Stratton VA Medical Center 113 Holland Avenue Albany, NY PGY2 PAIN MANAGEMENT AND PALLIATIVE CARE RESIDENCY MANUAL

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1 Strattn VA Medical Center 113 Hlland Avenue Albany, NY PGY2 PAIN MANAGEMENT AND PALLIATIVE CARE RESIDENCY MANUAL Jeffrey Fudin, B.S., Pharm.D., FCCP, DAAPM Directr, PGY2 Pharmacy Pain Residency Prgram HOSPITAL MANAGEMENT Linda W. Weiss, MS, FACHE Medical Center Directr Lurdes Irizarry, M.D. Chief f Staff Terri Wank, Pharm.D. Chief f Pharmacy Amy Murdic, Pharm.D. Supervisr Clinical Pharmacy Sectin PRECEPTORS Susan Casler, MS, FNP-BC, ACHPN Palliative Care Nurse Practitiner Cynthia Carlyn, MD Chief, Infectius Disease/Lngitudinal (+elective ptin) Jacquelyn E. Canning, PharmD, BCCP Assistant Prfessr, Department f Pharmacy Practice Albany Cllege f Pharmacy and Health Sciences Preceptr in Psychiatry, Strattn VA Medical Center Dnald Higgins, MD Chief, Neurlgy/Neurlgy Elective Prashant Kaushik, MD Chief, Rheumatlgy Andras Laufer, M.D. Attending, Anesthesia Pain Management 1

2 Sheran Mahatme, D.O., M.P.H. Divisin f Infectius Diseases/Lngitudinal Ry Mathew, MD Medical Directr, Dialysis Lngitudinal (+elective ptin) Amy Murdic, Pharm.D., BCPS Pharmacecnmics/Practice Management, ESA Clinic, Nephrlgy/Dialysis Elective Annette Payne, B.S., M.A., Ph.D. Chief, Psychlgy Service Julie Phillips, M.D. Staff Physician, Hspice and Palliative Care Ishtpreet Uppal, M.D. Attending Physician, Hspice and Palliative Care Clinical Pharmacy Supervisr & Residency Directr Natalie H. Hsu, MD Staff Nephrlgist Dalia Perez-Gnzalez, MD Staff Psychiatrist PHARMACY ADMINISTRATRIVE PERSONEL Terri Wank, Pharm.D. Chief, Pharmacy Service Heather Clum Pharmacy Management Assistant Amy Murdic, Pharm.D., BCPS Pharmacecnmics/Practice Management ESA Clinic, Nephrlgy/Dialysis Elective 2

3 Backgrund: Overview The Strattn Veterans Administratin (VA) Medical Center prvides cmprehensive inpatient care as well as a full range f utpatient services. The primary care prgram prvides services at this facility as well as in eleven Cmmunity-Based Outpatient Clinics (CBOC's). In additin t primary care, there are numerus specialized services within the Medical Center. The services ther than Primary Care that mst ften cllabrate with Pharmacy Pain Service include Acute Medical and Surgical, Behavir Health (Psychlgy and Psychiatry), Infectius Disease, Nephrlgy, Neurlgy, Onclgy/Hematlgy, Orthpedics, Palliative Care, Physical/Rehabilitatin Medicine, and Rheumatlgy. Pain Service als rutinely cllabrates with the diagnstic labratries (chemistry, medicine and radilgy), all f which are extensive and well develped including cmputerized tmgraphy, mammgraphy and magnetic resnance imaging. The American Cllege f Surgens designated the Albany VA as a Cmprehensive Cancer Center. Affiliated residency prgrams in medicine and pharmacy are fully integrated with Unin University. Residents and medical students frm Albany Medical Cllege and Albany Cllege f Pharmacy & Health Sciences rtate thrugh the Strattn VA Medical Center n a cntinuus basis. Pharmacy Services at Strattn VAMC Management team Directr Clinical supervisr Supervisrs, inpatient and utpatient Sterile prducts Sterile prducts preparatin Centralized Onclgy satellite Medicatin distributin system Carts/cartless Autmated dispensing cabinets prfiled t hspital-wide infrmatin system Clinical crdinatr versees Clinical services prgram Clinical Pharmacy Specialists: Gastrenterlgy Surgery/Critical Care Infectius Disease Psychlgy Onclgy Transitinal Care Als respnsible fr quality imprvement prgrams in the department and are 3

4 mentrs fr the decentralized pharmacists 4

5 Pharmacists n flrs in decentralized integrated practice mdel (7-days per week): Order entry, IV t PO switch, therapeutic interchange, patient educatin Drug infrmatin Crdinate distributin system Cllect data fr MUE, ADR Cardilgy Surgery/SICU Internal medicine/micu Onclgy/Hematlgy Telehealth Currently with Dr. Annette Payne. A separate Pharmacy pain Telehealth Clinic is under develpment. Residency prgram: Three PGY1 Pharmacy Practice One PGY2 Pain Management & Palliative Care 5

6 Intrductin Gal: The intentin f this PGY2 Pain Management & Palliative Care (PMPC) Residency Prgram is t transitin PGY1 residency graduates frm generalized practice t specialized practice fcused n the pain management and palliative care needs f patients. The resident will be scheduled t rtate thrugh a series f prgrams and experiences addressing chrnic malignant and nn malignant pain, palliative care, substance abuse, interventinal pain prcedures and alternative therapies with the bjective f becming prficient in all aspects f pain management and palliative care practice. The candidate will develp expertise in pain therapeutics, risk stratificatin, and essential pharmackinetic mnitring. The PGY2 Pain Management & Palliative Care Residency Prgram is a ne-year pst-pgy1 prgram designed t prvide the resident with the knwledge, expertise, skills and abilities required in PMPC as a member f an interdisciplinary health-care team. In additin, the prgram is meant t prvide the resident with cncentrated clinical experience alng with expsure t all available aspects f PMPC. The ultimate gal f the prgram is t enhance the resident's cmpetence and skills in patient care, as a prductive member f the Interdisciplinary Pain Management & Palliative Care Teams, and t btain an in-depth wrking knwledge n all aspects f pain management and palliative care including pharmaclgical and nn-pharmaclgical interventins. Educatinal Gals and Objectives: Serve as an authritative resurce n the ptimal use f medicatins used t treat patients in pain and fr palliative care. Establish neself as an expert fr pain and palliative care-related infrmatin and resurces. (Synthesis) Develp a strategy fr earning credibility within the rganizatin t be an authritative resurce n the pharmaceutical care f patients in pain. Identify barriers t the pharmacist fr earning credibility with members f the interdisciplinary team. Identify barriers t the pharmacist fr earning credibility within the rganizatin. Lead the develpment and implementatin f medicatin-related guidelines/prtcls fr pain management and/r palliative care. (Analysis) Identify the need fr a medicatin-related guideline/prtcl. (Synthesis) Develp a medicatin-related guideline/prtcl fr pain management and/r palliative care based n best evidence and analyses f the rganizatin s patient data. 6

