Pharmacy Services

Pharmacy Services Residency

Pulmonary Internal Medicine

 (PGY1 Rotation - Transitions of Care)

 
Preceptor:

David Young, PharmD

 
Site Description:

The University of Utah Hospital is a level I trauma center that serves critical and acute care patients in 425 beds, and is a referral hospital for a 5-state region. Over 100 FTEs of pharmacy staff serve the patients of University Hospital, and the residents are a part of patient care and multi-disciplinary teams. The Huntsman Cancer Institute also serves patients with 100 inpatient beds, an infusion center, and several clinics. Clinics at the hospital and surrounding communities serve patients with pharmacy care both through retail pharmacies, MTM services, thrombosis services, and clinic-based services. The University Health Care system also includes a Drug Information Service.

 
Rotation Description:

This learning experience will provide the resident with the opportunity to develop the skills necessary to provide patient-centered, evidence-based, collaborative care for adult medicine cystic fibrosis patients. The resident will receive patient care experiences and skills necessary to become proficient and innovative internal medicine pharmacy practitioner and gain experience in providing education to patients, pharmacy students, physician assistant students, and other health care professionals.  The pulmonary internal medicine cystic fibrosis acute and continuity care rotation will consist of rounding daily and providing clinical pharmacy services for the Adult Internal Medicine Cystic Fibrosis inpatient and ambulatory Cystic Fibrosis and Asthma care teams at the University of Utah Health Care.  The primary practice site will be the University of Utah Health Care Acute Internal Medicine Units (AIMA, AIMB) and Internal Medicine Clinic 3.  The resident will develop the ability to design, evaluate, monitor, and adjust patient specific pharmacotherapy regimens for adult internal medicine cystic fibrosis patients taking into consideration any organ dysfunction that may be present.  The resident will be in integral member of the multi-disciplinary Adult Internal Medicine Cystic Fibrosis acute and ambulatory Asthma and Cystic Fibrosis care teams and will be responsible for all pharmacotherapy services for assigned patients.  The resident will provide the following patient care services: admit and discharge medication reconciliation, review and verification of computerized physician order entry (CPOE) medication orders, screening, ordering, and documentation of appropriate vaccinations, review and make recommendations of treatment plans, monitor pharmacotherapy treatment plans for beneficial and potential adverse outcomes, pharmacokinetic and nutritional support consults of appropriate medications, provide drug information when necessary, assist the team in adhering to current policies and procedures and formulary management, coordinate care by communicating with all of the appropriate multidisciplinary team members (e.g. physicians, physicians assistants, nurse practitioners, nurses, respiratory therapists, social workers, and occupational therapists), coordinating transitions of care between the acute and ambulatory care settings.

 
RLS Outcomes, Goals, Objectives & Learning Activities:

Outcome R2: Provide evidence-based, patient-centered medication therapy management with interdisciplinary teams.
Goal R2.1:            As appropriate, establish collaborative professional relationships with members of the health care team.
Goal R2.4:            Collect and analyze patient information.
Goal R2.6:            Design evidence-based therapeutic regimens.
Goal R2.7:            Design evidence-based monitoring plans.
Goal R2.8:            Recommend or communicate regimens and monitoring plans.
Goal R2.9:            Implement regimens and monitoring plans.
Goal R2.10:          Evaluate patients’ progress and redesign regimens and monitoring plans.
Goal R2.11:          Communicate ongoing patient information.
Goal R2.12:          Document direct patient care activities appropriately.
Outcome R5: Provide medication and practice-related education/training
Goal R5.1              Provide effective medication and practice-related education, training, or counseling to patients, caregivers, health care professionals, and the public.

 
Activities Evaluated:

Outcomes, Goals, Objective Number  (Level of Learning Required) & Description

Methods

Rotation Activities

Outcome R2: Provide evidence-based, patient-centered medication therapy management with interdisciplinary teams.

Goal 2.1 As appropriate, establish collaborative professional relationships with members of the health care team.

OBJ R2.1.1     (Synthesis)  Implement a strategy that effectively establishes cooperative, collaborative, and communicative working relationships with members of interdisciplinary health care teams. 

Coaching, Modeling, Facilitation

Formulate a strategy to become an integral member of multidisciplinary Internal Medicine Cystic Fibrosis acute and ambulatory care teams including identifying potential barriers.

