Pharmacecutical care preceptor training and assessment in community pharmacy clerkship sites
Scott, David M
This training model used self-study, home-based therapeutics instruction and a clerkship strategy to train rural community pharmacy preceptors in pharmaceutical care (PC). Specific aims were to: (i) provide intensive instruction in clinical and managerial aspects of setting up a PC model in a rural community pharmacy setting, and (ii) assess effectiveness of the instruction through post-training assessment of PC activities. Through this training, ten rural community pharmacy externship sites are being converted to PC sites that can support experiential training. Following a therapeutics course of study, faculty members conducted a case-study review for primary care disease states (i.e., diabetes, hypertension and asthma) and patient assessment skills were demonstrated and practiced. Preceptors enhanced their skills in documenting patient interventions and computer usage. Preceptors toured two rural community pharmacies with ongoing PC programs with an accompanying interactive session. Action plans (business plans) were presented on the last day of training, revised and submitted by each preceptor. Each preceptor was mailed a follow-up survey at 18 months post-training. All ten preceptors completed the survey. Three of ten preceptors directly charge patients for PC. “Time” followed by “lack of reimbursement” was rated the most problematic obstacles in implementing PC into their practice. Areas of the program rated most favorably by preceptors were the therapeutic reviews, case presentations, and monitoring techniques. Most have implemented some component of the training, although each preceptor stated they were at an early stage. As pharmacy schools struggle to integrate PC into their experiential training, this project provides a model that can be transferred to other colleges/schools of pharmacy.
Community pharmacy’s future has been described as the successful application of pharmaceutical care (PC) in these settings. Specifically, PC addresses the application of drug knowledge and patient counseling to promote proper drug usage(1). The essence of PC is embodied in pharmacists’ abilities to work with patients and health care providers to assure appropriate use, safety and compliance toward the goal of identifying, resolving and preventing drug therapy problems. Successful pharmacists of the future will be distinguished by their ability to deliver effective PC(2). Effectively implemented PC requires competence and confidence by the pharmacist. For PC to be accepted, pharmacist’s must first overcome pharmacy’s product-focus, opposition from other health care entities, financial and logistical problems, and their own lack of knowledge and inertia(3). Currently, the U.S. health care system is fragmented, yet striving to provide a “seamless,” more continuous care. Seamless care assumes that treatment initiated in hospital settings (secondary and tertiary care) is continued and therapeutic outcomes are achieved in primary care settings and vice versa(4). Health reform movements such as managed care have forced a rethinking of health care priorities and how each health professional is integral in providing continuous care. ff pharmacists are to contribute to the provision of continuity of care within our health care system, they require specific training in pharmaceutical care.
Review of Other Pharmaceutical Care Training Programs.
As pharmacy educators are revising curricula, many pharmacists are -retooling” to remain competitive in the marketplace. Colleges of pharmacy have responded to this demand by offering nontraditional pathways leading to the doctor of pharmacy degree, and some schools have also developed PC training programs(4). The Minnesota Pharmaceutical Care Project has trained approximately 100 community pharmacists in PC(2). The Iowa Center for Pharmaceutical Care (ICPC) implemented a collaborative partnership between the Iowa Pharmacy Foundation and the Colleges of Pharmacy at Drake University and University of Iowa. The ICPC has trained 230 pharmacists and is a two-session training program. After a oneday session focused on re-engineering, pharmacists were given eight weeks to implement the objectives indicated in their action plan. Session II, encompassing three days focuses on communication skills, documentation and writing SOAP notes, The Iowa investigators compiled a list of obstacles impeding PC implementation into six categories: pharmacists’ attitudes, lack of advanced practice skills, resource-related constraints, system-related constraints, intra-professional obstacles, and academic/educational obstacles(5).
