Interprofessional Practice in the Ambulatory Care Arena Chrystian Pereira, Pharm.D BCPS Associate Professor University of Minnesota College of Pharmacy Smiley’s Family Medicine Clinic Pereira@umn.edu

Objectives Explain how the Interprofessional Education Collaborative (IPEC) 2016 core competencies align with an ambulatory care practice experiences. Identify potential opportunities and challenges that may arise when building an interprofessional practice (IPP). Demonstrate approaches and strategies to incorporate learners involvement into an interprofessional collaborative practice. Describe possible assessment criteria and approaches to use in practice settings

IPEC 2016 Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative.

IPEC 2016 IPE IPP Values and Ethics Understanding where each other are coming from Roles and Responsibilities Know where each other is going Communication How to talk to each other Teamwork Understand how we support each other

Opportunities Each competency leads to an opportunity Values: allow you to approach someone different to see if you could work together Communication: Keeps the channels open for more discussion

Challenges Understanding boundaries and limitations In Ambulatory Care, different members will be present in different sites Realize that these will present themselves at a later time – even under best intentions

Learners Learners are part of the team Sharing learners is a great way to begin to communicate Teaching learners about others can serve as a bridge to improve a professional relationship

Assessment of IPE Yes/ No FM Interperprofessional Team Meeting Evaluation Leads care teams to consistently and appropriately manage patients with chronic conditions and co-morbidities Understands the roles and responsibilities of oneself, patients, families, consultants, and interprofessional team members needed to optimize care, and accepts responsibility for coordination of care Accepts responsibility for the coordination of care, and directs appropriate teams to optimize the health of patients Communicates collaboratively with the health care team by listening attentively, sharing information, and giving and receiving constructive feedback

Interprofessional Practice in the Ambulatory Care Arena Chrystian Pereira, Pharm.D BCPS Associate Professor University of Minnesota College of Pharmacy Smiley’s Family Medicine Clinic Pereira@umn.edu

Implementing Interprofessional Collaboration in the Community Pharmacy Setting Chelsea Phillips Renfro, PharmD Assistant Professor and Coordinator for Simulation-based Education Department of Clinical Pharmacy and Translational Science University of Tennessee Health Science Center College of Pharmacy crenfro@uthsc.edu

Objectives Explain how the Interprofessional Education Collaborative (IPEC) 2016 core competencies align with community pharmacy practice. Describe a process for implementing an interprofessional practice (IPP) in the community pharmacy setting. Identify potential opportunities and challenges that may arise when building an IPP. Demonstrate approaches and strategies to incorporate learners in IPP in the community pharmacy setting.

Why is a Team Effort Important?

Interprofessional Collaboration Competency Domains

Opportunity for Collaboration

Identify the Need/Opportunity Help me!!

Identification of Shared Goals

Identification of Shared Goals

Patient Identification

Development of Communication Strategy Community Pharmacy Health System Electronic Health Record

Potential Challenges Dedicated pharmacist time outside of dispensing Technician support Prescriber buy-in Workflow

Incorporating Learners Written and verbal communication with other members of healthcare team (i.e., nurses, prescribers) Identification of potential opportunities Identification of shared patients Documentation

Implementing Interprofessional Collaboration in the Community Pharmacy Setting Chelsea Phillips Renfro, PharmD Assistant Professor and Coordinator for Simulation-based Education Department of Clinical Pharmacy and Translational Science University of Tennessee Health Science Center College of Pharmacy crenfro@uthsc.edu

Expanding pharmacist involvement in multidisciplinary management of pain, agitation and delirium in an intensive care unit Patricia Louzon, PharmD, BCPS, BCCCP Clinical Manager, Critical Care and Emergency Department AdventHealth Orlando Clinical Assistant Professor University of Florida College of Pharmacy Patricia.Louzon@adventhealth.com 15 min

Objectives Explain how the Interprofessional Education Collaborative (IPEC) 2016 core competencies align with clinical pharmacy practice in an intensive care unit Identify potential opportunities and challenges that may arise when building an interprofessional practice (IPP) Demonstrate approaches and strategies to incorporate student involvement into an interprofessional collaborative practice in an intensive care unit Describe possible assessment criteria and approaches to use when evaluating new intensive care unit services

Background AdventHealth Orlando Part of 7 hospital system 160 ICU beds Community teaching hospital 27 pharmacy residents Student 3 month block rotations ~100 APPE and ~30 IPPE rotations/year 40 interns 3 Colleges of Pharmacy

Background Pharmacist collaboration on patient care protocols can improve outcomes Awakening Breathing Coordination Delirium Early mobilization bundle recommended to coordinate ICU patient care Pain, Agitation and Delirium management by pharmacists identified as a potential area of service expansion Guldbrand P et al. Acta Anaesthesiol Scand 2004;48:944-50. Devlin J et al. Crit Care Med 2008;36:626-8. Barr J et al. Crit Care Med 2013;41:263-306.

