Implementation of a direct observation and feedback tool using an interprofessional approach: a pilot study.

Primary care trainees must learn how to communicate effectively with patients during brief outpatient encounters, and direct observation and feedback is necessary to improve these skills. At the same time, programs are seeking more interprofessional learning opportunities for skills that transcend professions. We sought to assess the feasibility of implementing a direct observation tool, the Patient Centered Observation Form (PCOF), for communication training across three professions at the graduate level. The PCOF was introduced to trainees at an interprofessional workshop, while faculty completed PCOF training online or in person. Following use of the PCOF, we surveyed participants to determine if using the PCOF increased a) trainee-reported confidence in providing patient-centered communication, and b) faculty-reported confidence in giving feedback about patient-centered communication. The PCOF appears to be a useful adjunct to standard precepting for teaching patient-centered communication skills, extending beyond medical residents to pharmacy residents and less so, to advanced practice nursing students. In addition, PCOF training and implementation can successfully occur simultaneously across disciplines, leveraging resources and encouraging interprofessional learning.

OPIOIDS: cultivating interprofessional collaboration to find solutions to public health problems.

This study evaluated perceived effectiveness of an interprofessional case-based activity that allowed medical and pharmacy students to engage in problem-solving around the role of social determinants of health (SDOH) in opioid misuse. Students participated in a case-based activity, and then completed a post-activity survey that included five open-ended questions and the Interprofessional Collaborative Competency Attainment Survey. Twelve pharmacy students (100%) and 47 medical students (75%) completed the post-activity survey. Results indicate the activity resulted in a statistically significant increase in student ability to: 1) recognize interprofessional team members' knowledge, skills, and contributions to the interprofessional team; 2) communicate effectively across professions; and 3) learn with, from, and about interprofessional team members to develop a patient care plan. Students also reported enhanced understanding of treatment considerations with opioid misuse, the role of SDOH, and recognition of the value of interprofessional collaboration in their future practice. This interprofessional case-based activity appeared to promote collaboration among students from different professional programs as they engaged in problem-solving around a contemporary public health issue that intersects their future practices. This activity may serve as a model for health professional programs, practitioners, healthcare systems, and communities that seek interprofessional solutions to combat opioid misuse.

Opioid prescribing patterns for non-malignant chronic pain for rural versus non-rural US adults: a population-based study using 2010 NAMCS data.

BACKGROUND: Non-malignant chronic pain (NMCP) is one of the most common reasons for primary care visits. Pain management health care disparities have been documented in relation to patient gender, race, and socioeconomic status. Although not studied in relation to chronic pain management, studies have found that living in a rural community in the US is associated with health care disparities. Rurality as a social determinant of health may influence opioid prescribing. We examined rural and non-rural differences in opioid prescribing patterns for NMCP management, hypothesizing that distinct from education, income, racial or gender differences, rural residency is a significant and independent factor in opioid prescribing patterns. METHODS: 2010 National Ambulatory Medical Care Survey (NAMCS) data were examined using bivariate and multivariate techniques. NAMCS data were collected using a multi-stage sampling strategy. For the multivariate analysis performed the SPSS complex samples algorithm for logistic regression was used. RESULTS: In 2010 an estimated 9,325,603 US adults (weighted from a sample of 2745) seen in primary care clinics had a diagnosis of NMCP; 36.4% were prescribed an opioid. For US adults with a NMCP diagnosis bivariate analysis revealed rural residents had higher odds of having an opioid prescription than similar non-rural adults (OR = 1.515, 95% CI 1.513-1.518). Complex samples logistic regression analysis confirmed the importance of rurality and yielded that US adults with NMCP who were prescribed an opioid had higher odds of: being non-Caucasian (AOR =2.459, 95% CI 1.194-5.066), and living in a rural area (AOR =2.935, 95% CI 1.416-6.083). CONCLUSIONS: Our results clearly indicated that rurality is an important factor in opioid prescribing patterns that cannot be ignored and bears further investigation. Further research on the growing concern about the over-prescribing of opioids in the US should now include rurality as a variable in data generation and analysis. Future research should also attempt to document the ecological, sociological and political factors impacting opioid prescribing and care in rural communities. Prescribers and health care policy makers need to critically evaluate the implications of our findings and their relationship to patient needs, best practices in a rural setting, and the overall consequences of increased opioid prescribing on rural communities.

Bridging Community Mental Health and Primary Care to Improve Medication Monitoring and Outcomes for Patients With Mental Illness Taking Second-Generation Antipsychotics-Phase 2: Quality Improvement Initiative Over 15 Months.

