- Email: [email protected]
Incorporating the American Pharmacists Association's Delivering Medication Therapy Management services certificate program into an accelerated pharmacy curriculum
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
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Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Experiences in Teaching and Learning
Incorporating the American Pharmacists Association's Delivering Medication Therapy Management services certificate program into an accelerated pharmacy curriculum ⁎
Jennifer L. Donovana, , Jason Crossb, Amanda M. Morrillc, Paul P. Belliveaud, Cheryl A. Abelc, Anna K. Morine, Michael J. Malloyf a
Curriculum and New Programs, MCPHS University, 19 Foster Street, Worcester, MA 01608, United States MCPHS University, 19 Foster Street, Worcester, MA 01608, United States c MCPHS University, 1260 Elm Street, Manchester, NH 03101, United States d School of Pharmacy, MCPHS University, 19 Foster Street, Worcester, MA 01608, United States e School of Pharmacy, MCPHS University, 19 Foster Street, Worcester, MA 01608, United States f William Carey University, 498 Tuscan Avenue, Hattiesburg, MS 39401, United States b
AR TI CLE I NF O
AB S T R A CT
Keywords: Medication therapy management MTM, certificate American Pharmacists Association, accelerated school of pharmacy
Background and purpose: To describe the incorporation of the American Pharmacists Association (APhA) Delivering Medication Therapy Management (MTM) Services program into a PharmD curriculum and to describe student perceptions of the program. Educational activity and setting: The program was delivered over 12 months to students on two campuses via two didactic courses in the second professional year and during the first two advanced pharmacy practice experiences in the third professional year of an accelerated school of pharmacy program. Findings: Student perceptions were assessed by review of responses to the APhA MTM program evaluation survey. Discussion and summary: Incorporation of the APhA MTM program into an accelerated PharmD program required careful planning and coordination amongst faculty and course coordinators. Students perceived that the program was valuable, met their educational needs, and incorporated effective learning experiences and cases. These perceptions were reinforced by the high percentage of students who completed the program.
Background and purpose The Accreditation Council for Pharmacy Education (ACPE) Accreditation Standards for doctor of pharmacy (PharmD) programs have long recognized the importance of preparing students to participate in patient-centered care and medication therapy management (MTM) services.1 More recently, the 2016 ACPE accreditation standards furthered the importance of MTM education and training by incorporating a philosophy meant to ensure that programs graduate practice-ready and team-ready students.2 This approach includes preparing students to collaboratively contribute to patient care via the pharmacists’ patient-care process, the backbone of which is MTM services.3 To prepare students for participation in the patient-care process, colleges and schools of
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Corresponding author. E-mail addresses: [email protected] (J.L. Donovan), [email protected] (J. Cross), [email protected] (A.M. Morrill), [email protected] (P.P. Belliveau), [email protected] (C.A. Abel), [email protected] (A.K. Morin), [email protected] (M.J. Malloy). http://dx.doi.org/10.1016/j.cptl.2017.05.005 Received 25 May 2016; Received in revised form 5 January 2017; Accepted 20 May 2017 1877-1297/ © 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Donovan, J.L., Currents in Pharmacy Teaching and Learning (2017), http://dx.doi.org/10.1016/j.cptl.2017.05.005
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pharmacy must ensure that students acquire the requisite knowledge, skills, and attitudes to deliver MTM services. The importance of pharmacist involvement in patient-care is recognized by the healthcare industry.3 Pharmacists contribute to the Centers for Medicare and Medicaid Services quality measures, which include a focus on improving adherence to medications, and ensuring patients with chronic disease conditions receive recommended therapy and patients older than 65 years are appropriately prescribed high risk medications. These measures, which are also important aspects of MTM initiatives, are utilized to establish Medicare Star Ratings. These ratings, in turn, are used as an indicator of the quality for Medicare Part D and other health insurance plans.4 Pharmacists can positively impact Star Ratings of health plans and become part of a preferred pharmacy network by contributing to medication use improvements which impact these important quality measures. Pharmacist employers desire that pharmacy school graduates have education and training which allows them to participate in patient care and MTM services.5 To understand pharmacist employer expectations of pharmacy graduates, ACPE sought feedback from the American Society of Health-System Pharmacists, National Community Pharmacy Association, National Association of Chain Drug Stores Foundation, and Academy of Managed Care Pharmacy.5 These organizations recommended additions to the educational outcomes that impact MTM training and education.5 They desire that graduates be able to collaboratively participate in the patientcare process, conduct a comprehensive medication review, advocate on behalf of patient needs, and document MTM services. Students at Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, School of Pharmacy-Worcester/ Manchester (SOP-W/M) are exposed to course content that addresses knowledge required to perform the MTM components described in the pharmacists’ patient-care process.3 However, the escalation of influences (2016 ACPE Standards, Center for the Advancement of Pharmacy Education (CAPE) Educational 2013 Outcomes, employer expectations) motivated the SOP-W/M to consider ways to further supplement the education and training that is already part of our curriculum.2,3,5,7 It was decided that the nationally-recognized American Pharmacists Association Delivering Medication Therapy Management Services (APhA MTM) program would serve the purpose of providing students with additional practice opportunities and further highlight the applicability of MTM services to their future practice.6 This report is novel in that it is the first to provide a complete description of the integration, implementation, and assessment of the APhA MTM program into a PharmD curriculum. The lack of literature describing the incorporation of this program into pharmacy curricula could be an indication that schools have struggled to develop a means of effectively delivering this program. Such struggles might be expected given that this program has several components, making incorporation into a curriculum challenging. Hence, this report may help other schools or colleges seeking to incorporate the APhA MTM program in their curricula. Since the integration was new to our curriculum, we sought to capture students’ perceptions of the APhA MTM program to determine if they found it a valuable and practice-relevant learning experience. Use of the data included in this report was approved by our Institutional Review Board.
Educational activity and setting The SOP-W/M program is a year-round, 34-month, accelerated program. There is a main campus (Worcester, MA), which enrolls approximately 250 students each year and a satellite campus (Manchester, NH), which enrolls approximately 55 students each year. Distance education technology allows for the synchronous delivery of classes to each campus. In the second professional year, there is a required, two-course series entitled Introduction to Advanced Pharmacy Practice (IAPP). These courses are offered concurrently with pharmacotherapeutics and pharmacology, medicinal chemistry, and toxicology Table 1 Introduction to Advanced Pharmacy Practice-1 course outline. a
Date
Week Week Week Week Week Week Week Week Week
Topic 1 2 3 4 5 6 and 7 8 9 10
Week 11 Week 12 Week 13 Week 14 Week 15 Finals week
Orientation/Drug consult writing/Plagiarism Navigating through the medical record Statistics Evidence based medicine Journal club workshop No class; complete APhA MTM pre-live seminar requirements: self-study materials, pre-seminar case, self-study exam APhA MTM session 1 lecture Spring break APhA MTM session 2; breakout rooms Patient “Toni” case discussion Medication safety/Interprofessional education project discussion APhA MTM session 3; breakout rooms Patient “Carl” case discussion APhA MTM session 4 lecture APhA MTM session 5; breakout rooms Patient “Donna” case discussion APhA MTM session 6; breakout rooms Patient “James” case discussion Cumulative exam
APhA = American Pharmacists Association; MTM = Medication therapy management a Introduction to Advanced Pharmacy Practice −1 (IAPP-1_ is a 2-credit course. Each topic was scheduled once per week for 1 h and 50 min.
