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Transitions in a Student Run Clinic

Tuesday, August 22, 2017  
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Student Submission -  Transitions in a Student Run Clinic

Bailey Colvin, Doctor of Pharmacy Candidate 2018
Nicole Schroeder, PharmD, Preceptor

Introduction to the Clinic

Cooper Rowan Clinic began in 2012 with the collaboration between Cooper Medical School of Rowan University and the Philadelphia College of Pharmacy at the University of the Sciences. The mission since the introduction of the clinic has been to provide high-quality, patient-centered health services at no expense to the underserved, uninsured community members of Camden, New Jersey. Interdisciplinary teams of pharmacy and medical students work under supervision to employ their clinical skills and serve as primary care providers. As the students and patients navigate through both the clinic and the overall healthcare system, there are many transitions of care that must be handled carefully to avoid unfavorable outcomes.

Review of the Literature

Project RED (Re-Engineered Discharge) supported by the Agency for Healthcare Research and Quality1 defined twelve components of the hospital discharge process in order to reduce re-admission rates. These components fit under the umbrella of four medication-related areas: (I) accessing care, especially post-discharge; (II) comprehending medications and conditions on the discharge plan; (III) following an at-home care plan; and (IV) recognizing and addressing health problems. The patients who are most at risk for discrepancies in transitions, and therefore re-hospitalization, are those with low income, complex disease states, cognitive or behavioral disabilities, or who are homeless or medically underserved.2

The American College of Clinical Pharmacy White Papers on improving transitions of care2 describe that the predominant role of the pharmacist in the ambulatory care setting is to ensure that the medication list of the patient is all encompassing of their prescription and non-prescription regimens and is up-to-date. They are accountable for the patient’s comprehension of the use, effect, and administration of his or her medicines. The ambulatory clinic serves as the connection between services on the in-patient and community sides of health care.

Models of Transitions of Care at the Clinic

Medication Histories and Reconciliation

At the Cooper Rowan Clinic, the first encounter the patient has is with a pharmacy student. In accordance with the ACCP White Paper recommendations2 the pharmacy student collects a medication history for every patient appointment. After matching all indications with medications, the student gathers information on as needed and over-the-counter medications, as well as herbal therapies. Following the encounter, the pharmacy student reconciles the medications with the EMR profile if the individual has used the Cooper University Hospital health system before. The medical and pharmacy students consult each other to discuss the goals for the patient that day and possible discrepancies found in the reconciliation process. With the pharmacy completing these patient medication history interviews, students have successfully intervened on numerous drug therapy problems. 

Access to Medications

Due to the low-income and uninsured status of the patients in the clinic, providing access to medications is a critical step in the clinic process. There is a limited formulary that consists of mostly one medication per therapeutic class, and does not include any proprietary or controlled drugs. Due to the small formulary, the pharmacy has an access committee that is responsible for finding medications from outside resources that incur little to no cost on the patients. Drug coupons, pharmaceutical company programs, and low-cost medication lists are all tools that are utilized. The pharmacy finds not only where the medication is supplied, but also creates a plan to obtain the appropriate pharmacologic treatment for the patient. Just as Project RED found that navigating health care with the patient avoids re-admission1, the students of the clinic have discovered improvements in patients’ quality of life when they collaboratively lead an individual through the systems for medication access.

Medication Counseling

After coordinating with the medical students about medications to be filled and follow-up plans, the pharmacy students conduct a counseling session. Every patient is counseled on new medications and refreshed on older medications if adherence is a barrier. When a new medication is filled, the pharmacy student counsels by explaining three aspects of pharmacologic therapies: what the drug is for, how to take the drug, and what side effects and benefits can be expected. For the clinic students, this is the best method that describes key aspects of the medications in order to help patients practice self-care at home. 

Barriers to Transitions

Over the years since the establishment of the Cooper Rowan Clinic, there have been several obstacles that the students have worked to surpass. The major complicating factor is language barriers. The community of Camden is largely Spanish speaking, however, most of the students are not. This barrier is the very first component of the Project RED Toolkit1 because if the patient cannot understand the care, they will receive no further benefit from interventions. Students have tried to resolve this problem via employing the use of over-the-phone translators, and recently adding volunteer translators to the clinic staff. Pharmacy itself has found many tools to help Spanish-speaking patients, such as Spanish medication guides and prescription labels.

Students have also tried to mitigate another limitation of the clinic: limited space for patient appointments. As a free service, the Cooper Rowan Clinic is a highly used resource in Camden’s health system. In order to avoid turning patients away, a schedule has been created to accept ten planned appointments and five potential walk-in appointments during the three hours the clinic is open. This pre-specified quantity of patients accounts for cancelled appoints and no-shows. It also allows for a generous period of time for patients to be seen, over an hour if necessary, so that no appointment is rushed and all of their transitions occur smoothly.       

Conclusion

In the four years since its establishment, the Cooper Rowan Clinic has come a long way to expand its services to positively affect more community members of Camden. With increasing access to medications and more translators the students are now working on introducing social workers and other professions into the workflow for better patient services.

Acknowledgments

I would like to thank Dr. Behjath Jafry, Clinic Director, as well as all of the attending physicians and pharmacy preceptors who dedicate their evenings at the Cooper Rowan Clinic.

References

1. Agency for Healthcare Research and Quality (AHRQ). Re-Engineered Discharge (RED) Toolkit. http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/redtool1.html#Purpose. Accessed November 17. 2016.

2. Hume AL, Kirwin J, Bieber HL, et al; American College of Clinical Pharmacy (ACCP). ACCP white papers: improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012 Nov;32(11):e326-37.

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