Objective: To evaluate the effectiveness of a quality improvement (QI) initiative to improve family medicine residents' metabolic monitoring of second-generation antipsychotics (SGAs) for patients comanaged across nonintegrated community mental health and family medicine clinics.Methods: Patients were aged ≥ 18 years seen by family medicine residents and prescribed at least 1 SGA (N = 175). Preparative and scheduled QI interventions were nonblinded and included collaboration across organizations, education, and monthly interprofessional care conferences. The QI outcome included evaluation of pre-post metabolic monitoring laboratory data over the 15-month study period. A subset of patients (n = 26) was reviewed at least once at monthly interprofessional care conferences. Patients were stratified by diagnosis of diabetes (n = 45) and no diabetes (n = 130) at baseline. Analyses of the QI intervention outcomes were framed by the time period of monthly care conferences (January 31, 2019-April 30, 2020) and compared to baseline (the historical time period) (October 31, 2017-January 29, 2019).Results: Improved adherence in glycated hemoglobin (HbA1c) (P = .042) and lipid (P < .001) monitoring per guidelines from baseline to follow-up was seen in the total patient population (N = 175). Patients without diabetes (n = 130) had significant improvement (P = .001) in HbA1c monitoring from baseline to follow-up. The subgroup of patient cases that were discussed at a care conference showed no significant improvement in HbA1c or lipid monitoring.Conclusion: Preparative and scheduled QI interventions provided family medicine residents powerful reminders of the SGA monitoring guidelines that improved the metabolic monitoring behaviors for all patients on SGAs.Prim Care Companion CNS Disord. 2023;25(3)22m03432. Author affiliations are listed at the end of this article.

Addressing Hidden Curricula That Subvert the Patient-Centeredness "Hub" of the Pharmacists' Patient Care Process "Wheel".

Objective. This systematic review's purpose is to improve clarity for the meaning of patient-centered care in the JCPP Pharmacists' Patient Care Process and to provide an initial foothold for faculty to address "hidden curricula" that undermine the concept. Our corresponding objectives were to identify and describe the conceptualizations defining patient-centered care from the pharmacy literature; and compare the meaning of patient-centeredness in the pharmacy literature with the construct's seminal conceptualizations from other professional groups.Findings. The search protocol produced 61 unique sources from the pharmacy literature. More than two-thirds of these results lacked precise use of terminology consistent with the literature or operational depth or theoretical exploration of the term's meaning. The remaining sources yielded two separate conceptualizations of patient-centeredness with three commonalities but key differences between their grounding in the construct's seminal sources in the broader health care literature.Summary. The pharmacy literature clarifies the meaning of patient-centered care in the patient-pharmacist encounter, but additional understanding is needed at meso- (ie, health care) and macro-levels (ie, legislation, accreditation, payment, workforce dynamics) of care. This expansion of understanding may reduce dissonance between the formal and hidden curricula on patient-centeredness associated with health professional student disillusionment, contempt for faculty and institutions, and reductions in empathy and ethics. Increasing use of integrative case-based training, equitably blending patient-centeredness considerations with other curricular content, represents one strategy for reducing the presence and negative impact of hidden curricula.

Impact of Interprofessional Care Conferences Across Primary Care and Mental Health Organizations on Family Medicine Resident Learning.

BACKGROUND AND OBJECTIVES: Patients with severe mental illness often lack care coordination between primary care and mental health providers which can negatively impact patient outcomes. Team-based care is integral in the effective management of patients with multiple comorbidities, with the family physician central in coordinating holistic care. Family medicine residency programs must provide models of effective interprofessional collaboration and mental health treatment to prepare residents to navigate an evolving health care landscape. The objective of this study was to evaluate family medicine residents' learning about providing holistic care with an interprofessional team and medication safety monitoring from the interprofessional cross-organizational care conference experience. METHODS: To bridge care and cultivate the necessary skills, a family medicine clinic and mental health clinic implemented monthly interprofessional care conferences to coordinate care for their shared patients during 2019. Residents who participated in the care conference each (n=11) completed a retrospective pre/postsurvey (11/11=100% response rate) to gather perceptions of what they learned from the interprofessional care conference experience. RESULTS: After participating in the care conference, all residents agreed they understood the elements that must be considered to provide holistic patient care, were confident conducting medication safety monitoring for their patients taking second-generation antipsychotics (eg, lipids, A1C, ECG), and agreed the care conference helped them develop a more comprehensive patient-centered care plan. Additionally, they all intend to work collaboratively across professions in the future. CONCLUSIONS: Interprofessional and cross-organizational care conferences create an authentic learning environment that enhances family medicine residents' understanding and confidence in providing collaborative and holistic care for patients with severe and persistent mental illness.

