Rotation 2/3: Ambulatory Care in the Community

Posted by Unknown at Thursday, August 30, 2018

Hi everyone! My name is Laura Hayes and I am one of this year's P4 bloggers. I am excited to write about my experiences during fourth year and hope my reflections can help you in your pharmacy journey!

A little about me before I jump into my first reflection: 
I grew up in Rochester, MI and went to the University of Michigan for undergrad where I majored in Biomolecular Science and minored in Anthropology. I got married last summer and love being with friends/family and being outside. 

We just celebrated our one year wedding anniversary this August!

 My husband and I went to Europe for 2 weeks after P3 exams ended. This is me at the Cliffs of Moher. 

 We also had the opportunity to go to Denver, CO this summer and went hiking in the Rocky Mountains! It was so majestic!!

This is me on my birthday at Dom's Bakery in Ypsilanti. These apple fritters had just been taken out of the oven and were the BEST I've ever had! I would definitely recommend you check it out.

Now that you know a little about me, let me tell you about my last two rotations; Rotation 2 was Ambulatory Care and Rotation 3 was Community Pharmacy.

Ambulatory Care
For Ambulatory Care I had the privilege of being in two family medicine clinics 2.5 days a week and mostly managed diabetes, but also saw a lot of hypertension and hyperlipidemia. I met with patients in person for 40 minutes or talked to them on the phone for 20 minutes and discussed how their diet, exercise and medication regimens were going. I was able to build relationships and really connect with people to help them help themselves. While I absolutely loved this rotation, it was extremely busy. I worked up patients before clinic, finished notes after clinic and had to complete all the rotation requirements set for this rotation. This included a journal club, topic discussion, case presentation and Anticoagulation discussion. I learned a lot about time management and making sure I took time to relax in the midst of being very busy.
Of the three rotations I have completed, this one has been my favorite. I loved connecting with the patients and helping them with such important aspects of their lives. This experience was very encouraging as I had been interested in ambulatory care for about 1.5 years prior and after this rotation, I feel quite confident and excited to work in the ambulatory care setting.

Community Pharmacy
Community pharmacy was not a rotation I was very excited about. I had never worked in community pharmacy (I had an internship at UofM in the Cardiovascular Center inpatient pharmacy) and have heard a lot of horror stories about chain pharmacies. Needless to say, I was a little worried about how it would go.
I was placed in a grocery store/big box store pharmacy for this rotation. It was a slower store and had what I feel an independent pharmacy may feel like (based on what others have told me). The pharmacist has worked there for over 15 year and the patients deeply trust and respect him. Because we weren't running around crazily filling scripts, I had lots of time to engage in clinical services with patients. I did over 10 blood pressure screenings and made recommendations, counseled countless people on their medications and over the counter drugs, completed comprehensive medication reviews and had the opportunity to build relationships with patients who came back multiple times during my 5 weeks. These aspects felt so similar to my ambulatory care rotation and I was pleasantly surprised.
This experience helped break down some strongly held assumptions I had about community pharmacy,  has helped me realize just how important community pharmacist are and what roles they can play in patient's healthcare. Even though I do not plan on going into community pharmacy, it has become my 'Plan B', which feels like a big step from not even wanting to consider it before this rotation.

My advice to you, take every opportunity to learn and grow. Go into it with an open mind and learn all you can. I never thought I would enjoy being in the community pharmacy as much as I did, and I am so thankful I went in with a desire to learn and experience new things.

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

Posted by James Shen at Monday, January 02, 2017

My 6^th 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. 

Rotation 1: The Art of Pimping

Posted by Unknown at Sunday, July 19, 2015

What is ambulatory care like in Ann Arbor?

My first rotation started off in your local doctor’s office with nurse practitioners and physician assistants called ambulatory care pharmacy. Here pharmacy acts as a consult service for the physicians. Since my preceptor, Dr. Anne Yoo, specializes in chronic conditions of diabetes mellitus, hypertension, and hyperlipidemia, our pharmacy service was consulted when patients has uncontrolled diabetes (Hemoglobin A1C >9%), uncontrolled blood pressure (BP>140/90 for diabetic and chronic kidney disease patients or BP >150/90 for adults over the age of 60 years old without diabetes or chronic kidney disease). Hyperlipidemia are usually accompanied in patients with diabetes or hypertension. Additionally, in recent year, the guidelines have changed and there is no longer a goal target range for lipoproteins (i.e. LDL, HDL).

