PGY2 Ambulatory Care Pharmacy Residency

Philadelphia College of Pharmacy at The University of the Sciences in Philadelphia
In Conjunction with Philadelphia Veteran’s Affairs Medical Center, Penn Presbyterian Medical Center, and Cooper University Hospital

Introduction

The Philadelphia College of Pharmacy (PCP) at the University of the Sciences in Philadelphia (USP) in conjunction with affiliated teaching hospitals located in the Philadelphia area offers a one-year post-graduate year 2 residency program in ambulatory care.

The PGY 2 Ambulatory Care Residency at PCP is designed to further refine skills attained during a PGY 1 Pharmacy Residency – specifically skills in (1) providing direct care to patients in an ambulatory care setting; (2) developing new clinical services, and (3) educating doctor of pharmacy students. The resident will practice in pharmacist-managed medication management/chronic disease state management and anticoagulation clinics, family medicine clinic, and HIV clinic at an affiliated teaching center in the Philadelphia area. Elective rotation experiences are available. There will be opportunities for the resident to assist with developing new clinical services. The resident will develop teaching skills by participating in didactic and experiential education for doctor of pharmacy students and by attending teaching seminars given by faculty at the Philadelphia College of Pharmacy. The resident will complete a teaching certificate program.

The Goals and Objectives of the program are those of the ASHP-accredited PGY2 Ambulatory Care Residency program.

Outcomes

Establish a collaborative interdisciplinary practice.
In a collaborative interdisciplinary ambulatory practice provide efficient, effective, evidence-based, patient-centered treatment for chronic and/or acute illnesses in all degrees of complexity.
Demonstrate leadership and practice management skills.
Promote health improvement, wellness, and disease prevention.
Demonstrate excellence in the provision of training or educational activities for health care professionals and health care professionals in training.
Complete a teaching certificate program (Appendix A).
Demonstrate project management skills.
Complete data collection and analysis of a residency project.
Demonstrate skills required to function in an academic setting.
Where the ambulatory pharmacy practice is within a setting that allows pharmacist credentialing, successfully apply for credentialing.
Understand the role of the ambulatory care pharmacy leader in the development of public health policy.
Demonstrate skills required to function in an academic setting.

Goals

Participate in the development and implementation of collaborative interdisciplinary practice agreements.
Contribute the development of a new ambulatory pharmacy service or to the enhancement of an existing service.
Establish collaborative professional relationships with members of the ambulatory health care team.
Place priority on the delivery of patient-centered care to ambulatory patients.
Establish health care partnerships with ambulatory patients.
Collect and analyze information specific to an ambulatory patient.
Provide evidence-based, patient-centered medication therapy management with interdisciplinary teams.
Appropriately triage patients.
Design evidence-based medication, non-medication, health improvement, wellness, and/or disease prevention regimens for ambulatory patients presenting with a wide range of disease states and conditions.
Design evidence-based monitoring plans for ambulatory patients.
Design education for a specific ambulatory patient’s regimen and monitoring plan
Recommend or communicate regimens and monitoring plans for ambulatory patients.
Implement medication, non-medication, health improvement, wellness, and/or disease prevention regimens; monitoring plans; and education for ambulatory patients.
Evaluate ambulatory patients’ progress and redesign medication, non-medication, health improvement, wellness, and/or disease prevention regimens and monitoring plans.
Communicate ongoing patient information.
Document patient care activities appropriately.
Exhibit essential personal skills of a practice leader.
Conduct a clinical, humanistic or economic outcomes analysis of an ambulatory service.
Design and deliver programs that contribute to public health efforts.
Provide effective education or training to health care professionals and health care professionals in training.
Understand faculty roles and responsibilities.
Exercise teaching skills essential to pharmacy faculty.
Successfully petition for credentialing as an ambulatory care pharmacy practitioner.
Understand faculty roles and responsibilities.
Exercise teaching skills essential to pharmacy faculty.

