Ambulatory Care Clerkship Rotation



Ambulatory Care APPE Rotation

Butler University COPHS

Indianapolis, IN

|Contact Information |

|Preceptor |Office |Phone Numbers |Clinics |

|Primary Preceptor |Healthy |Office: 317-940-8143 |Main Site: Heathy Horizons (Butler Employee |

|Heather Folz, PharmD |Horizons |Cell: 919-819-2264 |Wellness) |

|Adjunct Professor of Pharmacy Practice | | |COPHS: 4600 Sunset Ave, Indianapolis, IN 46208 |

|Clinical Pharmacy Specialist, Ambulatory Care | | | |

|Email: hfolz@butler.edu | | |Mondays: Richard L. Roudebush VAMC (Green Team |

|Personal: hnfolz0707@email.campbell.edu | | |Primary Care) |

| | | |Parking: 2669 Cold Spring Road, Indianapolis 46222|

| | | | |

| | | |Wednesdays: Community Health Network Family |

| | | |Medicine |

| | | |FMC: 10122 East 10th Street #100, Indianapolis, IN|

| | | |46229 |

|Description |

This ambulatory care advanced pharmacy practice (APPE) rotation exposes the student to clinical pharmacy services in an outpatient setting and academia. The main site of this program is an employee wellness clinic; thus, the rotation is designed to give students an understanding of disease prevention and wellness screenings in addition to chronic disease state management and related pharmacotherapy. Daily activities will emphasize supervised direct patient care through the provision of lifestyle, medication, and disease state counseling, comprehensive review of patient profiles, and documentation within the medical record (limited to Healthy Horizons). Therapeutic areas of focus include diet and physical activity, cancer screenings, diabetes, dyslipidemia, hypertension, weight management, and smoking cessation. The APPE student will also enhance professional communication skills with various healthcare professionals including physicians, physician assistants, nurses, nurse practitioners, pharmacists, and other faculty members. Students will gain further understanding of various disease states and interventions in an ambulatory care setting by completing topic discussions, personal reflections, presentations, and other activities.

|Goals & Objectives |

Upon completion of this rotation, the student should be able to demonstrate his/her ability to:

1. Apply practice guidelines in a patient specific manner with an emphasis in prevention

2. Interpret lab values and accordingly recommend appropriate action

3. Determine monitoring parameters and therapeutic endpoints for medication therapy

4. Adequately obtain medication and allergy histories and perform medication reconciliation

5. Thoroughly review medication profiles for:

a. Therapeutic indication

b. Drug-drug, drug-disease, drug-food, and drug-lab interactions

c. Appropriate dose, route, and frequency of administration

d. Therapeutic duplications

e. Timeliness of refills/non-compliance

f. Current OTC medication use

g. Contraindications for drug therapy

h. Adverse drug reactions/adverse drug effects

6. Advise health care professionals on appropriate drug therapy based on clinical efficacy, safety, and cost-effective prescribing. AFTER preceptor verification of accuracy and appropriateness of information, provide medication information to health care professionals and patients including:

a. Potential side effects

b. Medication interactions

c. Appropriate dose and frequency

d. Contraindications

7. Effectively communicate with various healthcare professionals and patients.

8. Document clinical activities (i.e. SOAP notes, medication reviews, medication counseling, allergies/adverse reactions, etc.) in the electronic medical chart (Titanium) following institution specific policies and procedures. NOTE: Avoid unapproved abbreviations, first person pronouns, typos, and informal/slang language.

9. Successfully deliver presentations consistent with expected levels of competency for a clerkship student, including:

a. Comprehensive literature review with reputable references listed appropriately

b. Demonstration of sufficient preparation and practice

c. Effective use of Microsoft© PowerPoint program

d. Provision of supplementary handout

NOTE: all recommendations/suggestions (both written and verbal) involving patient care MUST first be discussed with a pharmacy preceptor.

|Pharmacy Program Student Learning Outcomes (SLOs) |

1. Promote health improvement, wellness and disease prevention.

2. Apply knowledge and skills to make appropriate decisions regarding the safe and effective use of medications or the need for referral to other health care providers. These decisions should include consideration of social, economic and cultural factors.

3. Find, understand, analyze evaluate and use information to make informed and rationale decisions.

4. Effectively communicate pharmaceutical and health-related information and collaborate with other healthcare professionals to ensure the provision of quality patient care.