At Purdue University, a Pharmaceutical Care Certificate Program (PCCP) model was developed and has trained 34 community pharmacists from chain, independent, and HMO practice settings. PCCP involves 108 hours of didactic and experiential training over a nine-month period. Pharmacists in the program are trained at using the components of PC in correcting drug therapy problems and have adjusted workflow and physical layouts. However, time to provide these services remains a formidable barrier(6).
Nebraska Infrastructure. The Rural Health Education Network (RHEN) was developed to help address the needs of the citizens of Nebraska for rural health care. Nebraska is primarily rural with one-half of the population residing in two cities in the eastern end of the state, and the remaining 800,000 citizens residing in the western two-thirds of the state. As a RHEN participant, the College of Pharmacy (COP) has developed programs to attract rural students into the COP, and a curriculum track focusing on delivery of PC in rural settings. Hopefully, some of these students will return to practice in rural areas. This approach is supported by a recent study that found that pharmacists locate in communities similar in size to where they grew up and received clerkship/internship training(7). Located in the eastern end of the State, the COP has rural education programs in hospital, community, geriatric, and psychiatric pharmacy practice in more than 35 communities. Sixty volunteer COP pharmacy preceptors provide clinical instruction in these practice settings. Beginning with the 199495 academic year, COP students had the option of completing their fourth year clerkships in western Nebraska. Two full-time pharmacy faculty, who provide education and clinical services at a regional medical center, have developed and supervise clerkships specifically designed to prepare students for rural practice.
The Nebraska Drug Information Network (Network), initiated in 1993, developed computerized health and drug information centers in thirty-one rural community pharmacies(8), Each site is provided with a computer with multimedia capabilities and is linked to the Medical Center through the Internet/Intranet that allow access to various databases including Medline(TM), International Pharmaceutical Abstracts (IPA)(TM) and Micromedex(TM). Patient education software available at each site includes: Dynapulse(TM), Mayo Clinic Family Health Book(TM), Home Medical Advisor Pro(TM), Wellness Checkpoint(TM), Womb with a View(TM), and Bodyworks(TM).
PRECEPTOR PC TRAINING PROGRAM
The University of Nebraska Medical Center (UNMC) College of Pharmacy (COP) developed a PC training program in 1991 94 in which seven rural preceptors trained at the Medical Center for one to two weeks to upgrade their clinical skills. The purpose of the 1996 preceptor training program was to adapt the 1991-94 in-house training model to one involving homebased therapeutics training, clinical training, strategic planning, and follow-up support. Ten rural community pharmacy preceptors chosen from established Network sites were recruited for participation in this project. Chosen sites were community pharmacy externship sites with competent and motivated preceptors as perceived by student and faculty evaluations. Preceptors selected had expressed an interest in the project and showed aptitude and leadership potential in PC. A curriculum was developed to ease training of preceptors through homebased self-study to learn therapeutics and PC training to develop clinical skills.
Self-Study Therapeutic Modules. Each preceptor completed three therapeutic modules (asthma, diabetes, and hypertension) over eight weeks. Each module comprised five hours of continuing education credit and was completed at their home through self-study. Each module consisted of learning objectives, two readings and an examination. The hypertension module included a continuing education review of therapy for hypertension(9) and the Joint National Committee on High Blood Pressure(10). Readings were selected by the clinical faculty member who teaches the therapeutic sequence in the specific disease state and have presented continuing education programs for Nebraska community pharmacists. Readings for the asthma module(11,12) and the diabetes module(13,14) are given in the references.
Before they could advance to PC training, each preceptor had to score a minimum of 80 percent on the competency-based examination over the material covered in each module. All preceptors passed each of the three examinations and no one scored below an 85 percent. For the three examinations, the overall mean score was 95.9 percent (asthma 95.6 percent, diabetes 96.7 percent and hypertension 95.6 percent).
