience; APPE = advanced pharmacy practice experience.
community hospitals and associated tools to guide students. The faculty spent approximately one month of dedicated time to develop these learning experiences. Peer-to-peer and layered learning The student learning experiences overlap for IPPE and APPE student pharmacists, allowing for peer-to-peer and layered learning. All student pharmacists are educated on the concept of layered learning and their roles in this method of experiential learning. Student pharmacists can be paired up with their peers of an equal (i.e. IPPE student with another IPPE student) or different level (i.e. IPPE student with an APPE student) when performing patient encounters. In these scenarios, one student takes the lead and the other student serves as a collaborator. Such pairing allows students to receive reinforcement from their collaborating peer if they require assistance or miss a critical piece of the encounter. Additionally, the pairing allows students to learn from and with each other. Students provide constructive feedback to their peer after each encounter, which benefits each student. Additionally, when student pharmacists are paired with a different level peer, the APPE student pharmacist serves as a collaborator and supervisor for the encounter. As a peer supervisor, the constructive feedback provided by the APPE student focuses on providing performance strengths and areas of improvement for the IPPE student. Intention/reflection Students are required to complete a three-part intention and reflection activity throughout the learning experience. The intention portion occurs prior to the start of the learning experience and allows students to set individual goals to achieve during the learning experience that will benefit their future career. The reflection portions of the activity occur at the midpoint and end of the learning experience. At midpoint, student pharmacists reflect on their progress and set goals for the remainder of the learning experience. The final reflection at the end of the learning experience allows the student to determine achievement of goals and to identify areas of focus for future learning experiences. This activity allows students to set individual goals and approach the learning activities intentionally in order to meet their self-identified goals. 1043
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Table 2 Learning experience educational activities mapped to Pharmacists' Patient Care Process.15,16 Pharmacists' Patient Care Process step Collect
Assess
Plan
Implement Follow-up: monitor and evaluate
Tasks completed on TOC focused learning experience
of electronic medical record for vital signs, laboratory values and information from health care • Review professional notes patient interview for medication history and identify barriers to medication adherence • Conduct • Contact outpatient pharmacy for medication fill history verbal patient presentation to preceptor and fellow students regarding information collected and analysis • Provide of information comprehensive medication review • Perform prioritized medical and drug related problem list • Develop control of disease states • Discuss • Identify pertinent discrepancies through completion of admission or discharge medication reconciliation goals of therapy • Identify evidenced – based recommendations to achieve therapeutic outcomes taking into account patient – specific • Develop factors with other healthcare professionals to achieve goals and reconcile discrepancies • Collaborate • Identify transitions of care needs and work collaboratively with healthcare professionals to overcome the barriers therapeutic recommendations to providers to help improve achievement of therapeutic outcomes • Deliver • Provide counseling to patients and/or caregivers regarding medications and disease states patient adherence to medication therapy regimen • Assess achievement of therapeutic goals and patient tolerance through review of: • Assess o Vital signs o Laboratory values o Patient tolerance
TOC = transitions of care.
Guided chart review Students utilize a guided chart review worksheet developed by the faculty to assist with collecting and organizing patient specific subjective and objective information from the electronic medical record. The guided chart review worksheet serves as a standardized approach for collection of the following patient specific information: demographics, chief complaint, history of present illness, past medical history, medication history, allergies/intolerances, immunizations, family history, social history, review of systems, vital signs, lab results, physical exam, and diagnostic tests. It also includes a section for the prioritized medical and drug problem list and associated assessment and plan. This activity is designed to increase the student pharmacist's skill and confidence performing thorough and accurate chart reviews. It also instills in the student a consistent practice process aligned with the PPCP for them to draw upon and incorporate into their future practice.19 Patient case discussions Student pharmacists present their patient case(s), including a detailed assessment and plan, to their faculty preceptor and other learners. Student pharmacists may also present the patient