Ambulatory Care APPE

Rotation Manual

2019-2020

Alyse “Aly” Briggs, PharmD

PGY-2 Pharmacy Resident – Ambulatory Care
Saint Joseph Health System
Mishawaka, IN
 Background Description

The Saint Joseph Health System (SJHS) is a member of Trinity Health Network, a non-profit Catholic health system that
consists of ninety-four hospitals within twenty-two states and is among one of the largest multi-institutional Catholic
health care delivery systems in the nation. Here at Saint Joseph, we have two acute care hospitals (located in Mishawaka
and Plymouth Indiana), one rehabilitation institute, independent/assisted/skilled-nursing/rehabilitation centers, and
clinics located throughout North Central Indiana. The Family Medicine Center (FMC) is located on the fourth floor of the
Medical Office Building (MOB), which is connected to Saint Joseph Regional Medical Center (SJRMC). Members of the
team who provide care to patients within this clinic consist of medical residents, pharmacy residents, podiatry residents,
medical directors, and pharmacy directors.

The pharmacists who work within this clinic can practice in both an independent and collaborative manner. The
following are some examples of different services provided by pharmacists within this clinic setting:
- Anticoagulation Management - Pharmacotherapy Clinic
- Dyslipidemia Management - Heart Failure Clinic
- Diabetes Management - Asthma/COPD Clinic
- Diabetes Classes - Medication Assistance
- Smoking Cessation - Medicare Annual Wellness Visits
- Weight Loss Management - OutcomesMTM Services

This Advance Pharmacy Practice Experience (APPE) rotation here at Saint Joseph FMC was developed to provide fourth
year pharmacy students the opportunity to experience a mixture of pharmacist-driven clinics or services, as well as the
value of interdisciplinary team-based care within the outpatient setting.

Preceptors

Alyse Briggs, PharmD
PGY-2 Pharmacy Resident –
Ambulatory Care
e-mail:
alyse.briggs001@sjrmc.com
phone: (574)-335-6566
Sunitha Johns, PharmD Miranda MacFarlane, PharmD Stephanie Schenkel, PharmD
PGY-2 Pharmacy Resident PGY-1 Pharmacy Resident – PGY-1 Pharmacy Resident –
– Ambulatory Care Ambulatory Care Ambulatory Care
e-mail: e-mail: e-mail:
sunitha.johns@sjrmc.com miranda.macfarlane@sjrmc.com stephanie.schenkel@sjrmc.com
phone: (574)-335-6567 phone: phone: (574)-335-6493

Chris Gildea, PharmD, BCACP,
CDE
Ambulatory Care Pharmacist
e-mail:
christopher.gildea@sjrmc.com
phone: (574)-335-4679
Jason Isch, PharmD, Lauren McNace, PharmD, BCPS Angelina Sagarsee, PharmD
BCACP, CTTS Ambulatory Care Pharmacist Ambulatory Care Pharmacist
Assistant Professor of e-mail: e-mail: sagarsea@sjrmc.com
Pharmacy Practice lauren.mcnace@sjrmc.com phone: (574)-335-6548
Manchester University phone: (574)-335-6563
e-mail:
jish@manchester.edu
phone: (574)-335-6520

Ed Battjes, PharmD, BCACP, Ed Sheridan, PharmD,

BC-ADM, CDE
Associate Director, PGY-1
Ambulatory Pharmacy
Residency Program
Manager, Ambulatory
Pharmacy Services
e-mail: battjese@sjrmc.com
phone: (574)-335-6513
BCPS, BCACP
Director, Graduate
Pharmacy Education and
Ambulatory Pharmacy
Services
e-mail:
sheridane@sjrmc.com
phone: (574)-335-6514
 Expectations Prior to the First Day

