Medication therapy management services provided by student pharmacists

Earthquakes, Hurricanes, Pandemics: Pharmacy Students Impacting Pharmacy Practice in Puerto Rico Through Medication Therapy Management Services During Disasters

BACKGROUND

Community-based medication therapy management advanced pharmacy practice experiences (MTM APPE) can engage pharmacy students in public health initiatives, including emergency response preparedness, to successfully impact patient care. This study aimed to evaluate pharmacy students' perceptions of their experience on an MTM APPE during disasters in Puerto Rico.

METHODS

After completing the MTM APPE during times of hurricanes, earthquake or pandemic, pharmacy students were asked to voluntarily participate in a questionnaire about their perception of assisting during a disaster. The survey consisted of 5 questions. Four questions were based on a Likert scale with answers choices ranging from Agree, Not Sure, Disagree, or Not Applicable. One question requested free text comments from participants.

RESULTS

Sixteen students completed the survey. Pharmacy students agreed that the MTM APPE taught them the clinical skills needed to assist and educate individual patients and the community that suffered from a disaster, and that the role of the pharmacist is vital when a disaster disrupts a community's health-care system.

CONCLUSIONS

Training in emergency response to disasters should be a considered component of MTM APPE.

Incorporation of Student Pharmacists into a Proton Pump Inhibitor Deprescribing Telehealth Program for Rural Veterans

Background: Proton pump inhibitors (PPIs) are among the most widely prescribed class of medications in the United States. Although effective in the treatment of acid related disease, inappropriate PPI use is prevalent, and long-term PPI use has been associated with adverse effects. Objectives: This evaluation explores the novelty of a student-pharmacist directed PPI deprescribing telehealth program with the goals of (1) determining whether PPIs are appropriately prescribed in Veterans via remote student-led chart reviews, (2) identifying if a gap exists between urban and rural Veterans prescribed a PPI, and (3) assessing the feasibility of integrating student pharmacists into the PPI deprescribing process utilizing telehealth visits through a pilot study. Methods: Student pharmacists evaluated PPI appropriateness in Veterans at the William S. Middleton Veterans Hospital. Students collected data via remote chart reviews, compared appropriateness of PPI therapy in rural versus urban Veterans, and conducted a deprescribing pilot call study in rural Veterans with inappropriate PPI indications. Clinical decision-making was agreed upon in collaboration with pharmacist preceptors, however all means of communication with Veterans was performed by student pharmacists. Results: 51% of Veterans were found to have an inappropriate indication for their PPI, though comparison of inappropriate PPI use in rural versus urban Veterans was not statistically significant (n=170, p-value 0.34). 83% of Veterans agreed to proceed with PPI deprescribing and 71% of Veterans ended the pilot study with at least some degree of PPI dose reduction (n=33). Conclusion: Inappropriate PPI use among rural and urban Veterans is prevalent, however a significant difference was not observed between the two cohorts. Student pharmacists are capable of successful telehealth deprescribing interventions in collaboration with pharmacists.

Implementation and evaluation of a student scholarship program to increase care initiatives in rural pharmacies

INTRODUCTION

Availability of patient care services in rural areas is often lacking, which can reduce access to care for patients living in these areas. Patient care within community pharmacies is vital to care access in rural areas, but expanding pharmacy services can often be challenging. Pharmacy students, especially those on advanced pharmacy practice experiences, are positioned to make an impact on sites.

METHODS

The objective of this study was to describe the implementation, evaluation, and impact of a student scholarship program designed to increase patient care initiatives in rural community pharmacies. Scholarships were provided to students to expand patient care initiatives targeting chronic disease in select rural community pharmacies. Before and after participating in the scholarship program, students completed a survey assessing their perceived ability and confidence to initiate new patient care activities. In addition, patient care services provided by students were tracked and reported cumulatively.

RESULTS

During the first year of implementation, 24 student scholarship rotations were completed. Throughout the 24 rotations, 369 patients were screened for prediabetes, 391 were screened for hypertension, and 552 patients were screened for immunizations. Of the 27 items presented in the survey, 20 items showed a mean statistically significant change indicating an increase in student confidence in leading, developing, and performing patient care activities.

CONCLUSIONS

A student scholarship program designed to increase patient care initiatives in rural community pharmacies led to new patient care services in rural areas and increased student confidence in leading, developing, and expanding upon patient care activities.

Medication review in multi-morbid geriatric patients: A training program for pharmacy students in Germany

INTRODUCTION

Medication reviews can reduce the geriatric risk of experiencing drug-related problems (DRPs), but medication review training programs in pharmacy education are infrequent and inconsistent. Data on education programs that practice DRP management skills and DRP prioritization should be collected as such training requires a tailored student evaluation at the DRP level.

METHODS

A geriatric patient medication review training was developed and implemented for eighth-semester pharmacy students. Students' DRP management skills were evaluated using audiotaped, 15-min simulated patient scenarios before and after the training using a newly developed algorithm (score 1-9, adequate management defined ≥7). The scenarios included 17 DRPs, five of which were identified as a high priority. Students rated their DRP management and knowledge by self-assessment before and after the training and supplied feedback about the training.

RESULTS

Student comprehension and handling of DRPs improved after the training. The median number of adequately managed DRPs increased from 4 to 7 (P = .001) and the median number of high-priority DRPs identified increased from 4 to 5 (P = .007). Students felt they improved their overall competency, DRP management, and knowledge, and 85% rated the training essential to their university education.

CONCLUSIONS

This training provided students with an objective evaluation algorithm for complex patient simulations in elderly patients. The training improved students' DRP prioritization and management, providing a basic template for future geriatric medication review training programs.