Objectives

By the completion of the ambulatory care residency, the resident will be able to:

Patient Care and Practice Site Activities

Explain the process by which collaborative interdisciplinary practice agreements are developed and implemented.
Develop a hypothetical proposal for a collaborative interdisciplinary practice agreement that could be used in a specific area of the ambulatory practice.
Assess a current ambulatory pharmacy service or program to determine if it meets the stated goals.
Participate in the writing of a proposal, real or hypothetical, for a marketable, new or enhanced ambulatory pharmacy service.
Formulate an effective strategy for promoting a proposal, real or hypothetical, for a new or enhanced ambulatory pharmacy service.
When applicable, manage the implementation of a new or enhanced ambulatory pharmacy service or program.
Implement a strategy that effectively establishes cooperative, collaborative, and communicative working relationships with members of interdisciplinary ambulatory health care teams.
Choose and manage daily activities so that they reflect a priority on the delivery of appropriate patient-centered care to each ambulatory patient.
Formulate a strategy that effectively establishes a health care partnership with a particular ambulatory patient.
Exercise proficiency in the application of physical assessment skills commonly employed by ambulatory care pharmacists to secure needed patient-specific information.
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, non-medication, health improvement, wellness, and/or disease prevention recommendations.
Determine the presence of any of the following medication, non-medication, or adherence problems in a patient's current therapy:
- Medication used with no medical indication
- Patient has medical conditions for which there is no medication or non-medication therapy prescribed
- Medication or non-medication therapy prescribed inappropriately for a particular medical condition
- Immunization regimen is incomplete
- Current medication therapy regimen contains something inappropriate (dose, dosage form, duration, schedule, route of administration, method of administration)
- There is therapeutic duplication
- Medication to which the patient is allergic has been prescribed
- There are adverse drug or device-related events or potential for such events
- There are clinically significant drug-drug, drug-disease, drug-nutrient, or drug-laboratory test interactions or potential for such interactions
- Medication or non-medication therapy has been interfered with by social, recreational, nonprescription, or nontraditional drug use by the patient or others
- Patient not receiving full benefit of prescribed medication or non-medication therapy
- There are problems arising from the financial impact of medication or non-medication therapy on the patient
- Patient lacks understanding of medication or non-medication therapy
- Patient not adhering to medication or non-medication regimen
- Patient not adhering to prescribed monitoring plan
Using an organized collection of patient-specific information, prioritize ambulatory patients’ health care needs.
When presented with a patient with health care needs that cannot be met by the ambulatory care pharmacist, make a referral to the appropriate health care provider based on the patient’s presenting problem and acuity.
Assure a plan for follow-up for a referred ambulatory patient.
Specify therapeutic goals, compatible with long-term management of the ambulatory patient, incorporating the principles of evidence-based medicine that integrate patient-specific data, disease and medication-specific information, ethics, quality-of-life, and end-of-life considerations.
Design a patient-centered regimen, compatible with long-term management of an ambulatory patient 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.
Design a patient-centered, evidenced-based monitoring plan for an ambulatory patient’s medication, non-medication, health improvement, wellness, and/or disease prevention regimen that effectively evaluates achievement of the patient-specific goals.
Accurately identify what education will be essential to the patient’s or caregiver’s understanding of the medication, non-medication, health improvement, wellness, and/or disease prevention regimen and monitoring plan; how to adhere to it; and the importance of adherence.
Design an effective and efficient plan for meeting the educational needs of a specific ambulatory patient, including information on medication therapy, adverse effects, adherence, appropriate use, handling, and medication administration.
Recommend or communicate a patient-centered, evidence-based medication, non-medication, health improvement, wellness, and/or disease prevention regimen and corresponding monitoring plan to other members of the interdisciplinary team, patients, and/or caregiver in a way that is systematic, logical, accurate, timely, and secures consensus.
When appropriate, order tests according to the ambulatory environment's policies and procedures.
Use effective patient education techniques to provide and evaluate the effectiveness of the regimen’s patient education.
Use a working knowledge of the organization’s referral process to make any necessary patient referrals.
Make follow-up appointments as specified in the monitoring plan.
Accurately assess the patient’s progress toward the specified goal(s).
If necessary, redesign a patient-centered, evidence-based medication, non-medication, health improvement, wellness, and/or disease prevention regimen as necessary based on evaluation of monitoring data and outcomes.
When given an ambulatory patient who is transitioning to a different health care setting, communicate pertinent medication, non-medication, health improvement, wellness, and/or disease prevention information to the receiving health care professional(s).
Ensure that accurate and timely medication-specific information regarding a specific ambulatory patient reaches those who need it at the appropriate time.
Document all direct patient-care activities into the patient’s medical record.
Use effective communication practices when documenting a direct patient-care activity.
Explain the characteristics of exemplary documentation systems that may be used in the ambulatory environment.
Explain the pharmacist’s role in public health, including specific contributions to public health efforts.
Design and deliver programs for health care consumers that center on health improvement, wellness, and disease prevention.

