Rotations

Ambulatory Care Rotation

The final weeks of the pharmacy practice residency are devoted to the ambulatory care rotation. This rotation is designed to have the resident draw on skills attained during previous rotations to efficiently manage the multifaceted responsibilities of an ambulatory care pharmacist; such as, medication control, performance improvement, patient assistance, education, and direct/collaborative patient care.

Anticoagulation Clinic Rotation

The Family Medicine Center (FMC) established an anticoagulation clinic (AC) in 2002, while the Healthy Family Center (HFC) located at the Mishawaka campus established their AC in 2005. Each clinic carries the responsibility of safely managing patients' anticoagulation and educating them regarding their medication and disease state.  The clinic at the FMC must also provide for the education of the resident physicians. A pharmacist staffs the AC two to three half days per week depending on the site. Currently, approximately twenty-five patients per site are under the care of the AC. Staff of HFC also have the unique opportunity to manage anticoagulation therapy at the Holy Cross House, a long-term care facility associated with the University of Notre Dame, and be responsible for the anticoagulation services at a fourth clinic, the Sister Maura Brannick Health Center, when the medical director is away from the site.

The anticoagulation rotation is a 6-week rotation consisting of providing anticoagulation services at all four sites as well as reading literature on anticoagulation and having topic discussions with the preceptor. The resident may continue to manage the care of a small amount of patients over the course of the residency year for further experience as part of the ambulatory longitudinal rotation.

Diabetes Rotation

A diabetes clinic was initiated at Healthy Family center in 2007.  Patients with diabetes are also commonly referred to the medication review clinic started at the FMC in 2007.  Patients with diabetes are referred to the pharmacist for both education and management regarding their disease state.  The clinics function in much the same way as the AC. Group visits for patients with diabetes are being planned for initiation during 2008 at the FMC

Dyslipidemia Rotation

The Family Medicine Center established a dyslipidemia service (DS) in 2004. The DS has the dual responsibility of collaboratively managing as well as educating resident physicians on the management of dyslipidemia. A pharmacist staffs the DS; resident physicians may staff the clinic during a pharmacotherapy rotation in conjunction with the pharmacist. Patients who have had lipid panels drawn are forwarded to the pharmacist. The pharmacist assesses the risk factors of the patient. With the risk factors and calculation of the Framingham risk assessment, the pharmacist sets the goals of therapy for the patient. TThe pharmacist then meets with the resident physician to discuss the patient case and next steps for management, including lifestyle modifications, choice of agents, and necessary laboratory monitoring.  The patient is contacted and the plan is then implemented.

Critical Care Rotation

The Intensive Care Unit at Saint Joseph consists of 16 beds. An interdisciplinary team performs rounds on the patients who are receiving ventilator support every morning at 0830. The team consists of physicians and representative members from nursing, dietary, respiratory, pharmacy, clergy, and other disciplines as needed. Each specialty provides input at rounds regarding the specific patient allowing a more complete clinical picture to be seen by the team.

Education Rotation

Pharmacists at Saint Joseph Regional Medical Center play a crucial role in the education of medical students, PharmD Candidates, and resident physicians through several different venues. They are affiliated with the Indiana University Medical School coordinating, lecturing, and administering examinations to the 2nd year medical students during the pharmacology class in the fall semester. They also instruct 3rd year medicals students participating in their Family Medicine clinical rotation on pharmacotherapy and prescription writing.

The pharmacists play an active role coordinating multiple PharmD Candidate rotations including ambulatory rotations at the Family Medicine Center and Healthy Family Center, advanced adult inpatient medicine through the resident physician's medicine service in Saint Joseph Regional Medical Center, introductory hospital experiences, infectious disease, and critical care. The resident pharmacist also formally instructs at Purdue University.

The pharmacists educate resident physicians informally through drug information questions, in concert with the PharmD Candidate rotations, and formally through the 2nd or 3rd year elective pharmacotherapy rotation.

The education rotation consists of a 4-week block rotation along with a longitudinal component for the duration of the year. The 4-week rotation involves structuring of the pharmD candidate rotation, beginning to form teaching philosophy, and preparing lectures and exams for IU School of Medicine lectures. The longitudinal component consists of precepting pharmD candidates and family medicine residents, lecturing to 2nd and 3rd year medical students, and completing the Indiana Pharmacy Resident Teaching Certificate Program.

General Medicine Rotation

The general medicine team consists of a chief resident-usually a third year, four or five other residents, two attending physicians, a psychologist, and a pharmacist.  The chief resident organizes the call schedule for and assigns patients to the other residents. The attending physicians-one internal medicine, one family practice-write daily notes on the medicine patients and have ultimate control over the patient's treatment. The psychologist offers insight into the patient's social situation and cognitive function. The pharmacist provides drug information to the team. The time at which daily rounds start vary from month to month due to the availability of the different attending physicians, and the number of patients. The medicine team may have anywhere from two to twenty patients on the service.  This multi disciplinary team discussion provides more complete direct patient care.

The adult general medicine rotation is a 4-week experience. Residents are encouraged to intermittently, as time allows, participate in rounds long term to see the change in atmosphere that different team composition makes.