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in the spring (IAPP-1) and summer (IAPP-2) semesters. Both IAPP courses consist of two credit hours of instruction. The goal of these courses is to prepare students for advanced pharmacy practice experience (APPEs) activities and expectations. The courses’ objectives encompass subdomains from Domains 1-4 of the CAPE 2013 Outcomes.7 These subdomains include preparing students to provide culturally sensitive patient-centered care, optimize medication use, identify and solve problems, provide patient education, advocate for the patient, and promote leadership and professionalism in an interprofessional practice setting.7 Since the courses’ objectives are consistent with the APhA MTM program objectives, the IAPP course series was a logical location for incorporating components of this program into the curriculum. The APhA MTM program for student certification includes completion of 20 hours of self-study materials, a self-study examination, eight hours of live seminar and patient case discussions (with four APhA-provided patient cases), an APhA program evaluation (administered after the live seminar and case discussions), and five student-identified post-seminar cases. To understand expectations for the spring and summer semesters, second professional year students were introduced to the APhA MTM program towards the end of their fall semester. At that time, students were provided an enrollment code and instructions for the training. This provided on-line access to the APhA MTM program materials prior to the holiday break, allowing sufficient time to begin work on the program pre-seminar components. This preparation consisted of competing 20 hours of self-study materials, completing one APhA-provided pre-seminar patient case with the required APhA MTM documentation, and taking the self-study examination. These APhA MTM program components were a requirement for IAPP-1. They were to be completed by week 8 of the spring semester in preparation for attending the live APhA MTM program seminar sessions in IAPP-1. The self-study examination was purposely designed by APhA to be a take-home open-resource exam. Students had two opportunities to achieve a score of 70%, which is considered a passing grade by APhA. Table 1 outlines content for the IAPP-1 course and the APhA MTM program. Didactic sessions were delivered to the entire student cohort by faculty who had received the APhA MTM Train-the-Trainer training. For the case discussion sessions, students were divided into groups of approximately 30 with one to two faculty members facilitating discussion. APhA also requires APhA MTM Train-theTrainer training for faculty who deliver the slides associated with the case discussions. These faculty facilitated case discussions and delivered the case-related APhA slides within each discussion room. The second faculty member facilitator was not required be APhA MTM Train-the-Trainer trained; the only requirement was to be familiar with the MTM process. Student assessments in IAPP-1 are outlined in Table 2. The score earned on the self-study examination was recorded as part of the course grade. The APhA-provided pre-seminar case was submitted individually by each student and the APhA MTM documentation was checked by faculty for completeness; this was graded in a pass/fail fashion. Therapeutic accuracy of the case content was not assessed because students had not yet completed components of the curriculum that would allow for accurate clinical decisionmaking skills. There was no preparation required by students for the other three APhA-provided cases. These were discussed during small group sessions, and students received full credit by participating in these discussions. IAPP-2 has traditionally included a patient-care plan presentation meant to provide students with a practice opportunity prior to APPE rotations. Since the APhA MTM program requires students to identify and interview patients for the purposes of practicing the MTM process, it was determined that this presentation could serve as a practice opportunity that would fulfill an IAPP-2 course and an APhA MTM program requirement (one of the five required student-identified post-seminar cases). Given the increased emphasis on interprofessional education (IPE) in the 2016 ACPE Standards, this activity was also seen an opportunity to include an IPE component into this course. Students were paired with another healthcare professional student to identify a patient to interview and develop a comprehensive, collaborative care plan that reflected both disciplines (see APhA MTM presentation, Table 2). The other healthcare professional student was from the nursing, nurse practitioner, optometry, or physical therapy programs. Per APhA requirements, the interviewed patient needed to have at least three medical conditions requiring pharmacotherapy and at least five Table 2 Integration of content from the American Pharmacist Association's Delivering Medication Therapy Management Services certificate program into Introduction to Advanced Pharmacy Practice Courses. Introduction to Advanced Pharmacy Practice-1 Assignment Drug consult Pre-seminar case submission - patient case “Toni” Cumulative exam APhA MTM self-assessment exam APhA MTM breakout session I - patient case “Carl” APhA MTM breakout session II- patient case “Donna” APhA MTM breakout session III- patient case “James” Journal Club workshop assignment
Percentage of final grade 20 10 20 10 10 10 10 10
Introduction to Advanced Pharmacy Practice-2 APhA Immunization Self-Study Assignment APhA Immunization final exam APhA MTM post-seminar presentation Drug consult Inter-professional activity reflection
15 15 30 30 10
APHA = American Pharmacist Association; MTM = Medication Therapy Management
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medications. Patients could be anyone with whom students had contact including neighbors or family members if the patient consented to the interview. Students submitted the required APhA MTM documentation and orally presented the comprehensive care plan to their faculty preceptor for the course. Students had the opportunity to complete the remaining four post-seminar cases during their first two APPE rotations in their third professional year. These cases needed to meet the same criteria as previously stated. These cases were in addition to the required work from the APPEs. Students’ APPE preceptors were not asked to be involved in identifying cases, verifying that the cases met the criteria, or that APhA MTM documentation was completed; the student's faculty preceptor for IAPP-2 reviewed the cases. These faculty reviewed the post-seminar cases to ensure they met defined criteria and that the APhA MTM documentation forms were appropriately and adequately completed. As with the pre-seminar case, faculty did not focus on therapeutic accuracy of case submissions. Rather, the focus was on ensuring students adequately completed the MTM process as demonstrated by the completeness of the APhA documentation forms. There was no penalty for not completing these four post-seminar cases as they were not included in APPE grades. To be eligible to receive the certificate of completion for the APhA MTM program, students had to complete all required components of the program. Students who were absent or tardy from any class sessions where there was delivery of APhA MTM program content or did not complete the post-seminar cases were instructed to not print a certificate of completion. There was no opportunity for students to make-up or view recordings of missed IAPP-1 seminar or case-discussion sessions; recording was prohibited by APhA. The faculty member coordinating the APhA MTM program for the IAPP-1 and IAPP-2 courses was responsible for ensuring that the integrity of the program was maintained. This responsibility included continuous monitoring to confirm that only eligible students used attendance codes and printed a certificate of completion. Given the complexities of the APhA MTM program requirements, coupled with a large student cohort, all practice faculty were needed for successful implementation. In the department of pharmacy practice, there are 28 faculty on the Worcester campus and eight faculty on the Manchester campus who were available to participate as a preceptor in the APhA MTM program. Two faculty were identified to complete the APhA MTM Train-the-Trainer program, which authorized them to deliver the live APhA MTM content. Of the 36 faculty who facilitated the sessions, 21 of them had completed the APhA MTM program (but did not complete the Train-the-Trainer program). However, these trainings were not required to participate as preceptors for pharmacy student presentations and MTM case submissions or to assist Train-the-Trainer educated faculty with facilitation of case discussion sessions. Each department faculty was a preceptor to groups of 8–10 students. In the second offering of the APhA MTM program, nine additional faculty completed the Train-the-Trainer program to allow for involvement of more faculty in the case-discussion slide presentations. Findings Currently, two student classes (class of 2015 and 2016) have been provided an opportunity to complete the APhA MTM program. This report describes an assessment of the first class to be offered this opportunity. All analyses were calculated using GraphPad. All students in the class of 2015 (n=289; 232 main campus and 57 satellite campus) enrolled into the APhA MTM program and completed the self-study assessment and program evaluation questions. The mean score on the self-study assessment was 97.64 ± 3.51% (Table 3). There was no difference in scores between campuses. All students (n=289) successfully achieved the APhA-required 70% or greater passing score on the first attempt. Most students (n=279, 96.54%) received credit for attending the live seminar sessions. Several students did not receive credit for attending the live seminar sessions because they were absent or tardy (n=10). These students were not eligible to receive a certificate of completion, but were still required to attend and participate in the remaining seminar sessions (for IAPP-1) and complete one of the five post-seminar patient cases (for IAPP-2) because these were course requirements. Most students successfully completed all the components of the APhA MTM program (83.39%; n=241; 201 (86.63%) main campus and 40 (70.17%) satellite campus). There was no difference in completion rate between campuses. The reasons that students did not complete the program are listed in Table 4. There were nine APhA-developed program evaluation questions that were helpful in assessing students’ perceptions of the program (Table 5). Students were asked to use a Likert scale or answer "yes" or "no" to these questions. All students (n=289; 232 main campus and 57 satellite campus) completed the evaluation. The sum of excellent/very good/good responses was above 90% for all of the Likert questions indicating that students believed the program was valuable, met their educational needs, incorporated effective learning experiences and cases, and was a valuable learning experience (Table 5). Students would recommend this program to a colleague (93.53% overall; 91.35% main campus and 89.47% satellite campus) and felt that future activities on this subject matter are necessary and/or important to their practice (93.10% overall; 91.35% main campus and 94.74% satellite campus). Table 3 American Pharmacist Association's Delivering Medication Therapy Management Services certificate program self-study exam scores (first attempt).
