Service and education within a student-run pharmacy: An evaluation of the Butler University Community Outreach Pharmacy

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Currents in Pharmacy Teaching and Learning 5 (2013) 245–255 http://www.pharmacyteaching.com

Service and education within a student-run pharmacy: An evaluation of the Butler University Community Outreach Pharmacy Eliza A. Dy, PharmD, BCPSa,b,c, Tyler D. Trueg, PharmD, MBAc,e, John M. Mulvaney, MHAa,f, Kristal L. Williams, PharmD, CDEa,c,d,* a

Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN b Indiana University Health, Indianapolis, IN c Butler University Community Outreach Pharmacy, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN d St. Vincent Health Wellness and Prevention Care Institute, Indianapolis, IN e Semio Clinical Delivery Team, Eli Lilly and Company, Indianapolis, IN f Epidemiology/Biostatistics, C9Spring, Inc., Indianapolis, IN

Abstract Objective: To evaluate the quality of activities rendered through the service and education domains of Butler University Community Outreach Pharmacy’s (BUCOP) mission statement. Methods: Anonymous evaluations of service and education amongst patients receiving prescriptions from BUCOP and student–pharmacists volunteering at BUCOP were performed respectively. Patient’s confidence in students’ ability to render retail-based pharmaceutical care was assessed via a questionnaire. A student questionnaire solicited feedback on pharmacy practice experiences (PPE) obtained through BUCOP volunteering. Descriptive statistics are reported where appropriate. Responses are reported as likelihood ratios (Chi-squared). Results: Approximately 80% of the patients reported favorable experiences at BUCOP. The majority (97.9%) of patients stated that they would use BUCOP again and would refer to BUCOP. Patients viewing services as ‘‘Very Good’’ or ‘‘Excellent’’ expressed confidence in the students’ ability to explain medical conditions (80.43%; LR ¼ 42.02; df ¼ 9; p o 0.001); explain medications (78.72%; LR ¼ 50.93; df ¼ 9; p o 0.001); and how to take medication (81.25%; LR ¼ 9.72; df ¼ 3; p ¼ 0.021). All student–pharmacists (n ¼ 21) who were surveyed reported increased confidence counseling/interacting with patients secondary to this experience. Regarding interdisciplinary interaction, 70% of the student–pharmacists felt ‘‘Very’’ or ‘‘Somewhat’’ utilized by the student–physicians and 70% felt that the interactions with student–physicians were either ‘‘Very’’ or ‘‘Somewhat’’ beneficial. All students stated that they would volunteer again and recommend other student–pharmacists to volunteer. Conclusion: Results suggest a positive experience on student learning and patient satisfaction with this student-run pharmacy. While quality improvements can be made, BUCOP is fulfilling its service and education mission statements. Published by Elsevier Inc. Keywords: Student; Pharmacy; Clinic; Underserved; Service Learning

Introduction History * Corresponding author at: Department of Pharmacy Practice, Butler 4600 Sunset Ave Indianapolis, IN 46208. E-mail: [email protected] 1877-1297/13/$ – see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.cptl.2013.01.005

Data deprived from the American Community Service report that for the 46201 Eastside community (EScommunity)

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of Marion County Indianapolis 26% of the residence live at or below poverty levels.1 For this particular community, like many others across the United States, access to affordable healthcare poses a major problem. In an attempt to assist such populations, federally funded healthcare systems were established as part of the War on Poverty.2 In response to the War on Poverty initiative, Citizens Health Center became the first federally funded clinic in Indianapolis.2 Additionally, for over 150 years, Wishard Health Services has provided care for underserved patients at its main hospital campus and eight satellite clinics throughout the city.3 Further efforts to assist underserved communities included the establishment of several free clinics, such as the Gennesaret Free Clinic, Shepard Community Center and Kingsway Community Care Center. Increasing affordable access to healthcare has been at the forefront of American culture in recent years. In 2010, President Obama signed the Patient Protection and Affordable Care Act and the Healthcare and Education Reconciliation Act of 2010 with a vision and goal to dramatically reform healthcare and to allow individuals to obtain affordable healthcare coverage over the next several years.4,5 Preceding these Acts were the development of programs such as patient medication assistance and incomebased sliding scale and free clinics in order to fulfill this same vision. In recent years, several student-run free clinics have been established. Student-run clinics accomplish several goals. Foremost they increase access to affordable healthcare; secondly, they serve as innovative and realworld teaching sites for several disciplines; and thirdly they enable medical and health professional schools to meet accreditation standards that focus on service-learning and multidisciplinary approaches to healthcare. Reportedly, there are 60 student-run free clinics in the United States; at the time this article was submitted, the Butler University Community Outreach Pharmacy (BUCOP), in conjunction with the Indiana University Student Outreach Clinic (IUSOC), was the only student-run free healthcare provider in the state of Indiana.6 The IUSOC and BUCOP operate out of a local church, the Neighborhood Fellowship Church in the heart of the ESCommunity, on Saturdays from 10:00 am to 2:00 pm.7 This paper discussed the impact of the BUCOP on pharmaceutical care to the underserved and student training and learning. August 1st, 2009, BUCOP was opened as a free, studentrun pharmacy.7 The services provided by the student– pharmacist to patients included: (1) free medications, (2) non-drug therapies, and (3) medication counseling. Additionally, the student–pharmacists provided drug informationrelated knowledge, such as initial doses, recommended indication for medication therapy, and monitoring parameters to student–physicians of the partnering IUSOC. The student executive board, in consultation with the faculty advisor, conducts the supervision of BUCOP. In addition to the student executive board and the advisor, the BUCOP operates with the assistance of student–pharmacist volunteers and pharmacist