Infectious Disease Rotation

The goal of this rotation is to provide an environment of infectious disease and clinical laboratory medicine.  The resident will have the opportunity to apply clinical, communication, and teaching skills to interactions in a multidisciplinary care setting.

The resident/student will provide clinical pharmacy services to Infectious Disease/Kinetic consult patients under the preceptorship of a clinical pharmacy specialist in infectious disease.  The rotation will require daily interactions with ID physicians, nurses, pharmacy staff, and other healthcare providers to maximize therapeutic outcomes for patients.

The preceptor will be available on a daily basis to discuss patient care issues, facilitate learning experiences, provide guidance for development of educational programs, and evaluate residents’/students’ performance.  

International Health Experience

The International Health Track (IHT) is a unique feature of the Saint Joseph Pharmacy Practice Residency Program. We have partnered with Purdue University in offering a rotation in Kenya. It is an optional opportunity for residents interested in health care for medically underserved people both in the United States and internationally. It gives residents a chance to serve the underserved while gaining knowledge in the diagnoses and treatment of common tropical diseases and conditions. It also allows residents the opportunity to expand their clinical management skills in a setting of limited resources, and acquire knowledge in the areas of travel medicine and public health. We also seek to foster respect and compassion for the medically underserved and those from a different culture. Flexibility, creativity, and adaptability are all attributes we seek to develop.

Medication Assistance

The medication assistance program has the goal of assisting patients in the access of pharmaceuticals at no cost. The medication assistance program is staffed by the pharmacists, pharmacy technicians, and patient financial services. Medication assistance is a part of a larger overall sliding scale program that also entitles qualified patients to sliding scale discounts on physician office visits. The benefits coordinator evaluates the patient's financial resources in a standardized manner. Patients who are eligible for the sliding scale fee then have their charts reviewed by the pharmacist or PharmD candidate. The pharmacist or PharmD candidate gathers forms for all the potential pharmaceutical company programs. If there is no pharmaceutical company program available for a medication, or if there is an easier pharmaceutical company program available, the resident physician is contacted to get authorization to switch the medication to the medication available. Please note, therapeutically sound regimens are not sacrificed. Medications are then checked by the pharmacist upon arrival and dispensed to the patient.

The Medication Assistance Rotation is a 4-week required rotation for the program with an emphasis in ambulatory care and is an elective for the institutional program. It consists of learning the medication assistance process at the Family Medicine Center (FMC), Healthy Family Center (HFC), and Sister Maura Brannick Health Center, followed by overseeing this process at the FMC and HFC.

Medication Review Clinic (Pharmacotherapy)

The medication review clinic was conceived in 2004.  The concept was implemented in 2007.  The pharmacist in the medication review clinic assesses the appropriateness of the pharmacotherapy regimen based on current evidence, and the compliance of the patient based on patient interview.  Recommendations for changes in therapy are communicated back to the physician.  The pharmacist gives education and compliance aids to the patient.  At the completion o f the residency program the resident pharmacist will be able to care for complex patients with multiple different disease states.  Resident pharmacist will be able to determine and impact potential causes of noncompliance.

Orientation

General

Orientation to the pharmacy practice residency program in June/July has two goals: it provides the resident pharmacist with a broad overview of the site; the resident pharmacist gains technical skills and fulfills necessary human resource programs to function in the residency on a daily basis. Also, orientation allows the resident to develop professional relationships; the resident pharmacists’ orientation integrates with the incoming first year family medicine resident physicians where appropriate and possible.

PGY-1 in an Ambulatory Setting

Recognizing the support received from Saint Joseph Regional Medical Center as well as from the Sisters of the Holy Cross and the Sisters of Mercy (the two congregations who have formed Trinity Health) who sponsor our health care system, we strive to support their Mission in the care we provide to a large number of the underserved in our community.

Both the Family Medicine Center and Healthy Family Center function as a private office with a separate billing system, full time business manager and regularly scheduled office hours. Each resident physician spends time in the Family Medicine Center according to his or her level of training. 

At the Family Medicine Center, eight family medicine residency directors, two podiatric medicine directors, one pharmacy residency director, and one psychologist oversee twenty-seven family medicine resident physicians, three osteopathic resident physicians, three podiatric resident physicians and one resident pharmacist caring for a population of approximately 13,000 patients who are responsible for 25,000 patient visits annually.

Healthy Family Center employees two physicians, one nurse practitioner, and one pharmacist to oversee a patient population of 7,000 that account for 14,000 patient visits annually.

PGY-1 in an Acute Care Setting

The Department of Pharmacy Resources at the South Bend Campus of the Saint Joseph Regional Medical Center conducts numerous, diversified and progressive programs within the hospital, and has made significant contributions to improving patient care. The mainstay of our commitment and involvement is the responsibility of assuring patient safety relative to the prescribing and administration of all medications.  We have 3 other hospitals in the St. Joseph family: Mishawaka, Our Lady of Peace Hospital, and Plymouth.  St. Joseph Regional Medical Center is a member of Trinity Health.  The orientation will provide an overview and training to the resident pharmacist in the essential functions of the pharmacy department.