PC Training. Training components were PC skills (36 hours) and computer skills (four hours) (Figure 1). On-site preceptor training included the development of patient monitoring skills for blood pressure, peak flow meters, and glucose monitoring in patients with diabetes. Drug therapy of each disease state was reviewed in a case-based format. Preceptors also toured two rural community pharmacies with ongoing PC programs (Barr Pharmacy in Blair, Nebraska and Travis Pharmacy in Shenandoah, Iowa). Both sites were chosen for this purpose because of their geographic location making it accessible during the one-week intensive PC training and existing PC services being provided. Preceptors visited and toured both sites to gain an appreciation of the layout and development, and how to overcome barriers that they may face as they implement PC into their pharmacy practices. Preceptors also participated in clerkships in family practice, internal medicine and geriatrics at UNMC. PC training also included patient assessment skills, drug therapy monitoring and patient counseling.
Computer skill development included “hands on” keyboard instruction by a University Computing Center (UCC) instructor and the Network Director on communication packages, Internet and abstracting services accessible through online retrieval (e.g., Medline, IPA). Each Network externship site had computerized drug and health information resources already established at the site. Each site has a personal computer that offers multimedia capabilities using a variety of patient education software. As previously discussed, an electronic telecommunications package links each community site with the Medical Center mainframe computer, Medical Center library, and other health information databases including the National Library of Medicine.
Action Plans. Before finishing the PC training, each preceptor was requested to complete a PC action plan for their community setting. Action plans were directed at implementation of PC for one of the three disease states (i.e., asthma, diabetes, hypertension). The action plan addressed both short-term (within one year) and long-term goals (two to three years). Action plan components included needs’ assessment, chosen disease state, marketing of the plan to physicians and patients, workflow changes incorporating supportive pharmacy personnel and other pharmacists, proposed changes in layout, computer use, student involvement, follow up support, and an evaluation plan to assess their PC program’s success.
Follow-up Support. Upon return to their pharmacy, as the preceptor initiated their action plan, problems emerged that required follow-up technical support. Preceptors could contact COP faculty or other Network preceptors by the Network electronic mail or by telephone for assistance. Network and PC updates were communicated by electronic mail to the network sites.
FOLLOW UP SURVEY OF PRECEPTOR PHARMACISTS
Survey Design and Mailing. A survey was adapted from the 1996 Nebraska Pharmaceutical Care (NPC) Survey and included items regarding practice characteristics and obstacles to PC(5,15). In February 1998, this survey was mailed to the 10 pharmacists. Each questionnaire was coded with an identification number permitting name and address location to avoid sending duplicate mailings to those who have responded. A repeat survey mailing was sent at eight weeks to nonrespondents.
Data Analysis. Respondents were categorized into urban and rural area pharmacists. The Office of Management and Budget (OMB) metropolitan statistical areas (MSAs) designation was used to distinguish between urban and rural areas(16). Only five counties in Nebraska, surrounding and including Lincoln and Omaha, qualify as MSAs. Pharmacists living in the nonMSA county areas (zip codes) were categorized as rural. All ten pharmacist preceptors met the rural criteria. For most items (i.e., practice characteristics, PC skills assessment and desired PC skills by pharmacy graduates), preceptor responses were compared to rural pharmacists collected previously in the NPC survey(15). All data were entered into a SAS database(17) using the IBM mainframe at UNMC. Assessment variables were evaluated by descriptive analysis.
Respondent and Pharmacy Practice Characteristics. All of the 10 surveys mailed were returned (100 percent response rate). Nine pharmacist preceptors were male and one was female. Four of ten pharmacists (40.0 percent) had a Doctor of Pharmacy degree. Half of the pharmacists had graduated from UNMC (n=5), and the second highest number graduated from Creighton University (n=4). Seven respondents reported more than 10 years practicing pharmacy and had practiced at the same pharmacy site for more than 10 years. Nine pharmacist preceptors practiced independent community pharmacy in rural settings. One preceptor described his practice setting as a rural health system integrating hospitals, nursing homes and community pharmacies. Owners and part-owners comprised 70 percent of the sample. Concerning the number of prescriptions filled each week, 70 percent of preceptor pharmacists dispensed more than 100 prescriptions each day, compared with 44.3 percent of NPC surveyed rural pharmacists (Table 1).
