PGY1 Pharmacy Residency (Ambulatory Care) Greenville - Learning Experiences

The academia learning experience is designed to develop the resident’s knowledge, skills, and abilities in various aspects of academia that include teaching, scholarship, and service. The experience emphasizes: (1) components of a clinical faculty position (i.e., clinical practice, teaching, scholarship, service); (2) direct patient care of ambulatory patients with a variety of chronic disease states; and (3) role as a practitioner, teacher, researcher, educator, and scholar throughout the learning experience.

This learning experience is designed to provide a basic overview of administrative and financial aspects of managing ambulatory pharmacists in primary care within a complex medical system. The learning experience consists of focused experiences with various pharmacy leaders. The experiential component of this rotation centers on actual projects, teams and process improvement activities currently underway rather than theoretical activities. The primary preceptor is the Ambulatory Clinical Pharmacy Manager. The learning experience is intended to provide the resident with “hands on” experience to demonstrate leadership skills, self-evaluation, medication safety, identification and resolution of administrative and clinical problems, forming and functioning within a team-work environment, compliance with accreditation and safety regulations, and developing new pharmacy initiatives. In addition, the resident becomes knowledgeable about key elements of ambulatory pharmacy and its relationship to the pharmacy enterprise and health care system.

Residents will have the opportunity to co-precept fourth year pharmacy students at least once during the residency year. This month gives pharmacy residents an opportunity to participate as a direct preceptor for a pharmacy student’s clinical rotation while at Prisma Health – Upstate. It is designed to develop the resident’s clinical preceptorship and mentorship skills.   

While it is a co-precepting experience with the residency preceptor, the resident takes the lead as much as feasible by providing instruction to the student where needed and appropriately modeling, coaching, and facilitating activities for the student. Additional activities typically include designing an individualized student curriculum, conducting pharmacotherapy discussions, and providing feedback/evaluations to the student. This experience takes place in a familiar ambulatory care rotation site once the resident has already completed a clinical experience in that setting (anticoagulation, diabetes, or primary care). This set up ensures the resident has a strong clinical foundation to build upon but is ready to precept. While there is still some clinical assessment of the resident, the residency preceptor focuses on teaching and evaluating the resident’s preceptor skills.  

Note, residents who elect to take the longitudinal Clinical Teaching Certificate (CTC), will co-precept at least twice. In this case, the first experience is considered a “modified” precepting experience where both the resident and student are learning new clinical skills, but the resident is also building precepting skills to prepare for the dedicated preceptorship month. This “modified” precepting experience could take place on any scheduled clinical rotation but should precede the preceptorship month which is the second experience. Opposite of the preceptorship month, the residency preceptor will focus on teaching and evaluating the resident’s clinical skills, though there will be some assessment of teaching skills as well.   

The geriatrics learning experience will introduce residents to the essentials of ambulatory and community-based care for older adults. Residents will have the opportunity to learn about transitions of care for geriatric patients, complete DRR (drug regimen reviews) for new and existing patients, as well as patient-based medication dosing and monitoring in the post-acute setting. The resident will work in a variety of workspaces to include our PACE primary care clinic, our Lila Doyle LTC facility, and Prisma Health Pharmacy in Greer which is our dispensing pharmacy for our post-acute facilities. The residents will work alongside nurses and providers to help assist with medication dosing and recommendation of safe and effective mediations regimens. The resident will attend quality improvement meetings and will present recommendations for quality improvement at the PACE and Lila Doyle practice locations. Other services provided by the resident will include researching drug information, pharmacokinetic evaluation/dosing and patient education. 

The specialty pharmacy learning experience will give a resident an overview of the knowledge and skills necessary to provide clinical management, access mitigation, and financial assistance for various specialty medications. Residents will work alongside pharmacists, technicians, patient care coordinators, and medication assistance specialists. They will gain experience in a variety of specialty areas including but not limited to: oncology, hematology, hemophilia, inflammatory conditions, neurology, and cardiology. This rotation will also familiarize the resident with the accreditation processes and requirements, limited drug distribution models, and financial assessment of the business opportunities. 

