Enhancing an advanced community pharmacy practice experience through use of a student pharmacist manual

TOOLS for advancing pharmacy practice

Enhancing an advanced community pharmacy practice experience through use of a student pharmacist manual Jeegisha Patel

Received March 26, 2007, and in revised form May 25, 2007. Accepted for publication May 29, 2007.

Abstract

Objective: To present a model to preceptors in a community setting for a structured and quality advanced community pharmacy practice experience (ACPPE). Design: Experiential report. Setting: Chain pharmacy. Participants: Not applicable. Intervention: Development and use of a student pharmacist manual in a structured, organized ACPPE. Main outcome measures: Not applicable. Results: The manual, in addition to introductory materials and competencies for the ACCPE, contains five modules that focus on dispensing, management and law, nonprescription medications, consultation, and patient care. The student pharmacist is also provided with a schedule and calendar showing how goals and objectives for the rotation are distributed throughout the modules and activities of the ACCPE. Activities and assignments during the ACCPE include topic discussions, physical assessment skills review, “living with diabetes for the weekend,” developing patient handouts, implementing a new pharmacy patient care service, patient consultations, and presentations. Evaluations conducted during the ACCPE help student pharmacists monitor their progress and identify strengths and weaknesses. Conclusion: Efforts to enhance a community practice experience can be rewarding and beneficial to both the student pharmacists and the pharmacy. A structured ACPPE gives student pharmacists an opportunity to develop skills to improve patient care in the community. Keywords: Community pharmacy, advanced practice experiences, experiential training. J Am Pharm Assoc. 2008;48:64–70. doi: 10.1331/JAPhA.2008.07037

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Jeegisha Patel, PharmD, was Assistant Professor of Clinical Pharmacy, University of the Sciences in Philadelphia, at the time this study was conducted; she is currently Assistant Professor of Clinical Pharmacy, College of Pharmacy, Oregon State University, Corvallis. Correspondence: Jeegisha Patel, PharmD, College of Pharmacy, Oregon State University, 3303 SW Bond Ave., CH12C, Portland, OR 97239. Fax: 503-494-8797. E-mail: [email protected] Disclosure: The author declares no conflicts of interests or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria.

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he Accreditation Council for Pharmacy Education (ACPE) standards and guidelines require advanced pharmacy practice experiences that focus on patient care.1 Supporting these ACPE requirements, the Center for the Advancement of Pharmaceutical Education (CAPE) Advisory Panel on educational outcomes has defined criteria for professional and ability-based outcomes.2,3 The pharmacist’s dispensing role has increasingly changed to a more patient-centered, outcomesoriented practice that requires collaboration with the patient and the patient’s health care providers.4 Developing a site that provides these experiences can be an overwhelming task for preceptors. Having a structured, organized plan of activities for students, including goals, objectives, and evaluation components to provide a high-quality experience that meets ACPE standards and CAPE criteria, is crucial. This article reviews the contents of the student pharmacist manual used at an advanced community pharmacy practice rotation site in the Philadelphia area. The manual and site experience were designed and developed by a faculty preceptor. The manual is a collaboration of activities and assignments from many other community pharmacy student manuals published by faculty from colleges of pharmacy across the country who have used it at other sites.4–7 Comments and suggestions from student pharmacists’ evaluation of various community practice sites, along with input from many preceptors, were taken into consideration when developing the manual. Student pharmacists’ experiences in community practice vary from site to site. Some topics in the manual may be useful at one site but not another, depending on the preceptor, patient mix, and time. Consistency

At a Glance Synopsis: Presented in this Tools article are the contents and use of a student pharmacist manual that can be used during an advanced community pharmacy practice experience (ACPPE). While facilitating rotations at a Philadelphia-area chain pharmacy, a faculty preceptor designed and developed the manual, which combines activities and assignments from several other community pharmacy student pharmacist manuals published by faculty from colleges of pharmacy and incorporates the comments and suggestions of student pharmacists and preceptors. Analysis: Exposing student pharmacists to the changing role of pharmacists in a community setting is invaluable, yet designing and implementing an ACPPE can be challenging for preceptors. The usefulness of the topics described in this manual may vary depending on the preceptor and the timing of the ACPPE, but preceptors will find the manual’s consistency in the basic concepts useful in assuring that student pharmacists cover the topics that should be covered during an ACPPE.

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in the basic concepts that student pharmacists are required to learn during an advanced community pharmacy practice rotation is needed. Community pharmacy preceptors can use this article to develop templates that reinforce those concepts during advanced community practice rotations.