interview and/or education points to the preceptor prior to the patient encounter. Similarly, student pharmacists present their recommendations to the preceptor prior to their interaction with other healthcare professionals. The student's presentation(s) provide the opportunity for their preceptor to coach them in order to increase their preparedness and confidence when interacting with patients and healthcare professionals. Topic discussions The faculty members lead joint topic discussions with all APPE students on each learning experience. The topics include common disease states with a focus on those with high readmission rates such as pneumonia, heart failure, and chronic obstructive pulmonary disease. A unique component of these topic discussions is the focus on TOC from the inpatient and outpatient perspective in collaboration with an ambulatory care faculty preceptor. This allows the students to gain perspective and recognize the pharmacist role in medication management throughout the continuum of care. Data supporting student learning and evaluation of strategy Learning experiences with an emphasis in TOC allow students to learn knowledge and skills related to acute care in addition to the unique skills necessary to assist patients across the continuum of care. Mapping experiences to the PPCP ensures students develop a consistent approach to pharmacy practice.16 The perceived benefit of these learning experiences is illustrated through the appraisal of preceptor evaluation of student performance and student evaluation of the learning experience. 1044
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Table 3 Evaluation of student performance for TOC specific competencies. IPPE (Based on 3-point scale) Midpoint (n = 22)
Review and interpret medication orders, including effectively reconciling medications safely and effectively during TOC Demonstrates effective communication with patients, caregivers and the public Demonstrates effective communication with providers and health care professionals
APPE (Based on 5-point scale) Final (n = 22)
Midpoint (n = 38)
Final (n = 38)
Median
Mean
SD
Median
Mean
SD
Median
Mean
SD
Median
Mean
SD
2
2
0
2.5
2.5
0.51
4
3.68
0.47
4
4.39
0.55
2
2.05
0.21
3
2.86
0.47
4
4.16
0.68
5
4.74
0.45
2
2
0
2
2.41
0.50
4
3.68
0.53
4
4.42
0.50
TOC = transitions of care; IPPE = introductory pharmacy practice experience; APPE = advanced pharmacy practice experience; SD = standard deviation.
Evaluation of student performance For every IPPE and APPE learning experience, the preceptor and student complete a midpoint formative and final summative evaluation of student performance. The preceptor and student utilize the same rubric, which assesses core competencies within the overarching elements of patient care, communication, and professionalism. IPPE and APPE students are assessed on a 3-point and 5point scale, respectively. Both rubrics assess student performance in relation to practice expectations. The IPPE rubric is comprised of 12 questions, where 3 = exceeds expectations, 2 = meets expectations, and 1 = needs improvement. The APPE rubric is comprised of 15 questions, where 5 = significantly exceeds expectations, 4 = above expectations, 3 = meets expectations, 2 = below expectations, and 1 = significantly below expectations. Although all competencies are important for experiential learning, three assess the uniqueness of TOC and the associated direct patient care activities. These competencies assess effective medication reconciliation during TOC, communication with patients and/ or caregivers, and communication with health care professionals. In each of the three competencies, both IPPE and APPE students demonstrated improvement in performance between midpoint and final evaluation. The IPPE data represents 22 students who completed the learning experience from August 2016 to June 2018. The APPE data represents 38 students who completed the learning experience from June 2016 to October 2018 (Table 3). Evaluation of learning experience Similar to the evaluation of student performance, for every IPPE and APPE, students complete an evaluation of the learning experience and preceptor following completion of the experience. Student evaluations of learning experiences completed between June 2018 and October 2018 were not yet available when analysis was performed. In general, students had an overwhelmingly positive experience with the TOC focused learning experience as demonstrated by an approximately 3.8 overall rating of the learning experience on a 4-point scale for both IPPE and APPE learning experiences. Moreover, students felt the learning experience provided them with opportunities to master skills necessary to be successful in future practices. Detailed data regarding student perceived benefit of the learning experience are included in Table 4. Students also have the opportunity to provide comments regarding the most beneficial portions of the experience, strengths of the experience, and impact of working with other preceptors. Analysis of these open comments revealed several themes. First, IPPE students felt the most beneficial portions of the learning experience were providing direct patient care, learning about the role of Table 4 Student evaluation of TOC focused learning experience.