volunteers. A more detailed overview of the roles and responsibilities of the various parties involved in the operations of the BUCOP can be found in Table 1. Furthermore, the service-learning and public health components of the student-run pharmacy reflect the academic public health and interdisciplinary education initiatives of the Accreditation Council for Pharmacy Education (ACPE). According to the 2011 ACPE Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree, a pre-advanced pharmacy practice experience core domain is Health and Wellness—Public Health.8 It states that students should, ‘‘Know and apply principles of health and wellness in provision of individual and population-based health and wellness information’’ and ‘‘Integrate unique characteristics of individuals and populations in design of health and wellness information.’’8 Additionally, in accordance with the American Association of Colleges of Pharmacy (AACP) Center for Advancement of Pharmaceutical Education (CAPE) 2004 Educational Outcomes, the ACPE Accreditation Standards recommend that students fulfill their public health and other education experiences, such as experiential experiences ‘‘in cooperation with other members of an inter-professional team of healthcare providers.’’8 BUCOP mission statement Service: To provide medically underserved and uninsured populations within Indianapolis with access to basic medication for acute disease states, information on non-drug therapies, and education on chronic disease prevention at no cost to the patient. Education: To provide pre-professional and professional students with the opportunity to expand clinical skills, explore aspects of clinic administration, build interdisciplinary skills with other professional students, and better understand community resources available to uninsured patients. Understanding: To provide a setting in which medical research regarding social, cultural, and financial influences on the delivery of healthcare to underserved and uninsured populations can be conducted. Advocacy: To advocate for universal access to adequate and affordable healthcare and medications for the underserved and uninsured populations of Indianapolis. Objectives The objective of this study was to evaluate the quality of the services rendered through the service and education domains of the BUCOP mission statement to assess progress and identify areas of improvement. Methods This study was approved by the Butler University Institutional Review Board in accordance with the principles

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Table 1 Brief overview of roles and responsibilities of the Butler University Community Outreach Pharmacy (BUCOP) staff Student executive board of directors Student–pharmacist manager The board is responsible for developing, updating, and/or A BUCOP executive board member who manages the pharmacy operations of the clinic day. Responsibilities include, but not limited conducting quality assurances with the BUCOP policies and to: coordinating patient care efforts with the IUSOC staff and procedures, operating manual, and medication formulary. The volunteers, managing volunteers and databases, assisting with leadership positions are: Chair, Vice-Chair, and the Finance, overall clinic operations and function. Promotions, Resources and Records, and Student Volunteer Directors. Each of these positions has specific roles and responsibilities for the operations of the BUCOP. Each member of the board of directors additionally serves as the student–pharmacist manager of the day on a rotational base. The faculty advisor, a licensed pharmacist, assisted the board with their responsibilities. Volunteering student–pharmacist Volunteering licensed pharmacist Requirements: Student–pharmacists must be enrolled in pharmacy Requirements: any pharmacist licensed in the state and who is in school at the sponsoring university, attended their first day of class good professional standing, regardless of university affiliation. as a professional student, and completed the BUCOP orientation training and its requirements. Student–pharmacists will be under the supervision of a licensed pharmacist. Responsibilities: Fill and dispense medications, provide medication Responsibilities: foster student learning through precepting and and health counseling to patients, assist patients with the acquisition supervising clinical and dispensary activities of the student– of non-formulary medications, and interact with student–physicians pharmacists. by discussing patient cases, answering drug information questions, and providing drug therapy recommendations.

outlined in the Declaration of Helsinki.9 All participants of the BUCOP were under the jurisdiction of IUSOC and their institutional review board as the pharmacy is considered to operate under the presets of physician dispensing. All subjects provided informed consent, which, given the design of the study, was implied with completion of the questionnaire. Unique questionnaires were created to assess the study domains. Furthermore, the primary investigators were responsible for patient recruitment and data collection efforts. All study participants were at least 18 years of age, cognitively competent and English speaking. Additional participantspecific inclusion criteria can be found in the above specific questionnaire section. At the time of the study invitation, participants were educated on the study design, purpose, time commitment, and voluntary nature of the study. Investigators emphasized that there was no penalty for choosing to not participate and, that at any time, study participants were allowed to withdraw from the study and/or choose to not fully complete the questionnaire. In all cases, participant-initiated withdrawal could occur without the knowledge of the investigator(s). Questionnaires were provided after the individuals accepted the study invitation. The unique questionnaires can be found in Appendix A and B. Service questionnaire procedures To evaluate the quality of service and pharmaceutical care products (defined as medication dispensing and medication counseling) rendered by BUCOP, patients or caregivers receiving prescriptions from BUCOP, on randomly