General description The advanced community pharmacy practice experience (ACPPE) empowers student pharmacists to fulfill new roles and expectations as community pharmacists. During the ACPPE outlined in this student manual, student pharmacists spend most of their time in the pharmacy care center, located in a separate room near the pharmacy. This arrangement allows student pharmacists to consult with patients privately yet still have access to the pharmacy. In pharmacies without such a room, a partition can be used in the waiting area to provide a semiprivate area for patient consultations. The manual begins by identifying the goals of the ACPPE; The first involves training student pharmacists to function as community pharmacists who provide direct patient care and develop innovative practice models for disease management. The second goal is to introduce student pharmacists to the duties and responsibilities necessary to the provision of pharmaceutical care in a community pharmacy setting. Student pharmacists are directly involved in pharmacy operations, including pharmacy management and law, patient counseling, physical assessment, and community service; they also gain knowledge in nonprescription medications and herbal remedies, drug interactions, and community-related diseases. The student pharmacists’ ability to perform the duties of a community pharmacist in the above areas is assessed through completion of competency examinations. The student pharmacists are also exposed to current projects undertaken by the pharmacy practice site, such as grant proposal writing, protocol design, application processes, conduction of a study, seminar or lecture participation, and any new patient care center initiatives. The student pharmacists fulfill oral and written presentation requirements as determined by personal interests and areas of improvements. The third goal of the ACPPE is to develop professional and personal skills. The student pharmacists’ strengths and weaknesses with regard to community practice are assessed during an evaluation conducted by the preceptor. The manual was created for student pharmacists to complete; it is not intended to cover all areas of an ACPPE or to limit the experiences of student pharmacists while at the site. Student pharmacists follow the manual in order to successfully accomplish the goals described above.

Components of the manual The student manual is divided into eight sections and follows a 5-week clerkship schedule. The first section provides an overview describing the clerkship, the goals of the ACPPE, and the course objectives of the college. The second section outlines the w w w.p h a r m a c i s t . c o m

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five competencies that were created to fulfill the goals of each of the modules. The next five sections are the actual assignments (modules, as described below), and the final section describes the elective component. The manual also includes documentation forms, evaluation forms, project templates, orientation material, and a schedule/calendar that coincides with the learning activities. The student manual is contains five modules: (1) orientation and community practice (dispensing), (2) community practice (management and law), (3) nonprescription products, (4) consultation, and (5) patient care. Each module correlates with activities that must be completed in order to pass the competencies, which were established by faculty involved with ACPPEs.7 Upon completion of each module, the following five competencies are evaluated by the preceptor: (1) pharmacy operations, (2) pharmacy law, (3) nonprescription medications, (4) drug interactions, and (5) community-related diseases.7 The pharmacy operations competency assesses the student pharmacists’ ability to perform daily pharmacy functions as staff pharmacists in a community setting. The pharmacy law competency assesses student pharmacists’ knowledge of practical use of pharmacy laws and regulations in daily pharmacy activities. The overthe-counter competency assesses the student pharmacists’ knowledge of common nonprescription medications, herbal remedies, vitamins, and home diagnostic testing kits. The drug interactions competency assesses student pharmacists’ ability to identify drug interactions among prescription drugs, nonprescription medication products, and herbal remedies. Finally, the community-related diseases competency assesses the student pharmacists’ knowledge of diabetes, asthma, hypertension, dyslipidemias, and other conditions commonly encountered in community-dwelling patients. These competencies, which have been used at other colleges, were selected to assess the student pharmacist’s proficiency in community pharmacy–related issues.7 Module 1 (orientation and community pharmacy practice [dispensing]) contains activities and exercises that introduce student pharmacists to the community pharmacy practice environment in a pharmacy. The goal is to familiarize student pharmacists with technology and other tools that allow pharmacists to focus their time on the professional duties of prescription verification and consultation. Some of the activities included in this module are Health Insurance Portability and Accountability Act (HIPAA)/privacy rules and regulations, checklist on workflow duties, pharmacy filling station exercises, verification practice scenarios, and listing the most dispensed drugs. The goal of this module is the completion of the pharmacy operations competency. Module 2 (community practice [management and law]) introduces student pharmacists to the basic principles needed to be successful pharmacy managers and provides a basic review of pharmacy law and legal matters. This section helps student pharmacists gain an understanding of how the pharmacy man66 • JAPhA • 4 8 :1 • J a n / F e b 2 0 0 8

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ager deals with difficult situations, describes how a pharmacy manager works with a team, reviews economic and accounting responsibilities of the pharmacy manager, and emphasizes the importance of marketing special services that the pharmacy provides. In addition, this section helps review controlled substances, record keeping, and management of inventory. Some of the activities in this section include management worksheets, a description of a day with the district manager, how to develop a business plan to improve the pharmacy, and a law exercise worksheet. The goal of this module is the completion of the pharmacy law competency. Nonprescription medication products and dietary supplements are the core elements of module 3. The goal of this section is to help student pharmacists learn more about nonprescription medications, vitamins and minerals, and herbal products and their respective active ingredients and uses. After completing these activities, student pharmacists should be able to provide recommendations and counsel patients on nonprescription and herbal products more effectively. This section includes hypothetical patient counseling and case scenarios related to nonprescription products, an nonprescription product selection worksheet, patient counseling on disease states and nonprescription recommendations for the diseases, home diagnostic product review and counseling (see Appendix 1 in the electronic version of this article, available online at www.japha.org), research and participation in the preparation of a product guide for use in the pharmacy, and herbal product review and activity sheets (online Appendix 1). The goal of module 3 is the completion of the nonprescription medication competency. The goal of module 4 is to develop consultation and communication skills in a community setting. This module allows student pharmacists to spend a substantial amount of time counseling patients and making product recommendations. After completion of the activities in this module, student pharmacists should be able to provide recommendations and counsel patients comfortably and professionally. Student pharmacists should be able to identify drug interactions with prescription drugs, nonprescription medications, herbal remedies, vitamin supplements, and food. Once they identify these interactions, student pharmacists should be given the opportunity to counsel the patients and/or make recommendations, if any. The section’s activities include completing consultation worksheets, spending time in the consultation window providing counseling on specific topics (i.e., family planning, wellness), an antibiotic counseling activity, and documenting patient counseling interventions (online Appendix 2). The goal of this module is the completion of the drug interaction competency. Patient care is essential in an ACPPE. The goal of this section, module 5, is to provide more information on common diseases to patients and the role of the pharmacist regarding treatment. The module helps student pharmacists gain the skills to work with patients and counsel them on medications and diseases. Student pharmacists are able to monitor patients and Journal of the American Pharmacists Association