7 (Synthesis) Frmulate a strategy t successfully implement a medicatin-related guideline/prtcl fr pain management and palliative care. (Evaluatin) Assess the results f implementing a medicatin-related guideline/prtcl fr pain management and/r palliative care. Explain hw a medicatin-use evaluatin can be utilized t measure the effects f implementing a guideline/prtcl. Explain hw a medicatin-use evaluatin can be utilized t measure adherence t a guideline/prtcl. Explain hw a clinical research prject can be utilized t measure the utcmes f implementing a new guideline/prtcl. Prvide cncise, applicable, cmprehensive, and timely respnses t frmal r infrmal requests fr drug infrmatin pertaining t the care f patients in pain. (Analysis) Discriminate between the requester s statement f need and the actual drug infrmatin need by asking fr apprpriate additinal infrmatin. (Synthesis) Frmulate a systematic, efficient, and thrugh prcedure fr retrieving drug infrmatin. State surces f pain and palliative care-related bimedical literature. Explain the ptential need fr increased reliance n alternate surces (e.g., abstracts frm natinal meeting presentatins, drug cmpany mngraphs, package inserts, expert pinin) when researching pain and palliative care-related medicatin questins. (Analysis) Determine frm all retrieved bimedical literature the apprpriate infrmatin t evaluate. (Evaluatin) Evaluate the usefulness f bimedical literature gathered. (Evaluatin) Determine whether a study's cnclusins are supprted by the study results. (Synthesis) Frmulate respnses t frmal drug infrmatin requests based n analysis f the literature. (Synthesis) Prvide apprpriate respnses t infrmal drug infrmatin questins that require the pharmacist t draw upn his r her knwledge base. (Evaluatin) Assess the effectiveness f drug infrmatin recmmendatins. Explain all factrs that must be assessed t determine the effectiveness f a respnse. 7

8 Develp a cre library apprpriate fr pain management and palliative care pharmacy practice. (Applicatin) Use a knwledge f standard pain management and palliative care related resurces t develp and maintain a cre library f primary, secndary, and tertiary references apprpriate fr pharmacy practice, educatin, and research. Explain hw t access and withdraw infrmatin frm natinal databases Participate in clinical, humanistic and/r ecnmic pain management and/r palliative care utcmes research. (Evaluatin) Cntribute t a prspective clinical, humanistic and/r ecnmic utcmes analysis. Explain the principles and methdlgy f basic utcmes analyses. Explain the purpse f prspective clinical, humanistic r ecnmic utcmes analyses. Explain study designs apprpriate fr prspective clinical, humanistic and ecnmic utcmes analyses. Explain the types f data that must be cllected in prspective clinical, humanistic and ecnmic utcmes analyses. Explain pssible reliable surces f data fr clinical, humanistic and ecnmic utcmes analyses. Explain methds fr analyzing data in prspective clinical, humanistic and ecnmic utcmes analyses. Explain hw results f prspective clinical, humanistic and ecnmic utcmes analyses can be applied t clinical practice decisins. Explain the regulatry prcess when trying t implement a prspective clinical, humanistic, and r/ecnmic utcmes analysis. (Evaluatin) Cntribute t a retrspective clinical, humanistic, and/r ecnmic utcmes analysis. Explain the purpse f retrspective clinical, humanistic r ecnmic utcmes analyses. Explain study designs apprpriate fr retrspective clinical, humanistic and ecnmic utcmes analyses. 8

9 Explain the types f data that must be cllected in retrspective clinical, humanistic and ecnmic utcmes analyses. Explain pssible reliable surces f data fr retrspective clinical, humanistic and ecnmic utcmes analyses. Explain methds fr analyzing data in retrspective clinical, humanistic and ecnmic utcmes analyses. Explain the impact f limitatins f retrspective data n the interpretatin f results. Explain hw results f retrspective clinical, humanistic and ecnmic utcmes analyses can be applied t prcess imprvement r clinical practice decisins. Optimize the utcmes f pain management and palliative care patients by prmting and/r prviding evidence-based medicatin therapy as an integral part f an interdisciplinary team in acute and ambulatry settings. Establish cllabrative prfessinal relatinships with members f interdisciplinary health care teams invlved in the care f pain management and palliative care patients. (Synthesis) Implement a strategy that effectively establishes cperative, cllabrative, and cmmunicative wrking relatinships with members f the interdisciplinary health care team invlved in the care f pain management and palliative care patients. Explain the training and expected areas f expertise f the members f the interdisciplinary pain management/palliative care team with which ne wrks. Fr each f the prfessins with which ne interacts n the interdisciplinary team, explain the prfessin s view f its rle and respnsibilities in cllabratins n patient-centered care. Explain the expectatins f the pharmacist s rle n the pain management/palliative care team frm the viewpint f different prfessins. Explain the prfessinal dynamics f the different services that cntribute t the care f the pain management/palliative care patient. Distinguish the interpersnal dynamics f each member f the pain management/palliative care team. Participate in the selectin f patients. (Evaluatin) Cntribute the pharmacy perspective t the selectin prcess and listing f pain management/palliative care patients. 9