selected clinic days, were invited to participate in this study. Patients were recruited in the waiting room area of the pharmacy while they were waiting for prescriptions to be filled. Recruitment procedures included informing the patients of the voluntary nature, purpose, and time commitment of the study. Patients were informed to complete the questionnaire for the pharmacy only and were instructed to complete the questionnaire after they received counseling on their medications and their pharmacy visit was complete. Patients who expressed an interest in participating in the study were given the questionnaire and asked to read the consent statement at the beginning of the questionnaire. Patients who reported to previously completing a service questionnaire were not asked to complete another questionnaire; and these individuals were not included in the ‘‘declined questionnaire’’ data. Patients who voluntarily elected study participation were given the nine-item questionnaire, which asked them to rate general aspects of the pharmacy operation and their confidence in the students’ abilities to render general aspects of pharmaceutical care. Lastly, the questionnaire gathered information about where the patient usually received healthcare, where they most often filled prescriptions, and how they heard about BUCOP. Refer to Appendix A for a complete list of the service questions. Participants completed the questionnaire immediately after their interaction with the BUCOP student– pharmacists. Once the patient completed the questionnaire, as defined at the discretion of the patient, the study participation was complete. To avoid changes in practice behaviors, the volunteering student–pharmacists, who were

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the ones rendering the pharmacy services, were blinded to and unaware of the details of the questionnaire and project. Education questionnaire procedures To evaluate the value-added benefit and effectiveness of this unique service-learning experience, professional-phase pharmacy school students who volunteered for at least one entire clinic session (approximately four hours) at BUCOP on the randomly selected data collection days were invited to participate in this study. The duties and responsibilities of the student volunteers can be found in Table 1. Student volunteers were recruited at the end of the business day for the clinic and were unaware of this study until such time. All students, with the exception of the study investigators, remained blinded to the patient questionnaire phase of the study until study completion. Student volunteers choosing to participate were given a four-part, investigator-designed questionnaire. The questionnaire consisted of questions soliciting positive and negative feedback on the BUCOP volunteer pharmacy practice experience (PPE). Additionally, student volunteers were asked to reflect on aspects of the PPE including: (1) interactions with the IUSOC medical staff, (2) application of previous classroom material, and (3) comparison to other pharmacy work experiences. Furthermore, the questionnaire contained a selfreflection section to identify three skills at which the student performed well and three skills on which the student could improve. For a complete list of the education questions, refer to Appendix B. Once the student volunteer completed the questionnaire, per their discretion, their participation was complete. One questionnaire was completed per student per volunteering day. Given the fact that experiences differ clinic day-to-clinic day, students who volunteered at the BUCOP multiple times during the data collection period were eligible to complete a questionnaire for each day volunteered. Collection of questionnaires All questionnaires were completed and collected on-site directly after the respective encounter. To avoid the threat of coercion, participants submitted the questionnaire into a labeled folder located near the exit of the pharmacy, which was not in the direct viewing field of the investigators. At the end of the business day, once all patients and students were gone, the investigators collected the questionnaires. Statistical analysis All data analysis was performed using SPSS 17.0, Microsoft Excel 2007 Analysis Toolpak, and SAS v 9.2 (SAS Institute, Cary, NC). Service The primary outcome was overall patient satisfaction with the BUCOP services provided by pharmacy students.

The secondary outcome analyzed patient confidence in the student-delivered BUCOP services. Descriptive statistics were used to report general questions relating to patient response frequencies of healthcare and other information as requested in the survey. Patient satisfaction was analyzed by conducting a Chi-squared test of association (Likelihood Ratio Chi-squared Test). The likelihood ratio test is a standard alternative to the traditional (Pearson’s Chi-squared Test) when analyzing a multi-way classification table.10 Subanalyses were also conducted to test certain variables against the group of ‘‘satisfied patients’’ to further evaluate the characteristics of the BUCOP that the satisfied patients rated most highly. For the sub-analysis of Question 1, (refer to Appendix A) ordered positive responses of ‘‘Very Good’’ or ‘‘Excellent’’ were combined (referred to as combined positive) and likewise, ordered negative responses of ‘‘Fair’’ or ‘‘Poor’’ were combined (referred to as combined negative). It is important to note that some patients did not answer each question. Analysis of the data was performed based on the total number of responses per question, not the number of completed surveys. It is noted if a question did not have a 100% response rate. Education The primary outcome was perceived benefit of BUCOP to the student volunteer. The secondary outcome was to determine impact, if any, of the BUCOP volunteering experience on the student–pharmacist’s confidence level as it relates to the provision of pharmaceutical care and the ability to integrate with other medical staff (IUSOC). Descriptive statistics were used to report the results from this survey. Results Service survey results Fifty-three individuals were invited to participate in the study. One patient declined to participate in the survey, and four patients were not eligible for study participation due to language barriers. Forty-eight (90.6%) individuals completed the survey and are included in the analysis. The service survey did not collect data on gender or age. For the purposes of this study, demographics are defined in terms of healthcare and pharmacy usage, including BUCOP (Table 2). Approximately, half of the patients surveyed responded that they had never been to BUCOP prior to taking the survey. Additionally, approximately 50% of the participants stated that they learned of BUCOP from street advertisements. Each patient averaged two prescriptions per visit. Of all available major retail pharmacies, CVS/Pharmacys was the most commonly used pharmacy for the surveyed patients. The most common healthcare institutions used by BUCOP patients were federally funded hospitals and ambulatory care centers. Approximately one-eighth (12.5%) of the patients reported