Mean (%), Standard deviation Median (%) Range (%)
Total (n=289)
Main Campus (n=232)
Satellite Campus (n=57)
*
97.64 ± 3.51 98.46 76.92–100
97.17 ± 3.51 98.46 76.92–100
97.38 ± 3.17 100 86.15–100
0.18
* P-Values were calculated using GraphPad Quickcalcs (http://www.graphpad.com/quickcalcs/)
4
P-Value
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Table 4 Reasons for students not completing the American Pharmacist Association's Delivering Medication Therapy Management Services certificate program.
Absent or tardy from live seminar session(s), n (%) Academic reasons (e.g., did not progress, out of sequence, plagiarism), n (%) Chose not to complete the remaining four post-seminar cases, n (%)
Total (n=48)
Main Campus (n=31)
Satellite Campus (n=17)
P-Value
10 (20.84) 19 (39.58)
6 (19.35) 15 (48.39)
4 (23.53) 4 (23.53)
0.73 0.13
19(39.58)
10 (32.26)
9(52.94)
0.51
*P-Values were calculated using GraphPad Quickcalcs (http://www.graphpad.com/quickcalcs/).
When students were asked to list three things they learned from APhA's MTM program, many stated: “how to interview patients,” “how to use active listening skills during a patient interview,” “how to document an intervention,” and “prioritizing medical problems.”
Discussion We hypothesized that students who participated in the APhA MTM program as a required component of the curriculum would consider this a valuable and practice-relevant learning experience. Students’ experiences were positive as indicated in their responses on the APhA MTM program evaluation. Students also appeared to appreciate how this experience will likely help in their future patient-care practice activities. The perceived value on the part of the students was further validated by the high percentage of Table 5 Summary of responses from the evaluation survey from the American Pharmacist Association's Delivering Medication Therapy Management Services certificate program. Main Campus (n=232)
Satellite Campus (n=57)
Both Campuses (n=289)
Please rate this activity for overall quality n,(%): Excellent Very Good Good Fair Poor
59 (25.43) 93 (40.09) 71 (30.60) 8 (3.45) 1 (0.43)
14 (24.56) 28 (49.12) 14 (24.56) 1 (1.75) 0 (0)
73 (25.26) 121 (41.87) 85 (29.41) 9 (3.11) 1 (0.35)
How well did this activity meet your individual educational needs n,(%): Excellent Very Good Good Fair Poor
56 (24.14) 90 (38.79) 69 (29.74) 16 (6.90) 1 (0.43)
17 (29.82) 26 (45.61) 11 (19.30) 3 (5.26) 0 (0)
73 (25.26) 116 (40.14) 80 (27.68) 19 (6.57) 1 (0.35)
Please rate the effectiveness of the active learning exercises n,(%): Excellent Very Good Good Fair Poor
56 (24.14) 83 (35.78) 70 (30.17) 21 (9.05) 2 (0.86)
14 (24.56) 24 (42.11) 14 (24.56) 4 (7.02) 1 (1.75)
70 (24.22) 107 (37.02) 84 (29.07) 25 (8.65) 3 (1.04)
Please rate the appropriateness of the case studies and self-study assessment questions n,(%): Excellent Very Good Good Fair Poor
61 (26.29) 88 (37.93) 70 (30.17) 12 (5.17) 1 (0.43)
15 (26.32) 22 (38.60) 18 (31.58) 2 (3.51) 0 (0)
76 (26.30) 110 (38.06) 88 (30.45) 14 (4.84) 1 (0.35)
How committed are you to making these changes n,(%): Excellent Very Good Good Fair Poor
78 (33.62) 111 (47.84) 36 (15.52) 4 (1.72) 3 (1.29)
26 (45.61) 22 (38.60) 7 (12.28) 2 (3.51) 0 (0)
104 (35.99) 133 (46.02) 43 (14.88) 6 (2.08) 3 (1.04)
Please rate the value of the content n,(%): Excellent Very Good Good Fair Poor
63 (27.16) 101 (43.53) 55 (23.71) 12 (5.17) 1 (0.43)
19 (33.33) 25 (43.86) 11 (19.30) 2 (3.51) 0 (0)
82 (28.37) 126 (43.60) 66 (22.84) 14 (4.84) 1 (0.35)
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students observed to have completed the program. This high completion rate was achieved even though the final four post-seminar patient cases required for program completion were not included in APPE rotation grades. Finally, although completion of the program took a substantial amount of time and may have caused students to prepare during their break between semesters, a large percentage still indicated that they would recommend the program to a colleague. Previous authors have reported outcomes of specific curricular initiatives designed to provide pharmacy students with the knowledge and skills necessary for participation in MTM activities.8–19 These reports have involved required and elective courses, lab-based courses, and experiential rotation settings.8–19 Kuhn et al.8 described an MTM-focused elective course, which included didactic components, active-learning activities, and direct interactions with patients during which students performed components of the MTM process. In an end-of-course survey, 88.9% of students strongly agreed that the course helped prepare them to practice MTM, and 55.6% indicated that they would like to work in a setting where MTM services are offered.8 Tomko et al.9 reported on an elective course in which teams of students from varying professional years provided MTM services to patients at a charitable health center that provides services to underserved and uninsured community members. Post-course survey responses showed statistically significant improvements over pre-course surveys.9 Participants perceived that they had a better understanding of MTM services and resources for the underserved; greater confidence in their recommendations and charting skills; and were more comfortable with knowing when to perform follow-up testing and refer patients for specialty care. Several authors have reported on initiatives related specifically to MTM education of pharmacy students in lab-based courses. Gallimore et al.10 reported on MTM instruction involving lecture and active-learning activities, which were incorporated into a required pharmacotherapy laboratory course. Upon completion of the course, 82% of students agreed that they had the necessary knowledge and skills to provide MTM services (compared to 42% at baseline, not statistically evaluated).10 The theory of planned behavior served as the basis of another survey, which assessed MTM service-related beliefs that may predict whether the educational intervention will impact future behavior.10 Mean scores improved significantly for all survey items within the domains of perceived behavioral control and subjective norms. Battaglia et al.11 reported on the incorporation of a diabetes-related online MTM program into a pharmacotherapy laboratory course. Content knowledge was significantly improved after course completion, and students’ theory of planned behavior survey responses revealed improved perceptions of control or mastery of the MTM process.11 Begley et al.12 and Eukel et al.13 reported on incorporation of MTM education in required pharmaceutical care lab courses. In the report by Begley et al.,12 students received a lecture related to MTM and learned how to use a propriety commercial MTM platform which would be used to record their recommendations following an interview of a fictitious patient. Student performance on MTM exercises improved with practice, and students’ confidence in their ability to perform MTM was enhanced.12 In the report by Eukel et al.,13 students received lectures focused on MTM, communication, and techniques used for point-of-care screenings. They also had opportunities to practice care plan formulation, documentation of MTM encounters, and physical assessment and point-of-care testing techniques.13 University staff and faculty were offered the opportunity to receive MTM services by these students. Students’ demonstrated exceptional performance (97.5% average score) on their staff/faculty patient encounters. Post-encounter survey responses showed statistically significant improvements over pre-encounter; students’ responses indicated greater confidence in their ability to perform the skills necessary for MTM encounters. A recent article by Poole et al.14 described the design and implementation of a required course that focused on improving students’ competence in MTM in a four-year professional program. The course framework was based on APhA's MTM program. However, there were additional components, such as patient encounters in which students followed their patient longitudinally during the semester. The results of a pre-/post-course student survey demonstrated a significant improvement in students’ selfreported perception of confidence and competence in performing MTM, but no change in students’ desire to perform MTM or their perceived