A compass for care: Evaluating first-year pharmacy students' philosophy of practice.

INTRODUCTION: A philosophy of practice serves as the foundation for any patient care practice. Understanding the philosophies of practice held by students entering the profession is important as this presents potential opportunities for educators to help shape students' professional values/beliefs. The objective of this work was to evaluate how first-year pharmacy students (P1s) conceptualize their philosophy of practice as future pharmacists. METHODS: P1s at the University of Minnesota College of Pharmacy were asked to write their philosophy of practice that best described them as a future practitioner. A sample of 80 student responses were inductively coded to develop an initial coding scheme. These codes were applied and refined to a random sample of 32 responses (20%) where inter-coder reliability (ICR) testing was carried out at three stages. The final codebook was applied to all responses. RESULTS: The exercise was completed by 155 (92%) students, including the 80 student responses used for developing the initial coding scheme and the 32 responses used for ICR. Thirteen unique codes emerged from student responses describing their philosophy of practice that were grouped into four themes: community partner, commitment to the patient, professional responsibilities, and interprofessional team-based care. CONCLUSIONS: There was variability in how pharmacy students articulated their philosophy of practice. This presents an opportunity to shape students' philosophy of practice as they progress through pharmacy school so that they graduate with a uniform set of professional values and beliefs.

Unpacking student learning from an early experience with the Pharmacists' Patient Care Process.

BACKGROUND: To illuminate learning, a case study approach was used to examine early, authentic experiences within Pharmacists' Patient Care Process (PPCP)-focused practices. EDUCATIONAL ACTIVITY: Six students were matched with five practitioners and spent five half-days in a primary care clinic in a PPCP-committed health system. Students practiced interviewing, determining the patient's medication experience, and formulating the beginnings of the assessment, as well as observing and debriefing on the completion of the process by a practitioner mentor. The Five R Model was used to prompt student learning reflection. In addition, instructors examined students' work for evidence of transformative learning and observations were captured using forms of reflective practice and collaborative debriefing. CRITICAL ANALYSIS OF THE EDUCATIONAL ACTIVITY: Reflection performance ratings varied; however, there was strong evidence of transformative learning for all students. Specifically, most student reflections demonstrated a focus on elaborating on existing frames of reference. The most prevalent indicator of transformative learning was exploration of options for new roles, relationships, and actions. The codes from instructors' observations revealed five categories of learning evidence, with the strongest in the patient centeredness category. The process of reviewing student work products, documenting instructor observations, and collaborative debriefing resulted in insights for curricular improvement and explanations for learning difficulties. Further work is needed in understanding student experiential learning intentions and their influence on learning and reflection. Additionally, further research should explore the value of longitudinal assessment of reflection and the value of assessing student work products using criteria beyond traditional reflection criteria.

A Dentist, Pilot, and Pastry Chef Walk into a Bar Why Teaching PPCP is Not Enough.

For both education and practice, the dissemination of the Joint Commission of Pharmacy Practitioner's Patient Care Process for Pharmacists has heightened attention to the need for a defined care process for pharmacists. Yet, when one compares this framework with those described in other disciplines, what makes it specific to pharmacy? Graduates must establish their unique role in patient care management among the health care team. Therefore, it is essential that pharmacy educators prepare students to contribute uniquely and communicate articulately about those contributions. This involves intentionally teaching an explicit clinical assessment process and a recognized taxonomy for communicating medication-related needs. In addition, educators must: ensure integration of patient care frameworks unique to pharmacists in curricula, commit to critical evaluation of care process instruction, and partner with external stakeholders to establish the distinct contributions of pharmacists to team-based care.

This is how I think: Evaluation of a preceptor development webinar on incorporating the Pharmacists' Patient Care Process into experiential teaching.