See adult asthma (average of 40/week) and cystic fibrosis patients (average 15/week) in the pulmonary medicine ambulatory clinic as a member of the multi-disciplinary pulmonary medicine team

Round daily as a member of the multi-disciplinary cystic fibrosis medicine team on adult cystic fibrosis patients admitted for  their acute exacerbations (average daily census of 8 patients)

Goal R2.4:      Collect and analyze patient information.

OBJ R2.4.1     (Analysis) Collect and organize all patient-specific information needed by the pharmacist to prevent, detect, and resolve medication-related problems and to make appropriate evidence-based, patient-centered medication therapy recommendations as part of the interdisciplinary team.   

Coaching, Modeling, Facilitation

Implement a systematic, patient-specific data collection system in order to develop a pharmacy care plan, and communicate this with the multi-disciplinary team and/or the patient.

Communicating recommendations with the multi-disciplinary team and documenting interventions, medication reconciliation and vaccine screenings in the electronic medical record.

OBJ R2.4.2     (Analysis)  Determine the presence of any of the following medication therapy problems in a patient's current medication therapy:
1.  Medication used with no medical indication
2.         Patient has medical conditions for which there is no medication prescribed
3.         Medication prescribed inappropriately for a particular medical condition
4.         Immunization regimen is incomplete
5.         Current medication therapy regimen contains something inappropriate (dose, dosage form, duration, schedule, route of administration, method of administration)
6.         There is therapeutic duplication
7.         Medication to which the patient is allergic has been prescribed
8.         There are adverse drug or device-related events or potential for such events
9.         There are clinically significant drug-drug, drug-disease, drug-nutrient, or drug-laboratory test interactions or potential for such interactions
10.       Medical therapy has been interfered with by social, recreational, nonprescription, or nontraditional drug use by the patient or others
11.       Patient not receiving full benefit of prescribed medication therapy
12.       There are problems arising from the financial impact of medication therapy on the patient
13.       Patient lacks understanding of medication therapy
14.       Patient not adhering to medication regimen

Modeling, Coaching, Facilitation

Perform medication reconciliations on all patients seen in the ambulatory and acute care settings.  Evaluate drug therapy regimens daily to identify potential medication therapy problems.

OBJ R2.4.3     (Analysis) Using an organized collection of patient-specific information, summarize patients’ health care needs.

Modeling, Coaching, Facilitation

Relate patient-specific recommendations with the multi-disciplinary team and discuss with preceptor daily.

Goal R2.6:      Design evidence-based therapeutic regimens.

OBJ R2.6.1     (Synthesis) Specify therapeutic goals for a patient incorporating the principles of evidence-based medicine that integrate patient-specific data, disease and medication-specific information, ethics, and quality-of-life considerations.

Modeling, Coaching, Facilitation

Formulate individualized therapeutic goals for patients that are being followed utilizing evidence-based medicine and guidelines (if available) and discuss with preceptor daily

OBJ R2.6.2     (Synthesis) Design a patient-centered regimen that meets the evidence-based therapeutic goals established for a patient; integrates patient-specific information, disease and drug information, ethical issues and quality-of-life issues; and considers pharmacoeconomic principles.

Modeling, Coaching, Facilitation

Design individualized pharmacotherapy plans for patients that are being followed utilizing evidence-based medicine and guidelines (if available) and discuss with preceptor daily

Perform pharmacokinetic analysis of once daily aminoglycoside and continuous infusion beta-lactam antibiotic regimens for inpatient cystic fibrosis patients;

Goal R2.8:      Recommend or communicate regimens and monitoring plans.

OBJ R2.8.1     (Application)  Recommend or communicate a patient-centered, evidence-based therapeutic regimen and corresponding monitoring plan to other members of the interdisciplinary team and patients in a way that is systematic, logical, accurate, timely, and secures consensus from the team and patient.

Modeling,
Coaching, Facilitation

Communicating recommendations with the multi-disciplinary team and documenting interventions, medication reconciliation and vaccine screenings in the electronic medical record. Discuss with preceptor daily.

Goal R2.9:      Implement regimens and monitoring plans.

OBJ R2.9.1     (Application) When appropriate, initiate the patient-centered, evidence-based therapeutic regimen and monitoring plan for a patient according to the organization's policies and procedures.