Targeted Medication Review of Falls-Risk Medications in Older Patients: A Community Pharmacy-Based Approach

Objective To assess a community pharmacist-provided targeted medication review (TMR) intervention to reduce the number of falls risk-increasing drugs (FRIDs) prescribed to older patients in a community pharmacy setting. Design A single-site, prospective, interventional pilot study with a historical control group. Setting A single independent community pharmacy in rural Western New York. Participants A convenience sample of subjects was recruited for the intervention group based on the following inclusion criteria: 65 years of age or older, at least one prescription filled at the pharmacy within the past 90 days from date of enrollment in study, enrolled in a local Medicare plan, and prescription for at least one prespecified FRID filled at the pharmacy within 90 days before date of enrollment in study. A control group was collected that had different Medicare Part D plans than the intervention group but otherwise met inclusion criteria and ensured that between all of the control-group patients we included at least one patient prescribed each of the FRID classes that were found in the intervention group. Thirty-six subjects completed the study intervention, and 63 controls were collected. This offset in numbers between groups resulted from intervention subjects taking multiple FRIDs and the control needing to take the same class of FRID, thus one intervention subject may have required multiple control subjects to parallel each FRID class. Intervention The intervention involved the community pharmacist assessing the patient's fall risk, then educating the patient on the risks of the FRID he or she was prescribed, and recommending to either replace or discontinue the FRID. The outcomes assessment occurred three months later, with the pharmacist repeating the falls-risk assessment and following up regarding the patient's agreed-upon action plan. Results The intervention group had 52 FRIDs identified while the control group had 89. The discontinuation rate of FRIDs at three months was significantly higher in the intervention group (7.7% versus 0%; P = 0.0172). Conclusion This study demonstrated that a community pharmacist TMR intervention can reduce the use of FRIDs.

Impact and Sustainability of a 10-year Community Pharmacy Disease Management Service

BACKGROUND

Community pharmacy practice needs to demonstrate services beyond traditional dispensing roles to continue to function in a changing marketplace. Pharmacists have established themselves as being capable of improving patient outcomes and saving healthcare dollars by providing disease management services to patients. This paper describes a sustained community pharmacy-run disease management program that continued after a grassroots grant-funding effort in 2007.

METHODS

The city of Colorado Springs recognized the successes shown by the pharmacy during the Ten City Challenge funded project, and decided to financially support pharmacy diabetes care services. Partnering with the local School of Pharmacy, the pharmacist obtained advanced training and continued to deliver individualized counseling and management to approximately 100 patients per year for the past 14 years. Objective lab measurements (systolic and diastolic blood pressures, A1C values, total lipid profiles) were obtained or performed, and clinical goals were set based on national guidelines. Patients received a series of appointments to learn how to control their diabetes, and later their cardiovascular disease. Financial estimates were calculated using 2008 baseline numbers and adding estimated inflation based on published Segal rates.

RESULTS

The pharmacy services successfully maintained participation of approximately 100 patients annually each year since its inception. Average lab value markers for disease control were at or close to clinical guideline recommendations for the population. Services were associated with estimated cost savings for the health system. Positive results led to expansion in services to include cardiovascular disease in 2017.

CONCLUSIONS

A community pharmacy has successfully sustained a disease management program for patients for over 14 years, demonstrating high patient enrollment, health outcomes at or near clinical guidelines for control, and positive financial outcomes associated with the program.

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.

Advanced pharmacy practice experience students at the intersection of education and practice transformation

BACKGROUND AND PURPOSE

Community pharmacy practice is transforming from traditional dispensing roles, and advanced pharmacy practice experiences (APPEs) could be a viable mechanism to assist pharmacies during transformation. A new type of APPE is described and the design, outcomes, and feedback from the first students and pharmacies piloting this rotation are discussed.

EDUCATIONAL ACTIVITY AND SETTING

A four-week elective APPE was designed to position fourth-year students as facilitators for community pharmacy transformation activities. The first transformation activity was clinical documentation using electronic care plans (eCare plans). Students spent a majority of the rotation in the pharmacy with only the first week and one day a week thereafter at the college of pharmacy. Students assessed current pharmacy workflow, developed an implementation plan, trained pharmacy staff, and created protocols and resources.

FINDINGS

Four student pharmacists completed the rotation during May, June, and August 2019. Student knowledge was assessed through a 12-question pre- and post-quiz on implementation science and the pharmacist eCare plan. Following orientation activities, students' scores increased from an average 44% to 86%. Course evaluations showed students learned about pharmacy business management and recognized challenges in teaching staff new concepts. All students indicated appreciation for innovative activity involvement and helping a pharmacy advance its practice.

SUMMARY

Early findings from this elective indicate a successful learning experience for students and pharmacy owners. The students gained skills in teaching, facilitation, and practice management, while pharmacy owners benefitted from staff training and implementation resources.

Pilot study of focus groups exploring student pharmacists' perceptions of a medication management center internship

INTRODUCTION

Student pharmacists are expected to participate in real-life, patient-centered experiences to help develop clinical knowledge and professional skills. This study explored student pharmacist intern perceptions of work experience at a medication management center (MMC). We also examined how working at the MMC helped fulfill curricular requirements, helped develop leadership skills, and provided professional development opportunities.

METHODS

Two focus groups were conducted with first-, second-, and third-year student pharmacist interns at the MMC in April 2019. The focus groups were audio recorded for verification purposes, transcribed, and analyzed thematically by two independent reviewers.

RESULTS

A total of five student pharmacist interns participated. Four main themes were identified: (1) knowledge; (2) communication; (3) time management; and (4) leadership, mentorship, and networking. Participants had opportunities to acquire new knowledge and skills outside the classroom, providing them an academic advantage while recognizing areas of deficiency. Students practiced communication skills that helped improve language skills and manage difficult patients, although telephonic consultations were challenging. Students learned to prioritize time with patients but reported difficulty managing their work schedules. Leadership, mentorship, and networking opportunities facilitated learning and improved their self-confidence.

CONCLUSIONS

This qualitative analysis identified four key themes, highlighting the many benefits available for student pharmacist interns working at an academic-based MMC. Further research is needed to address challenges reported in this study and should include a larger sample of student pharmacists for more generalizable results.

Expanding Pharmacy Services With an Intern Program at an Academic Medical Center

BACKGROUND

Organizations that implement pharmacy services to provide patient education have reduced hospital readmissions and improved the patient experience. The term "pharmacy extender" has been used to describe pharmacy technicians and pharmacy students who alleviate the workload of a pharmacist, enhance pharmacy visibility throughout an organization, and foster professional development for the individual.

OBJECTIVE

The objective of this pharmacy intern-driven program is to increase pharmacy reach for medication teaching.

