Successful Implementation of Student-Driven Virtual Transitions of Care Model During the COVID-19 Pandemic

October 19, 2020
Tricia Gangoo-Dookhan, PharmD, BSPharm

,
Noor Alawwa, PharmD Candidate

,
Khai Phan, PharmD Candidate

,
Dor Partosh, PharmD Candidate

,
Sean Shampansky, PharmD Candidate

,
Raquib Zaman, PharmD Candidate

Virtual transitions of care services are a valuable and viable opportunity for students to progress to graduation and gain valuable experience in preparation for professional employment.

As medication experts, pharmacists detect medication discrepancies and provide value through counseling on medication-related problems, such as adverse effects, drug interactions, and medication adherence. Pharmacists also play important roles in promoting a healthy lifestyle by educating patients on the importance of diet and exercise, while monitoring health parameters such as blood pressure and blood glucose. In addition, pharmacists emphasize patient-centered care through identifying any gaps in treatment, such as immunizations and smoking cessation.

As pharmacy interns progress through their coursework, they are taught that clinical acumen will develop as students apply the knowledge gained in the classroom to real-world clinical scenarios. Hospital-based advanced pharmacy practice experiences (APPEs) are traditionally conducted on-site, but the coronavirus disease 2019 (COVID-19) pandemic has prevented many students from entering the clinical facility. Preceptors have rapidly evolved their criteria and logistics to enable virtual components of the syllabi to complete the expectations of the rotation.

We as students are grateful for preceptors willing to offer virtual APPEs, as most are under no obligation to do so. These unexpected adaptations are being field-tested on students, many of whom may be conducting their first clinical experience. Projects, topic discussions, and Health Insurance Portability and Accountability Act (HIPAA)-compliant, deidentified patient case presentations are all activities that are valuable to student learning, but may lack coveted patient interactions and valuable interprofessional experiences.

Nova Southeastern University (NSU) College of Pharmacy Accountable Care Organization (ACO) Research Network, Services, and Education (ACORN SEED) is a hub for pharmacy activities maintained by pharmacy practice faculty members. One key function is the provision of transitional care management with affiliated ACO medical practices. The ACORN SEED Center receives patient referrals, resulting in a telepharmacy-based patient consultation by a pharmacy intern under the supervision of a pharmacist faculty member working remotely from the center.

Prior to the patient call, the pharmacy intern accesses the patients’ electronic health record (EHR) using a HIPAA-compliant encrypted laptop provided by NSU. The intern reviews and collects relevant patient health data including progress notes, consultation notes, laboratory and diagnostic results, and a hospital discharge summary.

The information collected is put into a standardized patient template, which is customized to include assessments for readmission risks, drug indications, therapeutic duplications, drug-drug interactions, drug-disease contraindications, Beer’s list of high-risk medications, proper dosages, adverse drug events, medication adherence, and vaccination history. The student intern then presents deidentified patient information and recommendations to the pharmacist faculty member via Zoom.

Once the patient care plan is approved by the faculty member, the intern contacts the patient prior to the patient’s physician’s follow-up visit post-discharge. The intern introduces themselves and the reason for the call, and 2 patient identifiers must be confirmed before proceeding to verification of the information collected from the hospital chart.

The intern confirms any comorbidities that the patient is aware of and performs a medication reconciliation of the prescription drugs, OTC medications, or nutritional supplements. During the encounter, the pharmacy intern evaluates patient health literacy, adherence, and barriers to care. Finally, the intern provides counseling under the supervision of the faculty pharmacist.

The findings are documented in the EHR progress notes with the use of a standardized script, and the active medication list is then updated to reflect any discrepancies and changes. A summary of any identified issues and pharmacy-related recommendations is sent to the providers through EHR-supported emails or messages.

The pharmacy intern is required to conduct a follow-up phone call to the patient 7 days later to provide continued support through the first 30 days post-discharge and following the intervention. During the second phone call, the intern also confirms whether the recommendations made to the provider were accepted.

Depending on the skill level and confidence of the student, 10 to 12 patient encounters are conducted throughout a 6-week rotation. Most recommendations made by the students and the pharmacy faculty member are well received, and the changes are reflected in the patients’ EHR. Most patients are open to the lifestyle and medication changes discussed during the encounter with the students, with an average call time of 30 minutes.

Medication-related issues after discharge, such as adherence, medication errors, and lack of titration, are common and can lead to unnecessary adverse drug events and readmissions. To close the gaps in care and decrease the high rates of medication errors during transitions of care (TOC), pharmacy interns engaged in APPEs are well equipped to complete TOC activities within the ambulatory setting.

The COVID-19 pandemic has created a variety of challenges for practitioners, patients, and experiential programs when APPE students cannot visit their sites. Student involvement in TOC centers provides an excellent educational experience and establishes pharmacy-provided, patient-centered care.

Use of telehealth meets the Accreditation Council for Pharmacy Education’s standards for direct patient contact as well as team-based interaction with medical providers. Virtual TOC services are a valuable and viable opportunity for students to progress to graduation and gain valuable experience in preparation for professional employment.