Modeling, Coaching, Facilitation

Determine if the individualized pharmacotherapy plans are in accordance to the University of Utah Health Care’s policies and procedures

Determine the most appropriate method to communicate the individualized pharmacotherapy plans to the appropriate member(s) of the multidisciplinary team(s)

OBJ R2.9.2     (Application)  Use effective patient education techniques to provide counseling to patients and caregivers, including information on medication therapy, adverse effects, compliance, appropriate use, handling, and medication administration.

Modeling,
Coaching, Facilitation

Assess the patient’s understanding of the medication regimen; provide counseling (including over-the-counter medications and supplements) regarding the medication regimens when appropriate

 

Goal R2.11:    Communicate ongoing patient information.

OBJ R2.11.1   (Application) When given a patient who is transitioning from one health care setting to another, communicate pertinent pharmacotherapeutic information to the receiving health care professionals.

Modeling, Coaching, Facilitation

Identify potential drug related problems in the therapy of patients experiencing a transition of care.  This may involve communication with outpatient /inpatient pharmacists and/or physicians who provided care to the patient.

Communicate concerns and recommendations orally and/or in writing regarding medication therapy and transitions of care. Discuss with preceptor daily.

Facilitate transitions of care between inpatient and outpatient settings when appropriate

OBJ R2.11.2   (Application) Ensure that accurate and timely medication-specific information regarding a specific patient reaches those who need it at the appropriate time.

Modeling, Coaching, Facilitation

Communicate concerns and recommendations orally and/or in writing regarding medication therapy and transitions of care. Discuss with preceptor daily.

Goal R2.10:    Evaluate patients’ progress and redesign regimens and monitoring plans.

OBJ R2.10.1   (Evaluation) Accurately assess the patient’s progress toward the therapeutic goal(s).

Modeling, Coaching, Facilitation

Assess each patient’s progress towards stated therapeutics goals and discuss with preceptor daily.

 

OBJ R2.10.2   (Synthesis) Redesign a patient-centered, evidence-based therapeutic plan as necessary based on evaluation of monitoring data and therapeutic outcomes.

Modeling, Coaching, Facilitation

Modify, when appropriate, the pharmacotherapy plans with each patient seen in clinic or daily throughout their hospital stay to achieve stated goals and outcomes. Discuss with preceptor daily.

Goal R2.12:    Document direct patient care activities appropriately.

OBJ R2.12.1   (Analysis) Appropriately select direct patient-care activities for documentation

Modeling, Coaching, Facilitation

Determine the appropriate individualized patient care activities to document in the EMR

OBJ R2.12.2   (Application) Use effective communication practices when documenting a direct patient-care activity.

Modeling, Coaching, Facilitation

Document the appropriate individualized patient care activities to document in the EMR

OBJ R2.12.3   (Comprehension)  Explain the characteristics of exemplary documentation systems that may be used in the organization’s environment.

Coaching, Facilitation

Describe the elements necessary for documenting patient care activities in the EMR.

Outcome R5: Provide medication and practice-related education/training

Goal R5.1        Provide effective medication and practice-related education, training, or counseling to patients, caregivers, health care professionals, and the public.

OBJ R5.1.1     (Application) Use effective educational techniques in the design of all educational activities.

Modeling, Coaching, Facilitation

 Provide medication and disease state education, when appropriate, to patients in both the ambulatory and acute care settings.

 
Typical Daily/Weekly/Monthly activities:

A typical day will be 0800-1600 but additional hours are usually necessary to complete projects, readings for topic discussions and journal club, and attend meetings. 
0800-0900       Round preparation- patient monitoring and medicine reconciliations
0900-1500       Internal medicine cystic fibrosis rounds & cystic fibrosis/asthma clinic
1500-1600       Patient presentations- identify and resolve follow-up issues with team
1600 +             Additional time to work on projects, topic discussions, resolve any remaining follow-up issues with team

 
Readings:

A dropbox folder will be maintained containing readings that includes but is not limited to current guidelines for review and topic discussion throughout the experience

 
Evaluation:

The resident will receive verbal feedback (formative evaluation) on a daily basis by the preceptor. They will have formative snapshot self and preceptor evaluations at the midpoint and self and preceptor summative evaluations of all goals at the end of the rotation. The resident will complete preceptor and learning experience evaluations at the end of the rotation. The evaluations will be documented in ResiTrak. All evaluations must be co-signed within 2 weeks of completion of the rotation.