METHODS

This is a single-center, IRB-approved retrospective cohort analysis. Pharmacist-led medication teaching is currently available to select high-risk populations including solid organ transplant and bone marrow transplant recipients at our organization. Clinicians working in the pharmacy satellites have structured operational and distributional workflow responsibilities, which precludes them from directly engaging with patients. Pharmacy interns can serve as extenders that can participate in medication teaching. An internally created digital medication teaching tool will be employed to expand the pharmacy reach for medication education.

RESULTS

During the period of study, the pharmacy interns screened 3,993 patients and educated 2,868 patients. Two-thirds of the pharmacy interns that participated in the program pursued post-graduate residency or fellowship training, while the rest assumed hospital pharmacist positions.

CONCLUSION

Deploying pharmacy interns as extenders for distribution of an internally created digital tool that provides general medication teaching has shown positive outcomes including greater pharmacy presence and visibility, better patient experience, and higher patient satisfaction. Continuous data collection and monitoring are warranted to demonstrate the benefits of the program once sustained and potentially justify more resources for further expansion.

Initial Validation of an Instrument for Measuring Entrepreneurial and Intrapreneurial Intentions in Student Pharmacists

Objective. To develop a questionnaire for measuring entrepreneurial and intrapreneurial intentions among student pharmacists and to identify characteristics and personality traits that are associated with these intentions. Methods. A 105-item survey instrument was developed and administered to all Doctor of Pharmacy (PharmD) students (incoming to third year) at a large public university. It consisted of nine scales pertaining to entrepreneurism including previously validated and some newly developed scales adapted for use among student pharmacists. Data analysis consisted of factor analysis to determine scale constructs, reliability assessment, and systematic item-reduction analysis. Multiple linear regression and structural equation modeling was used to determine and confirm the association of personality traits and demographic characteristics with entrepreneurial and intrapreneurial intentions. Results. Of 289 students surveyed, 286 useable survey instruments were included in the analysis. Factor analysis was conducted for each scale, and items that did not load on their theorized factor or had cross-loadings above the permissible limits were removed, reducing the survey to 69 items. Findings demonstrated that gender, joint degree program, and autonomy were significant predictors of entrepreneurial intentions, and achievement motivation, leadership self-efficacy, and problem-solving were significant predictors of intrapreneurial intentions. Conclusion. A multi-dimensional questionnaire to measure entrepreneurial and intrapreneurial intentions of student pharmacists was developed and a few key predictors of such intentions were identified. When fully validated, the questionnaire may be used in pharmacy schools for several purposes, including in the PharmD admission process to gain additional insights into a student's potential to become a future innovative entrepreneurial or intrapreneurial practitioner.

Pharmacy students' satisfaction with Introductory Pharmacy Practice Experiences (IPPE) at community pharmacy: The case of Saudi Arabia

OBJECTIVE

To assess pharmacy students' satisfaction with introductory pharmacy practice experiences (IPPE) at community pharmacy and the impact of the training on their future career.

METHODS

A self-administered questionnaire was made available to 74 male pharmacy students who completed 4 weeks community pharmacy IPPE. The questionnaire consists of 24 questions that were organized into 5 domains with a scale of six options were used to answer each question.

RESULTS

A total of 43 students completed the survey (58%). Most of them evaluated their training experience as either as good (41.86%) or excellent (41.86%). One third of students (34.88%) were very satisfied about the clarity of the community pharmacy IPPE goals and objectives given prior to the training period. About half of students (51.6%) received a good direction and feedback from their preceptors. Regarding the contact with the patient or guardian, (39.53%) of the students chose neutral while (25.58%) of the students were very satisfied. The learning environment was satisfactory for (32.56%) of students. Regarding skills domain, students strongly agreed that their skills were improved; Communication skills as reported by (48.84%) of students, documentation skills as reported by (34.88%) of students, and clinical skills as reported by (34.88%) of students.

CONCLUSION

Surveyed male students were in general satisfied with their training experience at community pharmacy. Providing an orientation to the community pharmacy preceptors and granted electronic access of necessary information to the students might increase their satisfaction.

A pharmacist-led pilot program to facilitate deprescribing in a primary care clinic

OBJECTIVE

To develop and pilot-test a model in which a community-based clinical pharmacist was incorporated as part of a Medicare Annual Wellness Visit (AWV) to make deprescribing recommendations targeted at potentially inappropriate medications (PIMs) in seniors.

SETTING

A family medicine patient-centered medical home (PCMH) clinic in Buffalo, NY.

PRACTICE DESCRIPTION

Implementation and evaluation of a pilot program incorporating a pharmacist-provided medication review targeting PIMs in seniors as part of a Medicare AWV.

PRACTICE INNOVATION

A community pharmacy-based clinical pharmacist provided face-to-face medication reviews for patients older than 65 years as part of their AWV with a focus on deprescribing PIMs. No clinical pharmacy service existed at the practice when this program was implemented.

EVALUATION

Identified PIMs, pharmacist recommendations, recommendation acceptance rate, time spent on intervention, health care utilization at 6 months postvisit, and barriers to implementation.

RESULTS

Of the 21 patients enrolled, 13 unique patients received a total of 20 deprescribing recommendations from the pharmacist. The overall acceptance rate for pharmacist recommendations was 20%. The pharmacist spent a mean (± SD) of 34 (± 6) minutes per patient encounter. One patient in the intervention group was hospitalized, and 1 was seen in the emergency department (ED) during the 6-month follow-up period compared with 1 patient in the control group who had an ED visit. We identified multiple logistical and organizational barriers to the implementation of the intervention.

CONCLUSION

In this prospective pilot study, a workflow to include a pharmacist medication review to facilitate deprescribing in the primary care setting was tested. We encountered several barriers to integrating the pharmacist into the AWV workflow to deliver the intervention. Future pragmatic clinical trials are warranted to improve provider awareness and comfort with deprescribing PIMs in seniors.

Prevalence and Impact of Pharmacy Students as Patient Care Extenders in Medically Underserved Community Pharmacies

Objective:

The objective of this study is to evaluate the prevalence and describe the patient care impact of student pharmacists completing community pharmacy rotations in medically underserved areas (MUAs) in Nebraska.