importance of providing MTM services.14 The latter negative findings were likely the result the students’ positive impressions prior to the course as indicated by highly positive pre-course responses. Although all instruction and the majority of the components in our program happen prior to the beginning of APPE rotations, it may also be of importance to note that several authors have reported outcomes with MTM-related experiential activities. Most of the described activities have included APPE rotations with a substantial focus on provision of MTM services to patients.15–18 As might be anticipated following involvement in actual MTM service opportunities, assessments generally suggested that students’ MTM-relevant knowledge improved and their confidence in providing MTM services increased from baseline assessments, preceptor assessments of competence in MTM-related activities were high, and theory of planned behavior related surveys demonstrated responses that would predict continued positive impact of these experiences on future practice. In the only report to have a pharmacy student control group, it was observed that students who completed an MTM-related APPE had statistically significantly greater self-efficacy related to specific components of the MTM process compared to classmates who completed APPEs without such a focus.16 The only authors to report outcomes following MTM activities during introductory pharmacy practice experience rotations described a course that included a series of assignments and workshops used to model components of the MTM process.19 The MTM assignments were specific to a patient that student teams interviewed. A survey of students revealed that they perceived having had “adequate” or “plenty” of experience with participation in many of the required components of MTM services. In a 2011 article “Development and Implementation of Curricula Strategies in Medication Therapy Management by Colleges and Schools of Pharmacy,” APhA summarized the results of their call for examples from pharmacy colleges and schools of successful initiatives to incorporate MTM education into pharmacy curricula.20 Two submissions described use of the APhA MTM program. The submission from Mercer University College of Pharmacy and Health Sciences highlighted an elective course modeled after the APhA MTM program. Students enrolled in this course are eligible for the certificate by documenting additional MTM encounters during APPE rotations. The Ohio State University College of Pharmacy program submission mentioned that third professional year students 6
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receive the didactic portion of the APhA MTM program and fourth professional year students have the opportunity to complete cases that are counted towards the requirements of the program. However, more detailed descriptions from these programs were not found in literature searches. There are limitations to the data presented regarding the value of this program to the students. As with any survey-based research, it is possible that students did not take their responses seriously and provided highly positive identical responses to most queries to rapidly compete this program requirement. Additionally, because they are students, their ability to accurately describe the current and projected future value of the program might be considered a limitation. A better indication of actual value might be obtained by a re-survey of these cohorts as practicing pharmacists. While the SOP was able to successfully incorporate the program into the SOP's curriculum, it did not come without challenges. This included conducting case discussions with a large distance education cohort, training an adequate number of faculty to deliver the material effectively, ensuring available space for breakout sessions, and the logistics of tracking student progression and achievement of program requirements. There are application limitations for schools considering integration of the APhA MTM program into a pharmacy curriculum. The program that is described herein required many participating faculty. This additional workload is an important consideration for successful implementation. Faculty also need to complete APhA training, which results in a time commitment as well as financial support by the College. The integration of the MTM program was done in a three-year accelerated program. However, the structure of a three-year program may allow the APhA MTM program to be incorporated in another manner, and the required resources to accomplish this may be different. Summary Incorporating the APhA MTM program into an accelerated PharmD program required careful planning and coordination amongst faculty and course coordinators. Students perceived that the program was valuable, met their educational needs, and incorporated effective learning experiences and cases. These perceptions were reinforced by the high percentage of students who completed the APhA MTM program. Conflict of interest None of the authors have conflicts of interest. Acknowledgements The authors would like to acknowledge all pharmacy practice faculty who helped make the implementation process a success both for our students and the school of pharmacy. References 1. Accreditation Council for Pharmacy Education. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (“Standards v2.0”). Published February 2011. Available at: 〈https://www.acpe-accredit.org/pdf/FinalS2007Guidelines2.0.pdf〉 2017. Accessed June 8, 2017. 2. Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (“Standards 2016”). Published February. Available at: 〈https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf〉 2015. Accessed June 8, 2017. 3. Joint Commission of Pharmacy Practitioners. Pharmacists' Patient Care Process. Published May. Available at: 〈https://www.accp.com/docs/positions/misc/JCPP_ Pharmacists_Patient_Care_Process.pdf〉. Accessed June 8, 2017. 4. Centers for Medicare and Medicaid Services. Medicare Part C and D performance data. Available at: 〈https://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/PerformanceData.html〉. Accessed May 19, 2017. 5. Vlasses PH, Patel N, Vlasses MJ, Ray MD, Smith GH, Beardsley RS. Employer expectations of new pharmacy graduates: implications for the pharmacy degree accreditation standards. Am J Pharm Educ. 2013;77(3):Article 47. 6. American Pharmacists Association. Delivering Medication Therapy Management Services. Available at: 〈http://www.pharmacist.com/delivering-medicationtherapy-management-services〉. Accessed June 8, 2017. 7. Medina MS, Plaza CM, Stowe CD, et al. Center for the advancement of pharmacy education 2013 educational outcomes. Am J Pharm Educ. 2013;77(8):Article 162. 8. Kuhn C, Powell PH, Sterrett JJ. Elective course on medication therapy management services. Am J Pharm Educ. 2010;74(3):Article 40. 9. Tomko JR, Runyon AL, Lassila H. Student self-assessed medication therapy management skills resulting from caring for uninsured patients using team-based care. Curr Pharm Teach Learn. 2011;3(1):63–70. 10. Gallimore CE, Thorpe JM, Trapskin K. Simulated medication therapy management activities in a pharmacotherapy laboratory course. Am J Pharm Educ. 2013;75(5):Article 95. 11. Battaglia JN, Kieser MA, Bruskiewitz RH, Pitterle ME, Thorpe JM. An online virtual-patient program to teach pharmacists and pharmacy students how to provide diabetes-specific medication therapy management. Am J Pharm Educ. 2012;76(7):Article 131. 12. Begley KJ, Coover KL, Tilleman JA, Haddad AM, Augustine SC. Medication therapy management training using case studies and the MirixaPro platform. Am J Pharm Educ. 2011;75(3):Article 49. 13. Eukel HN, Skoy ET, Frenzel JE. Provision of medication therapy management to university faculty and staff members by third-year pharmacy students. Am J Pharm Educ. 2010;74(10):Article 182. 14. Poole TM, Kodali L, Pace AC. Integrating mediation therapy management education into a core pharmacy curriculum. Am J Pharm Educ. 2016;80(4):Article 70. 15. Childress BC, Bosler JN, Beck M. Improving student knowledge in medication management through an advanced pharmacy practice experience. Consult Pharm. 2013;28(6):390–395. 16. Dahl JR, Hall AM. A scale to measure pharmacy students’ self-efficacy in performing medication therapy management services. Am J Pharm Educ. 2013;77(9):Article 191.
