Perspectives on a New Ambulatory Care Concentration at Wayne State University

BY HELEN BERLIE, Pharm.D., BHS, CDE, BCACP, associate clinical professor, Wayne State University, ambulatory care specialist, Health Centers of Detroit; and CANDICE GARWOOD, Pharm.D., FCCP, BCPS, BCACP, clinical professor, Wayne State University, ambulatory care specialist, Harper University Hospital, Detroit Medical Center

Part of the strategic vision of the Doctor of Pharmacy Program (Pharm.D.) at Wayne State University (WSU) is to advance pharmacy by producing differentiated graduates that are practice ready and prepared to work with diverse populations.(1)

In turn, the Pharm.D. elective pathways at WSU offer students the ability to differentiate themselves upon graduation and prepare for their future career goals. The program supports this by offering an array of electives and focusing some of these electives into specialized areas of focus, also known as concentrations. The most recent elective concentration approved within our program is the ambulatory care concentration (ACC).(2)

The ACC joins other WSU pharmacy curricular concentrations, such as research scholars and two graduate certificate programs (business and public health). The development of the ACC enables students to focus on a growing area of pharmacy to assist the profession in filling an unmet need.

Over the last several years, the importance of pharmacotherapy in preventive medicine, patient education, decreasing the number and duration of hospitalizations, and transitions of care have underscored the role of ambulatory care services in healthcare. Ambulatory care pharmacy services are an essential component of any comprehensive healthcare delivery system.(3) According to the American Society of Health-System Pharmacists, ambulatory care pharmacy practice is “...the provision of integrated, accessible healthcare services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients and practicing in the context of family and community. Ambulatory care pharmacists may work in hospital based or community-based settings and are involved in the direct care of a diverse patient population”.4 Pharmacists in the ambulatory care setting commonly practice in collaboration with other healthcare professionals. Highlighting the relevance of ambulatory care practice, the Accreditation Council for Pharmacy Education (ACPE) mandated the inclusion of an ambulatory care rotation for all students as part of their Advanced Pharmacy Practice Experiences.(5) However, the practice-readiness of recent pharmacy graduates to provide direct patient care is primarily developed after completion of didactic education and during postgraduate training.(6)

Beyond the ambulatory care setting, there is a growing focus in community pharmacy to provide direct patient care. According to Dr. Julie Akers, clinical associate professor of pharmacotherapy at the Washington State University College of Pharmacy and Pharmaceutical Sciences, the future of pharmacy practice will encompass more direct patient care in all practice areas. “More involved direct patient care is the future of pharmacy practice and schools need to ensure that they are graduating practice-ready pharmacists who are prepared to move into that role,” Akers said. Thus, to better meet the need for pharmacy graduates to provide direct patient care, pharmacy schools are faced with an opportunity to design targeted curricula that provide practical training in direct patient care activities. Preparing pharmacy graduates for practice in ambulatory care environments can help fill an unmet need. The Michigan Society of Health-System Pharmacists (MSHP) forecasted a growing demand for pharmacists to practice in ambulatory care environments in the state. As a result, MSHP established an ambulatory care committee in 2015 to address statewide status of practice, identify perceived gaps and formulate and prioritize recommendations to address the gaps.8 Since then, ambulatory care practice opportunities have expanded, accelerated by the 2016 establishment of the Michigan Pharmacists Transforming Care and Quality Initiative with Blue Cross Blue Shield of Michigan.(9) Today, several Michigan employers are seeking ambulatory care pharmacists. Current job recruitment websites identify multiple ambulatory care pharmacist openings across the state.10 Yet, Michigan has only seven postgraduate PGY2 ambulatory care residency programs.(11) While residency training or practice experience is typically listed as a desired qualification in the ambulatory care pharmacist job descriptions, postgraduate training programs alone cannot meet the demand. Priming pharmacy graduates with additional knowledge and skills in ambulatory care can help meet changing practice needs by preparing graduates to be competent in seeking entry-level ambulatory care positions. Further, ambulatory care-focused Pharm.D. curricula will enable graduates to seek postgraduate training and prepare for more advanced roles.

An overview of Wayne State’s ACC curriculum is provided in Figure 1. Pharmacy students can apply during the second year of the program and, if accepted, begin the concentration in the spring/summer of their third year. All students in the concentration are required to complete Medication Therapy Management (MTM) certificate training. Students in the concentration will dedicate their elective coursework to ambulatory care-designated classes. All electives approved within the ACC must meet prespecified criteria aligned with the Board-Certified Ambulatory Care Pharmacist (BCACP) domains – patient-centered care, translation of evidence and advancement of practice – and make up at least 60% of the course content.(12) In the fourth year of the program, each student enrolled in the concentration will complete one ambulatory care rotation and an additional ambulatory care or community clinical rotation. Participation in student organizations with an emphasis on ambulatory care is also encouraged.

Figure 1

In addition to meeting the needs of our changing healthcare landscape and the profession of pharmacy, student perspectives and preferences are also an essential part of the process when considering the importance of a career in ambulatory care. Furthermore, it can benefit current pharmacy students to understand the relevance of ambulatory care practice and how this may fit their professional identity formation. In the section below, trainees with a vested interest in ambulatory care provide their perspectives and discuss why they are pursuing a career in the field.