The purpose of anticoagulation learning experience is to allow the PGY-1 resident to develop skills in optimizing patients' medication therapy in a fast-paced ambulatory care setting. The resident will work in collaboration with other healthcare professionals to optimize patient care. Residents will spend their time at the Anticoagulation Clinics across the Prisma Health campuses.

Anticoagulants managed include warfarin, bridging anticoagulants (enoxaparin and fondaparinux), and the direct oral anticoagulants (apixaban, dabigatran, edoxaban, and rivaroxaban). The resident is responsible for managing patients’ anticoagulation therapy in its entirety. This includes educating patients and caregivers, responding to clinical phone calls, researching drug information questions, managing home health and home monitor patients. In addition, the resident will utilize policies and guidelines to assist with transition between anticoagulation agents and with periprocedural plans.

The Prisma Health Antimicrobial Stewardship Program (ASP) is a coordinated system level program that promotes appropriate use of antimicrobial therapy, reduces microbial resistance, decreases the spread of infections caused by multidrug-resistant organisms, and improves patient outcomes. The multidisciplinary program is led by an ID trained pharmacist and an ID physician.

Residents on this learning experience will complete targeted antimicrobial stewardship reviews and make patient specific recommendations to the primary teams, provide education to various services regarding antimicrobial stewardship topics, and complete antimicrobial stewardship related quality improvement projects for the system.

Topics focused on during this rotation include:

• Fundamental antimicrobial stewardship principles. 
• Application of diagnostic testing performed in the microbiology laboratory. 
• Antimicrobial resistance. 
• Bloodstream infections. 
• Urinary tract infections/asymptomatic bacteriuria. 
• Respiratory infections. 

The Cardiology Teaching Service (CTS) directly admits patients and accepts consults from various services at the Prisma Health – Upstate GMMC Hospital campus to manage a broad scope of cardiovascular conditions. This rotation is designed to provide a basic overview of the acute and chronic management of commonly encountered adult cardiovascular diseases. CTS provides medical; as well as, interventional management as treatment approaches. The resident will be assigned to a team consisting of an attending physician, medical resident(s), intern(s) and student(s). Disease states encompass: STEMI, NSTEMI/US, CHF exacerbations, arrhythmias, anticoagulation, hypertensive crises, interventional cardiology, and others.

The diabetes learning experience allows residents to work both outpatient, at various locations of Diabetes Self-Management Education and Support (DSMES), and inpatient at Greenville Memorial Hospital.

Residents will participate in multidisciplinary diabetes clinics with obstetric, family medicine, or internal medicine providers in addition to collaborating with certified diabetes care and education specialists of various disciplines. Prisma Health DSMES provides care to all patients with diabetes across their lifetime so residents may be exposed to adults or children with Type 1, Type 2, or gestational diabetes.

In addition to pharmacotherapy for diabetes, residents will gain experience in lifestyle medicine, insulin pumps, continuous glucose monitors, and remote patient monitoring. Inpatient care is focused on transitions of care, identifying barriers to successful outpatient glycemic management, and providing inpatient diabetes education. The resident will work closely with the preceptor to provide pharmaceutical care, diabetes education, and improve care delivery for patients with diabetes. Rotation goals include application of evidenced based medicine of diabetes pharmacotherapy, patient and family education, improving transitions of care, integrating diabetes technology, and improving resident oral and written communication skills. 

The family medicine learning experience creates a foundation for pharmacy residents on an inpatient general medicine service. The Family Medicine Teaching Service (FTMS) consists of an attending physician, clinical pharmacist, medical residents, interns and students and serves the acute medical needs of patients during hospitalization. The resident will: 

• Attend morning report and teaching rounds on a daily basis. 
• Present developed therapeutic plans for each of their patients to the preceptor. 
• Write pharmacokinetic and therapeutic consult notes as necessary. 
• Provide drug information services for the healthcare team. 
• Participate in topic discussions/journal clubs. 
• Be actively involved with ongoing projects. 
• Provide two formal presentations to the clinical service. 

Topics commonly encountered and/or discussed throughout the rotation will include both internal medicine and ambulatory care-based topics. This rotation can be tailored to resident-specific interests/needs. In addition, the resident will have the opportunity to conduct informal and/or formal educational services to physicians, nurses and pharmacists. 