10 Explain factrs t cnsider when determining thse patients wh are candidates fr pain management and/r palliative care as per service criteria. Explain factrs t cnsider when determining if a patient is suitable fr hspice/endf-life care. Explain factrs t cnsider when determining if a patient is a candidate fr medical r surgical interventin. Priritize the pharmaceutical care needs f the pain management/palliative care patient. (Synthesis) Devise a plan fr deciding which patient t fcus n if given limited time and multiple practice respnsibilities. Explain factrs t cnsider when determining pririty fr care amng patients. Explain hw the cmplexity r severity f patients prblems may mandate urgency f care and rerdering f current pririties fr care. Establish cllabrative pharmacist and patient and/r caregiver relatinship. (Synthesis) Frmulate a strategy that effectively establishes a patient-centered relatinship between the pharmacist and the patient and/r caregiver. Explain unique characteristics f patients that may influence the pharmacist-patient relatinship. Explain psychscial scial issues frequently assciated with the patient in pain and/r at the end-f-life. Cllect and analyze patient infrmatin. (Analysis) Cllect and rganize all patient-specific infrmatin needed by the pharmacist t anticipate, prevent, detect, and/r reslve medicatin-related prblems and t make apprpriate evidence-based, patient-centered therapeutic recmmendatins as part f the interdisciplinary team. Explain the types f infrmatin that are typically available n pain and palliative care prir t pharmacist invlvement. Explain the functins f the nervus system and hw they relate t pain transmissin. Identify the types f patient-specific infrmatin, including cmplementary and alternative medicines, the pharmacist requires t anticipate, prevent, detect, and/r reslve medicatin-related prblems and t make apprpriate evidence-based, patient-centered medicatin therapy recmmendatins fr patients. 10

11 Explain hw t interpret the varius diagnstic and labratry tests cmmnly perfrmed n pain management/palliative care patients including the prper interpretatin f urine txiclgy screens. Explain pharmackinetic and pharmacdynamic cncepts and hw these need t be cnsidered in develping dsing regimens fr pain management/palliative care patients. Explain signs and symptms, epidemilgy, risk factrs, pathgenesis, natural histry f disease, pathphysilgy, clinical curse, etilgy, and treatment f diseases r cnditins that are cmmnly seen in the pain and palliative care setting. Explain signs and symptms, epidemilgy, risk factrs, pathgenesis, natural histry f disease, pathphysilgy, clinical curse, etilgy, and treatment f diseases r cnditins that are cmmnly seen in patients with a histry f addictin and substance abuse. Explain the mechanism f actin, pharmackinetics, pharmacdynamics, pharmacgenmics, pharmacecnmics, usual regimen (dse, schedule, frm, rute, and methd f administratin), indicatins, cntraindicatins, interactins, adverse reactins, and therapeutics f piid and nn-piid agents used in pain management and palliative care. Explain the mechanism f actin, pharmackinetics, pharmacdynamics, pharmacgenmics, pharmacecnmics, usual regimen (dse, schedule, frm, rute, and methd f administratin), indicatins, cntraindicatins, interactins, adverse reactins, and therapeutics f medicatins used t prevent and treat diseases cmmnly ccurring in pain management and palliative care patients. Explain the principles and gals f pain and symptm management at the end-f-life. Identify patients in need f a referral r cnsult. (Evaluatin) When presented with a patient with health care needs that cannt be met by the pain management/palliative care interdisciplinary team, cntribute t the team s decisin t make a referral r request a cnsult. Design evidence-based therapeutic regimens fr pain management and palliative care patients. Criteria/Prcedures fr Resident Applicatin and Review: 1. Enrllment in ASHP Resident Matching Prgram r enrllment thrugh the Early Cmmitment 11

12 prcess f a Strattn VA PGY1 Pharmacy Practice Resident in which case items 2-9 will be waived. 2. Submitted thrugh PhORCAS; Cmpletin f VA Frm # c "Applicatin fr Assciated Health Occupatins", three letters f reference frm frmer faculty r emplyers, a letter f intent, and a recent curriculum vitae. 3. On-site interview-ral cmmunicatin skills and applicant site evaluatin 4. Cmpliance with VA Manual M-8, Part II, Chapter 2 [sec2.34a & d]: U.S. citizen 5. Graduate f ACPE apprved cllege f pharmacy with Dctr f Pharmacy degree. 6. Licensed as a registered pharmacist in any state in the United States r Puert Ric. 7. Cmpletin f a PGY1 ASHP Accredited Pharmacy Practice Residency 8. Ranking/Selectin f applicants will be perfrmed by the "Residency Cmmittee", the fllwing criteria will be assessed: a) Review f interview assessments b) Applicant statement f career gals, immediate gals, present skills (including written cmmunicatin), etc. c) Curriculum Vitae d) Level f educatin e) Specific practice experience cnsistent with assessment transcripts f) Areas f knwledge strength/weakness cnsistent with assessment 9. The Residency Applicant Cmmittee will cnsist f the Residency Prgram Directr(s), preceptrs, and the PGY1 Residency Directr. *Interviews are perfrmed using a Cmpetency-based interview tl. A candidate must achieve a scre f 150 (ut f 200 pssible pints) t be ranked. Candidates with a scre 100 will nt be ranked. Candidates receiving a scre f 101 t 149 will be ranked after evaluatin f items abve by cmmittee members and will require agreement by ¾ f the cmmittee fr ranking. 10. Current PGY1General Practice Residents will be cnsidered fr the Early Applicatin Prcess. The plicy fr this prcess is available n the shared Strattn VA cmputer drive and entitled Early Applicatin Prcess fr current Strattn Veterans Administratin Medical Center PGY1 Residents. 12