Methods:

A list of pharmacy student advanced pharmacy practice experience placements over a 3-year period were obtained from 2 pharmacy schools in Nebraska and then mapped in relation to MUAs in the state. A mixed-methods approach was used to compare and relate findings of a student-logged patient care activity database and semistructured interviews with pharmacy preceptors of participating students.

Results:

Pharmacy students were placed in 21 (13%) of 159 identified pharmacies located in MUAs. Pharmacy preceptors felt students improved the quality of patient care provided as a result of more uninterrupted time with the patient. Preceptors also indicated that student presence assists both the student and the practicing pharmacist engage in more patient care services.

Conclusion:

There exists a significant opportunity to utilize advanced pharmacy practice students to extend patient care services and address health-care needs in underserved communities, but student placement in MUAs should be optimized.

The New Era of Pharmacists in Ambulatory Patient Care

Pharmacy is evolving from a product-oriented to a patient-oriented profession. This role modification is extremely healthy for the patient, the pharmacist, and other members of the health-care team. However, the evolution will present pharmacists with a number of new challenges. Now, more than in the past, pharmacists must make the acquisition of contemporary practice knowledge and skills a high priority, to render the level of service embodied in the concept of pharmaceutical care. Pharmacy educators' organizations and regulatory bodies must all work together to support pharmacists as they assume expanded health-care roles. Pharmacy and the healthcare industry must work to ensure that the pharmacist is compensated justly for all services. But before this can happen it will be necessary for pharmacy to demonstrate value-added to the cost of the prescription. Marketing of the purpose of pharmacy in the health-care morass and of the services provided by the pharmacist is needed to generate an appropriate perceived value among purchasers and users of health-care services. Pharmacists should view themselves as dispensers of therapy and drug effect interpretations as well as of drugs themselves. Service components of pharmacy should be identified clearly to third party payers and be visible to consumers, so that they know what is available at what cost and how it may be accessed. In the future, pharmacy services must be evaluated on patient outcome (i.e., pharmaceutical care) rather than the number of prescriptions dispensed, and pharmacy must evolve toward interpretation and patient consultation, related to the use of medication technologies.

Impacting Student Self-Efficacy and Beliefs of Medication Therapy Management Through a Two-Week Elective

Objective. To develop and introduce an intensive, two-week Foundations of Medication Therapy Management (MTM) elective course into the Doctor of Pharmacy curriculum, and to determine whether the course impacted students' self-confidence in their abilities to perform MTM services and future plans and beliefs about implementing MTM in practice. Methods. The MTM course was an interactive learning environment where students performed actual comprehensive medication reviews within a real-world documentation platform. A 20-item, Likert-scale survey was administered before and after the course to measure students' confidence in learned skills, future plans for using MTM, and beliefs about MTM. Results. Students reported a significant improvement in 10 MTM-specific skill domains. There were significant changes in students' self-confidence in their ability to provide MTM services and in their beliefs about MTM-related services. Students reported overall improvement in self-perceived MTM specific skills. There was no significant change in students' willingness or plans to engage in MTM-related practice in the future. Conclusion. The findings showed that following participation in an MTM elective course, student pharmacists' perceived ability to deliver MTM care increased and their opinions about MTM services improved. Providing a brief MTM elective course that used first-person case studies may empower student pharmacists to confidently perform MTM services in subsequent courses and in their future practice.

Community pharmacists' educational needs for implementing clinical pharmacogenomic services

OBJECTIVES

Pharmacist leadership and knowledge of pharmacogenomics is critical to the acceleration and enhancement of clinical pharmacogenomic services. This study aims for a qualitative description of community pharmacists' pharmacogenomic educational needs when implementing clinical pharmacogenomic services at community pharmacies.

METHODS

Pharmacists practicing at Rite Aid Pharmacy locations in the Greater Pittsburgh Area were recruited to participate in this qualitative analysis. Pharmacists from pharmacy locations offering pharmacogenomic testing and robust patient care services were eligible to participate in a semistructured, audio-recorded interview. The semistructured interview covered 4 domains crafted by the investigative team: (1) previous knowledge of pharmacogenomics; (2) implementation resources; (3) workflow adaptation; and (4) learning preferences. Interviews were transcribed verbatim and independently coded by 2 researchers. A thematic analysis by the investigative team followed. Supporting quotes were selected to illustrate each theme.

RESULTS

Eleven pharmacists from 9 unique pharmacy locations participated in this study. The average length of practice as a community pharmacist was 12 years (range, 1.5-31 years). Pharmacist's pharmacogenomic educational needs were categorized into 5 key themes: (1) enriched pharmacogenomic education and training; (2) active learning to build confidence in using pharmacogenomic data in practice; (3) robust and reputable clinical resources to effectively implement pharmacogenomic services; (4) team-based approach throughout implementation; (5) readily accessible network of pharmacogenomic experts.

CONCLUSION

This study describes the educational needs and preferences of community pharmacists for the successful provision of clinical pharmacogenomic services in community pharmacies. Pharmacists recognized their needs for enriched knowledge and instruction, practice applying pharmacogenomic principles with team-based approaches, robust clinical resources, and access to pharmacogenomic experts. This deeper understanding of pharmacist needs for pharmacogenomic education could help to accelerate and enhance the clinical implementation of pharmacogenomic services led by community pharmacists.

The impact of a required course on third year pharmacy students' perceived abilities and intentions in providing medication therapy management

BACKGROUND AND PURPOSE

To examine the impact of a Medication Therapy Management (MTM) course on third-year pharmacy students' (P3s) perceived abilities and intentions to provide MTM services before and after the course.

EDUCATIONAL ACTIVITY AND SETTING

An anonymous 48-item self-administered survey was administered to P3s before and after the MTM course. Forty-six items using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) measured abilities in MTM provision using the following seven subdomains: general MTM ability (GA), medication therapy review (MTR), medication-related problems identification/recommendations (MRPIR), disease measurement/monitoring (DM), communication (CO), follow-up/referral (FR), and billing/documentation (BD). Two items assessed intent to provide MTM in practice. Descriptive statistics, Cronbach's alphas, and paired t-tests were used.