The adult Hematology/Oncology I outpatient learning experience serves as an introduction to adult oncology and benign hematology. Throughout the learning experience, residents will obtain knowledge and experience as it relates to the general principles of oncology pharmacy practice, including oncologic supportive care issues and chemotherapy considerations. Learning experience activities include, but are not limited to, chemotherapy order review, patient & family member education/counseling, and assisting providers with drug information questions. Residents will rotate through multiple outpatient clinics to observe a wide array of oncology practice. Additional opportunities to observe oncology specialty pharmacy may be available upon request. This is a prerequisite for the Hematology/Oncology II and Stem Cell Transplant learning experience. 

The Hematology/Oncology II and Stem Cell Transplant learning experience involves the provision of direct pharmaceutical care to patients with a variety of hematologic malignancies including, but not limited to, leukemia, lymphoma, multiple myeloma, and those undergoing hematopoietic stem cell transplant. The resident will obtain knowledge and experience as it relates to the general principles of hematologic oncology pharmacy practice, including oncologic supportive care issues and stem cell transplant therapy principles. The multidisciplinary team includes pharmacists, doctors, nurse practitioners, nurses, medical assistants, social workers, and associated with Prisma Cancer Institute. Residents will split their time between Greenville Memorial Hospital and the Eastside clinic location near the Patewood campus but may rotate throughout the different clinic sites in the Upstate region including Greenville, Greer, Boiling Springs, and Seneca. The resident will spend mornings rounding with the inpatient multidisciplinary team and spend select afternoons in clinic.

Outpatient Parenteral Antimicrobial Therapy (OPAT) Consult Rotation is a four-week clinical rotation, offered year-round by the Prisma Health-Upstate Department of Pharmacy Services. The OPAT Service manages a daily inpatient census of approximately 40 patients with complex diseases. The OPAT Service is managed by ID physicians, ID nurse practitioners, ID physician fellows, and a pharmacists. Pharmacotherapy of infectious diseases and medication management of anti-infectives are emphasized. The major goal for the resident is to learn principles of antibiotic therapy that can be applied to any future practice area.  Tailoring individual learning goals is an important aspect.  To facilitate the learning process, the resident should identify a few personal educational goals one week prior to the rotation beginning.   

The Internal Medicine Hospitalists Service learning experience is an inpatient general medicine service. The resident will be assigned to a portion of the Hospitalists Service (based on interest). The Hospitalists Service is comprised of 7 day-shift physicians rounding on patients throughout the hospital, 3 pharmacists, and students.  As a member of the patient care team, each resident will work closely with the preceptor to provide pharmaceutical care.  The resident will attend Grand Rounds each Friday morning, present developed therapeutic plans for each of his/her patients to the preceptor on a daily basis, independently round on patients daily, provide patient counseling on medications and disease-states, obtain medication histories, write therapeutic consult notes as necessary, participate in journal club, and give formal presentations to the preceptor. In addition, the resident will have the opportunity to conduct informal and/or formal educational services to physicians, nurses, and pharmacists.  Topics commonly encountered and/or discussed throughout the learning experience include internal medicine-based topics. 

Prisma Health-Upstate offers residents an optional teaching certificate through the University of South Carolina College of Pharmacy.  This program is designed for residents who are interested in enhancing skills needed in an academic environment. The purpose of the program is to prepare pharmacy residents to serve as educators, either in full-time or adjunct faculty positions. More information can be found at https://www.sc.edu/study/colleges_schools/pharmacy/pharmacy_education/certificates/ctc/index.php .  

While many of the required residency activities are also required for CTC, additional activities may include but are not limited to:  

• Seminar (classroom) attendance 
• Evaluation of PharmD student Grand Rounds presentations  
• Evaluation of PharmD student hand-on skills lab assessments (ex: OSLE, OSCE) 
• Grading of additional PharmD student assignments  
• Creating of a teaching and precepting philosophy 

ASHP requires PGY1 residents to create and be evaluated on at least one of the following assignments: drug monograph, class review, treatment guideline, or protocol.  The type of project selected depends on when the opportunity arises and operational priority. This strategy ensures that residents are matched up with a meaningful project. The project is assigned when the opportunity arises during the first half of the year. Residents can expect this project to last approximately six months.