Professional Growth and Development

Practice self-managed continuing professional development with the goal of improving the quality of one’s own performance through self-assessment and personal change.
Demonstrate commitment to the profession through active participation in local, state, and/or national professional organizations.
Demonstrate a commitment to advocacy for the optimal care of patients through the assertive and persuasive (not aggressive) presentation of patient care issues to members of the health care team, the patient, and/or the patient’s caregivers. Use effective negotiation skills to resolve conflicts.

Explain the nature of mentoring in pharmacy, its potential connection with achievement, and the importance of willingness to serve as mentor to appropriate individuals.
Use group participation skills when leading or working as a member of a committee or informal work group.
Follow established procedures to successfully apply (may be a hypothetical application if not permitted at the site) for credentialing as an ambulatory care pharmacy practitioner.
Understand the role of ambulatory care pharmacists in the development of public health policy.
Explain variations in the expectations of different colleges/schools of pharmacy for teaching, practice, research, and service.
Explain the role and influence of faculty in the academic environment.
Describe the academic environment. Describe the types and ranks of faculty appointments.

Discuss the promotion and/or tenure process for each type of appointment. Identify resources available to help develop academic skills. Explain the characteristics of a typical affiliation agreement between a college of pharmacy and a practice site (e.g., health system, hospital, clinic, retail pharmacy).

Research and Other Scholarly Activities

Identify a clinical, humanistic, or economic service issue that would be useful to study and can be completed in one year.
Use a systematic procedure for performing a comprehensive literature search.
Draw appropriate conclusions based on a summary of a comprehensive literature search.
Generate a research question(s) to be answered by the outcomes investigation.
Develop specific aims and design study methods that will answer the question(s) identified.
Use a systematic procedure to collect and analyze data.
Draw valid conclusions through evaluation of the data.
Use effective communication skills to report orally the study results and recommendations.
Prepare, using accepted manuscript style, the results of the outcomes your study.
Submit the manuscript to a biomedical journal for publication.

Instructional Activities (excluding patient care instructional activities)

Complete the Resident and Fellow Teaching Certificate Program.

Faculty

Residency Program Director:

Tyan Frazier, PharmD, BCPS
Assistant Professor of Clinical Pharmacy
Philadelphia College of Pharmacy
University of the Sciences in Philadelphia

Additional Preceptors:

To be selected by the resident in conjunction with the Department of Pharmacy Practice and Pharmacy Administration Residency and Fellowship Program Coordinator (list is not all-inclusive):

Cathy Poon, PharmD
Associate Professor of Clinical Pharmacy

Grace Earl, PharmD
Assistant Professor of Clinical Pharmacy

Tyan Frazier, PharmD, BCPS
Assistant Professor of Clinical Pharmacy

Jomy Joseph, PharmD
Assistant Professor of Clinical Pharmacy

Tanya Dougherty, PharmD, BCPS
Clinical Coordinator
Pharmacy Department
PENN Presbyterian Medical Center, and
Adjunct Assistant Professor of Clinical Pharmacy

Facilities

The primary training sites for the PCP Ambulatory Care PGY 2 resident are PCP and its affiliated training sites which may include, Philadelphia Veterans Affairs Medical Center, PENN Presbyterian Medical Center, and Cooper University Hospital. Practice sites will be selected based upon the resident’s rotation schedule and preceptor’s schedule.