The rotation improved and strengthened my patient care skills such as communication, care planning and problem – solving (5-point scale) The rotation increased my knowledge and abilities in the practices of pharmacy (5-point scale) The rotation prepared me for future practice by providing relevant experiences (5-point scale) The rotation provided a variety of opportunities and experiences to improve my skills and develop professionally (5point scale) Overall, how would you rate this rotation experience (4-point scale)
IPPE (n = 23)
APPE (n = 27)
Mean
SD
Mean
SD
4.74
0.42
4.85
0.45
4.74 4.70 4.35
0.42 0.42 0.97
4.89 4.85 4.82
0.30 0.42 0.40
3.78
0.37
3.91
0.42
TOC = transitions of care; IPPE = introductory pharmacy practice experience; APPE = advanced pharmacy practice experience; SD = standard deviation. 1045
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pharmacists within the hospital setting (including TOC services), and participating in interprofessional care. Similarly, they identified the strengths of the learning experience as increased exposure to a variety of clinical activities, participating in interprofessional practice, and communicating with patients. In regards to working with other preceptors, IPPE students felt the greatest benefit was gaining insight as to how similar services are provided at different health systems in addition to increased opportunities to gain knowledge. Analysis of open comments from APPE students reflected their progress through the experiential portion of the pharmacy program. They felt the most beneficial parts of the learning experience were topic discussions, precepting experience, improving interprofessional and patient communication, and participating in direct patient care activities. In addition to providing TOC services, like the IPPE learners, APPE student pharmacists felt the variety of experiences and providing interprofessional care were amongst the learning experience strengths. Finally, APPE students felt additional preceptors contributed most to their learning through delivery of topic discussions, providing additional clinical expertise and additional feedback on formal presentations. Critical analysis of the educational activity Developing IPPEs and APPEs from pharmacy-led TOC services allows student pharmacists to gain valuable knowledge, skills, and confidence performing direct patient care activities as evidenced by the evaluation data. Anchoring the activities to the PPCP helps student learners adopt standardized practices to collect and assess patient information. Students identified that the activities helped them develop their communication and interprofessional practice skills. Lessons learned The use of a consistent approach allows student pharmacists to comprehend the PPCP, which provides them structure for direct patient care. The repetitive use of the standardized process allows students to develop proficiency earlier in the learning experience, increase confidence in patient care skills, and grow as an autonomous practitioner. The confidence gained also facilitates their effective communication with patients and other healthcare professionals. The student pharmacist's participation in TOC related educational activities and patient care increased their awareness of the importance of interprofessional collaboration. The primary challenge experienced was the alignment of patient care opportunities with the times student pharmacists were present in patient care areas. Pharmacy TOC services are focused at admission and discharge and dependent upon patient load and provider workflow. In order to overcome this challenge, it is necessary to redirect students to other activities that support TOC services such as comprehensive medication review and role-play activities between peers and preceptors. A second challenge in developing the education experiences relates to the peer-to-peer learning experiences and is associated with proper pairing of peers and managing student apprehension towards delivering patient care services in front of their peer. Recognizing these issues and being flexible allows preceptors to manage these situations appropriately. Several influences may drive improvements to the learning experiences including changes in institution workflow, emerging technologies, and evolution in pharmacy practice. To identify the need for future improvements, student assessment data and changes in practice must be continuously monitored. The knowledge and skills used in TOC are aligned with the PPCP and can be applied to all practice settings regardless of preceptor affiliation. Therefore TOC experiential opportunities can assist schools of pharmacy in identifying gaps in APPE readiness. Within our curriculum, the benefits of these activities have already been realized through the implementation of a didactic elective in TOC. This elective has increased the awareness for the need to incorporate more TOC experiences in required coursework. The learning experiences developed to date also create opportunities for scholarly work to enhance student learning and advance pharmacy practice. In conclusion, TOC represents an ideal opportunity for faculty to develop and implement learning experiences that provide benefits to a variety of stakeholders (e.g. students, faculty, patients, and institutions). Disclosures None. Conflict of Interest None. Appendix A. Student checklist for medication history17 Category Setting the stage for the encounter18 Introduction and background
Information to collect and/or questions to ask
patient they are a student and what department they represent • Inform an estimate of how long the encounter will last • Give the reasoning for the visit • Describe • Verify patient
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Medication regimen