13 Requirements Fr Successful Cmpletin 1. Satisfactry cmpletin f all required rtatins 2. Cmpletin f all administrative assignments (P&T, MUE) as required 3. Develpment and implementatin f a medicatin-related guideline r prtcl fr pain management and palliative care fr the institutin 4. Design and deliver educatin and training related t pain management and palliative care fr patients and/r caregivers 5. Design and deliver educatin and training related t pain management and palliative care fr pharmacy students and PGY1 Residents 6. Design and deliver educatin and training related t pain management and palliative care fr health care prfessinals and health care prfessinals in training. 7. Actively participate in lcal, VISN and Natinal Pain Cmmittees in the develpment and versight f pain and palliative care related plicies and prcedures. 8. Satisfactry cmpletin f a residency prject. The resident will discuss several chices fr the subject matter f the prject and btain apprval f the resident's final selectin frm the Residency Prject Cmmittee prir t beginning the prject. The resident will be required t prepare a frmal manuscript which cvers in detail all aspects f the resident's prject. The resident must be prepared t present and discuss the findings f the prject with all apprpriate clinically riented clleagues. 9. Prepare a manuscript n a pain management -related tpic suitable fr publicatin. 10. Participate in the design and develpment f a pain-related service t include service lgistics, wrk area and wrkflw design and FTEE allcatins. VI. Residency Prject A) The gals f the residency prject are: 1. T expse the resident t prfessinal prjects in the field f Clinical Pharmacy 2. T gain experience in the varius prcesses invlved in cnducting a research r practice-riented prject, namely, literature evaluatin, frmulatin f study design, data cllectin, and data analysis. 3. T imprve the resident's writing skills thrugh the preparatin and final reprt f the residency prject. 4. T imprve analytical, rganizatinal, and time management skills f the 13

14 resident. 5. T allw residents t present their prject results (r interim reprts) t their peers at natinal, state, r lcal cnferences and pssibly the pprtunity t submit a manuscript fr publicatin. B) Time-Frame Determinatin f the residency prject tpic shuld be decided upn within the first tw mnths f the residency. This shuld allw fr adequate time fr cmpletin f the prject withut interfering with the resident's ther respnsibilities thrughut the prgram. Prject tpics must be apprved by the Prgram Directr(s) prir t initiatin. It is suggested that several tpics be develped by the resident befre deciding n the final selectin. Cmpletin f the prject is a requirement fr successful cmpletin f the residency. A cmpleted prject is ne that results in a final reprt apprved by the Prgram Directr(s). Deadline fr submissin f manuscripts by the residents is tw weeks befre the scheduled cmpletin f the residency. A written prject plan shuld be submitted within 2 mnths f initiatin f residency. The plan shuld be a duble-spaced, type-written dcument utilizing the fllwing frmat: 1. Ratinale f the prject 2. Gals and Objectives f the prject 3. Prject design 4. Resident's rle in the prject 5. Anticipated accmplishment at the end f residency year 6. Ptential cntributin f the prject 7. References C) Types f Prjects Acceptable prjects include but are nt limited t clinical, pharmackinetics, patient surveys, epidemilgical, pharmacecnmics, perfrmance imprvement, quality assurance and drug utilizatin reviews, and administrative tpics. Cnsideratin will be given t any ther relevant type f prject submitted by the resident. 14

15 VII. Residency Rtatins 1. Required rtatins will be perfrmed during the resident's year-lng tenure fr a minimum f the time frames indicated. Electives include rtatins in a minimum f tw f the ptins listed belw. Fr all required rtatins, 4-8 hurs per week thrughut the year will be required. This activity is in additin t ther daily respnsibilities during the balance f weekly hurs. a. Academia (Student Pharmacist, PGY 1 resident preceptrship, frmal classrm teaching is ptin lngitudinal) b. Teaching and Learning Certificate Prgram is available as an elective ptin thrugh the Albany Cllege f Pharmacy & Health Sciences. c. Acute Pain (Inpatient/Pst-p/Emergency Medicine elective) d. Administratin (Cmmittees, P&T, MUE - lngitudinal) e. Behavir Health (Lngitudinal with Clinical psychlgist, verseen by Dr. Canning) f. Behavir Health/Substance Abuse (Substance Abuse Clinic elective 4 weeks) g. Chrnic Nn-Malignant Pain (CNMP Clinic lngitudinal) h. Chrnic Nn-Malignant Pain (Primary Care Clinic/Telehealth lngitudinal) i. Emergency Medicine (elective - 4 weeks) j. End-f-life/Palliative Care (Lngitudinal) k. Infectius Disease (Lngitudinal and HIV/HCV) l. Malignant Pain (elective: Hematlgy/Onclgy Clinic 4 weeks) m. Nephrlgy (lngitudinal) n. Neurlgy (lngitudinal). Rheumatlgy (lngitudinal) *Variatins in the time frames indicated must be apprved by the Residency Prgram Directr and individual preceptrs. 2. Elective rtatins affrd the resident an pprtunity t spend 4 hurs per week fr 4 cnsecutive weeks in their chsen elective area. This activity is in additin t ther daily respnsibilities during the balance f weekly hurs. Further learning experiences may be tailred t the specific needs and interests f the resident. 3. The resident and the Residency Prgram Directr(s) will plan the resident's rtatins during the Credentialing rtatin which ccurs during the 50 days f the residency. VIII. Evaluatins 1. Resident Evaluatin The resident will be evaluated at the midpint and at the end f every rtatin. Cmpetency f the resident will be assessed by the preceptr thrugh persnal bservatin and by verbal and/r written challenge f the resident. Observatins are based n adherence t and cmpletin f the gals and bjectives as established in this Manual and as discussed with the resident n the first day f rientatin. All evaluatins are t be cmpleted n the ASHP ResiTrak system. 15