5. Practice independent learning and modify ideas and behaviors based on newly acquired knowledge.

6. Manage pharmacy operations including human facilities and fiscal resources to deliver quality patient care.

7. Demonstrate ethical conduct in personal and professional settings and respect and exhibit empathy for patients’ differences, values and preferences.

|Overview of Clerkship Activities |

Minimum Expectations

The clerkship student is expected to:

1. Review patient lists prior to clinic attendance*

2. Ensure any documentation that occurs in the electronic medical record is completed according to institution policies*

3. Communicate with the primary preceptor on a daily basis in person or via email when appropriate

4. Complete all assignments, topic discussions, and formal presentations by assigned deadlines

5. Demonstrate competence through satisfactory completion of end-of-block examination(s)

6. Display efficient drug information retrieval skills using common, reputable resources (i.e. Micromedex, UpToDate, PubMed, Lexicomp, Pharmacist’s Letter, Natural Medicines, etc.)

7. Exhibit an attitude of professionalism, maturity, and politeness

8. Develop an appropriate amount of professional confidence – Say “I don’t know, but I will be happy to look that up for you.” instead of providing incorrect or irrelevant information

9. Exert independence in performing assigned activities

10. Notify primary preceptor with suggestions for rotation improvement on a continual basis

*Denotes Healthy Horizons specific expectations due to limited EMR access at other sites

|Schedule |

▪ Detailed schedule will be provided on the first day of the rotation

▪ Please account for delays in transportation due to parking or traveling to off-site locations

▪ Students are expected to arrive each day by 8AM and stay in clinic until 5PM or later if patient related responsibilities require (hours will very)

▪ Project time will be on-site unless otherwise approved by the preceptor.

|Clerkship Activities |

Daily clerkship activities while in clinic, assignments, formal presentations, and therapeutic discussions will provide a heavy emphasis on pharmacology and treatment in the following areas:

|Diet |

|Physical Activity |

|Prevention Screenings |

|Diabetes |

|Hyperlipidemia |

|HTN |

|Smoking cessation |

|Weight Management |

|Potential exposure: anticoagulation, COPD/Asthma, |

|Transitions of Care |

|Assessing Outpatient Medications Lists |

The development of an accurate medication list is one of the most important aspects outpatient care, especially those in an ambulatory care setting. Determining and evaluating this medication list can often be difficult, and at times a daunting task for students. Use the steps below to help to more objectively assess patients on this rotation.

Determining medication appropriateness:

1. Do all medications have an indication?

2. Do all indications have a medication (is a medication needed)?

Evaluating medication lists:

1. Determine the current list of medications prescribed to a patient

2. Based on this list, what information do you want to know about each medication (i.e. the dose, frequency, time of day taken/administered, side effects, relation to a meal, proper administration technique, etc.)

3. What questions would you need to as the patient to determine the needed information from Step 2?

4. What is the next most logical change, if a medication change is needed?

a. If a medication change is needed, what is the magnitude of the change for the patient (i.e. simply increasing the dose of an existing medication vs. adding a new multiple-time per day dosed medication)

|Required Assignments (see calendar for specific deadlines) |

1. 10 minute formal presentation using Microsoft© PowerPoint slides and with relevant handout

▪ Presentation topic is due to the preceptor by end of the 1st rotation week

▪ Intended audience will typically be clinical pharmacists, physicians, and/or clerkship students

▪ May consist new drug or guideline update or other area relevant to outpatient care

▪ Presentation will be given twice: 1) ungraded for feedback only 2) final presentation to display application of feedback

▪ Written or electronic handout for the audience is required

▪ A minimum of 3 references should be used and cited

2. SMART goal Reflection

▪ The purpose of this activity is to promote the learner’s ability to self-assess and promoted greater understanding and empathy for patients

▪ 2-3 SMART goals should be identified by student during the first 1-3 days of rotation

▪ Using Appendix B, the student will journal on progress with goals during the course of the rotation (minimum of 6 entries) then complete final reflection

3. 60-120 minute topic discussions

▪ At least one formal disease state discussions to preceptor(s) and/or fellow students is required

▪ Any assigned readings should be completed prior to designated topic discussion date and time

▪ A written handout summarizing the disease and treatment using the available national guidelines should be developed to be used during the discussion (there is no firm page limit to the handout)

▪ Additional requirements:

o Should NOT be a “regurgitation” of your class notes

o Should include relevant primary literature and GUIDELINES for the topic presented

o Information in the written handout should be properly referenced

o Should include information on intra-class medication differences

o Should be used as an opportunity to learn new information about your topic

4. End of block short-answer assessment

▪ Will reflect many of the new facts and follow up points learned throughout the rotation

▪ Minimum competence must be demonstrated to pass the rotation

5. Patient counseling exercise

▪ Will expose students to a multitude of medical devices and dosage forms for an opportunity for hands-on practice with many devices commonly used in an ambulatory care or community pharmacy practice setting