Pharmaceutical Care Skills’ Self-Assessment. Pharmacists were requested to rate their level of performance on a 15-item PC skills list, using a four-point Likert scale (1=poor, to 4=outstanding). Counseling the patient or patient’s care-giver was rated highest overall, followed by communicating information to health providers, using ethical decision-making skills, using problem-solving skills, and referring to another health provider (Table II). Overall, preceptor pharmacists rated most items higher than the other rural area pharmacists. Performing physical assessments and interpreting physical assessment data, including signs and symptoms, were rated higher by the preceptors (fair to good) than by the NPC surveyed rural pharmacists (fair).
Desired Pharmaceutical Care Skills Needed by Pharmacy Graduates. Pharmacists were asked to rate 15 PC skills on a three-point Likert scale (1=not important, to 3= very important) and their responses are listed in Table 111. Communicating information to health care providers was rated highest by preceptor pharmacists. Counseling the patient or the patient’s care-giver was rated highest by NPC surveyed rural pharmacists. Rated as very important PC skills in the training of UNMC pharmacy students were: monitoring drug therapy, using problem-solving skills, using ethical decision-making skills, and using drug therapy decision-making skills. Preceptor pharmacists rated most items higher than rural pharmacists. Preceptor pharmacists rated performing physical assessments (e.g., pulse, blood pressure) higher than did NPC surveyed rural pharmacists.
Obstacles to Implementing Pharmaceutical Care. Preceptor pharmacists were asked to rate the extent to which each obstacle is problematic in implementing PC into their pharmacy practice, on a five-point Likert scale (1 =for not at all problematic to 5=very problematic). “Time” followed by “lack of reimbursement” were rated as most problematic by preceptor pharmacists. Preceptor pharmacists did not perceive “physician and nurse resistence” as problematic in implementing PC. Comparison with NPC surveyed rural pharmacists was not included since they did not complete this survey component (Table IV).
Current Pharmaceutical Care Assessment. Preceptor pharmacists were asked what percent of their time was spent on each of seven activities. “Dispensing prescription drugs” accounted for 39.8 percent of their time and was the primary category of time use. Commonly cited activities were “counseling patient or patient’s care-giver concerning prescriptions” (13 ).6 percent), “request for drug information from patient or a health provider” (10.6 percent), “monitoring drug therapy (i.e., dosage regimen, contraindications, drug interactions, and adverse effects)” (8.9 percent), “resolving reimbursement eligibility for service” (6.6 percent), and “communicating with the health care provider” (6.4 percent).
The average amount of time per new prescription spent providing PC was estimated by preceptors to be 3.7 minutes with a range from two to five minutes. For a refill prescription, the average amount of time providing PC was 1.4 minutes with a range from one to two minutes.
In an open-ended response format, pharmacists were asked what diseases or medications need more time than others for PC. Based on analysis of themes, diabetes was cited by 17.6 percent of rural pharmacists and 90 percent of preceptor pharmacists. Asthma and hypertension were mentioned more frequently by preceptor pharmacists (70 and 50 percent) than by rural pharmacists (7.8 and 2.8 percent), respectively.
Pharmaceutical Care Reimbursement. To assess reimbursement. respondents were asked to assume that PC included nondispensing activities (e.g., patient counseling, contacting physician for drug interaction, drug use review, drug therapy monitoring, disease state management, etc.). Respondents were asked if they were reimbursed by any pharmacy benefit manager (PBM) or third-party payer for PC. A 1996 NPC survey, 13.1 percent of rural pharmacists (23 of 176) had been reimbursed. However in 1998, no preceptor pharmacists reported that they have received this type of PBM reimbursement. Three of the ten preceptors reported charging self-pay patients for PC, compared with 5.7 percent of rural pharmacists. Of the three preceptors who charge self-paying patients, one charged $22 per encounter and two others charged $2.00 per minute.