FINDINGS

All enrolled P3s (n = 110) completed both surveys. Subdomain Cronbach's alphas ranged from 0.70-0.97. Paired t-test showed no significant difference in intention to provide MTM before and after the course; however, the results revealed a significant increase in perceived abilities (before vs. after, respectively) regarding MTR (3.2 ± 0.6;4.2 ± 0.4; p < 0.0001), MRPIR (3.3 ± 0.6;4.2 ± 0.4; p < 0.0001), DM (4.2  ±  0.6;4.5  ±  0.5; p = 0.0004), CO (3.9 ± 0.5; 4.3 ± 0.4; p < 0.0001), FR (3.7±0.8;4.2±0.6; p = 0.0002), and BD (2.4±0.9;3.9±0.8; p < 0.0001).

DISCUSSION AND SUMMARY

A required MTM course with both didactic and experiential components were instrumental in improving P3s' perceived abilities to provide MTM services. Additional research is needed to understand why students' intention to provide MTM did not change pre- to post-course completion.

A novel advanced pharmacy practice experience training model focused on medication therapy management delivery within provider offices

BACKGROUND AND PURPOSE

Pharmacist-delivered medication therapy management (MTM) services are an important part of practice, and students should be trained in MTM provision. Current MTM utilization falls short of the potential benefits that pharmacists could provide, and there are barriers to successful MTM completion. New MTM models need to be explored to demonstrate the pharmacist's role on the medical team and to provide models for cost saving to insurers.

EDUCATIONAL ACTIVITY AND SETTING

This manuscript describes a novel grant-funded MTM model supported by fourth year pharmacy students in partnership with several medical clinics. Qualifying patients receive MTM services in the provider office. Students are responsible for maintaining day-to-day operations of the MTM program.

FINDINGS

Twe pharmacy students completed their MTM training through this model between April 2016 and September 2017. 123 patients received MTM services, with the average time spent with patients estimated at 41 min. A total of 238 patient encounters were provided. Poor adherence, inappropriate drug dose/dosage form or frequency, and patient side effects were the most common problems addressed. Students reported high satisfaction with this model.

DISCUSSION

Providing MTM services, directly in the medical clinic, represents an innovative model of care where students have multiple interprofessional interactions. The extended period of time spent with patients is not supported by reimbursement rates, suggesting an expansion may be appropriate. Further cost analyses and health outcomes need to be collected to justify this increased expense.

SUMMARY

This MTM model represents an important alternative to current practice and promotes interprofessional collaboration.

Development and evaluation of an elective course that incorporates a standard medication therapy management certificate program

BACKGROUND AND PURPOSE

To describe the development and evaluation of a medication therapy management (MTM) elective that incorporates a nationally recognized certificate training program (CTP) by assessing changes in perceived abilities and values among student pharmacists, knowledge of course material, and performance conducting MTM services. Student satisfaction with course content and delivery model was also evaluated.

EDUCATIONAL ACTIVITY AND SETTING

University faculty developed a didactic elective course to provide third-professional year student pharmacists with the opportunity to meet the learning objectives of the American Pharmacists Association (APhA) "Delivering Medication Therapy Management Services" CTP. Additional learning activities developed by course faculty included supplemental didactic content, reinforcement exercises, simulated patient interactions, self-reflections, and detailed faculty assessment and feedback. Pre- and post-course surveys collected information about student perceptions and values. Course grades for quizzes, midterm, follow-up, and final comprehensive medication review (CMR) assessments were retrospectively analyzed to assess student performance. Student satisfaction with course content and delivery methods was assessed via a survey.

FINDINGS AND DISCUSSION

Student-reported perceived abilities improved across all survey items and there was high baseline agreement with MTM value statements. Quiz results suggested student achievement of course objectives. Student performance improved in most grading domains from the midterm to final assessment. A majority of students were satisfied with the course content and delivery methods.

SUMMARY

Evaluation of student perceived abilities and values, performance, and satisfaction support the successful incorporation of the MTM CTP along with faculty-developed supplemental content and activities into a longitudinal elective course in the pharmacy curriculum.

"How do I say that?": Using communication principles to enhance medication therapy management instruction

BACKGROUND AND PURPOSE

Medication therapy management (MTM) is a comprehensive, patient-centered approach to improving medication use, reducing the risk of adverse events and improving medication adherence. Given the service delivery model and required outputs of MTM services, communication skills are of utmost importance. The objectives of this study were to identify and describe communication principles and instructional practices to enhance MTM training.

EDUCATIONAL ACTIVITY AND SETTING

Drawing on formative assessment data from interviews of both pharmacy educators and alumni, this article identifies and describes communication principles and instructional practices that pharmacy educators can use to enhance MTM training initiatives to develop student communication strategies.

FINDINGS

Analysis revealed five key communication challenges of MTM service delivery, two communication principles that pharmacy teachers and learners can use to address those challenges, and a range of specific strategies, derived from communication principles, that students can use when challenges emerge. Implications of the analysis for pharmacy educators and researchers are described.

SUMMARY

Proactive communication training provided during MTM advanced pharmacy practice experiences enabled students to apply the principles and instructional strategies to specific patient interactions during the advanced pharmacy practice experiences and in their post-graduation practice settings.

Effect of an Advanced Pharmacy Practice Experience on Medication Therapy Management Services in a Centralized Retail Pharmacy Program

BACKGROUND

Medication therapy management (MTM) delivery is increasingly important in managed care. Successful delivery positively affects patient health and improves Centers for Medicare & Medicaid Services star ratings, a measure of health plan quality. As MTM services continue to grow, there is an increased need for efficient and effective care models. The primary objectives of this project were to describe the delivery of MTM services by fourth-year Advanced Pharmacy Practice Experience (APPE) students in a centralized retail pharmacy system and to evaluate and quantify the clinical and financial contributions of the students. The secondary objective was to describe the engagement needed to complete comprehensive medication reviews (CMRs) and targeted interventions.

PROGRAM DESCRIPTION

From May 2015 to December 2015, thirty-five APPE students from the University of Colorado Skaggs School of Pharmacy provided MTM services at Albertsons Companies using the OutcomesMTM and Mirixa platforms. Students delivered patient care services by phone at the central office and provided face-to-face visits at pharmacies in the region. With implementation of the MTM APPE in 2015, the team consisted of 2 MTM pharmacists and pharmacy students, as compared with 1 MTM pharmacist in 2014. The number of CMRs and targeted interventions completed and the estimated additional revenue generated during the 2015 time period were compared with those completed from May through December 2014. The patient and provider engagement needed to complete the CMRs and targeted interventions was summarized.