Please complete the following things prior to arriving on the first day of the rotation:
- Read the entire rotation manual
- Complete the Initial Questionnaire
- Complete the Goals for this Experience
- Read the Alere Monitoring Manual and complete associated quiz, attached to this e-mail
- Register and complete the OutcomesMTM online training
- Register and complete HealthStream online training (e-mail information confirming completion to preceptor)
- Print, read, and sign the Confidentiality Agreement Form attached to this e-mail
- Review the Dress Code Policy attached to this e-mail
- Notify the primary preceptor if there is any expected conflicts for the upcoming 4 weeks.
- E-mail the following to your primary preceptor:
o Documentation of Current CPR (or BLS) at the time of your rotation
o Documentation of a recent 8 panel drug screen (within 12 months from your rotation)
o Documentation of a criminal background check
o Documentation of vaccination status including Rubella, Chicken pox, and Hepatitis B
o Documentation of a recent PPD (within 12 months from your rotation)
o Documentation of a current season influenza vaccine

General Expectations

The APPE student must participate in rotational activities for a minimum of 40 hours per week. Patient care
activities will typically occur Monday through Friday between the hours of 8 AM and 5 PM, with an hour lunch. No
patient specific information should leave the clinic, thus no remote access to patient’s charts will be provided to
students. Electronic devices, such as laptops and cellphones, may be utilized for patient care and drug information
resources while working during clinic hours. Any absences must be approved by the preceptor in advance. Additional
community pharmacy opportunities (e.g. Navari Clinic) may be available to and/or required for the APPE student on one
or more Saturdays, typically between the hours of 8 AM and 1 PM. The APPE Student will refer to their calendar for
specific daily rotational activities, which are subject to change depending on the rotation and FMC needs. All students
are expected to follow their respective school’s APPE Manual for specific graduation requirements, objectives, and
expectations.
 Objectives

After completion of this APPE rotation, the student should be able to…
- Identify, evaluate, and apply current literature to patient analysis, journal clubs, topic discussions and other such
activities.
- Demonstrate, in an efficient manner, thorough and accurate patient case evaluations and presentations.
- Develop patient-specific treatment plans consisting of ,but not limited to, guideline-based medication therapy,
monitoring parameters, patient-specific education points and goals, non-pharmacological interventions, and
follow up plan.
- Use motivational interviewing techniques to provide meaningful and engaging conversation throughout patient
appointments
- Deliver patient-specific education about disease states, medications, devices, and non-pharmacologic treatment
options.
- Articulate, in both written and verbal form, plan or inquires for or about patient’s care with other healthcare
providers.
- Collaboratively work with other team members to provide comprehensive care to a patient through actions
including but not limited to, appropriate therapy recommendations, monitoring parameters, patient-specific
education points and goals, non-pharmacological interventions, and follow up plans.

APPE Student Clinical Experiences Expectations

Ambulatory Care Pharmacy Clinic Expectations

The student will have to opportunity to work in various ambulatory care pharmacy clinic experiences, however the
preparation for and role within each clinic should be universal. As such, the student is expected to complete the
following actions before or after attending a clinic:
- Using the appropriate monitoring form, evaluate all patients assigned to that clinic
- Arrive to discuss patients with clinic preceptor promptly with all necessary materials to discuss the patients
- During clinic, if the student is not actively leading the interaction, they should be documenting the interaction
for both subjective and objective information. At the end of your experience, they should be able to successfully
lead part or an entire patient interaction.
- After the clinic, the student should take direction from that clinic preceptor as to which patient interactions to
document. The student should take initiative to set a follow up time with the clinic preceptor to review your
completed documentation.

Medical Resident Clinic Expectations

The student will potentially have the opportunity to work alongside the family medicine residents during one-half of
their clinic day.
Prior to this experience, the student is expected to complete the following actions before attending clinic:
- Using the appropriate monitoring form, evaluate all patients assigned to that clinic (except well-child visits and
well-women visits)
- Print out the patient’s medication list and bring to clinic
- Arrive to discuss patients with preceptor promptly with all necessary materials to discuss the patients
During this experience, the student is expected to:
- Complete medication reconciliation and inform medical resident and nursing team members of results
- Provide medication counseling and education to patients utilizing appropriate patient literature or
demonstration devices