Ambulatory pharmacist have full autonomy under a specific collaborative practice agreement with the physicians in the office. With regards to our specific practice agreement, we can start, discontinue, or adjust dosages of patient’s diabetic, hypertensive, or hyperlipidemia medications and order any relevant labs. Additionally, there is a new program that was recently started called comprehensive medication review, where patients are recruited if they have 5 or more chronic medications. This service allows patients to meet with clinical pharmacist one-on-one to go over their medications, safety concerns, appropriate indications for each medications, and/or cost issues. The main aim is to catch any medications errors, duplication in therapy, and/or address any concerns the patients had. Additionally, it increases awareness to the broad service pharmacy can provide to the public and to the clinic.

What is the learning curve on this rotation?

As my first one, I had a lot to learn. Our classes prepare us for majority of the real life as a P4, specifically our P1 year communication class, our P2 year community IPPE, and P3 year chronic diseases management course. The biggest gap I had to make up was my ability to manage time and stay efficient. First hill I had to overcome was my data collection skills. Our University of Michigan system is fortunate to have an electronic medical record synch with inpatient and outpatient setting, allowing us to easily access past documentations and lab results. But it was challenging for me to quickly seek out pertinent information. Second hill goes hand-in-hand with my first, creating your own monitoring form. You will have practice during P3 disease management class, but the key is to tailor it specifically to our clinic’s need and present to your preceptor the most relevant information. For instance, if we are only have 15 minutes to see this patient for his or her blood pressure management, it is important to present on factors that may increase blood pressure. Your own monitoring form will prevent you from missing any relevant information and help you build a foundation within your own mind crucial labs or information to look out for when treating each condition. Overall, this rotation should be a refresher for your chronic diseases, but it should push you to perfect your time management skills and efficiently delivering patient presentations.

What makes this rotation difficult?

There are two main reasons. First, patient work load gradually increases over the course of 5 weeks. It would go up from 4 patients ---> 6 ---> 8-10 ---> 16-18. Typical full day involves 17-18 patients. Work for each patient involves initial work-up, patient specific questions/concerns, and post- note writing. Initial work-up is when you collect pertinent data about the past medical history of patient, current medications and dosing, and labs for your patient presentation to your preceptor. Patient specific questions is researching about a concern a patient may have brought up during the last visit that needs to be addressed during this one. This could range from herbals supplements to alternative drug therapy. Finally, post-note writing is exactly what it sounds, the note you write documenting the recommendations made at the visit.  Second, the art of pimping. This is a phrase used by Dr. Yoo when she fires off questions. Questions usually involve what evidence was used in your recommendation, what are the common side effects of a medication, what is your plan B and plan C if plan A does not work, what are the trends on this lab result etc. I struggled each time I received pimping; however, I felt those were the times I learned the most and recall it quickly at a later time.

Final thoughts?

This rotation is highly recommended for those that wish to pursue more direct patient communication and have a passion for preventive care. Even though you will become the treatment expert, majority of the time will be spent on you coaching your patient through their chronic conditions and being their support and encouragement. I enjoyed this rotation a lot as it made me realize to always look up the evidence that supports each recommendation and not rely on the words of your preceptor. It was a mistake I made which probably left a weak impression on the patient. So don’t shy away from these pimping questions when put to the test. Be glad you are getting pimped now rather than when you become a pharmacist. 

Diabetes, High Blood Pressure, High Cholesterol, and More Diabetes!

Posted by Rachel Lebovic at Wednesday, September 25, 2013

Rotation 3: Ambulatory Care with Dr. Trisha Wells

While many ambulatory care pharmacists are only in clinic a few days each week, I was fortunate to spend my ambulatory care rotation with Dr. Trisha Wells who sees patients five days a week. The physicians at the University of Michigan Brighton Health Center are currently scheduling patients’ next appointments at least six months out, so they rely on Dr. Wells to see patients with chronic diseases in between their physician visits. Specifically, the chronic diseases I helped manage on Dr. Wells’ rotation were diabetes, high blood pressure (hypertension), and high cholesterol (hyperlipidemia).

A typical morning on rotation with Dr. Wells consisted of a combination of 30-minute in-clinic appointments and 15-minute phone appointments. For the in-clinic appointments, I would first present the patient case to Dr. Wells and we would discuss my plan for the patient, including whether I wanted to order any labs and how I would adjust the patient’s medications. Then, I would collect the patient from the lobby, get their weight, and bring them into Dr. Wells’ office. Next, I would ask the patient a set of routine questions about their diet, exercise, home blood sugar readings, caffeine intake, and medications. Then, I would take the patient’s blood pressure and perform a foot exam (if the patient was due for one). Lastly, Dr. Wells would discuss our plan with the patient. Sometimes, the plan involved adjusting the patient’s insulin doses, oral diabetes medications, or blood pressure medications. Other times the plan involved improving the patient’s diet or exercise. In the latter case, we used a technique called motivational interviewing by asking the patient what changes he or she wanted make for diet and exercise instead of telling the patient what to do. I really enjoyed individualizing a plan for each patient based on the patient’s lifestyle, daily routine, and values.