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17. Hardin HC, Hall AM, Roane TE, Mistry R. An advanced pharmacy practice experience in a student-staffed medication therapy management call center. Am J Pharm Educ. 2012;76(6):Article 110. 18. Hata M, Klotz R, Sylvies R, et al. Medication therapy management services provided by student pharmacists. Am J Pharm Educ. 2012;76(3):Article 51. 19. Agness CF, Huynh D, Brandt N. An introductory pharmacy practice experience based on a medication therapy management service model. Am J Pharm Educ. 2011;75(5):Article 82. 20. American Pharmacists Association. Development and Implementation of Curricula Strategies in Medication Therapy Management by Colleges and Schools of Pharmacy. December. Available at: 〈http://www.pharmacist.com/sites/default/files/files/mtm_development_and_implementation_summary(1).pdf〉 2011. Accessed June 8, 2017.
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Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Experiences in Teaching and Learning
Incorporating the American Pharmacists Association's Delivering Medication Therapy Management services certificate program into an accelerated pharmacy curriculum ⁎
Jennifer L. Donovana, , Jason Crossb, Amanda M. Morrillc, Paul P. Belliveaud, Cheryl A. Abelc, Anna K. Morine, Michael J. Malloyf a
Curriculum and New Programs, MCPHS University, 19 Foster Street, Worcester, MA 01608, United States MCPHS University, 19 Foster Street, Worcester, MA 01608, United States c MCPHS University, 1260 Elm Street, Manchester, NH 03101, United States d School of Pharmacy, MCPHS University, 19 Foster Street, Worcester, MA 01608, United States e School of Pharmacy, MCPHS University, 19 Foster Street, Worcester, MA 01608, United States f William Carey University, 498 Tuscan Avenue, Hattiesburg, MS 39401, United States b
AR TI CLE I NF O
AB S T R A CT
Keywords: Medication therapy management MTM, certificate American Pharmacists Association, accelerated school of pharmacy
Background and purpose: To describe the incorporation of the American Pharmacists Association (APhA) Delivering Medication Therapy Management (MTM) Services program into a PharmD curriculum and to describe student perceptions of the program. Educational activity and setting: The program was delivered over 12 months to students on two campuses via two didactic courses in the second professional year and during the first two advanced pharmacy practice experiences in the third professional year of an accelerated school of pharmacy program. Findings: Student perceptions were assessed by review of responses to the APhA MTM program evaluation survey. Discussion and summary: Incorporation of the APhA MTM program into an accelerated PharmD program required careful planning and coordination amongst faculty and course coordinators. Students perceived that the program was valuable, met their educational needs, and incorporated effective learning experiences and cases. These perceptions were reinforced by the high percentage of students who completed the program.
Background and purpose The Accreditation Council for Pharmacy Education (ACPE) Accreditation Standards for doctor of pharmacy (PharmD) programs have long recognized the importance of preparing students to participate in patient-centered care and medication therapy management (MTM) services.1 More recently, the 2016 ACPE accreditation standards furthered the importance of MTM education and training by incorporating a philosophy meant to ensure that programs graduate practice-ready and team-ready students.2 This approach includes preparing students to collaboratively contribute to patient care via the pharmacists’ patient-care process, the backbone of which is MTM services.3 To prepare students for participation in the patient-care process, colleges and schools of
⁎
Corresponding author. E-mail addresses: [email protected] (J.L. Donovan), [email protected] (J. Cross), [email protected] (A.M. Morrill), [email protected] (P.P. Belliveau), [email protected] (C.A. Abel), [email protected] (A.K. Morin), [email protected] (M.J. Malloy). http://dx.doi.org/10.1016/j.cptl.2017.05.005 Received 25 May 2016; Received in revised form 5 January 2017; Accepted 20 May 2017 1877-1297/ © 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Donovan, J.L., Currents in Pharmacy Teaching and Learning (2017), http://dx.doi.org/10.1016/j.cptl.2017.05.005
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pharmacy must ensure that students acquire the requisite knowledge, skills, and attitudes to deliver MTM services. The importance of pharmacist involvement in patient-care is recognized by the healthcare industry.3 Pharmacists contribute to the Centers for Medicare and Medicaid Services quality measures, which include a focus on improving adherence to medications, and ensuring patients with chronic disease conditions receive recommended therapy and patients older than 65 years are appropriately prescribed high risk medications. These measures, which are also important aspects of MTM initiatives, are utilized to establish Medicare Star Ratings. These ratings, in turn, are used as an indicator of the quality for Medicare Part D and other health insurance plans.4 Pharmacists can positively impact Star Ratings of health plans and become part of a preferred pharmacy network by contributing to medication use improvements which impact these important quality measures. Pharmacist employers desire that pharmacy school graduates have education and training which allows them to participate in patient care and MTM services.5 To understand pharmacist employer expectations of pharmacy graduates, ACPE sought feedback from the American Society of Health-System Pharmacists, National Community Pharmacy Association, National Association of Chain Drug Stores Foundation, and Academy of Managed Care Pharmacy.5 These organizations recommended additions to the educational outcomes that impact MTM training and education.5 They desire that graduates be able to collaboratively participate in the patientcare process, conduct a comprehensive medication review, advocate on behalf of patient needs, and document MTM services. Students at Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, School of Pharmacy-Worcester/ Manchester (SOP-W/M) are exposed to course content that addresses knowledge required to perform the MTM components described in the pharmacists’ patient-care process.3 However, the escalation of influences (2016 ACPE Standards, Center for the Advancement of Pharmacy Education (CAPE) Educational 2013 Outcomes, employer expectations) motivated the SOP-W/M to consider ways to further supplement the education and training that is already part of our curriculum.2,3,5,7 It was decided that the nationally-recognized American Pharmacists Association Delivering Medication Therapy Management Services (APhA MTM) program would serve the purpose of providing students with additional practice opportunities and further highlight the applicability of MTM services to their future practice.6 This report is novel in that it is the first to provide a complete description of the integration, implementation, and assessment of the APhA MTM program into a PharmD curriculum. The lack of literature describing the incorporation of this program into pharmacy curricula could be an indication that schools have struggled to develop a means of effectively delivering this program. Such struggles might be expected given that this program has several components, making incorporation into a curriculum challenging. Hence, this report may help other schools or colleges seeking to incorporate the APhA MTM program in their curricula. Since the integration was new to our curriculum, we sought to capture students’ perceptions of the APhA MTM program to determine if they found it a valuable and practice-relevant learning experience. Use of the data included in this report was approved by our Institutional Review Board.
Educational activity and setting The SOP-W/M program is a year-round, 34-month, accelerated program. There is a main campus (Worcester, MA), which enrolls approximately 250 students each year and a satellite campus (Manchester, NH), which enrolls approximately 55 students each year. Distance education technology allows for the synchronous delivery of classes to each campus. In the second professional year, there is a required, two-course series entitled Introduction to Advanced Pharmacy Practice (IAPP). These courses are offered concurrently with pharmacotherapeutics and pharmacology, medicinal chemistry, and toxicology Table 1 Introduction to Advanced Pharmacy Practice-1 course outline. a
Date
Week Week Week Week Week Week Week Week Week
Topic 1 2 3 4 5 6 and 7 8 9 10
Week 11 Week 12 Week 13 Week 14 Week 15 Finals week
Orientation/Drug consult writing/Plagiarism Navigating through the medical record Statistics Evidence based medicine Journal club workshop No class; complete APhA MTM pre-live seminar requirements: self-study materials, pre-seminar case, self-study exam APhA MTM session 1 lecture Spring break APhA MTM session 2; breakout rooms Patient “Toni” case discussion Medication safety/Interprofessional education project discussion APhA MTM session 3; breakout rooms Patient “Carl” case discussion APhA MTM session 4 lecture APhA MTM session 5; breakout rooms Patient “Donna” case discussion APhA MTM session 6; breakout rooms Patient “James” case discussion Cumulative exam
APhA = American Pharmacists Association; MTM = Medication therapy management a Introduction to Advanced Pharmacy Practice −1 (IAPP-1_ is a 2-credit course. Each topic was scheduled once per week for 1 h and 50 min.