Questions related to medication regimen Important concepts to use during medication histories
what allergy or adverse reactions to medications patients have including details on medication name and • Ask reaction what outpatient pharmacy(ies) patient uses to fill medications • Ask what prescription medications the patient is currently taking • Ask what over-the-counter, herbal, vitamins or supplements the patient is currently taking • Ask what non-oral medications (i.e. topical, injectable, inhalers) the patient is currently taking • Ask how patient is taking each medication with a goal of collecting drug name, strength, dose, route, frequency • Ask and indication if possible if patient has any trouble affording their medications • Ask how often patient misses doses of their medications • Ask about efficacy and tolerance (i.e. safety) of their medications • Ask patient-friendly language • Use open-ended questions as much as possible. If needed can use close-ended questions to obtain specific • Use information • If medication adherence issues identified, ask probing question to determine reason for non-adherence
Appendix B. Student checklist for medication reconciliation Omission Commission Wrong dose or route or frequency Therapeutic duplication Drug-drug interactions Drug-disease state interactions Contraindicated medications Medications without indication Indications without medications Medications requiring dose adjustments (i.e. renal or liver dysfunction, age, weight) New medications Discontinued medications Medications with changes (i.e. change in dose or frequency of same medication)
Appendix C. Student checklist for TOC discharge counseling Areas of education Setting the stage for the encounter18 Transitions of care education
Medication counseling
Ending of encounter
Specific details to educate patients on
patient they are a student and what department they represent • Inform an estimate of how long the encounter will last • Give the reasoning for the visit • Describe started • Medications discontinued • Medications changed • Medications plan regarding next appointments • Follow-up the prime three questions to guide counseling • Utilize lifestyle changes for disease states • Discuss medication counseling per OBRA ‘90 requirements • Provide how to use medication devices (if applicable) • Demonstrate on importance of adherence and methods to improve adherence • Educate • Utilize teach-back method for TOC education and medication counseling to verify patient understanding
TOC = transitions of care; OBRA ‘90 = Omnibus Budget Reconciliation Act of 1990.
References 1. Eligible professional meaningful use menu set measures: measure 6 of 9. Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/downloads/7_Medication_Reconciliation.pdf Updated May 2014. Accessed 20 June 2019. 2. Hospital Readmissions Reduction Program (HRRP). Centers for medicare & medicaid services. https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Updated 27 September 2018. Accessed 20 June 2019. 3. 2019 hospital national patient safety goals. The Joint Commission. https://www.jointcommission.org/assets/1/6/2018_HAP_NPSG_goals_final.pdf. Published 16 October 2018. Accessed 20 June 2019. 4. American Pharmacists Association and American Society of Health – System Pharmacists. Improving care transitions: optimizing medication reconciliation. J Am Pharm Assoc. 2003;52(4):e43–e52. https://doi.org/10.1331/JAPhA.2012.12527 2012. 5. Rozich JD, Resar RK. Medication safety: one organization's approach to the challenge. J Clin Outcomes Manag. 2001;8(10):27–34. 6. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167. https://doi.org/10.7326/0003-4819-138-3-200302040-00007. 7. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345–349. 8. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals. Pharmacotherapy. 2006;26(6):735–747. 9. Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication
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reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441–447. 10. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178–187. https://doi.org/10.7326/0003-4819-150-3-200902030-00007. 11. Eltaki SM, Singh-Franco D, Leon DJ, Nguyen M, Wolowich WR. Allocation of faculty and curricular time to the teaching of transitions of care concepts by colleges of pharmacy. Curr Pharm Teach Learn. 2018;10(6):701–711. 12. Walker PC, Tucker Jones JN, Mason NA. An advanced pharmacy practice experience in transitional care. Am J Pharm Educ. 2010;74(2) https://doi.org/10.5688/ aj740220. 13. Donihi AC, Weber RJ, Sirio CA, Mark SM, Meyer SM. An advanced pharmacy practice experience in inpatient medication education. Am J Pharm Educ. 2009;73(1) https://doi.org/10.5688/aj73011. 14. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Accreditation Council for Pharmacy Education. https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf. Published 2 February 2015. Accessed 20 June 2019. 15. Pharmacists' patient care process. Joint Commission of Pharmacy Practitioners. https://jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-with-supportingorganizations.pdf. Published 29 May 2014. Accessed 20 June 2019. 16. Applying the pharmacists' patient care process to care transitions services. American Pharmacists Association; February 2019 , Accessed: 20 June 2019. 17. Medication reconciliation: a learning guide. Queen's University. https://meds.queensu.ca/central/assets/modules/mr/4.html. Published 2009. Accessed 26 April 2019. 18. AIDET patient communication. The Studer Group. https://www.studergroup.com/aidet. Updated 2019. Accessed 20 June 2019. 19. Boyce EG. The pharmacists' patient care process and more. Am J Pharm Educ. 2017;81(4) https://doi.org/10.5688/ajpe81462.
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