Methods- Phase 1 Engage IPP team Empower pharmacists to collaborate on sedation management Mitigate oversedation Improve delirium screening and treatment Create weaning order set and pathway Revise ABCDE Bundle Order set Daily monitoring and implementation Education Louzon, P et al. Am J Health-Syst Pharm. 2017; 74:253-62.

Methods- Phase 2 Multispecialty “ABCDE Bundle Team” created Expand to include hospital executives, physical therapists, respiratory therapists Daily ABCDE bundle rounds with pharmacist sedation management Expanded to 6 ICU’s at main campus followed by other 6 system ICU’s over 1 year Louzon, P et al. Am J Health-Syst Pharm. 2017; 74:253-62.

Goals Improve LOS and ventilator days Reduce hospital expenditures Advance pharmacist scope of practice Integrate learners into IPP Louzon, P et al. Am J Health-Syst Pharm. 2017; 74:253-62.

Role Delineation- Pharmacists Preceptor Identify champions from other disciplines Develop and maintain content Obtain approval from IRB and committees Supervise learners Educate and sustain Pharmacy resident Participation on rotations Layered learning

Role Delineation- Students Planning/research stages Order set development Data collection Manuscript and poster development Daily involvement on rotation Patient screening Sedation management recommendations to preceptor and multidisciplinary team Education provider

Challenges with building IPP Proof of concept needed Potential need for increased resources Other professional recognition of pharmacist expertise Concern for infringement on other profession scope Changing ingrained culture Deep sedation and continuous infusions

Challenges with student involvement in IPP Research inclusion in school agreements IRB enrollment as an investigator Length of rotation in comparison to project length Time to develop provider relationships Multiple student involvement

IPEC Competency alignment Competency 1 (values/ethics for IP practice) Relationship building with nursing, pharmacy and physician staff Confidentiality and ethics in data collection Competency 2 (roles/responsibilities) Communicate student roles in research Collaborate with different skillsets in direct patient care for sedation management This initiative demonstrates agreement with IPEC competencies in the interprofessional domain Competency 1- work with other professions in climate of mutual respect and shared values This was demonstrated in relationship building with nursing pharmacy and physician staff, through a shared desire for DEFINED patient outcome improvements The providers developed a trusting relationship in the ability of pharmacists to manage sedation Confidentiality and ethics were practiced by students involved in data collection and reporting Competency 2- use knowledge of role and other professions to advance health Unique roles in research were defined In depth medication knowledge positioned pharmacists in a role to make sedation management recommendations, while skills of other providers addressed other elements of the ABCDE Bundle such as nursing and physical therapy on mobility and respiratory therapy on breathing trials. By identifying each team member as a specialist in certain bundle elements, the team was able to capitalize on specialized skills of all parties. Without the interdependence of all team members, there was not have been a complete patient care bundle

IPEC Competency alignment Competency 3 (IP communication) Written and verbal communication Group and individual settings Competency 4 (teams and teamwork) Planning stages, evidence-based design Evaluation of patient profiles Deliver real-time recommendations through different formats Accountability for outcomes Competency 3 is to communicate with professionals in a manner that supports a team approach to promotion and maintenance of health -Involvement in this initiative enabled students to practice written communication through manuscript and poster development. There were many opportunities for verbal communication in group setting such as on ICU rounds, individual settings with a provider or preceptor Students had to identify the best time and setting for each recommendation, and the appropriate language to use so that all disciplines could understand assessment and recommendations Listening was important to identify expert assessment of each bundle element that may impact sedation management such as patient performance on breathing trials and ability to participate in mobility sessions Competency 4 is applying relationship building values and principles of team dynamics to perform effectively in different team roles Students were involved in roles throughout the initiative, including planning and evidence-based design Those involved long term were able to see the process of team development and changes as the initiative progressed The team shared responsibility for overall impact on patient outcomes

Assessment criteria Value added (each team member) Sustainability Short and long term outcomes Data availability Vent, ICU and hospital length of stay Alignment with best practices Sedation utilization tied to cost Return on investment

Key components IPP collaboration Nurses, physicians, leadership, educators Integration of learners Detailed and continued education Analysis of data to report outcomes

Patient care improvements Louzon, P et al. Am J Health-Syst Pharm. 2017; 74:253-62.

Other initiative outcomes Continued clinical improvements in Phase 2 42.9% reduction in drug expenses ($183,216) Student authorship at national venue Integrated sedation management into daily ICU practice and learner roles Expansion of pharmacy services 6.6 pharmacist FTE’s obtained Increased APPE rotations PGY-2 Critical Care residency

Expanding pharmacist involvement in multidisciplinary management of pain, agitation and delirium in an intensive care unit Patricia Louzon, PharmD, BCPS, BCCCP Clinical Manager, Critical Care and Emergency Department AdventHealth Orlando Clinical Assistant Professor University of Florida College of Pharmacy Patricia.Louzon@adventhealth.com 15 min