Philadelphia College of Pharmacy

The Philadelphia College of Pharmacy is the oldest College of Pharmacy in the United States. Since its origin in 1821, the College has continued to be a leader in pharmacy education providing Entry-Level Doctor of Pharmacy degree, and Flexible Doctor of Pharmacy degree programs. Other pharmacy-related baccalaureate programs are offered in the areas of pharmaceutical technology and pharmaceutical marketing and management. The College also offers graduate degrees in Pharmaceutics, Pharmacology and Toxicology, and Pharmacy Administration. Additional post-graduate pharmacy training programs offered by the College include clinical residencies or fellowships in pediatrics and cardiology.

Philadelphia VA Medical Center

The Philadelphia VA Medical Center, which has been in existence since 1952, serves more than 350,000 veterans who reside in eight county areas of Pennsylvania and New Jersey. The Medical Center has 133 operating beds, and supports a 220-bed Nursing Home. The Medical Center is affiliated with the University of Pennsylvania’s School of Medicine and has the distinction of being named as a National Research Center of Excellence for its Center for Health Equity, Research and Promotion (CHERP) and Mental Illness Research Education and Clinical Center (MIRECC). The Medical Center’s anticoagulation clinic is pharmacist-managed, and clinical pharmacists provide direct care to patients with diabetes, hypertension, dyslipidemia, and other chronic conditions in the Medical Center’s physician-referral pharmacy disease state management clinics. In addition to our pharmacy disease state management clinics, clinical pharmacists work with our health care providers in the hepatitis C/infectious diseases and pain management clinics. There is interest in expanding pharmacy’s role in the Medical Center’s smoking cessation and erythropoietin clinics, providing an opportunity the PGY 2 ambulatory care resident to gain experience with assisting in the initiation of new pharmacy services.

Penn Presbyterian Medical Center

Penn Presbyterian Medical Center, part of the University of Pennsylvania Health System, has served residents of Philadelphia for more than a century. The health care providers at the family medicine service at the Penn Family Care clinic are residents and faculty of the University of Pennsylvania Family Medicine Department. The affiliated family medicine residency is a 3-year program comprised of 18 family medicine residents who provide care both in our ambulatory care facility, Penn Family Care and hospital affiliates Penn Presbyterian Medical Center and the Hospital of the University of Pennsylvania. There are approximately 30 physicians who provide care across the age spectrum at Penn Family Care. In fiscal year 2008, there were 44,000 patient visits to the clinic. The clinic serves the West Philadelphia community with about 65% of patients receiving a form of
medical assistance. The faculty are experts in sports medicine, pediatrics, geriatrics, obstetrics and gynecology, women’s health and internal medicine.

Ambulatory care pharmacy services at Penn Family Care began in 2003. Services include a physician-referral pharmacy managed medication management clinic, group diabetes visits, anticoagulation surveillance program, multidisciplinary home visit program, and a diabetes transitions in care program.

Cooper University Hospital

Early Intervention Program (EIP) Clinic at Cooper University Hospital

The EIP Clinic offers assistance to adult patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Since 1990, the clinic has provided comprehensive medical, social, psychological, nutritional, research and educational services to approximately 700 patients in the south Jersey region. The care of each patient is monitored by a multi-disciplinary team which includes physicians, nurse practitioners, nurses, pharmacists, therapists, and social workers. The EIP clinic also serves as a large site for clinical research trials, including those conducted by the AIDS Clinical Trial Group (ACTG

Components of the Program

Professional Skill Development

Patient care-related responsibilities will vary according to the rotation but shall be directed toward providing clinical pharmacy services at affiliated teaching medical centers. These may include development of rational drug therapy, conducting patient interviews and physical assessment, prospective evaluation of drug therapy for efficacy, toxicity, and drug interactions, and assessment for need for and development of new ambulatory care clinical pharmacy services. These activities will involve approximately 50-60% of the resident's time.