16 Fllwing each evaluatin the resident and preceptr shall meet t discuss the prgress f the resident. A frmal assessment will be made n r within ne week f each rtatin which will be dcumented and saved thrugh the ResiTrak system. At the end f each rtatin, the preceptr is t cmmunicate the evaluatin f the resident with the Residency Directr, wh in turn will discuss it with the next rtatin s preceptr in rder t prvide cntinuity f gals still pending cmpletin. 2. Resident/Rtatin Self Evaluatin The resident is t evaluate bth the preceptr and his/her perfrmance during the rtatin at the cnclusin f each rtatin thrugh the ResiTrak system. IX. Attitude The resident is expected t demnstrate prfessinal respnsibility, dedicatin, mtivatin, and maturity with regards t all activities and respnsibilities assciated with the residency fr its entirety. The resident shall demnstrate the ability t wrk and interact with all the staff and patients f the Medical Center in a prductive and harmnius manner. Apprpriate attire, persnal hygiene and cnduct are expected at all times. The resident will adhere t all the regulatins gverning the peratins f the Department f Veterans Affairs Medical Center withut exceptin. X. Attendance Prmpt arrival and attendance is required at all clinics, cnferences, meetings, runds and ther scheduled activities during each and every rtatin thrughut the term f the residency. The resident is eligible fr annual and sick leave which is accrued at a rate f 4 hurs per pay perid. Administrative absences t attend seminars r cnferences shuld be arranged with the Residency Crdinatr(s) and the preceptr at the time f seminars r cnferences. Unexcused absences and r tardiness will nt be tlerated and can be a basis fr failure f the rtatin invlved. If the resident is sick r unable t cme in due t an emergency, it is the respnsibility f the resident t cntact by phne (n s r text messages) the Residency Directr(s) AND the pharmacy secretary at least 30 minutes befre scheduled wrk tur (all pertinent phne numbers will be given t the resident). The resident MUST speak t smene and shall NOT leave phne messages. If the resident is ut sick three cnsecutive days, he/she must submit a letter frm a physician r authrized health care prfessinal, including n the letter the date f the visit, a statement indicating the resident was unable t wrk due t illness and the perid fr which he/she was incapacitated. If the resident desires t be absent fr persnal reasns, such as religius hlidays, etc., the resident must fllw VA Prcedure requesting leave at least fur weeks in advance f the planned absence. All such requests must be apprved by the apprpriate preceptr and Residency Directr(s) befre entering it in the cmputer. Then leave may be entered in the cmputer t be reviewed and apprved by the supervisr 16

17 befre the absence will be cnsidered excused. Rescheduling r arranging alternate cverage fr all activities which will ccur during any planned absence, will be left at the preceptr r residency directr(s) discretin. XI. Leave Plicy POLICY: The leave prgram will be administered n a unifrm and equitable basis in accrdance with the Office f Persnnel Management and VA Regulatins. If any prvisin in this plicy cntradicts prvisins in the AFGE Master Agreement, the Master Agreement prevails fr bargaining unit emplyees. A. Annual Leave: Annual leave is earned at a rate f fur (4) hurs fr each full biweekly pay perid. Annual Leave will be cnsidered in the light f current and anticipated wrklads. T the extent pssible, cnsideratin will be given t the individual emplyee s preference. Annual leave can be used fr rest, relaxatin, and recreatin as well as time ff fr persnal business (e.g., licensure examinatins, jb interviews utside f the federal system) and emergency purpses (e.g., aut repair). It may be used nly after it has been earned. Advanced leave is nt permitted. Leave must be requested in advance, preferably 4 weeks, and apprved befre being taken. Annual leave requests during the first tw weeks r the last tw weeks f the residency year are discuraged, but will be cnsidered if extenuating circumstances. Request fr Annual Leave is carried ut by cmpleting the cmputerized SF-71 (applicatin fr leave) after apprval by the Residency Prgram Directr and Residency Preceptr f the learning experience yu are assigned. As a curtesy, it is the resident's respnsibility t directly ntify the Residency Prgram Directr and Residency Preceptr f his/her learning experience prir t taking apprved leave and ntifying the clinical crdinatr f any clinics that may need t be clsed during the time ff. All leave requests will be acted n in light f the residents ability t cmplete the prgram s required rtatinal experiences as well as the verall cmpletin f the residency requirements. Residents will be paid, upn separatin frm the VA, fr any annual leave that they have nt used. B. Sick Leave/Family Leave: Sick Leave will be granted t emplyees when they are incapacitated fr the perfrmance f duty because f illness, disease, injury, r pregnancy and cnfinement; and fr necessary medical, dental, r ptical examinatin r treatment. Emplyees currently emplyed fr a cntinuus perid f mre than 90 days accrue fur (4) hurs f sick leave each full biweekly pay perid. Sick leave is earned frm the first pay perid f emplyment. The resident must call in sick fr each cnsecutive day f illness. If yu require sick leave fr mre than 3 cnsecutive wrk days, yu must furnish medical certificatin by a health care prfessinal attesting t the need fr sick leave during the perid f absence. Sickness requiring leave time greater than 1 week during any learning experience will need t be made up and may require extensin f residency training as determined by the Prgram Directr and Preceptr. Family leave may be used t care fr an ill family member. Family member is defined as: (1) Spuse and parents f a spuse, (2) Children, including adpted children, and (3) Parents r as therwise described in Plicy/MCM (Leave Plicy). Time taken as family leave will be deducted frm the sick leave time accrued. Family leave requiring leave time greater than 1 week during any learning experience will 17

18 need t be made up and may require extensin f residency training as determined by the Prgram Directr and Preceptr. Upn returning t wrk, a cmputerized SF-71 must be cmpleted fr apprval by the immediate supervisr. If yur request fr sick leave exceeds the amunt f earned sick leave hurs, annual leave will autmatically be used. C. Leave Withut Pay: The granting f Leave Withut Pay (LWOP) is a matter f emplyee chice and administrative discretin except that emplyees wh are disabled veterans are entitled t LWOP when necessary fr treatment f their service-cnnected disability. Circumstances which wuld nrmally justify apprval f sick r annual leave will generally be sufficient basis fr apprving LWOP. Hwever, requests fr LWOP will be acted upn in light f essential services and verall needs f the Medical Center and with due regard t the welfare and needs f the individual emplyee. The emplyee's past leave usage may als be cnsidered. D. Authrized Absence: Emplyees may be authrized t be absent frm duty withut charge t leave when the service is cnsidered t be f substantial benefit t the VA in accmplishing its general missin r ne f its specific functins r when the service will clearly enhance an emplyee s ability t perfrm the duties f the psitins he/she presently ccupies. Emplyees may be excused frm duty withut lss f pay r charge t leave in a number f situatins. These include but are nt limited t the fllwing: attendance at meetings, attendance at training and vting. E. Maternity Leave: Requests fr maternity purpses may be fr sick leave, annual leave, leave withut pay, r a cmbinatin f these types f leave. Each case will be handled individually by the residency directr and chief f pharmacy in view f the circumstances surrunding the case, such as the emplyee s physical cnditin, type f wrk perfrmed, dctr s recmmendatins, etc. An emplyee shuld make knwn her intent t request leave fr maternity reasns including the type f leave, apprximate dates, and anticipated duratin, t allw the supervisr t prepare fr any staffing adjustments which may be necessary. If there is any questin as t physical ability relating t perfrmance f wrk, the emplyee may be required t furnish a medical certificate. Time away frm the residency fr maternity leave will need t be made up and will require extensin f residency training as determined by the Prgram Directr and immediate supervisr. F. Extended Leave: Extended leave requests frm the residency will be reviewed by the Residency Prgram Directr, the Chief f Pharmacy Services and a Human Resurces representative, if necessary. The decisin t grant an extended leave request will be made by the Chief f Pharmacy. If an extended leave request is granted prir t March 1 st, the resident wuld be granted an extensin* at the end f the residency year equivalent t the extended leave perid, but nt exceeding 12 weeks, t cmplete the prgram s requirements. If it is estimated befre March 1 st that the prgram s requirements wuld nt be able t be cmpleted during the extensin f the residency, the resident wuld have the ptin f reapplying t the residency prgram and ging thrugh the Natinal Match fr the next residency year. If the extended leave is granted after March 1 st, the resident wuld have t cmplete the prgram s requirements during an extensin* f the residency year as described abve. 18