Project final documents are presented at least once to a relevant committee or clinical group, though additional discussions with that same group may need to occur prior to project completion if input is required for any recommendations

The medication use evaluation (MUE) gives residents an opportunity to prepare an MUE important to the system, department, or respective committee. Medication usage evaluation (MUE), as defined by the American Society of Health-System Pharmacists (ASHP), is a performance improvement method focusing on evaluating and improving medication use processes with the goal of optimal patient outcomes. This project is longitudinal where residents work with their respective preceptor to initiate, design, and implement the project over the course of eleven months starting after orientation.

The purpose of the outpatient staffing learning experience is to provide an opportunity for the resident to gain experience in drug preparation distribution in a community pharmacy as well as to expose the resident to knowledge and skills which will aid in the residents' development and understanding of systems operations and leadership skills. Improving leadership and practice management skills will result in optimized patient care, improved medication safety, and enhanced pharmacy productivity. This experience will allow residents to practice in a community pharmacy by staffing every third weekend throughout the year starting after the orientation month. Shifts will typically be two eight-hour shifts (7-3:30pm or 8:30-5pm) per weekend and in compliance with duty hour requirements. 

The pharmacist will primarily function as a workflow pharmacist (checking Rxs, verification) as well as partnering with our satellite pharmacists in coordinating the Med to Bed program upon patient discharges in the retail pharmacy. Activities during the learning experience may include electronic order entry, medication preparation, insurance billing and issue resolution, order and medication verifications, and medication counseling. The resident will also have an opportunity to review and fill non-sterile compounds. In addition to clinical responsibilities, the resident will gain experience in supervising technical staff and working with other pharmacists on a team. One of the primary activities is to check the order entry and medication preparation work of pharmacy technicians and oversee the workflow process by prioritization of dispensing functions.

Throughout the residency year, the pharmacy resident will be paired with a primary care physician to assist with non-urgent drug information questions and consults. The pharmacy resident will build a longitudinal relationship with that primary care physician and serve as the consultant pharmacist for that physician. During orientation, the pharmacy resident will have the opportunity to shadow the physician to build rapport and establish a relationship. The majority of future communication will occur remotely through the EMR, and the resident will be expected to respond to all clinical and drug information questions in a timely and professional manner. A thorough response back to the physician within 72 business hours from the initial request.

The resident will also be paired with a pharmacist mentor for support. Both the primary care physician and pharmacist mentor will provide quarterly feedback to the resident as a part of the longitudinal experience requirements. This is a remote learning experience that happens periodically. The goal is to answer approximately 2-4 consults per month, although the minimum requirement is to answer 4 consults per quarter.

Residents are required to be primarily responsible for at least one major IRB- approved research project. Each year, a list of potential projects will be generated / approved by pharmacy management and clinical pharmacy faculty. This list will be distributed to the residents for review and selection.  The resident may also select a project of interest, not on the pre-selected list, with approval from the Residency Program Director. The goal of this learning experience is to gain experience in various aspects of research methodology. The objectives of the project include defining a research idea, protocol development, submission to the Institutional Review Board, data collection, data analysis, and presentation/publication of results.

The residents are required to present their projects at the Southeastern Residency Conference (SERC) which occurs yearly at the end of April. The residents are also expected to write at least one manuscript suitable for publication in a peer-reviewed biomedical journal. The resident must be first author and be responsible for submission/revisions to a journal. Residents are required to submit for publication prior to the end of residency.

Provides support for the Prisma Health Pharmacy and Therapeutics Committee by reviewing and preparing drug formulary reviews, medication usage evaluations, meeting agenda/minutes and other relevant meeting materials as appropriate. During the learning experience, the resident will gain an understanding of the organizations’ medication-use systems by applying medication safety principles and best practices.  This rotation will help equip residents to understand the complexity of medication safety and the need to identify and manage system failures to improve patient safety. 