▪ Instructs students to about how independently research and practice proper use of a variety of medical devices and proper counseling techniques

▪ Provides feedback and suggestions for improvement on students’ patient counseling skills for complicated medication administration techniques, dosing calculations, and dietary modifications

Other Projects:

As an effort to incorporate the student into the practice of the preceptor, students may be offered the chance to assist the preceptor with some of his responsibilities. Students will also be included on as many preceptor meetings, teaching responsibilities, and other activities as possible.

|Policies and Student Responsibilities |

Please refer to your Doctor of Pharmacy manual for a more extensive list and explanation of policies and student responsibilities. Butler COPHS policies/responsibilities will be strictly enforced on this rotation. Violation of any of the policies/responsibilities may result in failure of the Ambulatory Care rotation.

Professional Responsibilities:

1. Academic Integrity: Academic dishonesty in all its manifestations will not be tolerated. Students falsifying patient information will be subject to disciplinary action and possible rotation failure.

2. Plagiarism: Plagiarism will not be tolerated on this rotation. Any act of plagiarism will result in rotation failure.

3. Ethics: Students should act in an ethical manner by acknowledging that the patient, family members, other health care providers or any other person with whom they are in contact has the right to their own opinion and understanding of a situation. Patients have a right to know all aspects of their care and be incorporated into decisions related to that care. There is to be no judgment of the person regarding their decisions.

4. Respect: Students will treat all people with whom they interact with dignity and importance. If a student repeatedly acts in a manner that does not show respect to those involved, this behavior will be evaluated, and may result in a failure of the rotation.

5. Confidentiality/HIPAA: The student will have access to personal and private information throughout the course of this rotation. All such information must be kept confidential.

Remember NOT TO:

a. Discuss patient information in any public area (cafeteria, hallways, elevators, etc.) or with friends or family

b. Leave patient information unattended in your workspace or up on any computer screens

c. Take patient information off the premises.

Remember TO:

a. Discard all patient identifying material in labeled HIPAA bins located throughout the hospital

b. Remove all patient names from information presented during formal presentations or other assignments

6. Absence(s): Two excused absences will be allowed per each four-week clerkship rotation period. Excused absences must be approved in advance by the primary preceptor and assigned clinic preceptor for the day absent. Any additional absences may need to be made up at the preceptor’s discretion. Excessive absence from the clerkship rotation may result in failure of the rotation.

7. Dress Code: Professional attire, including a nametag is required. Short white coat may be required in certain situations.

8. Cell Phone Use: Use of cell phones or smart devices is limited to purposes of drug reference. They are not to be utilized for other functions during rotation hours.

|Minimum Ambulatory Care Competencies |

Upon completion of the Ambulatory Care Rotation, the Doctor of Pharmacy student will need to show satisfactory progress or proficiency in the following areas to pass this rotation:

1. Rotation objectives as listed above

2. General understanding of common disease states in relationship to the ambulatory care setting

a. Pathophysiology

b. Etiology

c. Symptomatology

d. Pharmacotherapy

e. Monitoring parameters

3. Professionalism

a. Demonstrates punctuality during rotation hours and regarding assigned projects

b. Interacts with patients and other health care workers in a professional manner

c. Appears motivated and comes to rotation prepared

d. Professional attire

4. Time Management

a. Complete and submit assignments on time. All assignments should be completed the morning they are due. Working on assignments during the day they are due may result in failure of the assignment. (Exceptions: photocopying handouts, rehearsing presentation if time permits)

b. Utilize time appropriately to collect pertinent data needed for patient discussions and counseling

c. Complete electronic progress notes for preceptor review in a timely manner (same day as patient appointment)

5. Drug Information Skills

a. Recognition of appropriate references in various situations

b. Ability to retrieve appropriate sources of information

c. Demonstrates understanding of literature

d. Critically evaluate applicable literature

e. Application of literature to patient care

f. Appropriate recommendations

6. Communication Skills

a. Written (drug information questions, journal club, presentation handout, progress notes, medication calendars, etc.)

b. Verbal (daily with health care workers, patients, preceptors and presentations, etc.)