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present a patient care plan for those seen at the patient care center. Student pharmacists also have the opportunity to set up a “brown bag” medication review—during which patients use a grocery bag to bring in all the medications from their homes for assessment—at a community senior center and conduct events focused on, for example, diabetes, blood pressure, or heartburn. Some of the activities included in this module are patient monitoring activities (case presentations, disease monitoring activities), presentation of disease to pharmacy staff and other health care professionals, and health screening days (online Appendix 3). The goal of this module is completion of the communityrelated disease competency. The elective section includes additional assignments that can enhance student pharmacists’ experience in a community practice setting. Activities in this section include presenting a journal club, undertaking an empathy assignment (“living with diabetes”), participating in topic discussions, and reviewing physical assessment skills that correlate with the topic discussions. Preceptors can use other community or ambulatory care preceptors, which is a great way to have student pharmacists work with others on similar clerkship experiences. Writing such documents as a pharmacy newsletter update or new drug or herbal remedy monograph can enhance student pharmacists’ literature search skills and writing skills. This new drug or herbal remedy information monograph can also be presented to the pharmacy staff. Planning outside visits, such as visiting the board of pharmacy or getting involved in legislative activities, and developing a new patient care service are other electives in which student pharmacists can participate. Elective assignments help give the clerkship variety and allow a student pharmacist to be involved in areas that may be of unique interest to him or her. Not overwhelming a student pharmacist is important, as is instructing him or her on time management. The preceptor can prepare a schedule and/or a calendar to coincide with the activities in the student manual to guide student pharmacists.

Schedule and calendar As published in other articles referring to community practice clerkships, a schedule of activities should be developed that meets the ACPPE-defined goals and objectives.4,5 A calendar format allows the preceptor to quickly outline daily activities and due dates for projects.4,5 The number of presentations and projects that are assigned during an ACPPE depend on the length of the rotation. The manual described above follows a 5-week rotation schedule. The student pharmacists have 1 week to complete each module, and progress is reviewed with the preceptor at the beginning of the following week. For example, during week 1, student pharmacists spend time in the pharmacy to learn the computer system and basic dispensing roles. This schedule allows them to complete the activities in module 1. The agenda of daily activities should be communicated to the student pharmacists and may or may not be included in the calendar. Journal of the American Pharmacists Association

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Community pharmacy practice settings can be unpredictable; therefore, the calendar is a guide for the student pharmacists. Discussions and activities may need to be changed to accommodate unexpected events. A sample calendar that uses the manual and other assignments is included in online Appendix 4. Posting the calendar near the pharmacy is important; this ensures that staff pharmacists, technicians, and front store staff are aware of the student pharmacists’ daily role.

Orientation As described in previous articles, gathering the materials needed for a successful orientation in advance will not only help the preceptors but also help structure the ACPPE.6,7 Orientation should be conducted on the first day of the rotation by the preceptor. Informing student pharmacists ahead of time via telephone call or e-mail about first-day expectations is recommended. The following is an example of factors that should be reviewed during orientation. n Site-specific requirements — Policies and procedures (pharmacy and patient care center) — Privacy rules and regulations, including requirements of the Health Insurance Portability and Accountability Act — Dress code and professionalism n Orientation of the site and staff n Review of goals and objectives of advanced community rotation — Mapping out 5-week plan; review of the modules — Daily duties u Pharmacy operations u Patient care center u Patient interventions/service u Drug information questions u Pharmacy support — Patient care documentation u Drug information questions u Pharmaceutical care interventions — Experiential assignments u Writing assignments u Oral presentations u Drug literature evaluations — Community pharmacy practice competencies — Pharmacy awareness days u Health screening table u Medication-review (“brown bag”) table u Blood pressure days Another major component of the orientation day may include an assessment of the student pharmacists’ baseline knowledge. The best way to do this is to either give a written pretest or orally review basic material the first day. The basic material may include topics that will be reviewed during the rotation or information that is relevant to the patient care services that are provided at the site (e.g., diabetes, hypertension, cholesterol). w w w.p h a r m a c i s t . c o m

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Examples of such basic material include review of nonprescription medication ingredients, measuring a patient’s blood pressure, or questions to ask patients before recommending a product. An example of a first-day review is shown in online Appendix 5. Last, a list of reading material that student pharmacists should have access to during the clerkship should be discussed. This material can include a list of suggested readings on innovative community practices or common disease guidelines. Reading about successful innovative clinical services implemented across the country can increase student pharmacists’ knowledge of community pharmacy practice and the importance of the pharmacist’s role. This knowledge is relevant for future discussions, patient cases, or projects. Suggested articles that have been useful for the student pharmacists are listed in the reference section.8–14 Having student pharmacists gather these articles before the clerkship helps them become familiar with expectations. Including the references in a “first-day” e-mail may be helpful (online Appendix 6).