OutcomesMTM Clinic Expectations

At Saint Joseph Health System we provide medication therapy management (MTM) services for all patients in the
network using OutcomesMTM. Alongside a preceptor, the student will have the opportunity to utilize this platform
throughout their rotational experience to provide targeted interventions (TIPS) or comprehensive medication reviews
(CMR).
Providing MTM Services – TIPS
1. Identify eligible patients on OutcomesMTM platform
2. Record the patient on Excel Tracking Sheet
3. Analyze patient information and determine course of action
4. Review evaluation and action times with preceptor
5. Contact patient/prescriber to discuss TIPs
6. Complete necessary documentation on Outcomes MTM and the Excel Tracking Sheet
Providing MTM Services – CMR
1. Identify eligible patients on OutcomesMTM platform
2. Record the patient on Excel Tracking Sheet
3. Contact patient to evaluate interest in CMR services
4. Schedule patient to receive CMR
5. Analyze patient information and determine course of action
6. If providing CMR over the phone or in clinic, provide CMR Service
7. Complete necessary documentation on Outcomes MTM and the Excel Tracking Sheet

APPE Student Experiences Expectations

In addition to the experiences listed below, there could be other opportunities the APPE student might be asked to
participate in or complete.
- Topic Discussion (15-30 minutes)
o The APPE student will collaborate with their primary preceptor to determine the topics of 1-4 topic
discussions throughout their rotation. These will take place in a small group setting (possibly with just
the APPE student and their primary preceptor).
o It is expected that the APPE student will research and develop a 1-2 page handout covering the topic in
addition to a half-page quick and easy-to-read summary for possible publication in the SJHS bi-monthly
newsletter.
- Disease State/Formal Topic Discussion Presentations (30 minutes, 25 minutes for presentation and 5 minutes for
questions)
o The APPE student will collaborate with their primary preceptor to determine the topics of 1-4 topic
discussions throughout their rotation. These will take place in a small group setting (possibly with just
the APPE student and their primary preceptor).
o It is expected that the APPE student will research and develop a 1-2 page handout covering the topic in
addition to a half-page quick and easy-to-read summary for possible publication in the SJHS bi-monthly
newsletter.
o The APPE student will lead a 25 minute presentation reviewing their 1-2 page handout (possibly
supplemented by a PowerPoint or other presentation style) while incorporating an interactive
component (ex: PollEv, BINGO, ect).
- Patient Case Presentation (30 minutes, 25 minutes for presentation and 5 minutes for questions)
o The APPE student will identify one patient case by the second week which they wish to present about in
a formal patient case presentation. This presentation will briefly cover the patient and clinical decision,
review a disease state and guideline driven medications, and at least 2 clinical trials or reviews. If the
APPE student is unable to identify or locate appropriate references, they will approach their primary
preceptor for additional assistance. Class notes are not an appropriate reference and all references must
be cited.
 o It is required that there is an interactive component to the presentation.
- Clinical Trial Presentation (30 minutes)
o The APPE Student will be assigned a 4-8 clinical trials within the scope of one disease state to formally
evaluate. They will then fill out a provided worksheet, breaking the trials down into key points.
o The APPE students will then be required to prepare a 30 minute interactive presentation about their
findings which will be presented in front of the ambulatory care pharmacy team.
o The student will likely complete 1 journal club or clinical trial presentation during your APPE rotation.
- Journal Club (20 minutes)
o The APPE Student will be assigned a journal article which they must formally evaluate using provided
journal club template. If the journal club is not assigned, the APPE student must identify three journal
articles related to ambulatory care (within the past year preferable) and submit them by the first
Thursday of their APPE experience to their primary preceptor. The final journal club article will be
selected by the primary preceptor by the first Friday of their experience.
o The APPE Student will then be required to prepare a 1 page (front and back) handout and present over
their findings for no more than 15 minutes.
o The student will likely complete 1 journal club or clinical trial presentation during your APPE rotation.
- Oral Examination (30 minutes)
o At the start of the rotation, the APPE student will be expected to participate in a Beginning of Block Oral
Exam, which the candidate will be provided 30 minutes to work up a mock patient case using drug
information sources as needed. Prior to presenting the case, the student will have the ability to ask 3
questions that they have which will help them guide their clinical decision making. They will then
present the case to team members for evaluation. At the end of the APPE rotation, the APPE student will
be expected to participate in an End-of-Block Oral Exam following the same procedures described
above.
- Patient Care Questions or Drug Information Questions
o If follow up questions must be addressed, the student will have 24-48 hours to e-mail both their
preceptor for that experience and their primary preceptor the response.
- Diabetes Group Class Presentation
o Depending on the time of year and availability, there is a possibility the student will be asked to present
a portion of the Diabetes Group Class held at this site. The student will be provided the slides, handouts,
and any interactive portion necessary to complete your session.
- Saint Joseph Health System Project Management
o Depending on the time of year and availability, there is a possibility the student will be asked to work on
a project for Saint Joseph Health System.
- Midpoint/Final Evaluation
o Midpoint Evaluation– Prior to the midpoint meeting, the student is expected to complete and present
the midpoint evaluation form below. This is done in addition to any other requirements from their
pharmacy school.
o Final Evaluation – Prior to the midpoint meeting, the student is expected to complete and present the
final student evaluation of resident form below. This is done in addition to any other requirements from
their pharmacy school.