19 * An extensin is cntingent upn apprval by VACO PBM and OAA. F. Other Types f Leave: Other types f leave (e.g. Military, Curt, etc.) will be granted in accrdance with applicable rules and regulatins and as per West Palm Beach VAMC Medical Center Memrandum NUMBER: : Leave Plicy. G. Duty Hur Plicy: This residency cmplies with the current duty hur standards as utlined in the Accreditatin Cuncil fr Graduate Medical Educatin (ACGME). A cpy is available nline at (last accessed 1/1/2015). In summary, per guideline VI.G.1, Duty hurs must be limited t 80 hurs per week, averaged ver a fur-week perid, inclusive f all in-huse call activities and all mnlighting. Mnlighting will be allwed, hwever the resident must infrm RPD in advance f this scheduled activity. Any hurs wrked utside f the Strattn VA r affiliated clinics must be summarized and prvided via t the RPD each Friday. If the Resident wrk exceeds 60 hurs n site at the Strattn VA r affiliated clinics fr any reasn in any week, the Resident agrees t track these hurs and infrm the RPD immediately by smartphne text r . XII. Grievance Prcedure Any prblem that may arise during the residency shuld first be dealt with by the apprpriate preceptr. If the attempts t reslve the prblem are unsuccessful, it shuld be brught t the attentin f the Residency Crdinatr. If fr sme reasn it is unable t be reslved at that level, the Chief, Pharmacy Service will have the authrity t make the final decisin. XIII. Terminatin Plicy A resident may be terminated at the discretin f the Chief, Pharmacy Service fr the failure t meet prgram bjectives as utlined in this text r fr failure t meet the terms f emplyment f the Strattn VA Hspital. As a VA PGY2 resident, it is expected that yu already pssess a valid license t practice pharmacy frm any State f the United States r the Cmmnwealth f Puert Ric. If this is nt the case, yu are expected t btain a license t practice pharmacy within the first 3 mnths f starting the residency prgram. Failure t d s will result in dismissal frm the prgram. XIV. Drug Distributin and Cntrl Systems 1. Outpatient Pharmacy Services: Strattn VAMC Pharmacy prvides cmprehensive dispensing services: drugs (prescriptin and selected nn-prescriptin items), nutritinal prducts (enteral and ral nutritinal supplements), and medical supplies (stmy, trachestmy, urinary catheters, glucse mnitring, surgical supplies and wund care supplies). Sterile and nn-sterile cmpunding with apprpriate quality cntrl is als prvided. The VA's Decentralized Hspital Cmputer Prgram (DHCP) is utilized fr standardized 19

20 label generatin and drug/nutritin/supply prfile maintenance fr all patients. The DHCP prvides an n-screen in-prcess warning n all restrictins/criteria-fr-use, drug class duplicatin, drug-drug and drug-fd interactins, and a critical labratry parameter link fr selected medicatins. Pharmacist-managed clinics ffer a variety f pharmaceutical care services frm patient medicatin cunseling, drug initiatin, disease management, labratry fllw-up t drug infrmatin fr healthcare prviders. Clinical pharmacists have clinical privileges t extend refills fr utpatients n maintenance medicatins thereby aviding unnecessary emergency rm visits. Clinical Pharmacy Specialists prvide a wide array f pharmaceutical services within the scpe f their practice including, but nt limited t, anticagulatin, gastrintestinal, hypertensin, hyperlipidemia, diabetes, psychiatry, infectius disease, nephrlgy, pain management, and nclgy. 2. Inpatient Pharmacy Services Acute and Intermediate care is prvided fr apprximately 150 beds. The Inpatient pharmacy is pen 24 hurs a day with clinical pharmacy cverage daily frm 7am t 4:30pm weekly. All rders are generated thru CPRS and verified by a pharmacist. Discharge rders are prcessed by a pharmacist in utpatient pharmacy and patients are cunseled by a healthcare prvider (RPh, nurse, prvider) befre being discharged. We als have a Psychiatric inpatient ward with 16 authrized beds. Our Hspice has an average daily census f apprximately 4-8 patients. Prvider cmputer rder entry (OE/RR) f medicatins with pharmacist verificatin is utilized thrughut the institutin. Unit dse drug distributin, utilizing an autmated dispensing machine, is prvided t all nursing units. A centralized Intravenus Admixture Service is prvided t all inpatients and utpatients receiving IV medicatins, chemtherapy, and parenteral nutritin. A cmputerized medicatin prfile (utilizing the DHCP) is maintained fr every patient. All acute care flrs and the nursing hme utilize Bar Cde Medicatin Administratin (BCMA) fr the administratin and dcumentatin f medicatins. The inpatient pharmacy dispenses all ral medicatins in a unit dse if available and all IV medicatins cntain barcdes t be prperly administered via BCMA. The frmulary is available n the DHCP cmputer system and the Natinal frmulary is available n the Internet. The use f flrstck medicatins is minimal. Cntrlled substances are stcked in Pyxis machines n each f the nursing units. Accreditatin Standards ASHP accreditatin standards have been develped fr Pstgraduate Year Tw (PGY2) Pharmacy Residency Prgrams that establish "criteria fr systematic training f pharmacists in advanced areas f pharmacy practice. Its cntents delineate the requirements fr PGY2 residencies, which build upn the fundatin prvided thrugh cmpletin f an accredited Dctr f Pharmacy degree prgram and an accredited pstgraduate year ne (PGY1) residency prgram." (Ref: ASHP ACCREDITATION STANDARD FOR POSTGRADUATE YEAR TWO (PGY2) PHARMACY RESIDENCY PROGRAMS. Apprved by the ASHP Cmmissin n Credentialing n 3/4/2012, Apprved by the ASHP Bard f Directrs n 4/13/12). ASHP Overview f the Principles f PGY2 Pharmacy Residencies" include the fllwing principals: 20

