key: cord-0987033-qe43s4z3 authors: Pennock, Danielle; Barbour, Lauren; Green, Robert; Fu, Denise title: A Medication Therapy Management Residency Rotation Adjusts to COVID-19 Constraints date: 2021-01-21 journal: J Am Pharm Assoc (2003) DOI: 10.1016/j.japh.2021.01.024 sha: a80a496840ab2253fde84910ba992ba2be9636a6 doc_id: 987033 cord_uid: qe43s4z3 Objectives The purpose of this commentary is to describe the Johns Hopkins Home Care Group’s (JHHCG) Community-based Pharmacy Residency Medication Therapy Management (MTM) rotation, summarize adjustments made to the rotation after the onset of the Coronavirus Disease 2019 (COVID-19) pandemic, describe key learnings from the adjustments, and provide a call to action for other residency programs seeking to improve their rotations amidst pandemic restrictions. Summary MTM clinical pharmacists at JHHCG collaborate with patients to identify barriers to adherence, review medications, and develop plans for improvement. Through improved medication adherence, the goals for this program are to reduce side effects, patient cost, and medical visits or hospital admissions. Central to this practice is the belief that strong patient relationships are necessary to uncover the root cause of medication non-adherence. In Postgraduate Year 1 (PGY-1) community-based pharmacy residency training, new pharmacists learn the value of building relationships with patients and working through complex problems during this clinical experience. By assisting patients with complex medical conditions and social situations, new pharmacists gain skills in patient care, pharmacy operations, and medication access challenges. As the COVID-19 pandemic forced the discontinuation of face-to-face interactions in this setting, rotation experiences for residents were adapted with the goal of continuing high-impact patient interactions and keeping everyone involved safe. Conclusion Although significant changes were made to the MTM rotation because of the COVID-19 pandemic, residents were still able to provide meaningful clinical care telephonically and continued to learn valuable patient care skills. Most importantly, high quality care was still delivered to the patients despite considerable challenges. The major drawback for the residents’ clinical experiences as a result of the adjustments has been finding an impactful volume of complex patients to enhance their skills. Other residency programs are encouraged to consider three recommendations to improve their rotations moving forward. • As a component of its PGY-1 community-based pharmacy residency programs, Johns Hopkins Home Care Group requires residents to participate in a longitudinal, year-long Medication Therapy Management (MTM) rotation. This rotation serves as a major portion of their clinical experiences. • In mid-March 2020, the in-person patient care aspects of the MTM rotation had to be adjusted because of the COVID-19 pandemic. Protecting the safety of the patients, residents, preceptors, and other pharmacy staff while still providing high quality care was the priority. Findings • In response to the COVID-19 pandemic, in-person clinical activities within the patient's home and in the pharmacy shifted to telephonic encounters. • Residents and clinical pharmacists started personally delivering pillboxes to patient residences due to lack of confidence in commercial delivery services and the proximity of most patients. • Despite significant adjustments made to the rotation, residents still managed to experience valuable patient care situations and continued to learn how to provide clinically meaningful pharmaceutical care telephonically. An ongoing challenge is finding an impactful volume of complex patients for residents to enhance their pharmaceutical care skills. The MTM team primarily serves Baltimore residents from local neighborhoods. HBMM patients have an average age of 63 years and are predominantly African American. 1 Diabetes, congestive heart failure, and asthma are the most common conditions in these patients. 1 Likewise, the majority of pillbox patients are over 60 years old and have multiple comorbidities. Patients seen by the MTM team have varied barriers to adherence including physical, cognitive, and organizational. Common referral reasons include complex medication regimens and significant changes to a medication regimen. Providers, case managers, and inpatient clinical pharmacists provide the majority of the referrals. By mid-March 2020, it was clear that in-person patient care aspects of the MTM rotation needed to be adjusted to mitigate unnecessary risks of spreading COVID-19 to the community. Protecting the patients' safety became a priority as most are in COVID-19 highrisk groups. 2 Safety of the residents, preceptors, learners, and other pharmacy staff were also considered. Yet, residents were still expected to achieve the residency goals through quality patient care experiences. The goal was to adjust the learning experiences to preserve high quality patient care while minimizing risk to the individuals involved. In-person home visits shift to telephonic CMRs HBMM visits are the backbone of the MTM rotation, with each resident performing two to three home visits each month. Because referrals come from within the health system, extensive information about the patient is available in the medical record. Once a referral for a home visit is received, a pharmacy technician calls the patient to schedule a date and time for the appointment. Residents are responsible for independently leading MTM encounters of all types, with preceptor assistance available as needed. On the home visit, residents and an accompanying student pharmacist perform medication reconciliation