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in the spring (IAPP-1) and summer (IAPP-2) semesters. Both IAPP courses consist of two credit hours of instruction. The goal of these courses is to prepare students for advanced pharmacy practice experience (APPEs) activities and expectations. The courses’ objectives encompass subdomains from Domains 1-4 of the CAPE 2013 Outcomes.7 These subdomains include preparing students to provide culturally sensitive patient-centered care, optimize medication use, identify and solve problems, provide patient education, advocate for the patient, and promote leadership and professionalism in an interprofessional practice setting.7 Since the courses’ objectives are consistent with the APhA MTM program objectives, the IAPP course series was a logical location for incorporating components of this program into the curriculum. The APhA MTM program for student certification includes completion of 20 hours of self-study materials, a self-study examination, eight hours of live seminar and patient case discussions (with four APhA-provided patient cases), an APhA program evaluation (administered after the live seminar and case discussions), and five student-identified post-seminar cases. To understand expectations for the spring and summer semesters, second professional year students were introduced to the APhA MTM program towards the end of their fall semester. At that time, students were provided an enrollment code and instructions for the training. This provided on-line access to the APhA MTM program materials prior to the holiday break, allowing sufficient time to begin work on the program pre-seminar components. This preparation consisted of competing 20 hours of self-study materials, completing one APhA-provided pre-seminar patient case with the required APhA MTM documentation, and taking the self-study examination. These APhA MTM program components were a requirement for IAPP-1. They were to be completed by week 8 of the spring semester in preparation for attending the live APhA MTM program seminar sessions in IAPP-1. The self-study examination was purposely designed by APhA to be a take-home open-resource exam. Students had two opportunities to achieve a score of 70%, which is considered a passing grade by APhA. Table 1 outlines content for the IAPP-1 course and the APhA MTM program. Didactic sessions were delivered to the entire student cohort by faculty who had received the APhA MTM Train-the-Trainer training. For the case discussion sessions, students were divided into groups of approximately 30 with one to two faculty members facilitating discussion. APhA also requires APhA MTM Train-theTrainer training for faculty who deliver the slides associated with the case discussions. These faculty facilitated case discussions and delivered the case-related APhA slides within each discussion room. The second faculty member facilitator was not required be APhA MTM Train-the-Trainer trained; the only requirement was to be familiar with the MTM process. Student assessments in IAPP-1 are outlined in Table 2. The score earned on the self-study examination was recorded as part of the course grade. The APhA-provided pre-seminar case was submitted individually by each student and the APhA MTM documentation was checked by faculty for completeness; this was graded in a pass/fail fashion. Therapeutic accuracy of the case content was not assessed because students had not yet completed components of the curriculum that would allow for accurate clinical decisionmaking skills. There was no preparation required by students for the other three APhA-provided cases. These were discussed during small group sessions, and students received full credit by participating in these discussions. IAPP-2 has traditionally included a patient-care plan presentation meant to provide students with a practice opportunity prior to APPE rotations. Since the APhA MTM program requires students to identify and interview patients for the purposes of practicing the MTM process, it was determined that this presentation could serve as a practice opportunity that would fulfill an IAPP-2 course and an APhA MTM program requirement (one of the five required student-identified post-seminar cases). Given the increased emphasis on interprofessional education (IPE) in the 2016 ACPE Standards, this activity was also seen an opportunity to include an IPE component into this course. Students were paired with another healthcare professional student to identify a patient to interview and develop a comprehensive, collaborative care plan that reflected both disciplines (see APhA MTM presentation, Table 2). The other healthcare professional student was from the nursing, nurse practitioner, optometry, or physical therapy programs. Per APhA requirements, the interviewed patient needed to have at least three medical conditions requiring pharmacotherapy and at least five Table 2 Integration of content from the American Pharmacist Association's Delivering Medication Therapy Management Services certificate program into Introduction to Advanced Pharmacy Practice Courses. Introduction to Advanced Pharmacy Practice-1 Assignment Drug consult Pre-seminar case submission - patient case “Toni” Cumulative exam APhA MTM self-assessment exam APhA MTM breakout session I - patient case “Carl” APhA MTM breakout session II- patient case “Donna” APhA MTM breakout session III- patient case “James” Journal Club workshop assignment
Percentage of final grade 20 10 20 10 10 10 10 10
Introduction to Advanced Pharmacy Practice-2 APhA Immunization Self-Study Assignment APhA Immunization final exam APhA MTM post-seminar presentation Drug consult Inter-professional activity reflection
15 15 30 30 10
APHA = American Pharmacist Association; MTM = Medication Therapy Management
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medications. Patients could be anyone with whom students had contact including neighbors or family members if the patient consented to the interview. Students submitted the required APhA MTM documentation and orally presented the comprehensive care plan to their faculty preceptor for the course. Students had the opportunity to complete the remaining four post-seminar cases during their first two APPE rotations in their third professional year. These cases needed to meet the same criteria as previously stated. These cases were in addition to the required work from the APPEs. Students’ APPE preceptors were not asked to be involved in identifying cases, verifying that the cases met the criteria, or that APhA MTM documentation was completed; the student's faculty preceptor for IAPP-2 reviewed the cases. These faculty reviewed the post-seminar cases to ensure they met defined criteria and that the APhA MTM documentation forms were appropriately and adequately completed. As with the pre-seminar case, faculty did not focus on therapeutic accuracy of case submissions. Rather, the focus was on ensuring students adequately completed the MTM process as demonstrated by the completeness of the APhA documentation forms. There was no penalty for not completing these four post-seminar cases as they were not included in APPE grades. To be eligible to receive the certificate of completion for the APhA MTM program, students had to complete all required components of the program. Students who were absent or tardy from any class sessions where there was delivery of APhA MTM program content or did not complete the post-seminar cases were instructed to not print a certificate of completion. There was no opportunity for students to make-up or view recordings of missed IAPP-1 seminar or case-discussion sessions; recording was prohibited by APhA. The faculty member coordinating the APhA MTM program for the IAPP-1 and IAPP-2 courses was responsible for ensuring that the integrity of the program was maintained. This responsibility included continuous monitoring to confirm that only eligible students used attendance codes and printed a certificate of completion. Given the complexities of the APhA MTM program requirements, coupled with a large student cohort, all practice faculty were needed for successful implementation. In the department of pharmacy practice, there are 28 faculty on the Worcester campus and eight faculty on the Manchester campus who were available to participate as a preceptor in the APhA MTM program. Two faculty were identified to complete the APhA MTM Train-the-Trainer program, which authorized them to deliver the live APhA MTM content. Of the 36 faculty who facilitated the sessions, 21 of them had completed the APhA MTM program (but did not complete the Train-the-Trainer program). However, these trainings were not required to participate as preceptors for pharmacy student presentations and MTM case submissions or to assist Train-the-Trainer educated faculty with facilitation of case discussion sessions. Each department faculty was a preceptor to groups of 8–10 students. In the second offering of the APhA MTM program, nine additional faculty completed the Train-the-Trainer program to allow for involvement of more faculty in the case-discussion slide presentations. Findings Currently, two student classes (class of 2015 and 2016) have been provided an opportunity to complete the APhA MTM program. This report describes an assessment of the first class to be offered this opportunity. All analyses were calculated using GraphPad. All students in the class of 2015 (n=289; 232 main campus and 57 satellite campus) enrolled into the APhA MTM program and completed the self-study assessment and program evaluation questions. The mean score on the self-study assessment was 97.64 ± 3.51% (Table 3). There was no difference in scores between campuses. All students (n=289) successfully achieved the APhA-required 70% or greater passing score on the first attempt. Most students (n=279, 96.54%) received credit for attending the live seminar sessions. Several students did not receive credit for attending the live seminar sessions because they were absent or tardy (n=10). These students were not eligible to receive a certificate of completion, but were still required to attend and participate in the remaining seminar sessions (for IAPP-1) and complete one of the five post-seminar patient cases (for IAPP-2) because these were course requirements. Most students successfully completed all the components of the APhA MTM program (83.39%; n=241; 201 (86.63%) main campus and 40 (70.17%) satellite campus). There was no difference in completion rate between campuses. The reasons that students did not complete the program are listed in Table 4. There were nine APhA-developed program evaluation questions that were helpful in assessing students’ perceptions of the program (Table 5). Students were asked to use a Likert scale or answer "yes" or "no" to these questions. All students (n=289; 232 main campus and 57 satellite campus) completed the evaluation. The sum of excellent/very good/good responses was above 90% for all of the Likert questions indicating that students believed the program was valuable, met their educational needs, incorporated effective learning experiences and cases, and was a valuable learning experience (Table 5). Students would recommend this program to a colleague (93.53% overall; 91.35% main campus and 89.47% satellite campus) and felt that future activities on this subject matter are necessary and/or important to their practice (93.10% overall; 91.35% main campus and 94.74% satellite campus). Table 3 American Pharmacist Association's Delivering Medication Therapy Management Services certificate program self-study exam scores (first attempt).