INTRODUCTION: There is a critical need to establish and teach a uniform pharmacists' patient care process (PPCP) to create consistency in the profession. Little is known about preceptor incorporation of the PPCP into experiential teaching. METHODS: Using a pre-/post-program survey, this study aimed to characterize preceptors' perception of PPCP incorporation in teaching, confidence in PPCP articulation to team members and students, and ability to identify precepting strategies before and after completing a continuing education (CE) webinar. RESULTS: 103 of the 158 preceptors enrolled in the CE program completed pre-/post-program surveys. Preceptors' perception of PPCP incorporation with introductory pharmacy practice experience (IPPE) students did not change significantly after the program (1.98 vs. 1.88, p = 0.317). However, advanced pharmacy practice experience (APPE) preceptors were less likely to strongly agree to PPCP incorporation after completing the program (1.91 vs. 1.72, p = 0.016). Preceptors felt increased confidence in their ability to articulate the PPCP to both team members (2.07 vs. 1.60, p = 0.000) and students (2.01 vs. 1.63, p = 0.000). Preceptors strongly agreed they had new strategies to use in precepting. CONCLUSION: In order to prepare student pharmacists, preceptors must be prepared to explicitly incorporate the PPCP into their teaching. A webinar with case examples and a preceptor tool can help equip preceptors to articulate the PPCP to colleagues and students, and to identify strategies to incorporate the PPCP into their precepting.

Improving advanced pharmacy practice experiences with an intention/reflection practice.

BACKGROUND AND PURPOSE: Experiential learning in pharmacy has the potential to offer transformative experiences for students. Advanced pharmacy practice experiences (APPEs) can be improved if students are encouraged and able to (1) identify and track individual learning gains and interests, and (2) develop self-awareness and intrinsic motivation. EDUCATIONAL ACTIVITY AND SETTING: The intention/reflection (I/R) practice was developed to address these educational concepts and help facilitate meaningful experiences during APPEs. The I/R tool is a simple, nontechnical, resource-light activity consisting of a set of three to five questions at the beginning, midpoint, and end of an APPE. The questions were designed to help students identify how they can attain meaningful gains from each APPE. Preceptors across three universities designed, implemented, and evaluated the impact of an I/R practice within the context of a variety of APPEs. The APPEs varied between 4, 5, 6, and 10 weeks and were focused on patient care and academia. FINDINGS: Three of the I/R questions were selected for thematic analysis, one at each point of the rotation. These questions were strategically selected because they demonstrate the value resulting from the progressive nature of the I/R tool. The answers to the three questions were descriptively coded to capture the main thought(s) of each student's response. A quarter of students indicated I/R helped them achieve their goals. SUMMARY: A retrospective pre-post survey demonstrated statistically significant improvements in all survey items, including (1) ability to identify learning outcomes, (2) focus and motivation, and (3) self-awareness and metacognition.

Educational Prescriptions to Document Evidence-Based Medicine Questions in Ambulatory Care Advanced Pharmacy Practice Experiences.

Objective. To design, implement, and assess the use of "educational prescriptions" or Education Rx assignments in advanced pharmacy practice experiences (APPEs) in ambulatory care, and to assess the impact of the assignments on Doctor of Pharmacy (PharmD) students' self-efficacy to practice evidence-based medicine (EBM). Methods. Students enrolled in select ambulatory care APPEs completed up to four Education Rx assignments. The assignments required students to report the context of the question, source of information, results, appraisal of validity, and relevance of the evidence, and to answer the clinical question. A rubric was used that contained three subparts: a patient/population, intervention, comparison, outcome (PICO) conformity score (8 points), presence of answer to the PICO (1 point), and quality of answer to the PICO (6 points). Demographic information was collected and students were surveyed at the end of the APPE to rate their self-efficacy executing seven evidence-based medicine (EBM) skills. Results. Thirty students completed 110 Education Rxs. The average score (SD) was 13.6 (2.2) with a PICO conformity subsection score of 7.3 (1.3), and quality of answer subsection score of 5.3 (1.2). Only one Education Rx did not have an answer. Students consulted point-of-care references for a majority of the answers (65%). Sixteen (53%) students completed the self-assessment survey, and all strongly agreed or agreed that the Education Rx activity improved their ability to formulate a well-constructed clinical question and evaluate and apply the evidence. Conclusion. Through Education Rxs, PharmD students' self-confidence and their skills in finding answers to clinical questions increased.

Drug Therapy Problem Identification and Resolution by Clinical Pharmacists in a Family Medicine Residency Clinic.

PURPOSE: There are limited data to evaluate the impact of ambulatory clinical pharmacist recommendations on family medicine resident prescribing and monitoring of medications. The purpose of this study is to begin to gain insight in this area by answering the research question, "How many ambulatory clinical pharmacist recommendations for drug therapy problem (DTP) resolution are implemented on the day of a medication therapy management (MTM) visit in an outpatient family medicine residency clinic?" METHODS: This is a retrospective chart review of face-to-face MTM encounters conducted by ambulatory clinical pharmacists (including pharmacist residents) from August 1, 2012 to June 30, 2015 at a family medicine residency clinic. Descriptive statistics were conducted to both quantify the number of DTPs identified and resolved on the day of the MTM visit as well as categorize the DTPs. RESULTS: Based on the 728 MTM encounters analyzed, patients were an average of 53.6 years old and took 11.9 medications to treat 5.7 medical conditions. A total of 3057 DTPs were identified in the 728 encounters, of which 1303 were resolved the same day as the MTM visit. This resulted in an average of 4.2 DTPs identified and 2.0 resolved per visit per patient. The most common DTP category identified in this study was the need for additional drug therapy (41.6%). CONCLUSIONS: Approximately half of the ambulatory clinical pharmacist's DTP resolution recommendations were implemented the same day they were identified, which highlights the strength of team-based patient care and interprofessional collaboration in a residency teaching clinic.