by reviewing the medications the patient has on-hand and observing medication taking behaviors in the home. Following each visit, residents write a comprehensive clinical note which is shared with the referring providers. Preceptors and residents meet weekly to review clinical notes and discuss the experience, resident decision-making, and rationale. In mid-March, home visits by pharmacists were suspended due to the COVID-19 pandemic. The HBMM visit experience was quickly replaced with telephonic CMRs from an online platform, which more accurately reflects how MTM is practiced across the country. Residents perform CMRs for patients living in all parts of Maryland, and often these patients are not seen within JHM and do not fill their prescriptions with JHOP. Due to these limitations, opportunities for reviewing the patient's chart prior to the telephonic visit were scarce and meaningful followup with providers was more difficult. Resident feedback and clinical discussions revolve around the review of the patient's personal medication record (PMR) and medication-related action plan (MAP), which are now the written products developed after the patient encounter. Although the patient population has shifted from complex ambulatory patients in an academic medical center setting to the more traditional MTM patient population, this new telephonic MTM experience is providing the residents with broader MTM practice skills. Residents also staff the Pillbox Teaching Clinic for four hours every month. In this clinic, pharmacists work one-on-one with patients to improve medication adherence and develop longitudinal relationships. Each resident class is expected to see 20 patients for at least three encounters throughout the year. During the clinic visit, the pharmacist reviews the returned pillboxes to assess adherence and discusses reasons for any missed doses with the patient. If the patient sees providers within the health system, recent medical visit notes and the current medication list are reviewed, along with medications the patient brought or picked up from the pharmacy. Patients are educated on medication indications, asked about common side effects, and medications are analyzed for potential adverse drug reactions. Pharmacists then guide the patient in pillbox assembly. Based on the patient's ability, the pharmacist assists the patient in filling the pillbox and encourages the patient to take the lead. Due to COVID-19, JHOP discouraged patients from coming into the pharmacy if not necessary and offered prescription delivery. To foster patient safety, in-person pillbox filling with patients was suspended. However, pharmacists continued to fill pillboxes for patients on the same schedule. Due to lack of confidence in commercial delivery services and the proximity of most patients, pharmacists hand-delivered pillboxes. Residents' Pillbox Teaching Clinic experience changed to a predominantly operational role and required them to work through billing issues, filling pillboxes, and coordinating delivery. Symptom analysis and medication review transitioned to telephonic interviews. The residents' safety was considered with the new task of delivering pillboxes containing various medications directly to the patients' homes. Residents attend a formal safety training prior to starting the rotation. For the transition to pillbox delivery, the residents were given the option to be accompanied by a preceptor if they were uncomfortable travelling alone. The residents who experienced the transition to the outlined modifications in March 2020 for this rotation quickly adapted. The change from home visits to telephonic MTM was not a difficult transition for them because they had already built strong patient interviewing and counseling skills over the preceding nine months, so they were able to use those skills in the telephonic environment. Likewise, adjusting to the new pillbox clinic format went well because they had already formed strong relationships with their pillbox clinic patients and knew how to communicate with them. The most difficult part of the new pillbox clinic format was coordinating the logistics of filling and delivering the pillboxes, but after the first month the residents developed new workflows and became more efficient. Although it was unclear at first how fruitful this rotation would be for the residents once the changes were made, in the end the transition to the modifications was relatively smooth and the residents' learning experience continued to be meaningful. The residents ended up learning new skills centered on care coordination and telephonic patient interactions. Refer to Table 2 for detailed reflections from a resident, preceptor, and clinical manager regarding the rotation changes. Despite the changes made to the MTM rotation, it has become evident that it is possible to properly train new residents on conducting clinical work virtually at the same level as in-person training. Onboarding the new community residents who started their training in June 2020 went well. Given that COVID-19 constraints were still in effect, the rotation modifications continued. Resident orientation adhered to social distancing policies and was held outside of the pharmacy when practical. To ensure the residents were still receiving comprehensive feedback from preceptors during the onboarding phase for telephonic MTM encounters, preceptors supervised scheduled CMR calls in-person in a socially distant manner and provided immediate feedback. In addition, productivity tools the organization subscribes to were leveraged as a forum where the resident could post their clinical notes and the preceptor could provide direct written feedback. During pillbox