OBSERVATIONS

125 CMRs and 1,918 targeted interventions were billed in 2015, compared with 13 CMRs and 767 targeted interventions in 2014. An estimated $16,575-$49,272 of additional revenue was generated in 2015. To complete the interventions in 2015, the team engaged in 1,714 CMR opportunities and 4,686 targeted intervention opportunities.

IMPLICATIONS/RECOMMENDATIONS

In this MTM rotation, students provided real-life care to patients, resulting in financial and clinical contributions. This model of education and care delivery can be replicated in the community pharmacy or managed care setting. APPE students are an important component of this model of care delivery, particularly when considering the level of patient engagement needed to complete MTM interventions.

DISCLOSURES

No outside funding supported this research. The authors have no conflicts of interest to disclose related to this work. All authors contributed to study concept and design. Rodgers collected the data, and data interpretation was performed by Vande Griend, along with Rodgers and Nuffer. The manuscript was written and revised primarily by Vande Griend, along with Nuffer and Rodgers. This project was presented at the Pharmacy Quality Alliance Annual Meeting in Arlington, Virginia, in May 2016.

Incorporating the American Pharmacists Association's Delivering Medication Therapy Management services certificate program into an accelerated pharmacy curriculum

BACKGROUND AND PURPOSE

To describe the incorporation of the American Pharmacists Association (APhA) Delivering Medication Therapy Management (MTM) Services program into a PharmD curriculum and to describe student perceptions of the program.

EDUCATIONAL ACTIVITY AND SETTING

The program was delivered over 12 months to students on two campuses via two didactic courses in the second professional year and during the first two advanced pharmacy practice experiences in the third professional year of an accelerated school of pharmacy program.

FINDINGS

Student perceptions were assessed by review of responses to the APhA MTM program evaluation survey.

DISCUSSION AND SUMMARY

Incorporation of the APhA MTM program into an accelerated PharmD program required careful planning and coordination amongst faculty and course coordinators. Students perceived that the program was valuable, met their educational needs, and incorporated effective learning experiences and cases. These perceptions were reinforced by the high percentage of students who completed the program.

Know your medicine: A novel student-led community service learning program

INTRODUCTION

The objective of this article is to describe the efforts of the student pharmacist organization called Know Your Medicine (KYM) as they conduct medication therapy management (MTM) for older adults and underserved communities.

METHODS

Patients brought medications, immunization records, and health concerns to KYM events during academic years 2012-2013 and 2013-2014. Student pharmacists performed health screenings, created personalized medication records (PMR), made recommendations, created personal action plans (PAP), and conducted follow-up phone calls.

RESULTS

Student pharmacists provided MTM services for a total of 107 patients. The mean duration of a KYM appointment was 62±21min, and student pharmacists provided a mean of 3.5±2.1 recommendations per patient. Patients had a mean age of 78±11 years, 4.5±3.2 disease states, 6.9±4.6 prescriptions, 1.9±1.9 OTC medications, and 2.8±2.6 vitamins or herbals. At the time of the follow-up phone call, a mean of 2.6±1.9 recommendations per patient had been followed.

DISCUSSION AND CONCLUSIONS

Student pharmacists successfully implemented a new MTM program for older adults and underserved communities. This program can serve as an example of how other pharmacy colleges and schools might implement MTM training and real-world MTM experience for their student pharmacists.

Establishment and Implementation of a Required Medication Therapy Management Advanced Pharmacy Practice Experience

Objective. To develop a community pharmacy-based medication therapy management (MTM) advanced pharmacy practice experience (APPE) that provides students with skills and knowledge to deliver entry-level pharmacy MTM services. Design. The University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences (SSPPS) partnered with three community pharmacy chains to establish this three-week, required MTM APPE. Students completed the American Pharmacists Association MTM Certificate Course prior to entering the APPE. Students were expected to spend 90% or more of their time at this experience working on MTM interventions, using store MTM platforms. Assessment. All 151 students successfully completed this MTM APPE, and each received a passing evaluation from their preceptor. Preceptor evaluations of students averaged above four (entry-level practice) on a five-point Likert scale. The majority of students reported engagement in MTM services for more than 80% of the time on site. Students' self-reporting of their ability to perform MTM interventions improved after participation in the APPE. Conclusion. The SSPPS successfully implemented a required MTM APPE, preparing students for entry-level delivery of MTM services.

Perceptions of pharmacists' role in the health care team through student-pharmacist led point-of-care screenings and its future application in health care

INTRODUCTION

The public is largely unaware of changing pharmacy roles and continues to underutilize pharmacists as mainly a dispensing service, often overlooking direct patient care components. This paper evaluates the public perceptions of pharmacists' through student led point-of-care screenings and comprehensive medication reviews.

METHODS

An IRB approved longitudinal retrospective study design was used to survey participants who attended College of Pharmacy sponsored health fairs in 2013. The survey contained questions related to patient understanding of the current pharmacy scope of practice, patient's reported level of comfort with the expanding roles of pharmacy, insurance coverage, demographics, income and whom the patients report that they seek first for medical related advice.

RESULTS

One hundred participants were surveyed. By a large majority, the health care practitioner that patients reported that they currently sought out for general health information was a physician. All of the participants reported that they considered pharmacists as reliable sources of general health information. Of the 96 participants that completed the survey question regarding their willingness to seek out a pharmacist in the future to have their blood pressure, blood sugar, cholesterol, and/or bone density checked, 89 (92.7%) surveyed answered yes. Only 50 patients (50%) reported being aware that pharmacists have the capability to perform these point-of-care screenings. Participants responded that they felt "comfortable" (78 patients, 83.4%) followed by "trusting" (36 patients, 38.7%).

DISCUSSION

The patients surveyed recognized pharmacists as the medication experts; however, many did not understand the capacity to which pharmacists' scope of practice allows them to deliver care to patients. In this study, almost all of the patients stated that they would consider seeking out a pharmacist to receive point-of-care screenings, but only half were aware that a pharmacist is capable of conducting these screenings. All felt that pharmacists are a reliable source of general health information and medication related needs, regardless of the patients' education level or household income.

