In the same way that IPPE, APPE, and residency clinical experiences can vary, rotations that incorporate telehealth pharmacy practice in full or in portions may also vary. Differences in care flow models for learning experiences include site setting, length of experience, type of learner(s), and option of remote care provided. The care flow model should also identify the points of learner contact and include a plan for transitions between live, telehealth, and/or hybrid models. For reference, a variety of Care Flow Model examples are included below.
Ambulatory Care IPPE Experience Layered with an APPE Student
The second pharmacy year ambulatory care IPPE experience met daily from 8–10:45 am. Students were prepared and precepted to engage in a pharmacy-run Diabetes Self-Management Education and Support (DSMES) service for a federally qualified health center (FQHC).
The ambulatory pharmacy practice site converted from providing live DSMES to providing services via telephone during the COVID-19 pandemic. Due to the confined space at the ambulatory site, learners transitioned from the clinic to meeting at the College of Pharmacy in order to meet social distancing guidelines. The preceptor had remote access to the clinic's electronic health record (EHR) and was provided a password-protected laptop for offsite use.
The clinic support staff scheduled 30-minute patient appointments (available times: 8:30 am–9:00 am; 9:30 am–10:00 am) for the diabetes education class. Patients usually had weekly 30-minute appointments for a total of four sessions. Thirty minutes were allowed between the end and beginning of patient appointments for student feedback and prep-work for the next patient. Second-year IPPE students were grouped into four students per day. Each group of IPPE students provided education to two patients per group.
Orientation and Student Preparation
Learners were provided the syllabus, clinical guidelines, patient education modules, expectations of professionalism, dress, and resources to review before the experience. Students were instructed to bring their laptops in order to access the materials during the experience.
Orientation to IPPE students was provided at 8:00 am on the first day to review the online prepping materials provided and to establish and evaluate baseline knowledge. The preceptor briefed the IPPE students on the evaluation methods that would be employed as well as the roles of the ambulatory pharmacist and APPE student. Expectations of professionalism were reiterated, as were due dates for self-directed learning. Students signed confidentiality agreements and the preceptor collected.
Before each patient session, the students were prepared to provide a quick medication reconciliation. The patient education module to be covered was reviewed with students. The preceptor or APPE student modeled communication strategies. Each of the four students was given responsibility for a section of the patient education module to discuss with the patient.
Following the patient visit, the preceptor debriefed students and assessed learner feedback and concerns.
The preceptor posed the following debriefing questions to the group:
“What did you think you did well?”
“In what areas could you improve on (list a specific event or tactic), or do you need more practice?”
“How did counseling via the telephone differ from in-person?”
“What patient care barriers may have been present today?”
“How did we ensure patient inclusivity and cultural sensitivity? Was this harder or easier via telephone?”
“What items would you want to convey to the patient's provider?”
In addition to the two mornings of telehealth patient encounters, a self-directed case study DSMES SOAP note was required to supplement the experience. In the event of patient no-shows or gaps in the schedule, alternate activities were available, including developing a SOAP note on the patient that would have been seen, providing glucometer and point-of-care technique education, discussing practice guidelines, and reflecting on patient barriers to care.
IPPE/APPE Layered Learning
A layered learning experience was provided with Pharmacy Year 2 (PY2) IPPE students and an APPE academic or ambulatory monthly rotation student. The APPE student was provided access to the online class materials for the IPPE experience and was oriented to the ambulatory site, as well as to the structure of the IPPE experience.
In addition to their ambulatory care learning experience, the APPE student layered-learning responsibilities included involvement in precepting the IPPE students. The APPE student learning activities included writing up patients, gathering supplies, preparing students on the patient education modules, modeling communication strategies, and reviewing IPPE student SOAP notes. The APPE student also assisted the preceptor in real-time formative evaluations of students and providing feedback. The preceptor modeled the patient care activities and IPPE activities initially, allowing the APPE student to grow until the student's entrustability reached independent precepting.
AMBULATORY CARE APPE ROTATION EXAMPLE: BLOCK EXPERIENCE
Fourth-year experiential pharmacy students completed a remote ambulatory care APPE experience over a six-week period. This rotation took place in an outpatient clinic from 8:00 am–5:00 pm. Students were prepared to participate in the management of chronic disease state management, with specific focus on anticoagulation, diabetes, hypertension, hyperlipidemia, and smoking cessation.
The ambulatory pharmacy practice site was converted from a fully live in-clinic rotation to students completing patient care services via telephone and video-conferencing software remotely. The students, residents, and preceptors had remote access to the clinic's EHR.