Initial Questionnaire
1. Why did you choose this rotation?

2. What rotations have you already completed?

3. Do you have prior experience working with a multidisciplinary team? If yes, please explain.

4. Have you worked in a pharmacy before? If so, where?

5. Currently, what areas of practice are you interested in?

6. Currently, what are three short term (within five years) career goals you have?

7. Please list three strengths about yourself that you bring to this rotation.

8. Please list three areas in which you wish to improve while on this rotation.

9. Please list two different disease states that you are interested in discussing.

10. Is there anything your primary preceptor should be aware of in order to help facilitate a successful rotation?

Goals for this Experience

Please take time and write down below what your personal goals are for this ambulatory care rotation.
Remember that this is YOUR rotation, so the more detailed and specific the student are in describing your goals,
the better we will be able to try and assist the student to achieve them during your experience.

Goal #1

Goal #2

Goal #3

Goal #4

Registering for OutcomesMTM

For your upcoming rotation at St. Joseph Health System, we will require that the student get registered for
OuctomesMTM. For those who are already registered, the student can go ahead and skip right to step #3.
1) Visit the website to get registered: https://secure.outcomesmtm.com/index.cfm?event=register
2) Complete the registration page as follows:
a. Your role: "Tech/Pharm Intern or Student"
b. Employee ID number: Skip this section
c. Address: 611 E. Douglas Rd. Suite #407, Mishawaka, IN, 46545
d. Username/Password: Make sure the student save these somewhere, so the student remember how to
login

3) Once the student are registered, the student will be asked to put in NCPDP# of your pharmacy. Please input
99A242 as this will get the student access to our patients that the student will need on rotation.

4) There will be some training that will need to be done, but the student can wait until the rotation and I will build
in an hour or so into the rotation, so the student can have time to be trained with the internet modules.

Registering for HealthStream

For your upcoming rotation at St. Joseph Health System, we will require that the student perform online training prior to
your arrival.
1) Visit the following site ( http://www.healthstream.com/hlc/trinityhealth) and log in using your non-employee ID # without
the last letter as both the username and password.
2) Complete the following 2 modules:
a. SJRMC – Student Safety Module
b. SJRMC – Confidentiality Agreement – 003892

Navigating St. Joe's Computer System

Most Important Applications: (Everything is in alphabetical order in ZENworks Window)

• Dynamed – Great tertiary literature source that helps pull PDFs and organize guidelines. Very similar to
UpToDate (but better!)
• Health eLibrary – This houses access to LexiComp and UpToDate. The student should be doing a drug interaction
check and assessing dosing for all patients that the student look up
• Natural Standards – Good resource to help with assessing safety and efficacy of natural products/supplements
• Power Chart MHIN – The student will live out of this app. This is the Electronic Health Record (EHR) for all of our
outpatient clinics