CONCLUSION

With the shortage of primary care providers, expansion of the scope of pharmaceutical practice is necessary. Although the public may not fully understand pharmacists' scope of practice, they are comfortable with pharmacists' knowledge related to general health needs outside of medications. The reported public comfort and trust of pharmacist knowledge and skills justify expanding the scope of pharmaceutical practice.

Qualitative Evaluation of a Practice-based Experience Pilot Program for Master of Pharmacy Students in Scotland

Objective. To determine the views of pharmacists in central Scotland regarding experiential education for MPharm students. Methods. A thematic analysis was completed by Ms. Gillian Hendry and Dr. Sally Wiggins of interviews conducted with ten practicing pharmacists paired with first-year master of pharmacy (MPharm) students during the 2011-2012 academic year. Relevant comments from the interviews were manually sorted in a Microsoft Excel spreadsheet to bring similarly themed material together to facilitate the identification and naming of recurring themes and subthemes. Results. The pharmacists were unanimous in their opinion that experiential education was valuable for MPharm students and, in particular, that it helped students to develop self-confidence. The pharmacists derived personal satisfaction in developing mentor/mentee relationships with students. They also recognized the value that students provided to the workforce as well as the educational value to themselves in supervising students. The participants' primary dissatisfaction was that the pharmacy workflow limited the time they could spend mentoring students. Conclusion. The results provide guidance to the academic community and the pharmacy practice community in the United Kingdom (UK) regarding the design and integration of experiential education courses in MPharm degree programs.

Description and Evaluation of an MPharm Practice-based Experience Pilot Program

Objective. To determine the level of support among pharmacists in central Scotland to serve as mentors and provide practice-based experience to students enrolled in a master of pharmacy degree program. Methods. A study was conducted during the 2011-2012 academic year in which first-year MPharm students in Scotland were paired with practicing pharmacists for 2 half-day visits per month. The students were integrated into the pharmacy workflow and engaged in activities ranging from date checking to counseling patients. The pharmacists and students who participated were asked to complete a survey in spring 2012 regarding their experiences and, in addition, the students were asked to maintain diary entries describing their experiences. Results. Thirty-nine students were paired successfully with 38 pharmacists. Every pharmacist stated their student was welcome to return in the 2012-2013 academic year and 29 agreed to accept a second student. Nine of 12 participating chain community pharmacies asked for program expansion and 11 chain community pharmacies and one other community pharmacy that did not participate in 2011-2012 asked to join in 2012-2013. Conclusion. Large numbers of pharmacists in central Scotland are willing to mentor and provide practice-based pharmacy education for students in a manner consistent with General Pharmaceutical Council accreditation standards for the master of pharmacy degree curriculum.

Pharmacy Student Learning During Advanced Pharmacy Practice Experiences in Relation to the CAPE 2013 Outcomes

Outcomes from The Center for Advancement of Pharmacy Education (CAPE) are intended to represent the terminal knowledge, skills, and attitudes pharmacy students should possess and have guided delivery of pharmacy education for more than two decades. Advanced pharmacy practice experiences (APPEs) are the endpoint of pharmacy curricula where demonstration and assessment of terminal learning occurs. This review examines published literature in relation to the most recent CAPE outcomes to determine the extent to which they have been addressed during APPEs since 1996. Details related to the APPE focus, intervention(s)/learning setting(s), and assessments are summarized according to the 15 CAPE outcomes. Further, the assessments are categorized according to the level of learning achieved using an available method. Common CAPE outcomes are highlighted, as well as those for which published reports are lacking for APPEs. The range and quality of assessments are discussed and emphasize the need for continuous improvement of scholarly design and assessment.

Implementation of a Student Pharmacist-Run Targeted Medication Intervention Program

Objective:

To evaluate the impact of a student pharmacist-run targeted medication intervention (TMI) program.

Methods:

Student pharmacists in their third professional year resolved TMIs at 5 independent pharmacies under the supervision of a pharmacist. A claims report of completed TMIs from the medication therapy management (MTM) platform, which captured the category and outcome of the TMIs and the estimated cost avoidance (ECA) level, was analyzed using descriptive statistics. Time spent was calculated using an estimation based on each of the tasks required to complete the TMI.

Results:

Of the 156 TMIs that were billed, 42 (26.9%) were accepted, 24 (15.4%) were rejected, and 90 (57.7%) were unable to be reached. For TMIs where the prescribers or patients were reached, the acceptance rates were 20% and 71%, respectively. Student pharmacists spent a total of 25.2 hours completing TMIs, and the pharmacist spent 2 hours on administrative tasks. Total revenue generated from all TMIs was US$1058, which led to a revenue generation of US$38.90/h. Successfully completing 42 TMIs resulted in a savings to the health care system of approximately US$121 000.

Conclusion:

This pilot study demonstrates an innovative model for community pharmacies to complete TMIs by utilizing student pharmacists under the supervision of a pharmacist.

Supervised pharmacy student-led medication review in primary care for patients with type 2 diabetes: a randomised controlled pilot study

OBJECTIVE

To pilot and feasibility-test supervised final year undergraduate pharmacy student-led medication reviews for patients with diabetes to enable definitive trial design.

METHOD

Third year pharmacy students were recruited from one UK School of Pharmacy and trained to review patient's medical records and provide face-to-face consultations under supervision while situated within the patient's medical practice. Patients with type 2 diabetes were recruited by postal invitation letter from their medical practice and randomised via automated system to intervention or usual care. Diabetes-related clinical data, quality of life, patient reported beliefs, adherence and satisfaction with medicines information were collected with validated tools at baseline and 6 months postintervention. The process for collecting resource utilisation data was tested. Stakeholder meetings were held before and after intervention to develop study design and learn from its implementation. Recruitment and attrition rates were determined plus the quality of the outcome data. Power calculations for a definitive trial were performed on the different outcome measures to identify the most appropriate primary outcome measure.