Appendix A

APPE Ambulatory Care Rotation

Oral Presentation

Pharmacy Student Oral Presentation Evaluation Form (Adapted from Eskenazi Health)

Presentation Title:

Student:

KEY: SD = strongly disagree; D = disagree; A = agree; SA = strongly agree

| |SD |D |A |SA |Comments |

|CONTENT / KNOWLEDGE / LITERATURE |

|1. Clearly identifies and presents pertinent background | | | | | |

|information relative to the topic | | | | | |

|2. Has a command of the subject area and topic presented. | | | | | |

|3. Selects appropriate literature for review and inclusion | | | | | |

|(i.e. primary literature if available, RCTs preferred, etc.) | | | | | |

|or indicates a lack of literature. | | | | | |

|4. Accurately summarizes and applies selected literature | | | | | |

|appropriately to the topic. | | | | | |

|5. References are appropriately utilized and do not contain | | | | | |

|formatting errors. | | | | | |

|ORGANIZATION / MATERIALS |

|1. Stated learning objectives were well-written (specific and| | | | | |

|measurable) and appropriate. | | | | | |

|2. Learning objectives were met by the presentation. | | | | | |

|3. The program subject and degree of detail were appropriate | | | | | |

|for the audience’s level of knowledge. | | | | | |

|4. Handout was appropriate, well-prepared, and contained no | | | | | |

|errors. | | | | | |

|5. Visual aids were well-prepared, visually appealing, easy | | | | | |

|to read, and contained no errors. | | | | | |

|6. Visual aids were used effectively and enhanced the overall| | | | | |

|presentation (i.e. animations were not distracting, graphics | | | | | |

|contributed to talk). | | | | | |

|7. The presentation was organized and presented in a logical | | | | | |

|fashion. | | | | | |

|8. Transitions were used effectively to connect topic areas. | | | | | |

|SPEAKER /COMMUNICATION SKILLS | | | | | |

|2. Utilization of notes or reading from the screen was not | | | | | |

|excessive or distracting. | | | | | |

|3. The speaker spoke in a strong voice and at an appropriate | | | | | |

|pace throughout the presentation. | | | | | |

|4. Distracting mannerisms were avoided (“ums,” “uhs,” etc.). | | | | | |

|5. Information was presented concisely, with authority, and | | | | | |

|in an organized manner. | | | | | |

|6. The presentation was unbiased and provided a fair balance | | | | | |

|of information. | | | | | |

KEY: SD = strongly disagree; D = disagree; A = agree; SA = strongly agree

| |SD |D |A |SA |Comments |

|CONCLUSIONS / QUESTIONS |

|1. The presentation topic was current and relevant to the | | | | | |

|practice of pharmacy. | | | | | |

|2. Stated conclusions and recommendations were appropriate | | | | | |

|given the literature presented. | | | | | |

|3. Answered questions logically and was able to theorize when| | | | | |

|unsure of answers. | | | | | |

|4. Accuracy/depth of answers corresponded with the expected | | | | | |

|competency level of the student. | | | | | |

|5. The program subject and degree of detail were appropriate | | | | | |

|for the time allotted. | | | | | |

Additional comments regarding the quality of the content and organization of the presentation (not speaker):

Additional comments regarding the speaker’s presentation style:

After reviewing the student’s overall performance, it is my opinion the student [PASSED / DID NOT PASS] this oral presentation.

Reviewer: __________________________________________ Date: ____________________

Appendix B

APPE Ambulatory Care Rotation

SMART goal Assignment

|SMART goal Assignment |

Consider your health portfolio results and our discussion on the different areas of health and wellness. Create 2-3 SMART goals that you would like to work on for the next week and complete the following assignment.

My health and wellness goals

1.

2.

3. (optional)

On a scale from 0-10, with 0 being not confident at all and 10 being extremely confident, my confidence in meeting these goals is __________

|Anticipated challenges (i.e. weather, time, …) |How I will address this challenge |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|Journal |

As you work toward your 2 health goals, choose at least 3 days to write a short reflection (3-5 sentences) on your progress.

Entry #1 (date____/____/2016)

Entry #2 (date____/____/2016)

Entry #3 (date____/____/2016)

Entry #4 (date____/____/2016)

Entry #5 (date____/____/2016)

Entry #6 (date____/____/2016)

|Final Reflection |

Reflecting on the past week, write a paragraph (at least 6 complete sentences – no more than ½ a page) about the experience. Include challenges you faced and if they were the same or different than you anticipated. Describe your progress (no progress, work in progress, achieved, maintenance). What things did you find beneficial with meeting your goals? Were your goals easier or harder than you anticipated? Would you keep your same goals if you could go back and change them?

**To be returned to the primary preceptor by Wednesday of Week 1 of the rotation**

Signature of Agreement and Understanding

I, _____________________________ , have read and understand all the information and instructions included within this syllabus. Failure of this APPE rotation may be possible if I fail to meet the minimum requirements or established deadlines.

Student Signature _________________________________________ Date ________________

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