21 1. The resident will be a pharmacist having sufficiently brad knwledge, skills, attitudes, and abilities in pharmacy practice necessary fr further prfessinal develpment at an advanced level f pharmacy practice. 2. The pharmacy residency prgram will prvide an exemplary envirnment cnducive t resident learning. 3. The resident will be cmmitted t attaining the prgram s educatinal gals and bjectives and will supprt the rganizatin s missin and values. 4. The resident s training will be designed, cnducted, and evaluated using a systems-based apprach. 5. The residency prgram directr (RPD) and preceptrs will be prfessinally and educatinally qualified pharmacists wh are cmmitted t prviding effective training f residents. 6. The rganizatin cnducting the residency will meet accreditatin standards, regulatry requirements, and ther natinally applicable standards and will have sufficient resurces t achieve the purpses f the residency prgram. 7. The pharmacy and pharmacy services related t the advanced area f practice will be rganized effectively and will deliver cmprehensive, safe, and effective services. Purpse and Desired Outcmes fr Strattn VA PGY2 Pharmacy Pain Residency Upn cmpletin f the Residency, successful candidates will develp knwledge f: 1. Cmmunicatin techniques (e.g., clse-ended reflective listening, pen ended questins, active listening) 2. Interviewing techniques (including mtivatinal interviewing) 3. Pain and symptm assessment tls 4. Physical assessment techniques (e.g., trigger-pint exams, jint exams, simple neurlgical exams) 5. Substance abuse and misuse risk assessment tls 6. Functinality assessment tls 7. Psychscial assessment techniques and tls (e.g., pst-traumatic stress disrder screening, depressin screening, Beck anxiety inventry [BAI]) 8. Elements f a fcused treatment and medical histry pertaining t pain and palliative care 9. Pathphysilgy f pain and symptms 10. Disease trajectry in end f life care 21

22 11. Apprpriateness f labratry and diagnstic evaluatins and applicability t pain and palliative care patients 12. Risk mitigatin techniques (e.g. medicatin/treatment agreements, infrmed cnsent, drug testing/screening, Risk Evaluatin and Mitigatin Strategies [REMS]) 13. Medicatin related prblems specific t pain, palliative, and end f life care 14. Therapeutic gals specific t pain, palliative, and end f life care (e.g., acute, chrnic nn-malignant, malignant) 15. Cmplementary and alternative therapies used fr pain and/r symptm management 16. Dsage initiatin, titratin, and discntinuatin f pain and palliative care medicatin 17. Equianalgesic cnversins fr piids 18. Cmmercially-available and cmpunded pharmaceutical preparatins fr pain and/r symptm management 19. Rutes f administratin and medicatin delivery techniques fr pain, palliative, and end f life care 20. Specialty needs requiring referral t ther prviders 21. Apprpriate/available resurces fr specialty referral 22. Unique pain and palliative care treatment needs fr special ppulatins (pediatric, geriatric, cgnitively impaired) 23. Rle f interventinal pain management techniques 24. Alteratins f pharmacdynamics and pharmackinetics in pain, palliative and end f life care 25. Applicatin f evidence-based pain and palliative care literature and clinical practice guidelines in designing a patient-specific plan f care 26. Patient-related variables (e.g., pathgenesis and severity f pain and symptms, rgan functin, cmrbidities, ability t swallw, health beliefs, financial resurces) 27. Opiid tlerance, physical and psychlgical dependence, and addictin 28. Opiid induced neurtxicity and hyperalgesia 29. End f life management f chrnic r life-limiting diseases 30. Benefits and burdens f medicatin therapy at the end f life 31. Cmmn pain and palliative care emergencies 32. Ethical cnsideratins regarding life sustaining interventins 22

23 33. Impact f initiatin r discntinuatin f life sustaining interventins/therapies (e.g., dialysis, ventilatrs, feeding tubes) n medicatin management 34. Benefits and risks f artificial hydratin and nutritin at end f life 35. The dying prcess Practice Develpment and Administratin knwledge f: 1. Criteria fr hspice admissin 2. Factrs affecting medicatin prvisin based n admitting hspice diagnsis 3. Outcmes measurement t evaluate clinical pharmacy services in pain and palliative care 4. Prcess f develping a frmalized plan fr a pain and/r palliative care clinical pharmacy service 5. Cllabrative practice mdels 6. Quality assurance and prcess imprvement techniques 7. Interdisciplinary cmmunicatin techniques (e.g., Situatin-Backgrund-Assessment- Recmmendatin, Subjective, Objective, Assessment, and Plan ntes) 8. Pain and palliative care interdisciplinary team rles and dynamics 9. Published guidelines and prtcls fr managing pain and palliative care patients (e.g., APS, TJC, NCCN) 10. Practice-setting specific implicatins fr plicy/prtcl develpment 11. Plicy, prcedure, and prtcl develpment prcesses in pain and palliative care 12. Regulatry requirements fr pain and palliative care 13. Principles f frmulary management 14. Medicatin regimen review and recnciliatin prcess 15. Mnitring criteria fr piid abuse r misuse 16. Elements f dcumentatin fr piid mnitring (ADL s, analgesia, adverse effects, and aberrant behavir) 17. Healthcare system prcesses fr transitining patients Educatin and Infrmatin Management 23