RESULTS

792 patients were identified as eligible from five medical practices. 133 (16.8%) were recruited and randomised to control (n=66) or usual care (n=67). 32 students provided the complete intervention to 58 patients. Initial data analysis showed potential for impact in the right direction for some outcomes measured including glycated haemoglobin, quality of life and patient satisfaction with information about medicines. The intervention was found to be feasible and acceptable to patients. The pilot and feasibility study enabled the design of a future full randomised controlled trial.

CONCLUSIONS

Student and patient recruitment are possible. The intervention was well received and demonstrated some potential benefits. While the intervention was relatively inexpensive and provided an experiential learning opportunity for pharmacy students, its cost-effectiveness remains to be determined.

TRIAL REGISTRATION NUMBER

ISRCTN26445805; Results.

Pilot study of patient perception of pharmacists as care providers based on health screening encounters with student pharmacists

OBJECTIVES

To assess how patient perceptions of the clinical role of pharmacists may be affected by use of the AIDET communication tool during student-led health fairs, as well as how such events can help promote pharmacy practice.

SETTING

12 community health fair screenings throughout northeastern Minnesota and northwestern Wisconsin, from February to November 2012.

PRACTICE DESCRIPTION

University of Minnesota-College of Pharmacy students trained in the use of AIDET employed the tool's techniques in their communication with health fair patient attendees. Project participants were those patients aged 18 years and older who successfully completed a health fair survey.

PRACTICE INNOVATION

The AIDET communication tool is designed to provide consistency in patient encounters through the use of key words at key times. AIDET is a mnemonic acronym that stands for acknowledge, introduce, duration, explanation, and thank you. University of Minnesota-College of Pharmacy students are taught how to use the AIDET framework in classroom and laboratory settings prior to their interactions with patients at area health fairs.

INTERVENTION

Health fair attendees were asked to complete a survey to determine their satisfaction level with student pharmacist-delivered pharmacy services.

EVALUATION

87 patients were surveyed, with a response rate of 22.5% and a completion rate of 91.6%. The average age of the patient population for the study cohort was 52 years, with greater than 50% being 65 years or older. Patient ages ranged from 24 to 89 years.

RESULTS

When AIDET techniques were employed in a health fair setting, patients reported high levels of satisfaction with pharmacy services and said they felt "happy, comfortable, and trusting."

CONCLUSION

The AIDET framework provides a consistent process for patient-centered care delivery because it places emphasis on patient needs and expectations. Use of the technique is capable of enhancing student and pharmacist engagement with patients.

Assessing student pharmacists' ability to identify drug-related problems in patients within a patient-centered medical home

OBJECTIVE

To quantify, describe, and categorize patient drug-related problems (DRPs) and recommendations identified by fourth-year (P4) student pharmacists during a live medication reconciliation activity within a patient-centered medical home (PCMH).

METHODS

Fourth-year student pharmacists conducted chart reviews, identified and documented DRPs, obtained live medication histories, and immediately provided findings and recommendations to the attending physicians. Documentation of DRPs and recommendations were analyzed retrospectively.

RESULTS

Thirty-eight students completed 99 medication reconciliation sessions from June 2011 to October 2012 during their advanced pharmacy practice experience (APPE). The students obtained 676 patient medication histories and identified or intervened on 1308 DRPs. The most common DRPs reported were incomplete medication list and diagnostic/laboratory testing needed. Physicians accepted 1,018 (approximately 78%) recommendations.

CONCLUSION

Student pharmacists successfully identified and reduced DRPs through a live medication reconciliation process within an academic-based PCMH model. Their medication history-taking skills improved and medication use was optimized.

Reflective practice and its implications for pharmacy education

Pharmacy students require critical-thinking and problem-solving skills to integrate theory learned in the classroom with the complexities of practice, yet many pharmacy students fall short of acquiring these skills.(1-2) Reflective practice activities encourage learning from the student's own experiences and those of others, and offer a possible solution for the integration of knowledge-based curricula with the ambiguities of practice, as well as enhance communication and collaboration within a multidisciplinary team. Although reflective practices have been embraced elsewhere in health professions education, their strengths and shortcomings need to be considered when implementing such practices into pharmacy curricula. This review provides an overview of the evolution of theories related to reflective practice, critically examines the use of reflective tools (such as portfolios and blogs), and discusses the implications of implementing reflective practices in pharmacy education.

A demonstration study comparing "role-emergent" versus "role-established" pharmacy clinical placement experiences in long-term care facilities

BACKGROUND

Increasing challenges to recruit hospital sites with full-time on-site pharmacy preceptors for institutional-based Advanced Pharmacy Practice Experiences (APPE) has made it necessary to consider alternate experiential models. Sites with on-site discipline specific preceptors to supervise students have typically been referred to in the literature as "role-established" sites. In British Columbia, long-term care (LTC) facilities offered a unique opportunity to address placement capacity issues. However, since the majority of these facilities are serviced by off-site community pharmacists, this study was undertaken to explore the viability of supervising pharmacy students remotely - a model referred to in the literature as "role-emergent" placements. This paper's objectives are to discuss pharmacy preceptors' and LTC non-pharmacist staff experiences with this model.

METHODS

The study consisted of three phases: (1) the development phase which included delivery of a training program to create a pool of potential LTC preceptors, (2) an evaluation phase to test the viability of the LTC role-emergent model with seven pharmacists (two role-established and five role-emergent) together with their LTC staff, and (3) expansion of LTC role-emergent sites to build capacity. Both qualitative and quantitative methods were used to obtain feedback from pharmacists and staff and t-tests and Mann-Whitney U tests were used to examine equivalency of survey outcomes from staff representing both models.

RESULTS

The 76 pharmacists who completed the training program survey rated the modules as "largely" meeting their learning needs. All five role-emergent pharmacists and 29 LTC participating staff reported positive experiences with the pharmacy preceptor-student-staff collaboration. Preceptors reported that having students work side-by-side with facility staff promoted inter-professional collaboration. The staff viewed students' presence as a mutually beneficial experience, suggesting that the students' presence had enabled them to deliver better care to the residents. As a direct result of the study findings, the annual role-emergent placement capacity was increased to over 45 by the end of the study.

CONCLUSIONS

This study demonstrated that role-emergent LTC facilities were not only viable for quality institutional APPEs but also provided more available sites, greater student placement capacity, and more trained pharmacy preceptors than could be achieved in role-established facilities.