Daily workflow was divided into three major parts: morning check-in meeting, lunch meeting, and end of the day check-out. The morning check-in meeting consisted of dedicated time with the preceptor and student(s) to discuss the plan for the day. This meeting was conducted over video-conference technology. The discussion included setting out expectations for the day, assigning students to specific patients to work up for anticoagulation management, diabetes management, hypertension management, and hyperlipidemia management, and also assigning students specific patients to complete medication reviews. Student(s) would then spend the morning completing these assigned tasks from home, as they had access to the electronic health records using home laptops and computers. Throughout the morning, students had the ability to contact the preceptor through telephone calls and video-conferencing with questions or concerns.
After the morning tasks were completed, the preceptor and student(s) would complete a lunch meeting, and the lunch meeting was completed over video-conference software, in the same manner as the morning check-in was conducted. During this dedicated time, student(s) would present patients from their morning workup. A tentative care plan was developed for each patient with preceptor guidance. The preceptor would then designate students to specific patients to complete the encounter. These encounters happened over the phone, as well as over video-conference, depending on the patient's preference or technological abilities. The preceptor was available at all times for questions or concerns brought up by the student or the patient. The software used gave the preceptor the ability to three-way into telephone calls or to enter the virtual patient encounter room through video-conferencing to monitor student progress, as well as to step in as needed for patient care. In addition, during the lunch meetings, the students would rotate each day, presenting on a 10-minute clinical pearl. The focus of these pearls was to teach their peer students and preceptor something unusual they has uncovered while working up patients the previous day that required searching through the literature for more information.
The last portion of the day concluded with an end-of-the-day check-out. Depending on patient load and clinical activities completed throughout the afternoon, this check-out was conducted as either a meeting or an email summarizing the afternoon's learning activities. Due to limited patient care access, some days required more longitudinal projects and did not always call for a meeting at the end of the day. If students were completing patient care activities, a meeting was held. Some examples of longitudinal projects that were completed by the students were clinical pearl preparation, research/quality improvement projects, medication-use evaluations, drug information questions, and topic discussion preparation. Students also helped create counseling sheets for patients to take home or to be shared via video-conferencing software for education regarding home monitoring of blood glucose and blood pressure, as well as strategies to start a diabetes-friendly diet and how to use a wide variety of injectable medications. Finally, depending on the time of year, students helped develop patient cases based on the real-life patients they were encountering via telehealth and assessment questions for underclassmen.
Orientation and Student Preparation
On the first day of the rotation, students were provided the syllabus, and expectations were reviewed. Students were oriented to the EHR and video-conferencing software, as well as how to access remote clinical resources. Baseline clinical knowledge was determined, and goals were set for each student.
As daily workflow was divided into three major parts, students had the opportunity to ask questions at each of the designated meeting times, and at the same time preceptors provided students feedback. This formative feedback was in addition to formal feedback given at the halfway mark and at the end of the rotation experience.
Longitudinal Ambulatory Care Resident Rotation, Example 1
As part of a PGY1 community pharmacy resident and PGY2 ambulatory care residency, residents would staff a hospital-based anticoagulation clinic one day every other week. This longitudinal rotation took place every other Friday morning from 8:00 am to 12:00 pm (or until the last patient was seen). Residents were prepared to participate in anticoagulation management for low health literacy and low-income patient population.
The rotation originated as a fully in-person clinic and was transitioned to a fully telephonic clinic. The general patient population consisted of low health literacy and limited access to transportation and healthcare. Patients were scheduled from 8:00 am to 12:00 pm in 30-minute increments. Each time slot had a maximum of five patients scheduled. For example, at 8:00 am, a maximum of five patients would be scheduled, and at 8:30 am an additional five patients. Due to barriers to care and to ensure that patients had a consistent way of obtaining an INR, patients presented to the clinic at the designated appointment time in order to have point-of-care or venous INR completed. The lead pharmacist then assigned each resident a specific timeframe to contact patients. For example, one resident would cover from 8:00 am–9:00 am, contacting a maximum of 10 patients. Pharmacy residents had the responsibility to work up patients, call and interview the patient, and develop a plan with follow-up. A hematologist was present onsite to help manage acute complications related to anticoagulation therapy. To reduce the potential for missed calls or lack of communication for critical INR, the in-clinic provider saw any patients with resulting INR <1.5 or >6.
Orientation and Resident Preparation
On the first day of the longitudinal rotation, residents were provided a syllabus and expectations were reviewed. Residents were oriented to the EHR and were given access to both the EHR and remote clinical resources. In addition to the syllabus, the residents were also provided with the clinic's specific procedures and an “anticoagulation guide” to review prior to seeing and/or communicating with patients.
As this was a longitudinal rotation, residents received formative feedback throughout each shift covered. In addition, formal feedback was provided on a quarterly basis.