E.A. Dy et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 245–255 Table 2 Service survey patient characteristics Variable

Total patient count (n ¼ 48)

Usage statistics Average # of prescriptions Using BUCOP for the first time Will use BUCOP again Will refer BUCOP to others

2 25 (52.1%) 47 (97.9%) 47 (97.9%)

Most used pharmacy (Top 5) CVS/pharmacys Walmart Kroger Wishard hospital None

16 6 4 4 2

(33.3%) (12.5%) (8.3%) (8.3%) (4.2%)

Most used physician (Top 5) Wishard hospital None People’s health center IUSOC IU Health—Methodist hospital

10 6 5 5 4

(20.8%) (12.5%) (10.4%) (10.4%) (8.3%)

How do patients hear about BUCOP (Top 3) Street advertisement 21 (43.8%) Family member/friend 12 (25.0%) Fellowship church 9 (18.8%)

having no physician; this was the second most common response. Six patient-survey questions evaluated overall satisfaction and confidence in pharmacy students (Appendix A). Overall, patients were satisfied with their experiences at the BUCOP as it related to hours of operation, wait time for prescription filling, friendliness of student–pharmacist staff, and patient education (Table 3). Eighty percent (80%) or more of the patients rated the BUCOP services as ‘‘Very Good’’ or ‘‘Excellent’’ for three of the six questions assessing patient satisfaction. For the other three questions, at least 55% of the patients rated the services as ‘‘Very Good’’ or ‘‘Excellent’’. The lowest scoring services were hours of operation and pharmacy wait time. Furthermore, for the specific question asking how well the BUCOP experience compared to other pharmacies previously used

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(Appendix A Question 1f [A-1f]), approximately 80% of the patients reported perceiving their experience at BUCOP to be comparable to experiences obtained at retail pharmacies (Table 3). Solely considering this same question (A-1f), Table 4 outlines the factors that influenced the ratings for the combined positive responses (individuals answering ‘‘Very Good’’ or ‘‘Excellent’’) and the combined negative responses (those answering ‘‘Fair’’ or ‘‘Poor’’). The significance was statistical (p o 0.001) for all operational and service components with the exception of the BUCOP business hours. Four patient-survey questions evaluated patient confidence in the student–pharmacists’ abilities (Appendix A). In terms of overall confidence, 100% of patients were confident in students filling prescriptions accurately, 98% were confident in explanations of how to take their medication, 96% of patients were confident that students could answer questions about their medications, and 86% of patients were confident that they could help patients find medication at another location, if necessary. The confidence ratings from the combined positive respondents of Question A-1f are described in Table 5. Significant associations with a satisfied patient’s confidence in the student’s ability to explain how to take medications (81.3%, p ¼ 0.021) and to help with the acquisition of medications at a location outside of BUCOP (72.1%, p ¼ 0.004) are presented in Table 5. Overall, it appears that the BUCOP experience was a positive experience for patients. The majority (97.9%) of patients stated that they would use BUCOP again as their pharmacy and would refer others to use BUCOP (Table 2).

Education survey results Twenty-five student volunteers were invited to participate in the study. Two students declined to participate in the survey. Twenty-three (92%) student–pharmacists completed the survey. Two students took the survey twice. The first response only was used for these students in data analysis. The education survey did not collect data on gender or age. For the purposes of this survey, demographics are defined in terms of current year in the professional phase of pharmacy school (Table 6).

Table 3 Patient ratings of the operational and service components of BUCOP (1 ¼ Poor; 5 ¼ Excellent) Survey questions

Mean

Median

Mode

% Rating as ‘‘Very Good’’ or ‘‘Excellent’’

Hours/days of operation Wait time in the pharmacy Friendliness of pharmacy students How well did pharmacy students explain patient’s medical condition How well did pharmacy students explain patient’s medications How well does this experience compare to other pharmacies the patient has used

3.78 4.04 4.58 4.37 4.38 4.40

4 4 5 5 5 5

5 5 5 5 5 5

56.5 66.0 91.7 80.4 78.7 81.3

p o 0.001 4.3 76.6

LR ¼ 50.9302; df ¼ 9

p ¼ 0.013 p o 0.001 p o 0.001 p o 0.001 12 9 6 9 ¼ ¼ ¼ ¼ df df df df 25.330; 30.483; 38.775; 42.022; ¼ ¼ ¼ ¼ LR LR LR LR 10.9 4.3 0 6.5 56.5 63.8 79.2 78.3

* The Likelihood Ratio Chi-Squared Statistic is computed in cases where the assumptions of the Pearson’s Chi-Squared Test are violated. In each of these cases, the assumption of no more than 20% of cells can have an expected count less than five was violated so the LR test was used.

