Integrating pharmacy students into the hospice ...

Integrating pharmacy students into the hospice ...

INTEGRATING PHARMACY STUDENTS INTO THE HOSPICE INTERDISCIPLINARY TEAM AND NURSING PERCEPTIONS ON PATIENT IMPACT Traci White, PharmD, PhC, BCGP Regional Coordinator of Experiential Education Assistant Professor, UNM College of Pharmacy Pharmacist Clinician Mesilla Valley Hospice, MMC Palliative Care Team

Learning Objectives Describe the current state and delivery of palliative and hospice care education in the pharmacy curriculum Explain the need and desired outcomes for interprofessional training Discuss the opportunities for integration of pharmacy learners through an Advanced Pharmacy Practice Experience (APPE) Audience Questions

How many currently offer student experiences at your hospice organization? If not, what are some potential barriers you can identify? If you do, please provide an example of how your organization works with students EOL Education in Pharmacy School

Community and hospital pharmacists may encounter patients with terminal illness Need for reflection on own mortality, reduce anxiety about death, relate to a patient with terminal illness and support emotional competence Survey of 125 schools in 2012 with 49% response rate (N=61) 10% offered a separate course 82% offered a module or lecture or 2 18% indicated a topic on death and dying is not formally taught

1986 study: 38% not formally taught, 43% integrated into another course Increase in Pain and Palliative Care PGY-2 residencies Model of Professional Education Nursing Medicine Pharmacy Social Work

Psychology Why IPE Collaboration? Interprofessional Education (IPE) Psycholo gy Pharma cy

Social Work Nursing Medicin e

IPE Competencies Working towards interprofessional integration means: Recognizing Values & Ethics Understanding Roles of other Professionals Learning how to Communicate Effectively Practicing Service Delivery as a Team IPEC Competencies: www.aacn.nche.edu/education-resources/ipecreport.pdf Core Competencies for IPE Collaborative

Practice Competency Domain 1 Values/Ethics for Interprofessional Practice Competency Domain 2

Roles/Responsibilities Competency Domain 3 Interprofessional Communication Competency

Domain 4 Teams and Teamwork Palliative Care and Hospice Education and Training Act (PCHETA) Bipartisan bill that was recently unanimously approved by the House Energy and Commerce Subcommittee on Health Increase federal research funding for palliative care, including

symptom and pain management Establish palliative care education and training programs for doctors, nurses and other healthcare professionals Create a national public education and awareness campaign to educate patients and providers about the availability and benefits of palliative care ASHP Guidelines on the Pharmacists Role

Direct patient care Optimal symptom management Anticipate transitions of care related to pharmacotherapy plan Medication order review and reconciliation Medication-use process Education Medication counseling Provider and nursing in-services Administrative

Ensure safe use of medications Policy and procedure development Algorithms and protocols for best practices Student perceptions about palliative care Prospective, multi-centered study at 6 accredited colleges of pharmacy that offer a palliative care elective Primary aim of the study to compare student perception of the importance of

understanding palliative care issues before and after taking the elective Secondary endpoints Compare pharmacy students clinical reasoning of analgesia and other symptom management treatment approaches between the pre/post questionnaire Compare students post questionnaire clinical reasoning responses to case-based items with expert responses to the same questions Compare students self-perceived competency in palliative care. 89 students completed pre/post surveys No statistically significant difference in student perceived importance of palliative

care skills before and after the course Significant increase in confidence in palliative care skills Significant improvement in clinical reasoning skills across institutions Mesilla Valley Hospice Established in 1982 Non-profit community owned hospice Serves 60 mile radius in Dona Ana County La Posada built in 1998

Stand alone 16 bed inpatient facility and 15 bed assisted living facility NM Pharmacist Clinician Advanced practice pharmacist with prescriptive authority Completion of board-approved 60 hour physical assessment course Documentation of 150 hour, 300 patient contact preceptorship supervised by a physician or other practitioner with prescriptive authority

Collaborative protocol agreement with supervising physician Initiate, modify, discontinue medications within scope of practice Identify/recommend appropriate referrals Pharmacy Student Activities Medication regimen reviews Home visits Inpatient rounds Attend IDT meetings

Topic discussions Nursing in-services Research projects Journal club Topic Discussion Examples Opioid calculations and conversions Methadone Communication skills and empathy

Prognostication and progression of illness Formulary management and drug utilization Ethical considerations Delirium Nursing Perceptions Survey What level of value do you place on having pharmacy students complete clinical rotations at MVH?

Nursing Perceptions Survey In general, pharmacy students have a good understanding of how to care for a hospice patient. Nursing Perceptions Survey My time is well spent by having pharmacy students complete home visits with me. 100% agreement Pharmacy student interventions are valuable to the patients overall

plan of care. 100% agreement Nursing Perceptions Survey To what extent do you believe pharmacy students contribute to the patients overall plan of care? Nursing Perceptions Survey In what medication-related areas do you see pharmacy students

having the BIGGEST impact during home visits? 1. Medication deprescribing 2. Medication recommendations for symptom management 3. Medication teaching to patients and families 4. Medication reconciliation 5. Medication safety in the home 6. Symptom assessments 7. Assistance with obtaining meds from the pharmacy