AMBULATORY CARE APPE ROTATION EXAMPLE: LONGITUDINAL EXPERIENCE
In a required ambulatory experience for the PGY1 pharmacy practice residency program, learners transitioned to working 100% offsite from the clinic setting. This initial transition allowed the PGY1 residents to meet the increased demands for inpatient staffing during the COVID-19 pandemic and paved the way for an innovative and efficient use of resident time and experience.
A typical day of the rotation was broken into morning and afternoon. Most morning sessions began at 7:30 am with residents remotely reviewing the scheduled patient visits for the day. The PGY1 residents also conducted telephonic interviews for scheduled patient visits to collect patient-specific subjective information that would be shared with the preceptor. These visits focused on the chronic disease states of anticoagulation, hypertension, and diabetes management. Once patients presented to the clinic, they were seen by the pharmacist preceptor to obtain objective information such as vitals and any pertinent labs. The PGY1 pharmacy resident and preceptor then met together via instant messaging, phone, or video-conferencing to discuss the pharmacotherapeutic plan. The plan was then provided to the patient live by the preceptor, or HIPAA-compliant video-conferencing was utilized for the resident learner to present.
The afternoon session began soon after the common lunch hour, which also served as the time for administrative meetings, preceptor feedback, journal clubs, site in-services, patient case presentations, and the like. During the afternoon, the PGY1 pharmacy resident followed up on lab results, coordinated with other providers and specialties, and performed any other duties for the morning's patients.
Orientation and Resident Preparation
As is normally the case for the experience, the resident was oriented with preceptor and site responsibilities and expectations and was given an overview of the learning experience, together with a shared calendar of activities. The provided resources also included are described in Tool for Essential Resources Required for Learner Experience in Chapter 16.
The day concluded with an end-of-day check-out to discuss the lessons learned from the day, as well as any follow-up items and plan for the next day.
Longitudinal PGY1 Ambulatory Care Rotation/Ambulatory Care APPE Rotation: Example
As part of a PGY1 residency, residents participated in a longitudinal rotation that took place weekly from 8:00 am to 5:00 pm. Learners (both students and residents) were prepared to participate in the management of chronic disease state management, with specific focus on anticoagulation, diabetes, hypertension, osteoporosis, and smoking cessation. However, the needs of the physicians were met as patients were referred to the pharmacy service.
This rotation originated as a fully in-person clinic and was transitioned to a hybrid clinic setting. As a layered-learning model, preceptors and residents were stationed in the clinic, while student(s) were stationed from home. Patients were able to complete encounters via telehealth or in person based on the patient's preference. As preceptors and residents were stationed in the clinic, they were responsible for seeing patients that presented to the clinic. However, in certain instances students were able to complete these encounters via video-conferencing software. For example, the student stationed from home, using video-conferencing software, would be brought up on a laptop in the exam room. The student would then proceed to interview the patient, who was present in clinic. Once the interview was completed, the resident or preceptor would take the laptop from the room to discuss the care plan for the patient. The student and resident or preceptor then presented the care plan to the patient.
In addition, residents were also responsible for delegating both patient care activities and longitudinal projects to students. As residents were seeing patients in the clinic, students were assigned to specific patients to work up for anticoagulation, diabetes, hypertension, hyperlipidemia, and osteoporosis management or smoking cessation assistance. The patients that students were responsible for were seen over video-conference or over the phone based on patient preference. Prior to each telehealth pharmacy practice appointment, students would meet with the preceptor to discuss patient workup and create a tentative plan for the patient.
Orientation and Learner Preparation
At the beginning of residency, residents were provided with a syllabus and expectations were reviewed. Baseline clinic knowledge was determined and goals were set. Residents were responsible for precepting APPE students after the first rotation block was completed with preceptor guidance. At the beginning of each APPE rotation block, students were provided with the syllabus, and expectations were reviewed in a similar manner to the resident's first day. For all learners, the EHR and software used for video conferences was reviewed, and each was provided access to the EHR at home, as well as remote clinical resources.
For student learners, the preceptor and residents were available at all times during the telehealth encounter for questions or concerns brought up by the student or the patient. The software used provided the preceptor the ability to three-way into telephone calls or enter the virtual patient encounter room through video-conferencing to monitor student progress, as well as step in as needed for patient care. Formative feedback was provided to students after each patient encounter, and formal feedback was provided at both the midpoint of the rotation and the end of the rotation.
For resident learners, the preceptor was available at all times. However, more independence was given to the resident as the longitudinal rotation progressed. Formative feedback was provided as needed, and formal feedback was provided on a quarterly basis.
BARRIERS WITH SUGGESTED SOLUTIONS ASSOCIATED WITH CARE FLOW MODELS
Barrier 1: Technology Difficulties
Innate issues with technology can be a problem for learners, preceptors, and patients alike. Learners may not have the appropriate technology/hardware to be able to run specific telehealth software or the electronic health record. This situation can be further complicated if Internet connection is unstable or nonexistent.