Preceptor Training Evaluation Results. Ten pharmacy preceptors began and completed the training program. Each preceptor was asked to rate each training topic on a five-point scale (1 = for not at all useful to 5 = very useful). Table V summarizes preceptor opinions on the perceived usefulness of each topic to implementing PC in their practice setting. Therapeutic reviews and case presentations of the three disease states (diabetes, hypertension and asthma) Were rated very useful. Most topic areas were rated “useful” to “very useful.”
Preceptor Training Evaluation of Open-Ended Questions.
Preceptors’ opinions were compiled on six open-ended questions concerning the training program’s most useful material and recommended changes. Preceptors’ response to the training program’s most useful material item was similar to their rated responses. Commonly cited responses from preceptors for changes in the training program were “periodic updates and opportunities for the preceptors to get together to share ideas and problem solve,” and “more computer training.” All preceptors felt there is a need for a PC training program. Seven of 10 preceptors answered “yes” or “somewhat” to integration of PC into their pharmacy practice. However, most pharmacists also reported they had not gone far enough, Two preceptors indicated they had not integrated PC into their practice. One preceptor attributed this due to a lack of time and the other preceptor commented “No – if PC is defined as gaining reimbursement from third parties.” Five preceptors reported they had used their action plan to implement PC into their pharmacy practice. One who had not was a preceptor who changed jobs to a faculty position involving long term care. Only three of 10 preceptors reported they had updated their action plan. Preceptors were asked how the UNMC College of Pharmacy could provide follow up support to facilitate PC integration into preceptors’ practice. Four of 10 pharmacists suggested “periodic updates and meetings to get together and share ideas.”
Rural areas in Nebraska and throughout the United States are facing substantial changes in financing and delivery of health care. Combined effects of troubled rural economics, difficulties recruiting and retaining physicians and pharmacists, cutbacks in third party reimbursement, and reliance on increasingly expensive technology threaten the prospects for continued accessibility of health services in rural areas(18,19). Despite these factors, rural practice offers unique opportunities for pharmacists to provide PC and make a substantive impact on patients’ health. Many of our rural pharmacists are the first primary care providers seen. Pharmaceutical care opportunities abound in these rural settings(8,15).
The UNMC College of Pharmacy has developed clerkship and training programs with the goal to improve the pharmaceutical care and health of rural Nebraska citizens. Pharmacist response has been positive, however, time and financial constraints have limited these efforts. While pharmacists desire PC training in both urban and rural areas, most training programs have overlooked rural practice. Our study participants were selected from rural pharmacy preceptors in the UNMC experiential education program who are also members of the Nebraska Drug Information Network. These pharmacists were selected because of their quality of pharmacy practice and motivation to provide quality patient care in rural settings.
Based on follow up visits, most of the preceptor pharmacies are doing well financially and offer primarily traditional products and services. For these pharmacies, there has not been a substantive financial incentive to push them into pharmaceutical care. Such an incentive could be third parties who begin to reimburse for cognitive services or a further decline on third party prescription margins, which would force these pharmacists to seek alternative revenue sources.
If ten highly motivated pharmacists (2.7 percent of NPC respondents and 5.7 percent of rural respondents) are struggling to start pharmaceutical care programs after a rigorous albeit circumscribed training program (i.e., only three disease states), one is compelled to question what the implications are for the remaining 94 to 97 percent of practicing pharmacists. One must acknowledge the struggle and time management issues attendant to setting up PC in an existing, ongoing practice. Ultimately one would hope that the primary driving force for entering a health care profession, i.e., maximizing patient care, is a crucial factor in this decision-making process. It is an issue not easily resolved and largely is a matter of personal choice and commitment.