24 knwledge f: 1. Patient infrmatin resurces 2. Cultural cnsideratins in educating patients/caregivers 3. Analgesic risks, myths and miscnceptins 4. Benefits f grief and bereavement cunseling 5. Tlerance, addictin, and dependence 6. Abuse, misuse, diversin and aberrant behavir 7. Resurces fr develpment f pain and palliative care educatin and 8. Principles and methds f educating health care students, residents and prfessinals 9. Primary, secndary, and tertiary surces fr pain and palliative care infrmatin 10. Cntinuing prfessinal develpment pprtunities in pain and palliative care (e.g. prfessinal rganizatin membership, surces fr cntinuing educatin, mentrship) 11. Research design, methdlgy and statistical analysis 12. Clinical applicatin and limitatins f published data and reprts 13. Regulatry/Institutinal Review Bard/human subjects safety requirements and cncerns fr cnducting research with pain and palliative care ppulatin 14. Medical literature publicatin and review prcess 15. Opprtunities fr disseminating pain and palliative care knwledge and schlarly activity (e.g., presentatins, manuscripts, newsletters, abstracts, psters) Public Health and Advcacy knwledge f: 1. Lcal, state and natinal pain, hspice, and palliative care rganizatins and initiatives 2. Impact f regulatry and legislative prcesses and rules and regulatins n pain and palliative care practice 3. Balance between ensuring access t cntrlled substances and minimizing diversin and abuse 4. Prescriptin drug mnitring prgrams 5. Treatment disparities in and barriers t pain and palliative care 24

25 6. Epidemilgy f pain and advanced illness 7. Stakehlders (e.g., insurance cmpanies, health care systems, DEA and lcal law enfrcement) and their rle in pain and palliative care practice 8. Advanced directives and living wills 9. Ethical and physical implicatins f withdrawing r withhlding life-prlnging therapies. 10. Principles f medical ethics (e.g., dctrine f duble effect, physician-assisted death, euthanasia, Death with Dignity Act) 11. Patient bill f rights fr pain and palliative care 12. Evidence demnstrating value f pst dctral pain and palliative care training and the pain and palliative care pharmacy specialist (e.g., cst reductin, quality therapeutic utcmes) 3) G a l s a n d O b j e c t i v e s (R) Outcme R1: Demnstrate leadership and practice management skills in pain management and palliative care. Gal R1.1: Exhibit the nging develpment f essential persnal skills f a practice leader. Obj R1.1.1 (Characterizatin) Practice self-managed cntinuing prfessinal develpment with the gal f imprving the quality f ne's wn perfrmance thrugh self-assessment and persnal change. Obj R1.1.2 (Characterizatin) Demnstrate cmmitment t the prfessinal practice f pain management and palliative care pharmacy thrugh active participatin in the activities f lcal, state, and/r natinal pain management and palliative care and pharmacy prfessinal rganizatins. Obj R1.1.3 (Synthesis) Devise an effective plan fr balancing prfessinal and persnal life. Obj R1.1.4 (Characterizatin) Display integrity in prfessinal relatinships and actins. Obj R1.1.5 (Applicatin) Adhere t the requirements f the rganizatin's plicy in all interactins with the pharmaceutical industry. Obj R1.1.6 (Synthesis) Initiate and maintain a systematic apprach t dcumenting prfessinal activities and accmplishments. Obj R1.1.7 (Evaluatin) Appraise each jb respnsibility fr its relative imprtance t all jb respnsibilities and priritize apprpriately. Obj R1.1.8 (Organizatin) Demnstrate sensitivity t the perspective f the patient, caregiver, r health care clleague in all cmmunicatins. Obj R1.1.9 (Organizatin) Demnstrate the persnal characteristics required f specialists in pain management and palliative care pharmacy, including cmpassin, sensitivity, and tlerance. Gal R1.2: Establish neself as an expert fr medicatin-related infrmatin and resurces within an rganizatin. 25

26 Obj R1.2.1 (Synthesis) Implement a successful strategy fr earning credibility within the rganizatin t be an authritative expert n the medicatin-related care f patients. IO: Identify barriers t the pharmacist fr earning credibility with members f the interdisciplinary team. IO: Identify barriers t the pharmacist fr earning credibility within the rganizatin. Gal R1.3: Cntribute the pharmacy specialist s perspective t an rganizatin s technlgy and autmatin systems decisins. Obj R1.3.1 (Synthesis) When apprpriate, participate in the rganizatin's design f its technlgy and autmatin systems used in patient care. Obj R1.3.2 (Synthesis) When apprpriate, participate in the rganizatin's implementatin f its technlgy and autmatin systems. Obj R1.3.3 (Synthesis) When apprpriate, participate in the rganizatin's quality imprvement f its technlgy and autmatin systems. Gal R1.4: Cntribute t the leadership and management activities within the practice area. Obj R1.4.1 (Applicatin) Use effective negtiatin skills t reslve cnflicts. Obj R1.4.2 (Synthesis) Use grup participatin skills when leading r wrking as a member f a frmal r infrmal wrk grup. Obj R1.4.3 (Cmprehensin) Explain the cmpnents f a prpsal fr a new pharmacy service that wuld meet a perceived need f the rganizatin and its patients. Gal R1.5: Exercise practice leadership. Obj R1.5.1 (Characterizatin) Demnstrate a cmmitment t advcacy fr the ptimal care f patients thrugh the assertive and persuasive presentatin f patient care issues t members f the health care team, the patient, and/r the patient's representative(s). Obj R1.5.2 (Characterizatin) Display initiative in preventing, identifying, and reslving pharmacy-related patient care prblems. Obj R1.5.3 (Cmprehensin) Explain the nature f mentring in pharmacy, its ptential cnnectin with achievement, and the imprtance f being willing t serve as a mentr t apprpriate individuals. Obj R1.5.4 (Cmprehensin) Explain the general prcesses f establishing and maintaining a PGY2 pharmacy residency prgram. (R) Outcme R2: Optimize the utcmes f pain management and palliative care patients thrugh the expert prvisin f evidence-based patient-centered medicatin therapy as an integral part f an interdisciplinary team. Gal R2.1: Develp cllabrative prfessinal relatinships with members f the health care team. Obj R2.1.1 (Synthesis) Implement a strategy that effectively develps cperative, cllabrative, and cmmunicative wrking relatinships with members f the interdisciplinary health care team. 26