Survey questions

Hours/days of operation (n ¼ 46) Wait time in the pharmacy Friendliness of pharmacy students How well did pharmacy students explain patient’s medical condition How well did pharmacy students explain patient’s medications

Test statistic (Degrees of freedom)* % Rating as ‘‘Fair’’ or ‘‘Poor’’ of both BUCOP experience compared to other pharmacies and the experience listed % Rating as ‘‘Very Good’’ or ‘‘Excellent’’ of both BUCOP experience compared to other pharmacies and the experience listed

Eight student-survey questions evaluated volunteer satisfaction, specifically involving interactions with the IUSOC medical student team, thoroughness of the training session, improvement in confidence, and overall volunteering experience. Results can be found in Tables 7 and 8. Volunteer sessions, which were provided to students prior to volunteering at BUCOP, were rated as ‘‘Very Helpful’’ or ‘‘Somewhat Helpful’’ by 87% of students. The average rating of usefulness of the volunteer session was 1.87, with 2 being the median and mode (1 = Very Useful; 5 = Not at all Helpful). Regarding interactions with medical students, a small percentage of students felt that overall utilization of pharmacy student recommendations by the medical staff deserved a rating of ‘‘Very Utilized’’ (Table 8). A majority (68%) of the student volunteers expected to be either ‘‘Very Utilized’’ or ‘‘Somewhat Utilized’’ by the IUSOC medical student team (Table 8). For the actual rating of interdisciplinary interactions with medical students, such as discussing patient cases, answering drug information questions, and providing drug therapy recommendations, 68% felt that interactions were either ‘‘Very Beneficial’’ or ‘‘Somewhat Beneficial’’. Of the students participating in the survey, 65% reported working in a pharmacy, suggesting that 35% of students volunteering at BUCOP are gaining their initial pharmacy experiences through this unique setting. Of those who worked in a pharmacy, 46.7% of them felt that the interaction with volunteering BUCOP pharmacists was either ‘‘Very Beneficial’’ or ‘‘Somewhat Beneficial’’. Of the classes taken in pharmacy school prior to volunteering, students most commonly (57%) reported utilizing their knowledge and skills from the Introduction to Pharmaceutical Care series, which exposes 1st-year pharmacy students to ‘‘concepts of pharmaceutical care and develops skills in drug information retrieval, descriptive statistics and medical terminology’’.11 Other courses utilized included Therapeutics (33%), Self-Care (33%), Pathophysiology (27%), Principles of Drug Action (23%), Ethics (18%), Clinical Assessment (18%), Dosage Forms (14%), and Biochemistry/Biotechnology (5%). All (100%) surveyed pharmacy students reported increased confidence in ability to counsel and/or interact with patients as a result of their BUCOP volunteering experience. In the additional comments section of the questionnaire, many students reflected on positive patient counseling experiences and improved interactions with other health professionals in their self-reflections. When asked what competencies they would improve upon, all students, regardless of curricular level, commonly reported that they would improve on drug knowledge and disease-state management. All (100%) surveyed pharmacy students rated the overall volunteering experience at BUCOP as either ‘‘Excellent’’ or ‘‘Good’’. Thirty-nine percent of students rated the experience as ‘‘Excellent’’. Furthermore, 100% of all students stated that they would volunteer again and would recommend volunteering at BUCOP to future pharmacy students.

Significance

E.A. Dy et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 245–255 Table 4 Patient ratings of operational and service components of the BUCOP based on the question ‘‘How well does this experience compare to other pharmacies you have used?’’ [The characteristics upon which patients responded either positively or negatively].

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Table 5 Patient confidence in student dispensary and counseling related functions (responses from combined positive respondents) Survey questions

Not confident Unsure Confident Test statistic (Degrees of freedom)* Significance

Fill your prescriptions correctly and accurately (n ¼ 48)** Explain how to take your medicine (n ¼ 48) Answer questions about other medicines you take (n ¼ 48) Help you find ways to get medicine at another location (n ¼ 43)

0.00%

0.00%

81.25%

N/A

N/A

0.00% 0.00%

2.08% 2.08%

81.25% 79.17%

LR ¼ 9.721; df ¼ 3 LR ¼ 4.098; df ¼ 3

p ¼ 0.021 p ¼ 0.251

0.00%

6.98%

72.09%

LR ¼ 13.540; df ¼ 3

p ¼ 0.004

LR ¼ likelihood ratio; df ¼ degree of freedom. * The Likelihood Ratio Chi-Squared Statistic is computed for a multi-way classification table. In each of these cases, the assumption of no more than 20% of cells can have an expected count less than five was violated so the LR test was used. ** All respondents were ‘‘Confident’’ for this question. Therefore, the analysis of frequencies by group cannot be conducted.