Some rural pharmacy practices may survive by pharmacists continuing to practice in a traditional manner. One argument for PC in rural pharmacy practice is centered in the lack of access in rural areas to health care. Rural areas typically have reduced access to health care practitioners and by incorporating PC into their practices, pharmacists can meet patient needs that are currently unmet. In effect, pharmacists can assume a more active primary care role. Since Nebraska is a rural state, one of the UNMC College of Pharmacy goals is to train pharmacy students to deliver primary pharmaceutical care in rural -communities.
Pharmacists were asked to self-assess their own level of PC skills. Both rural and preceptor pharmacists assessed their “ethical decision-making skills” as very high and this concurs with public opinion as evidenced by the Gallup poll. “Counseling of patients” was rated very high in this selfassessment section, and in the desired PC skills section needed by pharmacy students. Compared to rural pharmacists, preceptor pharmacists rated “performing physical assessment skills” higher in their own self assessment and as a PC skill needed by pharmacy students. These findings suggest that preceptor pharmacists’ value physical assessment skills more than the larger rural pharmacist population. Physical assessment is listed as a curriculum content area for the Doctor of Pharmacy degree model program(20,21).
While pharmacists do not have to be experts at performing complicated physical assessments, community practitioners involved in PC should be able to do basic drug monitoring skills (e.g., pulse, blood pressure monitoring). Schommer and Cable found that Ohio pharmacists were more involved in “passive” PC activities such as a drug information source, and less likely to engage in “active” PC activities such as patient counseling and drug monitoring activities(22). In the NPC study, rural pharmacists reported being more active in patient counseling, but less likely to be involved in physical assessment activities(15). Preceptors who completed PC training were more likely to be engaged in “active” PC activities than were the rural pharmacists. Adoption of these activities into practice is important if pharmacy is to assume a role as a “care providing” profession.
Study Limitations. One limitation is the self-reported nature of the study. Percent of the pharmacist’s day spent in dispensing and performing cognitive services is an approximation. Actual time can be determined using direct observation techniques or a work sampling technique, but was beyond the scope of this study A second limitation arises by comparing the rural pharmacist’s group with the preceptor group, since the rural pharmacists’ responses were collected one year earlier(15). In this study, we provided comparison of frequency distributions from two cross-sectional surveys. Further statistical analysis was not completed, since the investigators believed this could produce misleading results. Any comparison of the small preceptor sample (n = 10) to the randomly selected rural pharmacist sample is compromised, since preceptor selection comprised a group of highly motivated practitioners from community practice settings, These preceptors were chosen as pharmacists whom the investigators expected would be more likely to implement pharmaceutical care into their practices.
It is our contention that PC is integral to pharmacy’s future. We further contend that PC is needed by our patients, and must be widely implemented by pharmacists if we are to achieve full professionalization in the 21st century. A concerted effort must be made across all settings to obtain recognition of pharmacists as health care providers and the associated reimbursement for PC services associated with this recognition. Such provider recognition must include private pay patients and third party payers, including the Health Care Financing Administration (HCFA).
We also contend that a rapid infusion of PC skills is needed to prevent the further decline in the number of independent rural pharmacy practices, This is particularly important, given the valuable role that rural pharmacists play as primary care providers. Our goal was to convert community pharmacy externship sites into PC sites by facilitating the training of preceptors. Our PC training program provides a start and a strong base for the motivated pharmacist clinician to build on.
Acknowledgments. Authors would like to acknowledge the training provided by Drs. Charles C. Barr, Susan Feilmeier, Kimberly Gait and Gina Westfall, and Mr. Pat Travis.
Am. J Pharm. Educ, 63, 265-271(1999) received 1/19/99, accepted 5/12/99.
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David M. Scott, Warren A. Narducci, Paul W. Jungnickel, Lucinda G. Miller, Anthony E. Ranno and Pierre A. Maloley
College of Pharmacy, University of Nebraska Medical Center 986045 Omaha NE 68198-6045
1Supported by a SmithKline Beecham Foundation Grant Award (GAPS) through the American Association of Colleges of Pharmacy.
Copyright American Association of Colleges of Pharmacy Fall 1999
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