P4 Student - Monica Aziz

“Even before pharmacy school, my experience in community pharmacy piqued my interest in direct patient care. During my APPE ambulatory care experience, I observed the meaningful relationships the pharmacist was able to build with both the patients and various healthcare providers. Through this experience, I was also able to participate in developing my own patient relationships. My role in the ambulatory care clinic included working one-on-one with patients to manage chronic disease states. I developed pharmacologic and non-pharmacologic regimens and counseled patients on medication compliance by addressing concerns like medication administration and adverse effects. My ambulatory care experience inspired me to pursue a residency with an ambulatory care focus so that, upon graduation, I am able to practice at the top of my license, providing excellent patient care in an interprofessional setting.”

PGY1 Resident - Stefania Cian

“Throughout my pharmacy journey I have been able to collaborate with a variety of healthcare professionals in various ambulatory care settings. In the ambulatory care setting, pharmacists are fortunate to have dedicated time with patients and work independently through collaborative practice agreements. This enables us to optimize patient care, improve patient outcomes and make positive contributions to public health. My experiences in ambulatory care have reinforced the importance of obtaining advanced pharmacy practice training and have led me to pursue a PGY2 residency in ambulatory care. I plan to dedicate my career to addressing the gaps in care for patients with chronic diseases and incorporating my passions of direct patient care while collaborating with other healthcare professionals. Overall, I believe that ambulatory care pharmacists are in a prime position to bridge gaps in care and positively contribute to the advancement of healthcare.”

PGY2 Ambulatory Care Resident - Rachel Kuo

“I have found that ambulatory care offers an opportunity to make clinically meaningful medication interventions, ensure these interventions are put to practice when working face-to-face with patients, and optimize therapy through delegated prescriptive authority. Many of the patients I see may not fully understand why certain medication changes are made, and I find that patients appreciate being able to hear a pharmacist’s expertise in drug mechanisms and safety. Some patients enter the appointment with limited knowledge of their condition(s) or medication(s), and they leave the appointment with a crash course of the pathophysiology, mechanisms of their medications, how to manage missed doses, and all the practical aspects of taking their medications. I am able to build long-term relationships through continuous follow-up. In collaboration with other healthcare professionals, my interventions as a pharmacist can optimize medication therapy management and help overcome therapeutic inertia. Overall, my experiences as a PGY2 are rewarding and highlight the impact pharmacists can have when engaging in patient-centered care.”

Conclusion

Ambulatory care pharmacy practice is growing in Michigan and nationally. To our knowledge, this is the first concentration in ambulatory care in the state of Michigan. The ACC at WSU will provide focused training in and increased exposure to ambulatory care pharmacy practice. The ACC is a distinctive program designed to enhance professional education and prepare graduates for direct patient care and a career in the field. Ultimately, the ACC may address an unmet need for pharmacists practicing in ambulatory care with the goal of improving patient health in the state of Michigan.

References:

1. Eugene Applebaum College of Pharmacy and Health Sciences. Vision, mission and strategic plan. https://cphs.wayne.edu/pharmd/mission.php. Accessed March 16, 2023.

2. Eugene Applebaum College of Pharmacy and Health Sciences. Ambulatory Care Concentration. https://cphs.wayne.edu/pharmd/acc.php. Accessed March 16, 2023.

3. American Society of Health-System Pharmacists. ASHP Guidelines: minimum standard for ambulatory care pharmacy practice. Am J Health-Syst Pharm. 2015; 72:1221–36.

4. American Society of Health-System Pharmacists. FAQ: Basics of Ambulatory Care Pharmacy Practice. 2019. https://www.ashp.org/-/media/assets/pharmacy-practice/ resource-centers/ambulatory-care/basics-of-ambulatory-care-pharmacy-practice. pdf. Accessed March 16, 2023.

5. Accreditation Council for Pharmacy Education. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Chicago, IL. Adopted January 15, 2006. Effective July 1; 2007.

6. Murphy JE. Practice-readiness of US pharmacy graduates to provide direct patient care. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy 2015;35(12):1091-5.

7. American Association of Colleges of Pharmacy. The Future of Community Pharmacy: Direct Patient Care. https://www.aacp.org/article/future-community-pharmacy-directpatient-care. Accessed March 16, 2023.

8. Smith AL, Garwood CL, Bailey T, Decator D, Elder J, Green A, Kostoff D, Lucarotti RL, MacDonald N, Malburg D, Ottney A, Remington T, Shuster J. State Affiliate Initiative to Advance Ambulatory Care Practice. Am J Health Syst Pharm. 2016;73(23):1909-14.

9. Michigan Summary of Care Report Michigan Pharmacists Transforming Care and Quality Presented by 5th Edition. https://www.aacp.org/sites/default/files/2022-06/ michigan-white-paper-2016.pdf. Accessed March 10, 2023.

10. Indeed.com. https://www.indeed.com/q-Ambulatory-Pharmacist-l-Michigan-jobs Accessed March 10, 2023.

11. ASHP Residency Directory. https://www.ashp.org/professional-development/ residency-information/residency-directory?loginreturnUrl=SSOCheckOnly. Accessed March 10, 2023.

12. Board of Pharmaceutical Specialties. Ambulatory Care Pharmacy. https://www. bpsweb.org/bps-specialties/ambulatory-care/#1517746856979-c1fe2e048ffb1517779729021. Accessed March 16, 2023.