Discussion While student-run clinics and pharmacies have become more prevalent throughout the United States in recent years, there is little literature reviewing the strengths and weaknesses of these organizations. This study evaluated two main goals of the BUCOP, and as a result, it provides an overall picture of the impact it has had on its underserved patients and pharmacy student volunteers. Consequently, this study has also helped to fulfill an additional objective of the mission statement, understanding, by completing the research within BUCOP. The study found promising results in terms of BUCOP fulfilling the service and education mission statement. In terms of service to underserved patients, the study found that the majority of patients were generally satisfied with the level of care provided by students at BUCOP. Additionally, there were no correlating negative responses from the two patients who stated that they would not use BUCOP again or refer BUCOP to family/friends in the future; they rated 100% satisfaction and confidence in BUCOP student volunteers. The positive feedback found in this study may be due to the philanthropic nature of BUCOP’s services; patients receive free medications, counseling, and medication resource information (i.e. medication assistance) from students and health professionals dedicated to bridging the healthcare gap. The fact that the majority of patients also plan to use BUCOP or refer its services to others in the future is also an indication of the satisfaction the patients have with the BUCOP services. Given the operational Table 6 Student–pharmacist demographics Characteristic

n (%)

Professional phase 1st-year 2nd-year 3rd-year

14 (60.9) 5 (21.7) 4 (17.4)

Work experience Previous/current pharmacy experience

15 (65.2)

uniqueness of this pharmacy setting, the patient satisfaction and confidence surveys were developed by the study investigators to assess the parameters of medication dispensing and counseling, which are the main services provided by the student-ran pharmacy. While this is not a validated survey, it provides some useful information regarding patients’ perceptions of the quality of service rendered by students and at a free clinic. Many validated satisfaction surveys are quite lengthy. This survey, which was comprised of 17 items total, was also designed with the intent of decreasing or eliminating the possibility of a ceiling effect, which is often observed with long, time consuming surveys. Additionally, it was hypothesized that patients would be more likely to complete the survey if it could be completed in less than ten minutes, given the fact that the average clinic visit time (from registration to completion) is between 60 and Table 7 Student responses regarding overall BUCOP experience % Volunteer training sessions Very helpful Somewhat helpful Neutral Not very helpful Not at all helpful

30.4 56.5 8.7 4.4 0

Rating of overall BUCOP IPPE experience Excellent Good Average Poor Very Poor

39.1 60.9 0 0 0

General % reporting utilizing their knowledge and skills obtained from class % reporting increased in confidence as a result of the BUCOP experience % reporting they recommend volunteering at the BUCOP to future pharmacy students IPPE ¼ Introductory Pharmacy Practice Experience.

100 100 100

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Table 8 Volunteer pharmacy student survey responses evaluating IUSOC medical students (1 ¼ very utilized/beneficial, 5 ¼ not at all utilized/ beneficial) Survey questions

Mean

Median

Mode

% Rating of 1 or 2

% Rating of 1

Pharmacy students feeling utilized by the IUSOC medical student team Rating of interactions with IUSOC medical student team

2.28 2.16

2 2

2 2

68.0 68.0

12.0 16.0

IUSOC ¼ Indiana University Student Outreach Clinic.

90 minutes. Through accounting for both of these factors, we believe we were able to increase both the quality and quantity of survey responses. Obtaining participant responses was important given the fact that the pharmacy had only been open for approximately 16 months at the beginning of the study and the overall volume of patients was approximately 25–30 patients/ day and given the need for student and service assessment and quality improvement for this pharmacy experiential site. When evaluating student PPE, the study demonstrated the value of BUCOP experiences on building professional confidence as a future pharmacist. This may, in part, be due to the fact that BUCOP is exposing students with no prior pharmacy work experience to a professional pharmacy setting and the responsibilities of the student–pharmacist extends beyond those that are typically obtained through interning at a pharmacy. Students volunteering at BUCOP have the opportunity to serve in the roles of a technician (filling prescriptions), pharmacist (counseling on medications), and medication resource specialist for underserved and uninsured patients. Younger students were presumed to have a larger presence in this study and in the weekly BUCOP sessions due to the Introductory Pharmacy Practice Experiences required prior to the second semester of the third professional pharmacy school year. Finally, BUCOP provides a setting in which early inter-professional interactions may take place, and students have the opportunity to provide drug information services to the IUSOC medical student staff. The study also revealed areas of needed improvement within the BUCOP. The service survey revealed that the most common patient complaints were hours/days of operation and the wait time within the pharmacy. Pharmacy wait time may be influenced by a number of factors, including student volunteers’ inexperience with pharmacy operations/workflow and the active learning environment of clinic. Furthermore, if the pharmacy student determined that an adjustment in the prescribed therapy was warranted, secondary to drug-drug or drug-disease interactions for instance, the pharmacy wait time was prolonged. In order to help combat this limitation, the authors recommend reviewing more of the pharmacy operations and workflow during student volunteer training sessions and to have a P3 student work directly with the student–doctors to assist with patient-specific medication therapy. Because the hours of operation are limited by the availability of the IUSOC medical staff, the authors recommend future conversations between BUCOP and IUSOC leaders to consider extending/ expanding future clinic hours.