Instructional Activities

The instructional activities of the resident are individualized and may include precepting Doctor of Pharmacy students on introductory (P1) or advanced experience (P4) rotations, lecturing in entry level Doctor of Pharmacy therapeutics courses (P3), serving as a clinical pharmacy skills (P1) or therapeutics laboratory instructor (P3). The resident will complete the Residency and Fellowship Teaching Certificate Program.

These activities will involve approximately 20% of the resident's time, or approximately 400 total instructional hours per year. For example, instructional hours will be counted as follows:
Advanced Pharmacy Practice Experience Precepting:
Primary Preceptor for 2-3 rotations of 2 students per rotation annually (100 hours per rotation of 2 students)
Didactic Lectures:
1-2 hours of lecture annually with 20 hrs of preparation time per lecture hour Small Group Instructor/Discussion Leader:
1-2 hours per week for 14 wks (1 semester) with 2 hours of preparation time per hour of class time

Scholarly Activity / Research

The resident will prepare, complete and present (external to the College) an investigational protocol. The resident will prepare an abstract and manuscript of the research. Typically, the research project results will be presented at the Eastern States Residency and Preceptor Conference held in May. The resident may also submit their research for presentation at a national meeting such as the American College of Clinical Pharmacy or American Society of Health-System Pharmacists meetings following completion of the PGY1 year. The resident may also be involved in data collection for other research projects of their preceptors during a particular patient care experience. In addition, the resident is required to present the results of the residency research project to the Department of Pharmacy Practice and Pharmacy Administration at the conclusion of the residency.

The resident is required to prepare a manuscript suitable for publication that is either a case report or review article.

These activities will involve approximately 15-25% of the resident's time.

Professional Growth and Development

The resident is a member of the Department of Pharmacy Practice/Pharmacy Administration and will participate in departmental activities including faculty meetings, committees and exam proctoring. The resident will complete the medication use skill development at the affiliated teaching medical center. This may require some staffing pharmacy experience depending on the entry skill level of the resident. The resident is encouraged to attend professional meetings.

Proposed Schedule

It is anticipated that the resident will spend a minimum of 2000 hours annually in program-related activities. The resident will start July 1, 2009. The first rotation is a 3-week orientation to the Medication Use Process at their primary clinical practice site. On or about July 22, 2009, the resident will begin rotations to include 8 patient care rotations and one residency project and writing rotation. An individualized schedule will be tailored to the needs and interests of the resident. Goals and objectives will be developed for each rotation.

Available Practice Experiences:

Required:

HIV Medication Management Clinic (Dr. Joseph)
Family Medicine (Dr. Dougherty)
Residency Project (one 5-week experience devoted to designing, collecting and analyzing data for the required residency research project)
Medication Management/Chronic Disease Management Clinic (Dr. Frazier)
Anticoagulation (Dr. Frazier)

Elective Experiences (to be determined based upon candidate’s interest and availability):

Transitions in care (Dr. Dougherty)
Internal Medicine (Dr. Dougherty)
Geriatric Medication Management (Dr. Frazier)

Evaluation and Residency Completion

All goals and objectives as set forth by the ASHP Residency Standards the additional objectives listed above must be achieved by the resident in order to successfully complete the residency.

Based upon a survey of incoming skills and experience, the resident will receive a modified set of residency goals and objectives by the end of the first month of the program. Some ASHP Residency goals and objectives may have already been met based upon prior experience and some additional residency goals and objectives may be added depending on resident interest and program requirements. This Customized Training Plan (CTP) and residency goals and objectives, will be assessed quarterly by a Residency Advisory Committee (RAC) composed of preceptors and faculty advisors to the resident and residency program director (RPD) and updated based upon a review of the residents narrative of progress towards goal and objective completion as well as preceptor evaluations. The CTP may be revised to include remedial work if required by the RAC or RPD to assist the resident with goal and objective completion.

All goals and objectives for the CTP must be achieved by the resident in order to successfully complete the residency. At the discretion of the RPD, the resident may be granted an extension of 6 months (until December 31st) without pay to complete any outstanding goals and objectives pertaining to manuscript submission and research project completion.

A certificate of residency completion will be awarded upon successful completion of the residency.