How to Navigate Power Chart MHIN

• Opening a Clinic to Find Patients

o
o
o
o The student will put in the clinic name in the space next to "Resource" and make sure the student are on
the correct date.
o The clinics "KEYWORD" for each of the clinics the student will be in are as follows
▪ FMC Pharmacy: Anticoagulation clinic with Dr. Ed Sheridan and Dr. Aly Briggs
▪ FMC Diabetes: Diabetes clinic and Classes with Dr. Ed Battjes and Dr. Sunitha Johns
▪ FMC Pharmacy 2nd Year Clinic: Pharmacy RESIDENT clinic with Dr. Kris Tupas
▪ "INSERT DR. LAST NAME": Med Resident Clinic/Ortiz/Wyncott Clinics
▪ MRFM PHARMACY: Miami Rd. Clinic with Dr. Jason Isch
▪ Wierman, Meredith: ID Clinic with Dr. Jason Isch
▪ FMC AWV: AWV Clinic with Dr. Kris Tupas
▪ FMFP AWV: AWV Clinic with Dr. Angelina Sagarsee
- NOTE: OutcomesMTM, Inpatient/Outpatient TOC do NOT have MHIN pools

• Printing a Patient Medication List

o Please do this in addition to filling out an "Outpatient Monitoring Form" for each patient that the
student work up.
o Printer 4519 is the supply room printer
• Writing a Note for Patients Seen in Clinic

o Click "ADD" from left sided menu

o Make sure the "Type" is "Pharmacotherapy Note"
o Click on the "Precompleted" tab

o Search for the template to fill out based on the clinic the student are in (Jason will be the author on all of
them):
▪ Diabetes Clinic: "Diabetes Education Follow-Up # X"
▪ Diabetes Class: "Diabetes Education Class #1/2/3/4" (depending on the class #)
▪ Med Resident Clinic/Ortiz/Wyncott: "Medication Therapy Management Consult"
▪ ID Clinic/Wierman: "ID – Medication Adherence Consult"
▪ *Smoking Cessation: "Smoking Cessation – Initial Visit" and "Smoking Cessation – Follow-Up"
▪ *Weight Loss: "Weight Loss Initial Visit"
▪ *AWV Clinic: "Medicare Annual Wellness Visit" (Author is Diana Mechelay)

o When writing the note, the student can save lots of time by pressing "F3" to skip to the next section (_)

o When done press "Sign/Submit" and send to your preceptor who will forward it on to the physician
when done
▪ *If writing, Smoking Cessation, Weight Loss,
Or AWV Clinic notes, the student will send them to your
preceptor via EMAIL and the preceptor will sign
and submit the note for the student
 Orientation Checklist

 Introduction of instructor(s) / preceptor(s) and other staff

 General tour of the facility
 Introduction to preceptor
 Collect, Review, and Upload Student Rotation Requirements
o Documentation of Current CPR (or BLS) at the time of your rotation
o Documentation of a recent 8 panel drug screen (within 12 months from your rotation)
o Documentation of a criminal background check
o Documentation of vaccination status including Rubella, Chicken pox, and Hepatitis B
o Documentation of a recent PPD (within 12 months from your rotation)
o Documentation of a current season influenza vaccine
o Alere Monitoring Quiz
o HealthStream Completion Documentation
o Confidentiality Agreement Form
 Discuss personal appearance and behavior standards
 Review rotation schedule
 Discuss time commitment for the rotation
 Discuss any expected conflicts for the upcoming 4 weeks
 Discuss Student’s Initial Questionnaire and Goals for this Experience
 Review requirements for experiences/presentations
 Review patient presentation format
 Review Oral Examination Expectations
 Discuss the evaluation process
o Expectations for Midpoint
o Expectations for Final Evaluation
 Review of all office, phone, and pager numbers and use
 Computer access and resources available - Drug information references (primary, tertiary, computerized)
 Providing Care/Skills Assessment
o General clinic room preparation
o Check Blood Pressure
o Using Scale
o Prepping Room for Anticoag Clinic and Check INR
o Cleaning room
 Sign to acknowledged that we have reviewed all information and expectations discussed above