Activities and assignments Activities can vary depending on the services provided at the site and the training of the preceptors. Many activities are chosen depending on the goals and objectives of the course related to the college and the core competencies for their graduates. In addition to the activities in the student pharmacist manual, other specific elective activities and assignments used in an advanced community practice rotation are described below. Topic discussions

Topic discussions are informative small-group presentations on specific diseases. These are coordinated with other community/ambulatory care preceptors. Disease topics are divided among the student pharmacists, and the preceptor of the student pharmacist who is presenting sits in on the discussion. Topic discussions generally occur once a week, and the presence of only one preceptor to evaluate is necessary. Topic discussions include reviewing guidelines regarding diabetes, hypertension (such as the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure), anticoagulation, National Cholesterol Education Program, immunizations, and geriatric pharmacotherapy. Student pharmacists are expected to be prepared to discuss the following topics during presentations: epidemiology, etiology, disease presentation, diagnosis, pathophysiology, nonpharmacologic treatment options, pharmacologic treatment options (classes of drugs, individual agents, mechanism of action, adverse effects, and monitoring parameters), and landmark clinical trials pertaining to the topic. Student pharmacists should have a handout prepared that will allow other participants to follow their discussion and take notes, and student pharmacists should lead the topic discussion with little prompting and discussion from the preceptor. Student pharmacists are evaluated using a rubric. Student pharmacists are notified well in advance about which 68 • JAPhA • 4 8 :1 • J a n / F e b 2 0 0 8

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topic they will be presenting and when. Physical assessment skills review

A review of basic physical assessment skills can be both informative and fun for the students. Physical assessment skills are reviewed once a week using the school’s pharmacy practice lab or the patient care room. The 1-hour review includes practicing basic skills such as blood pressure and glucose meter counseling. Student pharmacists learn about the variety of meters available, guidelines for recommending a crutch or cane, and use of anticoagulation and cholesterol machines. The physical assessment skills review is coordinated with other community/ ambulatory care preceptors and corresponds to the topic discussions. “Living with diabetes for the weekend”

As stated in previous articles, an empathy assignment is a great way to allow a student pharmacist to experience the challenges associated with a chronic disease.4,5 This assignment requires student pharmacists to follow specific lifestyle modifications and be adherent to medications. For example, for a diabetes empathy assignment, student pharmacists are given a kit that includes a blood glucose meter and strips, saline (as a substitute for insulin) and needles, a blood pressure monitor, a diary, and a monofilament. They are asked to check their glucose 3 times a day, inject saline in their abdomen twice a day, check their blood pressure, walk 30 minutes, and keep a diary of the foods they eat. They are also asked to examine their feet with a monofilament and practice proper foot care. Student pharmacists are asked to write a one-page paper on how it felt to live with diabetes for 2 days. The overall goal of the assignment is to help student pharmacists develop empathy and coping mechanisms that can be shared with patients.5 Patient handouts

Writing assignments are beneficial for both the student pharmacists and the pharmacy. Student pharmacists can gain experience on how to design a patient handout in lay persons’ terms on various community-related topics. After complete review and editing, pharmacists can use the handouts to educate their patients. Topics for patient handouts can include new drugs, herbal remedies, disease states, or specific nonprescription medication classes. An example includes preparing a product guide for use in the pharmacy. Student pharmacists can choose from a variety of topics, including nonprescription medication/herbal remedy use in pregnancy or nonprescription medication/herbal remedy use in patients with diabetes. These guides can include general information regarding product ingredients, indications, dosage recommendations, potential drug– drug and drug–food interactions, and restrictions. Students are told that these handouts should include all appropriate information pertaining to the topic along with illustrations. Emphasize the importance of creativity. Remind student pharmacists of the importance of using lay persons’ Journal of the American Pharmacists Association

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terms and to always reference their source material. The following is an example of a writing assignment. n Patient handouts include new drugs, herbal remedies, diseases, and general information. Your assigned patient handouts are the following: — Patient handout on drug (e.g., how to administer insulin) — Patient handout on herbal remedy (e.g., valerian) — Patient handout on new drug (e.g., pramlintide acetate [Symlin—Amylin]) — Patient handout on disease or condition (e.g., smoking cessation) Implementing a new pharmacy patient care service

Student pharmacists also participate and share their ideas on how to initiate a new patient care service for the pharmacy (e.g., smoking cessation program) during their ACPPE. Many student pharmacists are unaware of the advancements in the community practice setting. This project allows student pharmacists to research services that have been implemented in other pharmacies, develop a business plan using the SWOT (strengths, weaknesses, opportunities, and threats) theory, and create marketing materials for the service. District managers, clinical service coordinators, or other staff with a business background from the corporate level can speak to student pharmacists and share their marketing skills; this can teach student pharmacists about business plan development. The pharmacy can benefit from the student pharmacists’ work by implementing the new service and providing patient care. Student pharmacists enjoy learning how to develop these services and strive to make them successful. The goal is to teach student pharmacists about the business aspect of pharmacy. Patient consultations