Nursing Comments/Feedback The pharmacy students I have had with me have complimented my hospice visits by being another pair of eyes and ears in regards to what is happening with my patients. Their knowledge re medications has assisted in providing the best care possible to my patients. The students have added their thoughts and provided valuable information so that I may better understand what maybe going with a patient that I did not pick up on. All of my patients have enjoyed having them with me on my visits and they have all been very personable and kind to the patients they have encountered with me. All nurses should allow the pharmacy students to review medication lists and assess

symptoms during the visit. I would strongly recommend that pharmacy students be familiar with end of life medications and be prepared to educate patients and their families on how to utilize medications for common symptom management and what the possible side effects are. I feel they bring a lot to the table re: overall med management. They also get see the challenges we face in the field. For the most part they help round out the patients care experience. Dont be afraid to give suggestions, offer up different ideas, ask questions. I swear I always learn more from them than they learn from me!

Student Reflections I am grateful for all of the opportunities I was given to contribute to the care of patients. I felt that I was a meaningful part of home visits, IDT meetings and encounters with inpatients and their families. That is, for me, the very best outcome I could hope for. If I could take one thing away from this rotation, it would be my newfound respect of faith. Faith is something I think I can believe in now. I have seen peace come to the suffering and hope come to the fearful.

being able to hear patients complaints, their life lessons, their advice, their praises, and being able to hold their hand while they took their last breaths, being trusted enough to make medication changes and recommendations, and providing responses to other respected healthcare providers all ensured that his rotation had a monumental impact on my future career as a pharmacist Its hard to find the right words to let the patients and their families know what to expect and to keep them content with it at the same time. From this rotation, Ive seen both ends of the spectrum from a wife understanding the process completely and accepting her husbands death, to a sister not believing her sister is dying

right before her eyes. Its a hard process. Student Reflections I have come to the realization that it is best to have uncomfortable conversations early while your loved ones are still well and healthy. I have reflected a lot about what it would be like to lose my parents and what I should do in the future to help them as they get older. I still get teared up when I think about loss, but I have a much better understanding and appreciation for the services hospice provides.

My insights and recommendations were often accepted or drove meaningful conversations. The staff would often ask me questions regarding the medication and trusted my answers. I grew more confident in my knowledge and skills during throughout the rotation This experience helped me see the dying process as a normal process that everyone goes through; and that not everyone is fortunate enough to go through it by the hand of a caring and loving healthcare professional. I was very lucky I got to walk with patients and their families through the last steps of their lives and to be able to provide some comfort.

MVH Hospice Academy On-site Hospice Clinical Rotation Elective First resident June 2014 Presentation of three didactic sessions Three sessions over three months Participation in the Care of the Older Adult Clinical Rotation First resident October 2015

On-Site Hospice Elective Four weeks Topic discussions Advance directives Admission criteria Difficult conversations Physician billing for hospice Symptom management

Opioid conversions Hands on with the Hospice Team Admissions nurse Homecare social workers RN case managers Inpatient nurses Inpatient social worker Pharmacist clinician

IDT meetings Family meetings Grief and bereavement counselor Direct patient care Home visits Inpatient visits Didactic Sessions Advance Care Planning

Background information and case studies Faculty included an attorney to discuss legal aspects of advance directives Difficult Conversations Part 1 Background information and role playing Difficult Conversations Part 2 - End of life discussions Background information and role playing Care of Older Adult Rotation

Initiated by Family Medicine faculty 1-2 half days per week for four weeks with Mesilla Valley Hospice preceptor Condensed version of the Hospice Elective Difficult Conversations Part 2 Benefits to Mesilla Valley Hospice Increased referrals from Family Medicine

Increased exposure for the residents and faculty to hospice through required Care of the Older Adult rotation Two residents sought on-call experience Patients have verbalized specific discussions with residents to include statistics with CPR, outlook on prognosis and what hospice can provide 42% of all graduates from SNMFMR program stay in Dona Ana County our licensed area

Benefits to Residents/Faculty Increased hands-on experience and direct care of hospice patients through required Care of the Older Adult rotation Enhanced continuity of care Increased knowledge of hospice care Identification of appropriate hospice referrals Symptom management skills Communication skills

Challenges and Lessons Learned Time intensive Scheduling Organization buy in Student motivation Future Directions Patient care/family satisfaction surveys COP palliative care elective

Community outreach Facility education Qualitative research Live as if you were to die tomorrow. Learn as if you were to live forever. - Mahatma Gandhi

References 1. Dickinson GE. End-of-life and palliative care education in US pharmacy schools. Am J Hosp Palliat Care 2012;30(6):532-535 2. Herndon CM, Jackson K, 2nd, Fike DS, Woods T. End-of-life care education in United States pharmacy schools. Am J Hosp Palliat Care 2003;20(5):340-344 3. Herndon CM, Nee D, Atayee RS, et al. ASHP Guidelines on the Pharmacists Role in Palliative and Hospice Care. Am J Health Syst Pharm 2016;73(17):1351-1367 4. Atayee RS, Lockman K, Brock C, Abazia DT, et al. Multicentered study evaluating pharmacy students perception of palliative care and clinical

reasoning using script concordance testing. Am J Hosp Palliat Care 2018;( )1-8 5. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative 6. http://aahpm.org/uploads/advocacy/PCHETA_Summary.pdf

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