APPE Student:_____________________________________________________________________________________

Primary Preceptor: _________________________________________________________________________________

 Additional Forms and Resources

MIDPOINT SELF-EVALUATION FORM

Student Name: __________________________________
Primary Preceptor: _______________________________
Month of Rotation: _______________________________
Unique/Interesting Patient/Provider Interaction:
1. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
2. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
3. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
How are you doing with the personal goals you set at the start of this rotation:
1. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
2. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
3. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
4. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Self-Identified Strengths:
1. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
2. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
3. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Self- Identified Areas for Improvement:
1. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
2. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
3. _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Action Plan (to be completed with preceptor)
1. ___________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
FINAL STUDENT EVALUATION OF THE RESIDENT
Resident:
Please complete the following assessment items to provide feedback to your resident about his/her teaching skills.
1. The resident was readily available to assist me when I needed.

Strongly disagree Strongly agree

1 2 3 4 5 N/A

2. The resident provided me with constructive feedback to help me learn.

Strongly disagree Strongly agree

1 2 3 4 5 N/A

3. The resident motivated me to improve my performance.

Strongly disagree Strongly agree

1 2 3 4 5 N/A

4. The resident allowed me to express my opinions and raise questions.

Strongly disagree Strongly agree

1 2 3 4 5 N/A

5. The resident did an adequate job of facilitating discussion and explaning concepts related to the topic.

Strongly disagree Strongly agree

1 2 3 4 5 N/A

6. The resident is an excellent role model for students.

Strongly disagree Strongly agree

1 2 3 4 5 N/A

7. Rate the resident’s overall teaching skills.

Poor Excellent
1 2 3 4 5

Please list 2 areas of strength for the resident

1. ___________________________________________________________________________________________
___________________________________________________________________________________________
2. ___________________________________________________________________________________________
___________________________________________________________________________________________
Please list 2 areas for improvement for the resident
1. ___________________________________________________________________________________________
___________________________________________________________________________________________
2. ___________________________________________________________________________________________
___________________________________________________________________________________________
Patient Name: DOB (Age): Patient PCP:

Ht: Wt: BMI: Scr: GFR: CrCl: ASCVD:

SH: Allergies:

Meds w/o Indications: Indications w/o Meds:

Needed Immunizations:

Reviewed Medications for: Drug Interactions / Renal Function / Side Effects / BEERS
Prioritized 1. 2. 3. 4.
Problem
Patient Goals
(Controlled vs.
Uncontrolled)

Assessment
Vitals, lab values,
physical exam,
diagnostic tests,
calculations,
scores, etc.

Current
Medications

Correct dose (for

disease state, liver,
and kidney
function) drug-
drug interactions,
etc.

Medication
Recommendations

Non-
Pharmacologic
Recommendations

Monitoring w/
frequency

Follow Up Time

Counseling Points
Prioritized 5. 6. 7. 8.
Problem
Patient Goals
(Controlled vs.
Uncontrolled)

Assessment

Vitals, lab values,

physical exam,
diagnostic tests,
calculations,
scores, etc

Current
Medications

Correct dose (for

disease state, liver,
and kidney
function) drug-
drug interactions,
etc.

Medication
Recommendations

Non-
Pharmacologic
Recommendations

Monitoring w/
frequency

Follow Up Time

Counseling Points
Prioritized 9. 10. 11 12.
Problem
Patient Goals
(Controlled vs.
Uncontrolled)

Assessment

Vitals, lab values,

physical exam,
diagnostic tests,
calculations,
scores, etc

Current
Medications

Correct dose (for

disease state, liver,
and kidney
function) drug-
drug interactions,
etc.

Medication
Recommendations

Non-
Pharmacologic
Recommendations

Monitoring w/
frequency

Follow Up Time

Counseling Points