clinic training, the new residents were taught in-person how to fill the pillboxes and coordinate the patients' care independently. Additionally, preceptors introduced the residents to their patients over the phone to transition their care from the previous residents to the new residents. Preceptors and residents have continued to meet just as often before COVID-19 to discuss feedback and resident progress, but the main difference is the meetings occur virtually rather than in-person. The majority of MTM activities this year are self-directed which places more responsibility on the residents to evaluate their own progress and advocate for themselves. Providing several MTM patient care opportunities each week remains a goal for the rotation. However, it is more challenging this year. Despite scheduled MTM appointments, patients often do not answer the pharmacist's call, and as CMRs are completed through online platforms, the number of eligible patients remaining declines. Unlike previous years, preceptors have actively been recruiting MTM patients from other referral sources and encouraging residents to engage patients in telephonic medication reviews who would be candidates for home visits in the past. As the COVID-19 pandemic continues for the foreseeable future, it is likely these rotation modifications will stay in place until the end of the 2020-2021 residency year. Although the COVID-19 modifications have continued to provide a meaningful clinical experience, the community residents will return to in-person home visits and pillbox clinic once it is safe to do so. There are several action items the residency program is taking on as a result of the pandemic which other residency programs are encouraged to ponder as well. First, JHHCG is currently considering new efficiencies, such as leveraging technology for more streamlined communication between preceptors and residents, that have resulted from changes due to the COVID-19 pandemic and developing a plan to make them permanent changes to the residency program post-pandemic. Second, the residency program is continuing to think creatively as the pandemic continues about ways residents can still be provided with meaningful patient care experiences that foster pharmaceutical care skill-building, regardless of the mode. Lastly, JHHCG has quickly realized how important it is to keep lines of communication with residents open and honest to facilitate an environment which promotes quick adjustments based on resident feedback. Despite significant challenges posed to the MTM rotation because of the COVID-19 pandemic, adjustments were quickly made to ensure residents are still able to provide meaningful clinical care, patients are still receiving services, and everyone involved is protected. The shift from home visits to telephonic CMRs has continued to provide meaningful clinical experiences for the residents. Adjusting in-person pillbox clinic to a pillbox delivery service poses logistical challenges for the residents and preceptors but provides the pharmacists a chance to build deeper connections with patients. Overall, high quality care continues to be delivered to this patient population and residents continue to learn through the adjusted rotation experiences. The major challenge for the residents' clinical experiences has been finding an impactful volume of complex patients for them to care for and learn from to enhance their skills. Other residency programs are encouraged to consider new efficiencies resulting from COVID-19 rotation adjustments they want to keep post-pandemic, develop creative solutions to rotation activities due to pandemic restrictions to ensure residents are provided with similar patient care experiences, and keep lines of communication with residents open to facilitate real-time changes to rotation activities based on feedback from the residents. HBMM is a referral-based service where pharmacists visit the patient in their home to conduct medication reconciliation, provide patient education, and complete a comprehensive medication review. The pharmacist then follows up with the provider with medication-related recommendations. Pillbox Teaching Clinic meets weekly at one of the Johns Hopkins community pharmacies, and pharmacists work with patients to improve adherence by teaching skills appropriate to the patient. The visit includes reviewing medication indication, administration and side effects, supervising filling a pillbox, or filling the pillbox for the patient. While some patients participate for just a few sessions to improve their skills, a standing panel of patients return monthly or bimonthly for assistance. Comprehensive Medication Reviews (CMR) and Targeted Interventions Eligible patients are identified through an online MTM platform or referred through other providers within the health system. CMRs include the provision of a personal medication record (PMR), developing a medication-related action plan (MAP), and communicating with providers regarding the assessment and plan for medication-related problems identified. The encounter may take place over the phone or in person. Medication Adherence Counseling Medication adherence services are provided to complex patients who have a history of non-adherence and are not able or willing to attend Pillbox Teaching Clinic. Pharmacists provide telephonic medication adherence services such as monthly refill reminders, medication filling and delivery assistance, medication synchronization, check-ins to reinforce medication-related education, and follow up with patients referred to patient assistance programs. J o u r n a l P r e -p r o o f Medication management through pharmacist provided home-based services COVID-19)