The education survey revealed that one-third of student volunteers do not feel utilized by IUSOC medical students and do not view interdisciplinary interactions as beneficial. While BUCOP provides the opportunity for pharmacy and medical staff interaction, the authors suggest emphasizing more constructive, professional interactions between pharmacy and medical students during clinic operations. Younger students should be encouraged to participate in conversations with IUSOC staff when choosing drug therapies or when IUSOC students pose drug information questions. While the results from the study portray a picture of the overall successes and failures of BUCOP, there are some apparent study limitations. While patients and students were informed that their responses would in no way affect their future experiences with BUCOP and methods for discretion with completing the surveys were incorporated into the study design, the overall presence of the investigators, as surveyors, may have influenced some positive survey responses. Also, while patients were instructed to complete the service survey in regards to BUCOP only, patients may have found it difficult to distinguish between the services provided by BUCOP and those provided by IUSOC; it is unknown if evaluations may have reflected more on the IUSOC services. Finally, the overall participant survey pool was smaller than desired. This was due, in part, to limited numbers of patients and student volunteers at the clinic each week. At a maximum, the clinic pharmacy was staffed by a maximum of five student volunteers in order to provide services to a maximum of 30 patients per week. At the time of data collection, the average number of patients requiring pharmacy services was approximately six per week. The end result of this study was to obtain insight into the benefit of a student-run pharmacy from both the patient and student perspective and reveal weaknesses and areas of needed improvement for BUCOP, leading to the ultimate goal of quality improvement. Following study completion, the results of this study were presented to current BUCOP student Board of Directors. Since that time, BUCOP student leaders have made monumental strides in increasing positive interactions with the medical students of the IUSOC by creating a multidisciplinary clinic leadership group. Discussions have begun regarding expanding clinic hours and access. Furthermore, additional pharmacy services are being added such as a smoking cessation program. Overall, continuous quality improvement is needed to ensure patient satisfaction and a valuable educational pharmacy practice experience for students.

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Conclusion This pilot study demonstrates a positive experience on student learning, while providing the opportunity to utilize professional knowledge and provide patient care in a unique multidisciplinary clinical setting. Furthermore, the study demonstrates patient satisfaction can be

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achieved in a BUCOP. Two major missions of BUCOP are to provide pharmaceutical care to underserved populations and to provide student–pharmacists the opportunity to expand their clinical skills; while improvements can be made to better impact patients and students, BUCOP is fulfilling its mission statement in terms of service and education.

Appendix A: BUCOP service survey The purpose of this survey is to evaluate the patient experience at the Butler University Community Outreach Pharmacy (BUCOP). This survey will ask you questions about your experiences with the BUCOP. Your help with this survey will help BUCOP offer better services to patients. Please feel free to write down both good and bad things you see at the pharmacy today. This survey is 100% voluntary and is not required to receive healthcare or medication at BUCOP. The quality of medical care you receive at the IUSOC/BUCOP today or in the future will not be affected if you do not fill out this survey. No personal information will be required to keep your information safe. Thank you for your help with this research project. Your willingness to complete this survey serves as your consent to participate in this research study.

Please answer the following questions based on your experience TODAY in the PHARMACY area only.

1. Please rate these services in the PHARMACY from 1 (POOR)–5 (EXCELLENT). POOR FAIR GOOD VERY EXCELLENT GOOD a. Hours/days of operation 1 2 3 4 5 b. Wait time in the pharmacy (waiting for your prescription)

1

2

3

4

5

c. Friendliness of the pharmacy students

1

2

3

4

5

d. How well did the pharmacy students explain your medical condition (how it affects your overall health, lifestyle changes to make, drugs needed)?

1

2

3

4

5

e. How well did the pharmacy student explain your medicine(s), (including why you need this, how to take it and what to expect)?

1

2

3

4

5

f. How well does this experience compare to other pharmacies you have used (Walgreens, CVS, Wal-Mart etc.)?