Some of the patients had multiple appointments with Dr. Wells during my five weeks in her clinic, and it was a great experience to build relationships with these patients over time and get to know each patient individually. For example, I loved it when one patient brought her dog to clinic. This was one of the best-behaved dogs I have ever met. He even carried the patient’s glucometer and test strips in a saddlebag! I also enjoyed building a relationship with a patient who was starting to use insulin for the first time. We taught her how to inject insulin, showed her how to use her glucometer, and answered all of her questions about diabetes. Building these relationships with patients made my time in clinic a rewarding experience.

After mornings full of clinic appointments, the afternoons were spent writing clinic notes to document each patient’s appointment and preparing presentations. Throughout the rotation, I presented topic discussions on diabetes, hypertension, and congestive heart failure. The other student on rotation with me, Haya, presented topic discussions on hyperlipidemia, diet and exercise, and asthma. Preparing these topic discussions often felt time-consuming and tedious, but after discussing each topic with Dr. Wells and listening to her clinical pearls, I definitely have a better understanding for how to optimally manage each of these disease states. I also presented two journal clubs on recent primary literature and gave a presentation on a patient case to other P4 students on rotation with U of M ambulatory care pharmacists.

Overall, I truly enjoyed the plethora of patient care experiences on my ambulatory care rotation. I was pleasantly surprised by the autonomy pharmacists have in this role. Ambulatory care pharmacists can order their own labs, take blood pressures, perform foot exams, schedule follow-up appointments, and adjust patients’ medications. However, I did not like limiting my patient care to three disease states. Diabetes, hypertension, and hyperlipidemia are complex chronic conditions to manage, but I missed managing all of the patient’s disease states like I did in the inpatient setting. I still think an inpatient clinical specialist position is a better career choice for me, but ambulatory care was a great experience because of all the patient interaction.

Ambulating around with the geriatrics..

Posted by Elizabeth Kelly at Thursday, November 03, 2011

This month I have the pleasure of being on rotation with Dr. Tami Remington in ambulatory care practice. I don't know if people have heard but I am loving this rotation. It is a lot of work, but the amount of knowledge I am gaining from this rotation will help me a lot in the future.

Getting down to the basics with this rotation:

Mondays: Clinic day at West Ann Arbor. We see/phone new and returning patients for management of their chronic disease states: diabetes, hyperlipidemia, and hypertension. Some patients also get asthma action plans or get help managing their weight and diets.

Tuesdays and Fridays: Medication reconciliations and polypharmacy patients at East Ann Arbor. Patients are phoned after discharge to reconcile their medications with what they were taking when admitted to the hospital even before they have an appointment at the Turner Geriatrics Clinic.

Wednesdays and Thursdays: I review patients with Dr. Remington before we see the patients. We also do topic discussions, journal club, and a formal case presentation during that time.

Pros to this rotation:

1) I know a lot more about the three big disease states than I ever thought I would. I feel as is I have a much better understanding of how to monitor hypertension, hyperlipidemia, and diabetes therapy; when to make dosage changes; what starting doses should be; and when to discontinue therapy all together.

2) I know how to take one terrific manual blood pressure... that's for sure!

3) Dr. Remington is super smart and really pushes you to work your hardest, but she is also understanding and tries not to overwhelm you. She encourages you to focus in on your interests. She knows mine is about diet and exercise so she really encourages me to look more into those areas when it comes to patients. I was looking up the new myplate instead of the old food pyramid earlier today in order to help a patient with weight issues.

4) She has absolutely fun and pleasant patients to be around on Monday clinic.

5) You aren't hustling from one spot to another, 9-5. You are given plenty of free time to work up patients' therapeutic plans during your daily routinesa.

Cons:

1) You invest a lot of time and energy on your patients, but usually only on a couple nights a week, not every night.

2) Sometimes it can be disheartening to work so hard helping patients, and then they don't show up to clinic or answer their phones. It especially sucks when you have a bunch of good recommendations to offer.

3) I really can't even think of anything else.

I am really enjoying this rotation and looking forward to the next couple of weeks. I definitely recommend having your rotation at East Ann Arbor with Dr. Remington if you can!