Mean (%), Standard deviation Median (%) Range (%)
Total (n=289)
Main Campus (n=232)
Satellite Campus (n=57)
*
97.64 ± 3.51 98.46 76.92–100
97.17 ± 3.51 98.46 76.92–100
97.38 ± 3.17 100 86.15–100
0.18
* P-Values were calculated using GraphPad Quickcalcs (http://www.graphpad.com/quickcalcs/)
4
P-Value
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Table 4 Reasons for students not completing the American Pharmacist Association's Delivering Medication Therapy Management Services certificate program.
Absent or tardy from live seminar session(s), n (%) Academic reasons (e.g., did not progress, out of sequence, plagiarism), n (%) Chose not to complete the remaining four post-seminar cases, n (%)
Total (n=48)
Main Campus (n=31)
Satellite Campus (n=17)
P-Value
10 (20.84) 19 (39.58)
6 (19.35) 15 (48.39)
4 (23.53) 4 (23.53)
0.73 0.13
19(39.58)
10 (32.26)
9(52.94)
0.51
*P-Values were calculated using GraphPad Quickcalcs (http://www.graphpad.com/quickcalcs/).
When students were asked to list three things they learned from APhA's MTM program, many stated: “how to interview patients,” “how to use active listening skills during a patient interview,” “how to document an intervention,” and “prioritizing medical problems.”
Discussion We hypothesized that students who participated in the APhA MTM program as a required component of the curriculum would consider this a valuable and practice-relevant learning experience. Students’ experiences were positive as indicated in their responses on the APhA MTM program evaluation. Students also appeared to appreciate how this experience will likely help in their future patient-care practice activities. The perceived value on the part of the students was further validated by the high percentage of Table 5 Summary of responses from the evaluation survey from the American Pharmacist Association's Delivering Medication Therapy Management Services certificate program. Main Campus (n=232)
Satellite Campus (n=57)
Both Campuses (n=289)
Please rate this activity for overall quality n,(%): Excellent Very Good Good Fair Poor
59 (25.43) 93 (40.09) 71 (30.60) 8 (3.45) 1 (0.43)
14 (24.56) 28 (49.12) 14 (24.56) 1 (1.75) 0 (0)
73 (25.26) 121 (41.87) 85 (29.41) 9 (3.11) 1 (0.35)
How well did this activity meet your individual educational needs n,(%): Excellent Very Good Good Fair Poor
56 (24.14) 90 (38.79) 69 (29.74) 16 (6.90) 1 (0.43)
17 (29.82) 26 (45.61) 11 (19.30) 3 (5.26) 0 (0)
73 (25.26) 116 (40.14) 80 (27.68) 19 (6.57) 1 (0.35)
Please rate the effectiveness of the active learning exercises n,(%): Excellent Very Good Good Fair Poor
56 (24.14) 83 (35.78) 70 (30.17) 21 (9.05) 2 (0.86)
14 (24.56) 24 (42.11) 14 (24.56) 4 (7.02) 1 (1.75)
70 (24.22) 107 (37.02) 84 (29.07) 25 (8.65) 3 (1.04)
Please rate the appropriateness of the case studies and self-study assessment questions n,(%): Excellent Very Good Good Fair Poor
61 (26.29) 88 (37.93) 70 (30.17) 12 (5.17) 1 (0.43)
15 (26.32) 22 (38.60) 18 (31.58) 2 (3.51) 0 (0)
76 (26.30) 110 (38.06) 88 (30.45) 14 (4.84) 1 (0.35)
How committed are you to making these changes n,(%): Excellent Very Good Good Fair Poor
78 (33.62) 111 (47.84) 36 (15.52) 4 (1.72) 3 (1.29)
26 (45.61) 22 (38.60) 7 (12.28) 2 (3.51) 0 (0)
104 (35.99) 133 (46.02) 43 (14.88) 6 (2.08) 3 (1.04)
Please rate the value of the content n,(%): Excellent Very Good Good Fair Poor
63 (27.16) 101 (43.53) 55 (23.71) 12 (5.17) 1 (0.43)
19 (33.33) 25 (43.86) 11 (19.30) 2 (3.51) 0 (0)
82 (28.37) 126 (43.60) 66 (22.84) 14 (4.84) 1 (0.35)
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students observed to have completed the program. This high completion rate was achieved even though the final four post-seminar patient cases required for program completion were not included in APPE rotation grades. Finally, although completion of the program took a substantial amount of time and may have caused students to prepare during their break between semesters, a large percentage still indicated that they would recommend the program to a colleague. Previous authors have reported outcomes of specific curricular initiatives designed to provide pharmacy students with the knowledge and skills necessary for participation in MTM activities.8–19 These reports have involved required and elective courses, lab-based courses, and experiential rotation settings.8–19 Kuhn et al.8 described an MTM-focused elective course, which included didactic components, active-learning activities, and direct interactions with patients during which students performed components of the MTM process. In an end-of-course survey, 88.9% of students strongly agreed that the course helped prepare them to practice MTM, and 55.6% indicated that they would like to work in a setting where MTM services are offered.8 Tomko et al.9 reported on an elective course in which teams of students from varying professional years provided MTM services to patients at a charitable health center that provides services to underserved and uninsured community members. Post-course survey responses showed statistically significant improvements over pre-course surveys.9 Participants perceived that they had a better understanding of MTM services and resources for the underserved; greater confidence in their recommendations and charting skills; and were more comfortable with knowing when to perform follow-up testing and refer patients for specialty care. Several authors have reported on initiatives related specifically to MTM education of pharmacy students in lab-based courses. Gallimore et al.10 reported on MTM instruction involving lecture and active-learning activities, which were incorporated into a required pharmacotherapy laboratory course. Upon completion of the course, 82% of students agreed that they had the necessary knowledge and skills to provide MTM services (compared to 42% at baseline, not statistically evaluated).10 The theory of planned behavior served as the basis of another survey, which assessed MTM service-related beliefs that may predict whether the educational intervention will impact future behavior.10 Mean scores improved significantly for all survey items within the domains of perceived behavioral control and subjective norms. Battaglia et al.11 reported on the incorporation of a diabetes-related online MTM program into a pharmacotherapy laboratory course. Content knowledge was significantly improved after course completion, and students’ theory of planned behavior survey responses revealed improved perceptions of control or mastery of the MTM process.11 Begley et al.12 and Eukel et al.13 reported on incorporation of MTM education in required pharmaceutical care lab courses. In the report by Begley et al.,12 students received a lecture related to MTM and learned how to use a propriety commercial MTM platform which would be used to record their recommendations following an interview of a fictitious patient. Student performance on MTM exercises improved with practice, and students’ confidence in their ability to perform MTM was enhanced.12 In the report by Eukel et al.,13 students received lectures focused on MTM, communication, and techniques used for point-of-care screenings. They also had opportunities to practice care plan formulation, documentation of MTM encounters, and physical assessment and point-of-care testing techniques.13 University staff and faculty were offered the opportunity to receive MTM services by these students. Students’ demonstrated exceptional performance (97.5% average score) on their staff/faculty patient encounters. Post-encounter survey responses showed statistically significant improvements over pre-encounter; students’ responses indicated greater confidence in their ability to perform the skills necessary for MTM encounters. A recent article by Poole et al.14 described the design and implementation of a required course that focused on improving students’ competence in MTM in a four-year professional program. The course framework was based on APhA's MTM program. However, there were additional components, such as patient encounters in which students followed their patient longitudinally during the semester. The results of a pre-/post-course student survey demonstrated a significant improvement in students’ selfreported perception of confidence and competence in performing MTM, but no change in students’ desire to perform MTM or their perceived importance of providing MTM services.14 The latter negative findings were likely the result the students’ positive impressions prior to the course as indicated by highly positive pre-course responses. Although all instruction and the majority of the components in our program happen prior to the beginning of APPE rotations, it may also be of importance to note that several authors have reported outcomes with MTM-related experiential activities. Most of the described activities have included APPE rotations with a substantial focus on provision of MTM services to patients.15–18 As might be anticipated following involvement in actual MTM service opportunities, assessments generally suggested that students’ MTM-relevant knowledge improved and their confidence in providing MTM services increased from baseline assessments, preceptor assessments of competence in MTM-related activities were high, and theory of planned behavior related surveys demonstrated responses that would predict continued positive impact of these experiences on future practice. In the only report to have a pharmacy student control group, it was observed that students who completed an MTM-related APPE had statistically significantly greater self-efficacy related to specific components of the MTM process compared to classmates who completed APPEs without such a focus.16 The only authors to report outcomes following MTM activities during introductory pharmacy practice experience rotations described a course that included a series of assignments and workshops used to model components of the MTM process.19 The MTM assignments were specific to a patient that student teams interviewed. A survey of students revealed that they perceived having had “adequate” or “plenty” of experience with participation in many of the required components of MTM services. In a 2011 article “Development and Implementation of Curricula Strategies in Medication Therapy Management by Colleges and Schools of Pharmacy,” APhA summarized the results of their call for examples from pharmacy colleges and schools of successful initiatives to incorporate MTM education into pharmacy curricula.20 Two submissions described use of the APhA MTM program. The submission from Mercer University College of Pharmacy and Health Sciences highlighted an elective course modeled after the APhA MTM program. Students enrolled in this course are eligible for the certificate by documenting additional MTM encounters during APPE rotations. The Ohio State University College of Pharmacy program submission mentioned that third professional year students 6
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receive the didactic portion of the APhA MTM program and fourth professional year students have the opportunity to complete cases that are counted towards the requirements of the program. However, more detailed descriptions from these programs were not found in literature searches. There are limitations to the data presented regarding the value of this program to the students. As with any survey-based research, it is possible that students did not take their responses seriously and provided highly positive identical responses to most queries to rapidly compete this program requirement. Additionally, because they are students, their ability to accurately describe the current and projected future value of the program might be considered a limitation. A better indication of actual value might be obtained by a re-survey of these cohorts as practicing pharmacists. While the SOP was able to successfully incorporate the program into the SOP's curriculum, it did not come without challenges. This included conducting case discussions with a large distance education cohort, training an adequate number of faculty to deliver the material effectively, ensuring available space for breakout sessions, and the logistics of tracking student progression and achievement of program requirements. There are application limitations for schools considering integration of the APhA MTM program into a pharmacy curriculum. The program that is described herein required many participating faculty. This additional workload is an important consideration for successful implementation. Faculty also need to complete APhA training, which results in a time commitment as well as financial support by the College. The integration of the MTM program was done in a three-year accelerated program. However, the structure of a three-year program may allow the APhA MTM program to be incorporated in another manner, and the required resources to accomplish this may be different. Summary Incorporating the APhA MTM program into an accelerated PharmD program required careful planning and coordination amongst faculty and course coordinators. Students perceived that the program was valuable, met their educational needs, and incorporated effective learning experiences and cases. These perceptions were reinforced by the high percentage of students who completed the APhA MTM program. Conflict of interest None of the authors have conflicts of interest. Acknowledgements The authors would like to acknowledge all pharmacy practice faculty who helped make the implementation process a success both for our students and the school of pharmacy. References 1. Accreditation Council for Pharmacy Education. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (“Standards v2.0”). Published February 2011. Available at: 〈https://www.acpe-accredit.org/pdf/FinalS2007Guidelines2.0.pdf〉 2017. Accessed June 8, 2017. 2. Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (“Standards 2016”). Published February. Available at: 〈https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf〉 2015. Accessed June 8, 2017. 3. Joint Commission of Pharmacy Practitioners. Pharmacists' Patient Care Process. Published May. Available at: 〈https://www.accp.com/docs/positions/misc/JCPP_ Pharmacists_Patient_Care_Process.pdf〉. Accessed June 8, 2017. 4. Centers for Medicare and Medicaid Services. Medicare Part C and D performance data. Available at: 〈https://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/PerformanceData.html〉. Accessed May 19, 2017. 5. Vlasses PH, Patel N, Vlasses MJ, Ray MD, Smith GH, Beardsley RS. Employer expectations of new pharmacy graduates: implications for the pharmacy degree accreditation standards. Am J Pharm Educ. 2013;77(3):Article 47. 6. 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An online virtual-patient program to teach pharmacists and pharmacy students how to provide diabetes-specific medication therapy management. Am J Pharm Educ. 2012;76(7):Article 131. 12. Begley KJ, Coover KL, Tilleman JA, Haddad AM, Augustine SC. Medication therapy management training using case studies and the MirixaPro platform. Am J Pharm Educ. 2011;75(3):Article 49. 13. Eukel HN, Skoy ET, Frenzel JE. Provision of medication therapy management to university faculty and staff members by third-year pharmacy students. Am J Pharm Educ. 2010;74(10):Article 182. 14. Poole TM, Kodali L, Pace AC. Integrating mediation therapy management education into a core pharmacy curriculum. Am J Pharm Educ. 2016;80(4):Article 70. 15. Childress BC, Bosler JN, Beck M. Improving student knowledge in medication management through an advanced pharmacy practice experience. Consult Pharm. 2013;28(6):390–395. 16. Dahl JR, Hall AM. 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17. Hardin HC, Hall AM, Roane TE, Mistry R. An advanced pharmacy practice experience in a student-staffed medication therapy management call center. Am J Pharm Educ. 2012;76(6):Article 110. 18. Hata M, Klotz R, Sylvies R, et al. Medication therapy management services provided by student pharmacists. Am J Pharm Educ. 2012;76(3):Article 51. 19. Agness CF, Huynh D, Brandt N. An introductory pharmacy practice experience based on a medication therapy management service model. Am J Pharm Educ. 2011;75(5):Article 82. 20. American Pharmacists Association. Development and Implementation of Curricula Strategies in Medication Therapy Management by Colleges and Schools of Pharmacy. December. Available at: 〈http://www.pharmacist.com/sites/default/files/files/mtm_development_and_implementation_summary(1).pdf〉 2011. Accessed June 8, 2017.
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