Residents will have the opportunity to learn about different types of medication errors, factors that contribute to medication errors, the severity of those errors, and the steps that go into their prevention.  Residents will also gain experience in collecting data on medication errors, analyzing the findings, communicating with other healthcare professionals and administrators through a reporting mechanism, and tracking and trending an area of failure and success.  Residents will share the information obtained through various means such as a hospital-wide performance improvement initiative.  Residents may also have the opportunity to attend pharmacy and therapeutics committee meetings, interdepartmental performance improvement meetings, and monthly hospital-wide medication error rate reporting discussions. 

The resident will have the opportunity to explore a variety of areas within the medication-use system: computerized prescriber order entry (CPOE) systems, electronic health records (EHR), clinical decision support tools, automated dispensing machines, ‘smart’ infusion pumps, and bar code medication administration and medication error surveillance.

The orientation learning experience is a 5-week required rotation which occurs directly following the hospital's new employee orientation (NEO) toward the end of June. NEO is typically 2 days and covers hospital wide policies, procedures, and other information applicable to all clinical employees.

Following NEO, the initial week of the orientation month is led by various leaders including but not limited to residency program directors and pharmacy administrators.

Residents should note that while policies and procedures, including relevant clinical protocols, will be reviewed during orientation, in-depth training on clinical protocols and workflows will take place during learning experiences as applicable.

Following the initial week, the remaining 4 weeks take place in the community pharmacy setting to train for the staffing component at Upstate Medical Pharmacy (UMP). Introductory training will primarily focus on the distribution aspects of pharmacy services along with an overview of how all aspects of pharmacy services intersect. Topics may include: prescription order verification, drug interaction screening, prescription dispensing, over the counter selection, patient education, and med2bed coordination.  This month will serve as the foundation for ongoing development during the longitudinal staffing commitment.

The primary care learing experience gives the resident an opportunity to work collaboratively with physicians and nurses to provide high quality direct patient care. The resident will see patients independently and in conjugation with a physician in a primary care practice site. The resident will be responsible for Medicare annual wellness visits, anticoagulation visits, and chronic disease state management such as diabetes, COPD, heart failure, etc. During these visits, the resident will interact with patients and families to provide counseling on medications and disease processes while obtaining accurate and complete medication histories. Since medication access can be a barrier to patients obtaining guideline recommended therapies, residents will become familiar with various medication assistance programs and learn to connect patients with the right resources. Lastly, the resident may also have opportunities to assist with education and didactics for medical residents and medical students. Prisma Health Upstate has multiple primary care sites and preceptors and the site selected for each resident depends on schedule availability among other factors.

The Psychiatry learning experience covers pediatric, adult and geriatric patients with mental health diagnoses and often comorbid medical conditions. In this inpatient psychiatric setting, patient care is managed using a team-based approach that involves daily team interaction and direct patient care. Multidisciplinary team members include clinical pharmacy specialists, physicians, physician assistants, nurse practitioners, social workers, and nurses. As a teaching facility, the treatment team also includes a number of learners (students, residents and fellows) from a variety of disciplines. 

The resident will round with 2 to 3 treatment teams on a daily basis, attend Grand Rounds, and provide optimal, evidence-based patient-centered care by: 

• Collaborating with healthcare professionals, patients and/or caregivers to recommend, implement and monitor therapeutic regimens.
• Taking into consideration a patient’s health literacy, culture and psychosocial factors.
• Educating patients and caregivers on medications.
• Obtaining and recording detailed medication histories.
• Facilitating transitions of care with outpatient providers.
• Assisting with the management of treatment-related side effects.

Topics commonly encountered and discussed throughout the learning experience include general medical health conditions in addition to mental health conditions such as thought, mood, behavioral, personality and substance use disorders. This learning experience can be tailored to resident-specific needs/interests. In addition, the resident will have the opportunity to conduct informal and/or formal educational services to physicians. 