Seven Years of Teaching Communication With the Patient-Centered Observation Form.

BACKGROUND AND OBJECTIVES: For years, family medicine has taught patient-centered communication through observations and observation checklists. We explored the utility of one checklist, the Patient-Centered Observation Form (PCOF), to teach and evaluate patient-centered communication in our family medicine residencies. METHODS: We conducted a mixed-method study of five University of Minnesota Family Medicine Residencies' seven years of experience teaching and evaluating residents' patient-centered communication skills. All programs have a behavioral health (BH) faculty-led observation curriculum that uses the PCOF to assess resident skills and give feedback. We conducted a BH faculty focus group and interviews, generated themes from the BH responses, and then queried family medicine (FM) faculty regarding these themes through an online survey. RESULTS: Ten BH faculty participated in the focus group/interviews, and 71% (25/35) of FM faculty completed the survey about themes derived from the BH interviews. The residencies complete between 1 to 11 observations per resident per year. Since implementation, four programs have continuously used the PCOF due to its versatility, design as a formative rather than summative feedback tool, and relative ease of use. BH faculty believe longitudinal observations with the PCOF resulted in improved resident patient-centered communication. Most importantly, all faculty described a shift in family medicine culture toward patient-centered communication. Time for observations and feedback is the primary curricular barrier. CONCLUSIONS: Our findings support the utility of the PCOF for teaching and evaluating patient-centered communication in family medicine training.

An Opportunity for Pharmacists to Help Improve Coordination and Continuity of Patient Health Care.

Pharmacist workforce researchers are predicting a potential surplus of pharmacists in the United States that might result in pharmacists being available for engagement in new roles. The objective for this study was to describe consumer opinions regarding medication use, the health care system, and pharmacists to help identify new roles for pharmacists from the consumer perspective. Data were obtained from the 2015 and 2016 National Consumer Surveys on the Medication Experience and Pharmacist Roles. Out of the representative sample of 36,673 respondents living in the United States, 80% (29,426) submitted written comments at the end of the survey. Of these, 2178 were specifically about medicines, pharmacists or health and were relevant and usable for this study. Thematic analysis, content analysis, and computer-based text mining were used for identifying themes and coding comments. The findings showed that 66% of the comments about medication use and 82% about the health care system were negative. Regarding pharmacists, 73% of the comments were positive with many commenting about the value of the pharmacist for overcoming fears and for filling current gaps in their healthcare. We propose that these comments might be signals that pharmacists could help improve coordination and continuity for peoples' healthcare and could help guide the development of new service offerings.

Retrospective analysis of billing at a standalone medication therapy management clinic.

PURPOSE: Results of a study comparing reimbursement for medication therapy management (MTM) services with a resource-based relative value scale (RBRVS) versus a time-based billing model are reported. METHODS: Reimbursement claims for MTM services provided by a standalone clinic during a 6.5-year period were reviewed. Actual billing amounts calculated according to Minnesota's RBRVS for MTM services, which emphasizes case complexity as a determinant of payment rates, were compared with hypothetical billing amounts calculated using a strictly time-based method designed to more accurately capture the costs of providing MTM services. A paired t test was conducted to analyze differences in the billable amounts calculated via the two methods. RESULTS: Reimbursement claims for a total of 525 face-to-face MTM encounters with 60 patients were analyzed. Using the RBRVS method, the mean ± S.D. billing amount per encounter was $83.71 ± $36.67; using the strictly time-based method, the mean ± S.D. billing amount was $111.83 ± $34.55 per encounter (mean difference, $28.12; p < 0.0001). These findings indicate that the use of time-based versus RBRVS-based billing methodology would have resulted in an additional $14,763 in MTM services reimbursement for the 525 evaluated encounters. CONCLUSION: The RBRVS-based method consistently resulted in a lower billing amount per encounter than the strictly time-based billing method, suggesting that reimbursement for MTM services may not be aligned with the actual costs of providing those services.