Activities involving patients range from simple (e.g., recommending a nonprescription product) to more complex (e.g., antibiotic callback). Student pharmacists can document interventions pertaining to patient counseling on a daily basis (online Appendix 2). Student pharmacists may also perform extensive patient consultations on new prescriptions or a new diagnosis. The antibiotic activity is an excellent way to assess patient adherence. Student pharmacists are asked to counsel patients who are picking up a new antibiotic prescription on adverse effects, recommended dose, and adherence. Student pharmacists are then asked to follow up with the patient in a few days to ensure adherence. Other patient consultations include presenting care plans for patients enrolled in any of the services that are provided from the pharmacy care center (e.g., diabetes or hypertension service). Student pharmacists are asked to follow two to four patients and develop individual patient care plans, schedule appointments with the patients, and present the patient care plan to the preceptor. The goal of the assignment is to prepare student pharmacists for working with patients and evaluate their Journal of the American Pharmacists Association

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therapeutic knowledge base. Student pharmacists can follow a standard template that includes the SOAP (subjective, objective, assessment, plan) note format. Two to four patient cases is an appropriate load because it allows student pharmacists to learn and subsequently improve from one patient to the next. Patient consultation scenarios can also be beneficial for the student pharmacists. These scenarios can be handed to student pharmacists as cases. Examples of patient scenarios range from nonprescription product recommendation to identifying drug–drug interactions. The following are examples of a nonprescription case and herbal remedy case scenario. Nonprescription case: A mother presents to the pharmacist with her 5-year-old daughter and asks for assistance in selecting a product to stop the child’s itching. The mother explains that the child has intense perianal itching, especially at night, and has not been sleeping well. Physical observation reveals that the child seems exceptionally fidgety. Mother states that she noticed something small and white when she examined the child’s buttocks. n Assess the patient: —What can you recommend for this child (since perianal itching at night and being fidgety are common symptoms of pinworms in children, assume that is the clinical problem)? —E xplain the proper administration and possible adverse effects of the recommended product. —Educate the mother about the drug and nondrug measures. Herbal remedy case: John, a 59-year-old man, comes into the pharmacy to ask for recommendations on garlic herbal products. He was just at his physician’s office and was given his laboratory results. His results showed that his cholesterol is higher than normal. His physician did not start him on any medication for the elevated lipids but did recommend diet and exercise to help decrease these levels. John states that recently he read some literature on the use of garlic to help reduce cholesterol levels. John is taking the following medications: n Warfarin 5 mg; 1 tablet every day n Amlodipine (Norvasc—Pfizer) 5 mg; 1 tablet every day n Furosemide 20 mg; 1 tablet every day n Multivitamin; 1 tablet every day Assess the patient and provide the appropriate counseling for herbal remedies. Assess the therapeutic use of garlic as an agent to help decrease cholesterol level. Explain adverse effects, drug interactions, dosage and administration, and precautions for the use of this herbal product. Presentations

Presentations are helpful to assess student pharmacists’ knowledge base and verbal communication skills. Presentations can include small group in-service programs at a senior community center, journal club presentations, medical information updates to the pharmacy staff during lunch break or slow time, w w w.p h a r m a c i s t . c o m

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and disease management seminars to other student pharmacists and preceptors. Presenting community education seminars to a senior center can include providing education on a disease or performing a skill (e.g., checking blood pressure). An event such as this can also help market some of the services provided at the pharmacy and recruit patients to join the services. Journal club is an excellent way to keep the pharmacy staff and student pharmacists up to date on recent therapeutic topics. The selected journal article should focus on an area relevant to community pharmacy practice, and the research should be from a reputable pharmacy/medical journal and published within the previous 6 months. Journal club includes critique, evaluation, and presentation of the recently published article. The goal is to have student pharmacists evaluate and present an article and build their critical thinking skills. A medical information update prepared by student pharmacists provides pertinent information relative to the needs of pharmacists based on their site. Potential topics include drug information, pharmacy law, insurance information, residency programs, and pharmacy services. Disease presentations are an excellent way to assess student pharmacists’ formal presentation skills and evaluate their knowledge on a selected disease. Student pharmacists are asked to present a 30-minute PowerPoint presentation on a disease, including its etiology, diagnosis, pathophysiology, nonpharmacologic treatment options, pharmacologic treatment options, and landmark clinical trials pertaining to the topic. This activity works well with other community/ambulatory care student pharmacists and preceptors.

Evaluation Many colleges follow a standard evaluation form developed by the school that is used for all the experiential rotations. The manual includes the evaluation form required by the college. Evaluations are important throughout an ACPPE to help student pharmacists monitor progress and identify strengths and weaknesses. Providing informal feedback on a regular basis and performing written formal evaluations can be a mechanism of exposing student pharmacists to different ways of doing things to expand their horizons.6 Positive feedback should be included whenever possible to motivate the student pharmacists. In addition, student pharmacists should complete a self-assessment of their knowledge base and strengths and weaknesses to identify areas of improvement or enhance strong interests. Student pharmacists may also be asked to evaluate the preceptor and the overall experiential education. Evaluations should be performed as often as possible.