For learners without appropriate resources at their home (such as reliable Internet or a computer) additional accommodations may be required and will be dependent on the available resources of that site. If there are unused meeting spaces at the site, the learner may be able to be onsite in these nonpatient care areas in order to obtain Wifi Internet access through the institution while following appropriate physical distancing recommendations. Further, if they are onsite, it may be possible for the learner to utilize computers, tablets, and/or telephones owned by the institution in order to deliver the patient care services. This may be preferred by the institution to ensure the devices utilized are appropriately encrypted and protected to prevent the unauthorized spread of patient health information (PHI) inadvertently. Additionally, this will ensure that the software required will be available to the learner and be consistent with the software programs available and utilized by the institution, the precepting pharmacist, and the patient.
Telephonic services provided by learners at their house—Jabber, Google Voice, *67 (although “no show” rates may increase if a blocked number is displayed on the patient's call waiting) instead of using their personal phone number.
Solution 1: Advance Preparation for Technology Difficulties with Prespecified Protocol
Technology issues are inevitable and to a degree unavoidable. As part of rotation preparation, preceptors should develop a handout or flowsheet to help mitigate some of the avoidable issues associated with technology issues, as well as learn what to do if an inevitable technology issue occurs. For example, a handout to mitigate avoidable issues would consist of keeping technology and software up-to-date, completing training associated with software, available troubleshooting contact information for specific software, and so on. If technology issues arise, a flowsheet would consist of steps to take if the Internet connection is unstable or goes out.
Barrier 2: Counseling Can Be Challenging for Administration/Hands-On Activities
Patient education for telehealth comes with its own challenges. A major portion of a learner's job in an ambulatory care setting is to educate patients on the medications they are taking, including proper administration. One of the most common ways pharmacists educate patients is through the teach-back method. Via telehealth, the teach-back method can be completed for general counseling information, but it can be challenging to complete for proper administration of nonoral medications. This creates challenges for pharmacist preceptors and learners to come up with creative ways to overcome.
Solution 2: Early Preparation to Pptimize Communication
There are a variety of ways barriers associated with counseling can be overcome. For example, learners and preceptors can use screen sharing with administration videos when a sample drug or device is not available. It also may be beneficial to email instructions to a patient instead of relying on an after-visit summary to print. Learners can help set patients up with online health records so that it will be easier to communicate with their healthcare providers if they have questions after the appointment is completed. In addition, learners and preceptors can call the pharmacy where the patient will pick up their new medication and further discuss with the pharmacist to help with counseling.
Pharmacy practice and, in turn, pharmacy education will continue to expand and evolve as the needs of both learners and patients change. To meet current and future needs, telehealth rotations and learning experiences have been developed and have barely tapped potential benefits for learners. As previously stated, ACPE and ACCP do not give specific recommendations or requirements for creating or transitioning to telehealth rotations.1 The wide variety of “tools” presented throughout this section can be used to create innovative rotational experiences for students and residents, which will not only improve their learning and development, but also result in better patient care.
Preceptors, student pharmacists, and residents would be well served to embrace the telehealth platform. Market analyses and patient feedback all suggest that telehealth is not only increasingly popular, but increasingly expected within healthcare. As the Harvard Business Review forecasts, “In a few years, the idea of receiving medical treatment exclusively at a doctor's office or hospital will seem quaint…. by coordinating care more effectively and offering daily support—through mobile communication and remote monitoring—along with community outreach, companies can help shift care to more timely, home-based, and less costly interventions … in the next decade, these trends will create a veritable gold rush in patient data and consumer options.”2
SubramanianS, DumontC, DankertC, WongA.Personalized technology will upend the doctor-patient relationship. Harvard Business Review, June 30, 2015. hbr.org/2015/06/personalized-technology-will-upend-the-doctor-patient-relationship#. May 18, 2021.)| false
Because of a recent public health emergency, your clinic wants to limit the number of individuals onsite. You are going to start providing services remotely. You have an advanced pharmacy practice experience (APPE) student who is to start with you next week. You have no idea how long you will need to work remotely. What are some important questions that you need to consider as you are trying to design a remote learning experience for your learner?
One of the first items you should evaluate is whether your learner will be able to access the electronic health record from home. Ensure that your organizational/clinic policies allow learners to remotely access patient information and that the infrastructure allows nonclinic devices to connect to the electronic health record. A next step would be to determine if there is a platform that allows for three-way calling or group video visits so that you can include your learner on your CCM calls. You will want to ensure that expectations on a remote learning experience are clear, including applying HIPAA-regulations at home. You may even consider adapting your current APPE syllabus to account for remote experiences.
A more detailed list of considerations can be found in the “Site Preparation Checklist.”