The goal of the solid organ transplant learning experience is to provide insight to the resident on the role of a transplant pharmacist on a multidisciplinary team and to build better understanding of the immune system and the management of immunosuppressants. The pharmacist on the transplant team is in a unique position to make a significant impact and is recognized as an essential member of the multidisciplinary team by the Centers for Medicare & Medicaid (CMS) and the United Network of Organ Sharing (UNOS). The resident will work to provide comprehensive pharmaceutical care to transplant recipients and donors in the pre-, peri-, and post-operative phases of care. The resident will assist in managing transitions of care through medication coordination, discharge planning, and medication reconciliation and education. The resident will learn to evaluate transplant recipient medication regimens routinely, provide patient and family education on transplant medications including concepts of adherence, providing support to the Prisma Health kidney transplant department staff, researching, and answering drug information questions and communicating medication concerns to the transplant team. Residents will also have the opportunity to attend weekly transplant selection committees, transplant QAPI meetings, and opportunities to shadow in the operating room during a transplant case.

The purpose of Transitions of Care (TCP) learning experience is to allow the PGY-1 resident to develop skills in optimizing patients' medication therapy in a multi-disciplinary ambulatory care service. 

TCP visits focus on patients who have recently been discharged from the hospital. These patients are followed closely by the TCP team (physician, pharmacist, and nurse) through weekly visits for approximately 4 weeks to prevent further hospitalizations and ER visits. The resident will be exposed to many disease states including but not limited to heart failure, CAD, HTN, diabetes, COPD/Asthma, and anticoagulation management. 

The pharmacist is an integral part of the multidisciplinary team and contributes by completing medication reconciliations, assessing risk factors, lab values, drug interactions, and adherence or cost issues. Pharmacist recommendations are discussed with the physician(s), and the pharmacist educates patients on new medications, medication changes, and disease state related information.

The unit based learning experience is a clinical/distribution type learning experience.  The purpose of this experience is to allow the PGY1 resident to develop skills in optimizing medication verification and distribution in a fast-paced inpatient hospital setting. 
The unit based pharmacist is emersed within the inpatient pharmacy model through centralized distribution and clinical services amongst various units. Working to ensure adequate verification, preparation, and distribution of all medications within Greenville Memorial Hospital. In addition to these various duties, the unit-based pharmacist is responsible for medication history obtainment, discharge education, pharmacokinetic consultation, and therapeutic monitoring within coverage area. Additionally, the unit-based pharmacist is expected to provide patient education on agents such as warfarin, Eliquis, Xarelto, and new start insulin therapy (timing, administration technique, hypoglycemia, etc.).

The inVio Health Network is Prisma Health's Clinically Integrated Network (CIN). Through contracts, the network brings together: payors (plan sponsors), health systems (Prisma), and practices (Prisma Upstate and Midlands-owned and Independents). The network facilitates the provision of value-based care to patients, which aims to increase evidence-based quality performance and patient perceptions of care while reducing the cost of care. The network shares in financial incentives and risks with plans based partly on quality measure performance and medical and pharmacy spend within plans. The inVio health network has ~320,000 attributed lives throughout the state of SC that receive insurance through one of the following: Medicare Advantage plan contracts with UHC, Humana, and Aetna, Exchange plan contracts with BCBS, Medicaid plan contracts with BCBS, and Commercial plan contracts with UHC, Aetna (including the Prisma Employee Health Plan), and others. For those who qualify, centralized Care and Condition Management is available for the patients of the inVio Health Network through utilization of an NCQA accredited program. Members of this Integrated Care Management (ICM) team include: pharmacists, nurse care managers, social workers, behavioral health specialists, and health coaches.

The Vascular Health learning experience provides residents an opportunity to work on a specialized multi-disciplinary team in the outpatient setting. The team consists of Vascular Medicine, Vascular Surgery, Hematology/Oncology, Nursing, and Anticoagulation Pharmacy Specialists. The resident will work with patients taking anticoagulation for deep venous thrombosis (DVT), pulmonary embolism (PE), superficial venous thromboses (SVT), clotting disorders, and occasionally other vascular, arterial, or cardiac conditions. During patient visits, the resident focuses on anticoagulant selection, drug interactions, lab values, and education.  The resident will ensure patients have access to anticoagulants and if there are any barriers, work to resolve them. Although the focus is on anticoagulation, many patients have multiple comorbidities and complex medication regimens. A big part of managing the anticoagulation is reviewing disease state and medication interactions. The resident will also respond to clinical phone calls and faxes, dispense sample medications, or research drug information questions.