Monday, January 2, 2017

Ambulatory Care at the University of Michigan Canton Health Center (Rotation 6)

Posted by James Shen at Monday, January 02, 2017

My 6th rotation was at the University of Michigan Canton Health Center where I got to experience the day-to-day of an ambulatory care pharmacist. The University of Michigan is unique in that the structure of their ambulatory care model revolves around a patient-centered medical home (PCMH) model.  Essentially, clinical pharmacists are integrated throughout the various UMHS clinics, and are able to assist providers in managing chronic conditions, such as diabetes, hypertension, hyperlipidemia, or asthma through a collaborative practice agreement. 

There is always opportunity to improve patient care when it comes to chronic conditions, whether it is through medication related changes or lifestyle optimization. Typical services that I provided while I was at this clinic included medication reconciliations, medication adherence assessments, patient self-management and goal setting, medication initiation and dosage adjustments through the collaborative practice agreement, patient education on chronic conditions and medications, lab orders for diagnostic tests, and some physical assessments (blood pressure readings, pulse monitoring, diabetic foot exams). A large portion of my patient population was primarily diabetic, but many patients had concomitant hypertension and/or hyperlipidemia issues as well. Additionally, I also had a few pediatric asthma patients, which was an interesting change of pace from my typical patient base.

I saw approximately 5-10 patients each day, but the number could vary depending on who showed up to the clinic. We discussed everything from their lab values, their health goals, their diet and exercise, their medication adherence, their personal stress, etc. It was important to establish a strong rapport and relationship with each patient, because many of these patients would often be back within the next few weeks for follow-up visits. By the second week, I was seeing these patients independently without any preceptor backup, coming up with recommendations, and writing up full SOAP notes for each encounter. I finally felt like I was a real pharmacist – the patients truly respected my opinion and treated me as a healthcare professional, not just a student!

After meeting with each patient, it was up to me to come up with an assessment and plan for moving forward. How many episodes of hypoglycemia did they have in the past month? What is their average fasting blood sugar? Is the patient a smoker, and if so, how motivated are they to quit? Is there a major holiday coming up that may affect diet (ex: Thanksgiving)? How is the patient’s stress level at home and work? Is their A1C, blood pressure, or ASCVD risk score at goal? Do we need to order any new labs? These are just some of the many questions that I needed answers to before I could come up with a reasonable plan. Many times, patients just needed a little encouragement and reinforcement for sticking to healthy lifestyle goals. You would be surprised how far a little motivational interviewing can take you. However, we also frequently adjusted insulin regimens, started new medications, or discontinued current medications based on a patient’s status.  

Other projects during this rotation included comprehensive medication reviews, topic discussions, patient case presentations, and journal club presentations. Overall, this was an interesting rotation that provided me valuable insight into the role of an ambulatory care pharmacist. It was rewarding to establish a strong relationship with a patient, develop a plan of action, and then follow-up with the patient at the next visit to see if he or she improved. The patients were always very grateful, and enjoyed talking with us about their overall healthcare. For anyone interested in ambulatory care, the UMHS clinics and the PCMH model is definitely the way of the future. Not only do pharmacists partner with their patients and empower them to take an active role in managing their own health, but the pharmacists also have a lot of autonomy when it comes to making any medication related changes or recommendations. 

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