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Conclusion The efforts to enhance a community practice experience can be rewarding and beneficial to both the student pharmacists and the pharmacy. An ACPPE gives student pharmacists an opportunity to develop skills to improve patient care in the community. In addition, the experience can benefit the profession of pharmacy and may accelerate the evolution of patient care provided by the community pharmacist.  References

1. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. Accessed at www.acpe-accredit.org/standards/standards1.asp, June 1, 2006. 2. CAPE Advisory Panel on Educational Outcomes. Professional and general abilities based outcomes. Accessed at www.aacp. org/Docs/MainNavigation/ForDeans/5763_CAPEoutcomes. pdf, June 1, 2006. 3. Cerulli J, Malone M. Using CAPE outcome-based goals and objectives to evaluate community pharmacy advanced practice experiences. Am J Pharm Educ. 2003;67(2):article 34. 4. Dugan BD. Enhancing community pharmacy through advanced pharmacy practice experiences. Am J Pharm Educ. 2006;70(1):article 21. 5. Thomas RA. Developing structured-learning exercises for a community advanced pharmacy practice experience. Am J Pharm Educ. 2006;70(1):article 23. 6. Koenigsfeld CF, Tice AL. Organizing a community advanced pharmacy practice experience. Am J Pharm Educ. 2006;70(1):article 22. 7. Lee KW, Machado MR, Wenzel MW, et al. An advanced professional pharmacy practice experience in a community setting using an experimental manual. Am J Pharm Educ. 2006;70(2):article 42. 8. Westfall GR, Narducci WA. A community-pharmacy-based callback program for antibiotic therapy. J Am Pharm Assoc. 1997;NS37:330–4. 9. Bennett M, Wedret JE, eds. Building a successful collaborative pharmacy practice: guidelines and tools. Washington, D.C.: American Pharmacists Association; 2004. 10. Tsuyuki RT, Johnson JA, Teo KK, et al. A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP). Arch Intern Med. 2002;162:1149– 55. 11. Mangum SA, Kraenow KR, Narducci WA. Identifying at-risk patients through community pharmacy–based hypertension and stroke prevention screening projects. J Am Pharm Assoc. 2003;43:50–5. 12. Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical care services and results in Project ImPACT: Hyperlipidemia. J Am Pharm Assoc. 2000;40:157–65. 13. Cranor CW, Christensen DB. The Asheville Project: short-term outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:149–59. 14. Goode JV, Swiger K, Bluml BM. Regional osteoporosis screening, referral, monitoring program in community pharmacies: findings from Project ImPACT: Osteoporosis. J Am Pharm Assoc. 2004;44:152–60.

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Appendix 1. Home diagnostic kits and herbal activity assessment forms

Home diagnostic kits assessment form Name of Device:__________________________________________________________ What is the objective of using this test?________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What questions would you ask a patient before recommending this product?___________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What are some important features and limitations of this device?____________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What are some factors that can affect the test results?_____________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ How would you counsel a patient on how to use this home diagnostic test?____________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Worksheet available from the OTC Advisor Pharmacy Based Self-Care Services-National Certificate Training Program conducted by AphA

Herbal activity assessment form Product: ________________________________________________________________ List the primary source of this product. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ List the most common use(s) of this product. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ List the most common doses(s) of this product. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ List the most common side effects of this product. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ List the contraindications for using this product. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ List any other significant information found ( DI, etc.) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ References:______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Worksheet available from the OTC Advisor Pharmacy Based Self-Care Services-National Certificate Training Program conducted by APhA

Appendix 2. Daily intervention documentation, consultation worksheet activity, and antibiotic counseling activity forms Daily intervention documentation form University of the Sciences in Philadelphia Philadelphia College of Pharmacy Documentation Form Patient Name:___________________________________ Age: ___________ Sex: __________ Doctor: ___________________ Resident: _________________________ Date: ____________

Consultation Activity/Intervention (check one)

Comments

Inhaler training Blood pressure monitoring Smoking cessation Drug regimen review Adherence challenges Drug Information OTC/herbal counseling Medication access challenges Contact provider Identification of drug interaction (i.e., drug-drug, drug-herbal, drug-food) Other (specify)

Expected or Actual Outcomes (check one) Patient gained education Adherence improved Provider gained education Medication regimen simplified and reviewed Hospitalization avoided Cost savings Unable to document Medication effectiveness improved Patient in therapeutic control Patient responds to therapy Prevented drug interaction Other (specify)

Additional comments:

Time spent:

Comments

Preceptor signature: _________________________

Consultation worksheet activity 1. 2.

Select five products from different OTC categories. Using the Components of Patient Consultation forms on the following pages, write a consultation for each selected product. Stay in the Consultation Window and observe what OTC products patients are buying in addition to their prescriptions. Try to find a patient that is taking your selected OTC product. Explain that you are a pharmacy student, and can check to see if there are any interactions between the OTC products they are purchasing and their prescription medications. Components of a Patient Consultation

Patient’s Initials: Patient’s History: Allergies: __________________________________________________________________________________ __________________________________________________________________________________ Health Conditions: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Other medications (prescription, OTC, herbals): __________________________________________________________________________________ __________________________________________________________________________________ Conditions that prescribing physician wrote the script for: __________________________________________________________________________________ Name of medication: __________________________________________________________________________________ Description of medication: __________________________________________________________________________________ Indications for use: __________________________________________________________________________________ __________________________________________________________________________________ Administration and Dosage: __________________________________________________________________________________ __________________________________________________________________________________ Contraindications: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Drug Interactions: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Possible Side Effects or Adverse Reactions: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Specific Directions:

__________________________________________________________________________________ __________________________________________________________________________________ Storage: __________________________________________________________________________________ Duration of Therapy: __________________________________________________________________________________ Pharmacist Initials:______________

Antibiotic counseling activity • •

•

Prior to counseling, the student will review patient counseling components Under the supervision of the preceptor, the student will select five patients who have had a new antibiotic medication filled that day. After obtaining consent from the patient to be counseled and to receive follow up care, the student will counsel the patients. The student will document the counseling session using the documentation form. Under the discretion of the preceptor, after 72 to 96 hours, the student will follow up with the patient via telephone call to their home. The student will assess the patient’s antibiotic therapy, including any drug interactions or issues with the medication, or if therapy does not appear to be working. The student will seek the preceptor’s advice in contacting the prescriber if needed. The student will document any interaction with the patient, patient’s agent, or other health care professional related with the case, along with any recommended modifications to therapy.

Antibiotic Activity Consultation Documentation Form Date:____________________________________Time:________________________________________ Location (circle):

On Site

Telephone Inquiry

Individual Requesting Conusult: ( Patient, RN, PA, MD, RPH, etc.)____________________________ Patient Background ( gender, age, medication hx, disease states, etc.)

Question/Issue:

Reference Consulted:

Recommendation/Outcome:

Preceptor review ( signature):___________________________________________________________

Appendix 3. Disease state monitoring activity (diabetes) and brown bag day forms Disease state monitoring activity (diabetes) This section will help you review diabetes and the ADA guidelines. 1.

What are some risk factors associated with the diabetes?

2.

What are symptoms of hyperglycemia?

3.

What are some of the treatments currently available for diabetes?

4.

What are some possible side effects of these prescription medications?

5.

What are the most common contraindications for these medications?

6. What OTC remedies ( herbs, vitamins, etc) might be used to treat this condition and/or its symptoms?

7.

What are some complications that might develop from diabetes?

Patient Counseling: Identify 3-5 patients taking medications for diabetes. Perform a comprehensive DUR review of diabetes patients with the pharmacist. Develop a plan for counseling those patients. Try to schedule a 10-15 minute meeting with each patient to review your findings.

Monitoring: Many patients that suffer from diabetes must regularly monitor their blood glucose levels. Counsel your preceptor and/or patient on the proper technique for using one of the blood glucose meters. Counsel your preceptor and/or patient on the proper use of the ketone strips. Counsel your preceptor and/or patient on how to perform a diabetic foot exam. Counsel your preceptor and/or patient on how to mix and inject insulin.

Goal Blood Glucose and HbA1c Readings:

Brown bag day Pharmacies sometimes hold “brown bag days”, where patients are invited to bring all of their medications in a brown bag ( or any type of bag). The pharmacist reviews the medications with the patient and explains all indications, possible side effects, interactions, and any other pertinent information about the patient’s medications. This is also a great opportunity to enhance patient compliance and recommend the use of pillboxes, charts, etc. You can focus on specific topics such as asthma, diabetes, cholesterol, or hypertension. You will be asked to set up a brown bag day. You can set it up in the pharmacy, nursing homes, retirement centers, senior community centers, churches, or schools. Decide the date you would like to have your brown bag and the location. After your preceptor approves your event, plan to market the event. Audience:_____________________________________________________________________________ Topic:________________________________________________________________________________ Location:______________________________________________________________________________ Date/Time:____________________________________________________________________________

Marketing Plan:

List of items needed (i.e. flyers, tables, etc):

Student:_______________________________________________________________________________ Approved:_____________________________________________________________________________

Disease State Management Presentation The Disease State Management Presentation gives the student an opportunity to present a community pharmacy-related topic of his/her choice; the primary focus of the selected topic is the evaluation of potential pharmacological interventions. The information must be referenced. Presentation musts be presented using PowerPoint Slides and the targeted audience are health care professionals and students.

Appendix 4. Sample schedule and calendar designed to meet ACPPEdefined goals and objectives Monday

Tuesday

Wednesday

Thursday

Friday

13 Orientation HIPPA Computer System Dose limiting article Cough & Cold Review Review BP and Inhalers PharmacyOperations & Law Module

14 Data Entry Filling Station Doctor Calls Transfers

15 Verification DUR, Ordering Third Party Prior Auth Topic Discussion ( Anticoagulation) Campus ( Dr. Chan)

16 Record Keeping Controls Inventory

17

20 Discuss OTC Interaction Case Review Module 1&2 Diabetes Day Store # 1016 2-4:00 OTC & Herbals Module 27 Consultation Worksheet (5 Pts) -Antibiotic Activity ConsultationWindow: Family Planning Discuss Immunization Article Review Module 3 Consultation Module 6 Disease State: Asthma Pregnancy/ Fertility Monitors Smoking Prod/ERC

Review Disease State Management Articles

21 OTC Counseling 9-12 Hypothetical Pt Counseling How it was to be a diabetic for 2 days paper due 28 -Consultation Worksheet (5 Pts) -Antibiotic Activity Senior Center Visit BP/Med Review Patient Handout on Insulin & Lit Review #1 Due 7 Disease State: Hypertension