Pharmacy Resources provides 24-hour service to the patients and staff in our 250 bed facility. The hospital pharmacy department in comprised of the following: Pharmacy Director, Pharmacy Supervisor, Clinical Supervisor, Technician Supervisor/Buyer, 11 pharmacist FTE, and 12 technician FTE.

Medications are distributed in a unit-dose daily cart exchange. Pharmacy order entry is facilitated by a computerized profile system with physician's orders faxed from the nursing care units. The pharmacy operates two satellite pharmacies Monday through Friday. One is located in the surgery area (open 10 hours) and the other is in the critical care area (day shift).

The pharmacy department prepares all intravenous admixtures, intravenous antibiotics, chemotherapeutic agents, central and peripheral TPN. Sterile pharmaceuticals are also prepared for open-heart and cardiac cath-lab and other surgical procedures as well as extensive outpatient services. The IV Room utilizes Baxa automation to operate the parenteral nutrition compounding machines. Parenteral nutrition orders are filled with a 24-hour supply.

Clinical services provided to patients and hospital staff includes a formal Pharmacokinetic Service and Nutritional Support Service. The services are by consult from a prescriber except Oncology, where all parenteral nutrition is monitored and in the Emergency Department, where all aminoglycoside and vancomycin orders are automatic consults.

Pharmacokinetics/Parenteral Nutrition

The pharmacokinetic services and clinical nutrition services are by physician consult. The Pharmacokinetic Service is available 24 hours and accepts responsibility for all orders including the first dose and dosage interval. The Clinical Pharmacists are credentialed by Medical Staff and are authorized to order drug levels, ancillary labs, and subsequent regimen adjustment. The service also serves the regional outpatient renal population needs for antibiotic dosing. Inpatient consults average 30 per month, outpatient average is 10 per month.

The Nutritional Support service provides assessment of parenteral nutrition, patient’s electrolyte needs and preparation of the TPN prescription. Labs are ordered on clinical judgment with guidelines. In conjunction with the physician,  the pharmacist can change electrolyte and base components as well as drug dosing associated with the TPN, including the addition or adjustment of insulin.

Practice Management

The scope of service and structure of pharmacy services at Saint Joseph Regional Medical Center is a complex with many stakeholders and interactions with different health professions on a daily basis. To be successful in this environment the pharmacist resident must gain expertise in managing his or her pharmacy practice. This entails generalities such as the approach to or philosophy of pharmaceutical care down to specifics such as time management or medication control. The resident pharmacist will have opportunities in all rotations to hone their ability to manage their practice and observe how the preceptor manages his or her practice. However, because some topics may not be experienced during the course of a specific rotation, practice management will have longitudinal components as weekly topics and as required projects.

Project

The resident pharmacist will complete a pharmacy practice residency project that is either research or performance improvement based. The project will be relevant and useful to Saint Joseph Regional Medical Center. The resident pharmacist will present the project at ASHP Midyear Clinical Meeting and Great Lakes Pharmacy Residency Conference and will also prepare a manuscript upon completion.

Staffing

PGY-1 in an Ambulatory Setting

Staffing consists of managing the medication assistance program, medication control, and drug information questions that would occur during the course of the day. Medication control consists of recording the dispensing of medication samples and generic medications used by the resident physicians and inspecting the regular medication stock monthly for outdated medications. Drug information questions are answered on varying topics upon the request of resident physicians. This drug information can be given verbal, written, or in presentation format.

The resident pharmacist is responsible for staffing the medication assistance program and medication control process of the Healthy Family Center every other Wednesday and during times when the pharmacy practice residency director is offsite at the Family Medicine Center. During these times the resident pharmacist oversees the medication technician and PharmD candidates.

PGY-1 in an Acute Care Setting

Pharmacy Resources provides 24-hour service to the patients and staff in our 339 bed facility. The hospital pharmacy department in comprised of the following: Pharmacy Director, Pharmacy Supervisor, Clinical Supervisor, Technician Supervisor/Buyer, 11 pharmacist FTE, and 12 technician FTE.

Medications are distributed in a unit-dose daily cart exchange. Pharmacy order entry is facilitated by a computerized profile system with physician's orders faxed from the nursing care units. The pharmacy operates two satellite pharmacies Monday through Friday. One is located in the surgery area (open 10 hours) and the other is in the critical care area (day shift).

The pharmacy department prepares all intravenous admixtures, intravenous antibiotics, chemotherapeutic agents, central and peripheral TPN. Sterile pharmaceuticals are also prepared for open-heart and cardiac cath-lab and other surgical procedures as well as extensive outpatient services. The IV Room utilizes Baxa automation to operate the parenteral nutrition compounding machines. Parenteral nutrition orders are filled with a 24-hour supply.

The Pharmaeokinetic Service is available 24 hours and accepts responsibility for all orders including the first dose and dosage interval. The Clinical Pharmacists are credentialed by Medical Staff and are authorized to order drug levels, ancillary labs, and subsequent regimen adjustment. The service also serves the regional outpatient renal population needs for antibiotic dosing. Inpatient consults average 60 per month; outpatient average is 10 per month.