1

2

3

4

5

What is something the pharmacy student did that you greatly appreciated (write response below)? _____________________________________________________________________________________ Survey continued on next page &

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2. Based on your visit to BUCOP today, please rate your confidence in the pharmacy students’ ability to: NOT CONFIDENT UNSURE CONFIDENT a. Fill your prescription correctly and accurately 1 2 3 b. Explain how to take your medicine 1 2 3 c. Answer questions about other medicine you take 1 2 3 d. Help you find ways to get medicine at another location 1 2 3 3. How many prescriptions are you receiving today? ____________ 4. Is this your first time using the BUCOP pharmacy services? YES NO 5. Do you plan to use the BUCOP pharmacy services again in the future? YES NO 6. Would you refer friends and family members to get their medicine from this pharmacy? YES NO 7. Which hospital/physician’s office do you most often visit to receive your medical care? ________________________________________________________________ 8. Where do you most often fill your prescriptions? _________________________ ____________________________________ 9. How did you hear about the clinic/pharmacy? (please check all that apply) ___ Community Member ___ Fellowship Church ___ Family Member/Friend ___ Street advertisement ___ Website Other: _________________ Appendix B: BUCOP education volunteer survey The purpose of this survey is to evaluate the current status of volunteer experience within BUCOP. By participating in this survey, you will help us further understand the experience and needs of BUCOP volunteers. This survey is completely voluntary and is not required to participate in BUCOP. If you decide not to participate, your academic record/scholarship or your ability to participate in BUCOP in the future will not be affected. Your willingness to complete this survey serves as your consent to participate in this research study. Thank you for your consideration in helping analysis of the service-learning experience of the BUCOP.

1. Volunteer Training Sessions a. What is your current year in pharmacy school (circle one)? P1 P2 P3 P4 b. When was your volunteer training session (month or semester/year)? __________________ c.

How would you rate the volunteer session (circle one)? Very Helpful Somewhat Helpful Neutral Not Very Helpful

Not at All Helpful

d. What was positive about the volunteer session? __________________________________ _________________________________________________________________________ e.

What would you change about the volunteer session? _____________________________ __________________________________________________________________________

E.A. Dy et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 245–255

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2. Volunteering at the Clinic a. How were you expecting to be utilized by the medical student team (circle one)? Very Utilized Somewhat Utilized Neutral Not Very Utilized Not at All Utilized b. How would you rate your interactions with the medical student team (circle one)? Very beneficial Somewhat Beneficial Neutral Not Very Beneficial Not at All Beneficial c.

Were you able to utilize knowledge and skills you obtained in class? (CIRCLE ONE) YES If YES, which course(s)? (CIRCLE ALL THAT APPLY) Therapeutics Self-Care Dosage Forms PDA Pathophysiology Ethics Clinical Assessment Biochemistry/Biotechnology Other: ___________________

NO

d. Do you work at a pharmacy outside of school (circle one)? YES NO If YES, how would you rate your experience with the BUCOP pharmacist compared to the pharmacist(s) at your place of employment? Very Beneficial Somewhat Beneficial Neutral Not Very Beneficial Not at All Beneficial IN FAVOR OF BUCOP PHARMACIST IN FAVOR OF EMPLOYER PHARMACIST e.

Did your confidence in your ability to counsel/interact with patients at the clinic improve while at BUCOP (circle one)? YES NO

f.

How would you rate your overall volunteering experience at the BUCOP (circle one)? Excellent Good Average Poor Very Poor

g. Would you volunteer again at the clinic (circle one)?

YES

NO

h. Would you recommend volunteering at the BUCOP to future pharmacy students (circle one)? YES NO 3. Volunteer Reflection a. List three things you feel you did well at the clinic: 1. _______________________________________________________________________ 2. _______________________________________________________________________ 3. _______________________________________________________________________ b. List three competencies you would improve upon (For example: Counseling, Drug knowledge, Disease-state management, Communication with physicians, etc.): 1. _______________________________________________________________________ 2. _______________________________________________________________________ 3. _______________________________________________________________________ References 1. IBJ Staff. 24 percent in 46201 are below poverty level. Indianapolis Business Journal 2009;30(39):29. 2. History, Indiana Primary Health Care Association. /http://www. indianapca.org/aboutiphca/history.htmlS Accessed January 17, 2013. 3. A Brief History of W Health Service. /http://www.wishard. edu/en/about-us/our-historyS Accessed January 17, 2013. 4. Patient Protection and Affordable Care Act of 2010, H.R. 3590, 111th Cong., 2nd Sess.; 2010. 5. Health Care and Education Reconciliation Act of 2010, H.R. 4872, 11th Cong., 2nd Sess.; 2010. 6. Clinic Profiles, Society for Student Run Free Clinics. /http:// www.studentrunfreeclinics.orgS Accessed January 17, 2013. 7. Butler University Community Outreach Pharmacy. /http://www. butleroutreachpharmacy.org/Pages/default.aspx/S Accessed January 17, 2013.

8. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Adopted: January 23, 2011. Effective: February 14, 2011. American Council for Pharmacy Education, Chicago, IL 2011. /https://www.acpe-accredit.org/pdf/S2007Guidelines2. 0_ChangesIdentifiedInRed.pdfS Accessed January 17, 2013. 9. 59th WMA General Assembly. World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. World Medical Association. /http://www.wma.net/en/30publications/10policies/b3/S; 2013 Accessed January 17, 2013. 10. Field A. Discovering Statistics with SPSS. Thousand Oaks, CA: Sage; 2009. 11. Registration and records, Butler community outreach pharmacy.