22 OTC Product By Category Discuss Herbal Drug Info Herbal DI Case Discuss Community Pharmacy Articles 1 ConsultationWindow: Wellness OTC/Window 9-12 Pt Care Plan #1 Review Eye/ Ear Home Diagnostic Kit

Topic Discussion ( Geriatrics) Campus ( Dr. Hajjar) 23 OTC Counseling 9-12 OTC and Disease States Topic Discussion (Diabetes) Campus 2-3:00 (Dr. Patel) 2 -Consult. Sheets AntibioticActivity OTC/Window

Antibiotic Activity Sheets Due

Topic Discussion (JNC 7) Campus 2:00-3:00 (Dr. Hajjar) 9 Disease State: Diabetes Topic Discussion (NCEP) Campus 2-3:00 ( Dr. Chan)

14

15

16

OTC/Window 9-12

Disease State Presentation

OTC/Window 9-12

Clinical Pearls Newsletter Product Guide & Smoking Cessation Project Due

Campus

Lit Search # 2 and Herbal Patient Handout Due

Review Module 4

8 Disease State: Hyperlipidemia Consultations Due

Women’s Health Fair 8-3 Convention Center

24 OTC Counseling 9-1 Physical Assessment ( Meters) Campus 2:00-3:00

3 Midpoint Eval Work on Smoking Cessation Service Physical Assessment (Canes) 10 Physical Assessment Coagu/Choles Campus 2:00-3:00

Patient Care Module 13 Review Module 5 Pt Care Plan #2 Patient Counseling On Disease State Journal Club

Patient Care Module

1:00-5:00

New Drug Seminar and Patient Handout on New Drug Due

17

Hand in all forms Final Evaluation

*** Clinic days to see patients enrolled in services are Mondays, Wednesdays and Fridays.

Appendix 5. Sample 1st-day review to assess baseline knowledge of students Advanced Community Practice Rotation- Rite Aid Patient Care Center University of the Sciences in Philadelphia 1. Cough and Cold Products Ingredient Uses/Indications

Warnings/Precautions

2. Blood Pressure Monitoring a. Questions to ask the patient: b. Positioning of the patient: c. Technique: 3. Inhaler Technique a. Use of a MDI/DPI:

b. Use of a spacer:

c. Use of peak flow meters: 4. When to refer a patient

** Be prepared to review the following article: Pray, WS. OTC Products: Time Limits for Safe Use. U.S. Pharmacist. Vol. 24:6

Appendix 6. E-mail prior to starting APPE Advanced Community Pharmacy Practice Rotation Rite Aid Pharmacy Patient Care Center 8358 Bustleton Avenue Philadelphia, PA 19152 Preceptor: Dr. Jeegisha Patel Welcome to Rite Aid! I am sure you are not only excited but may be nervous to start your clinical experience. I will try my best to make your rotation fun and productive! As you know, this is an ADVANCED community pharmacy practice experience. It’s not your typical “retail” rotation. You will be providing direct patient care and learning how to develop a patient care environment in a community setting. You will only be spending the first week in the actual pharmacy just to learn how to use the computer system. The main focus on this rotation is to be able to provide clinical services in a community practice setting via the patient care center. On that note, the first day please meet me at Rite Aid on Bustleton Ave. The main cross street (can catch off of Route 1 or 95)is Rhawn Street. We are located in the Bell’s Corner Shopping Center. We are actually in the Rite Aid near the pharmacy. You will see a small room where you can find me. Please dress professionally and wear your white lab coat. You must have your nametag and any writing instruments. The first day is just orientation. There are some things you need to review before your first day. Please review cough & cold either reading the chapter in Nonprescription Handbook or any other source you feel is appropriate. In addition, please have the following guidelines on hand: Clinical Guidelines on Cholesterol Management in Adults ( ATP III) National Heart, Lung and Blood Institute ( www.nhlbi.nih.gov) Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) National Heart, Lung and Blood Institute ( www.nhlbi.nih.gov) Standards of Diabetes Care ( www.diabetes.org) Guidelines of the Diagnosis and Management of Asthma (www.nhlbi.nih.gov) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (www.nhlbi.nih.gov) Geriatric Pharmacotherapy ( Dipiro) A major component of this rotation is for you to see the diverse disease state management programs that are implemented in a community setting. You will be given the following articles the first day, but if you would like to read them before hand, you may find them on the web. Cranor CW, Bunting BA, Christensen DB. The Ashville Project: Long-Term Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care Program. J Am Pharm Assoc. 2003;43 (2): 173-184. Goode JV, Swiger K, Bluml BM. Regional Osteoporosis Screening, Referral, Monitoring Program in Community Pharmacies: Findings from Project ImPACT: Osteoporosis. J Am Pharm Assoc. 2004; 44(2): 152-160. Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical Care Services and Results in Project ImPACT: Hyperlipidemia. J Am Pharm Assoc. 2000; 40(2): 157-165 Finally, please review your physical assessment skills on the following material: Blood Pressure & Pulse, Asthma Inhaler, Diskus, &Peak Flow Meter, Glucometers and Weight ( BMI, Waist Circumference) I look forward in working with you and I hope to provide you with an worthwhile experience. If you have any questions, please email me or page me. See you on Monday! Dr. Patel [email protected]

215-596-8749 (office) 215-3303207 (pager) 215-728-1762 ( site)