An Eye-Opening Experience

The program’s goal, explained Gladys Antello, a program manager at Camden, is to engage students from health professions early in their careers so they understand the complexities facing these patients and the best way to work with them. “We’ve learned that it takes an interprofessional team to engage with this population,” she noted. “The student hotspotting teams reflect that. We have students who are studying to be pharmacists, and they are working with nursing, medical and social work students as well as others.”

The six-month-long program begins in September, with each team representing a minimum of three professions. Students follow a curriculum that has them engaging with three to five patients in their communities and working with preceptors and experts in the field as they see patients in healthcare settings. About a year or so ago, in the program’s fifth year, Camden decided to request proposals for institutions that wanted to serve as hubs, which would be responsible for recruiting interprofessional teams within their communities and partnering with nearby institutions to ensure professional diversity among the teams. “We found that there was a high cost for students to travel for these events,” Antello said. “We also wanted to build the field across the nation.” From numerous applications, the hubs selected were Thomas Jefferson University, in Philadelphia; Southern Illinois University, Springfield; Samuel Merritt University, in Oakland, CA; and the University of Utah, Salt Lake City.

According to Antello, Camden is exploring how the experience informs students’ perceptions: “Has it changed the way they work with patients with complex needs? Has it changed their thinking? Did it change their specialty?” The student hotspotting experience offers a framework for collaborating with other professions and gives students a greater appreciation for working on interprofessional teams. “The value of the student hotspotting program is that they are getting this orientation to patient-centered care,” said Vince Leone, Camden’s program manager of instructional design. “The onus isn’t just on the social worker or the nurse, it’s on every profession, including pharmacists.”

Reality Check

Samuel Merritt University’s first experience with Camden’s student hotspotting program in 2016 convinced the leadership to apply to become a hub. Last year about 75–80 students participated, three quarters of which were SMU students and the other quarter representing partner institutions. SMU, the only one of the four hubs that does not have a school of pharmacy, partners with other institutions on interprofessional education and relies on those partners to provide a pharmacy perspective. “This coming year we’re being much more selective when choosing students,” noted Dr. Michael Negrete, assistant vice president, academic affairs, who manages the program and holds a Pharm.D. “We’re probably going to end up with a total of 40 students on five teams. Each hub has its own internal teams and also supports external teams based out of other institutions. Last year we had two external teams from UCLA and this year we’ll have a team from the University of Washington.” Negrete’s work in the provost’s office on interprofessional education activities aligned with Camden’s hotspotting program and its priorities around health and wellness.

Each team has about six students as well as faculty advisers and practice advisers, who could be ER physicians, nurse case managers, social workers or other professionals who help identify prospective patients. “Students usually go into the hospital in pairs to talk to patients and tell them about the program and create expectations about what it is and what it is not,” Negrete explained. “The patient educates the students about what their needs are, including what their living conditions are and what social support structure they have. The students decide if that patient meets the criteria, and if the patient agrees to participate, they move forward. The experience can include home visits, or students may accompany patients to doctor visits or social service agencies. The program isn’t designed for students to intervene in the patient’s clinical care. Instead they help patients identify their underlying unmet needs and help them navigate the local resources that can meet those needs. The student’s role in this program is more along the lines of a community health worker.”

As Camden’s Vince Leone explained, the curriculum is made up of experiential events as well as asynchronous elements. “If students are working with a client in the community, they can access a short video on best practices. They can access a checklist with elements to consider if they are doing a home visit for the first time,” he said. “They have monthly case conferencing calls with the preceptors. There is a skills lab that solidifies the theoretical learning and experiential learning they’re doing in the field. It all culminates in a capstone presentation with the students thinking about how to continue this work.”

Feedback from SMU students has been positive, aside from some frustration in the first year with the program’s operational side and difficulty accessing resources. “These are patients with significant challenges,” Negrete admitted. “For some teams, their patients passed away. The fact that students got to see the world through their eyes and develop compassion and empathy, it really transformed their views on everything. They really get an appreciation for these social challenges and how they drive health.” He said it prompted students to ask questions such as: Does the patient have a way to get to the doctor? Do patients have a refrigerator to store the healthy foods they should be eating? Is their neighborhood a safe place to get exercise?

Negrete said the student hotspotting experience provides a good reality check regarding what advice pharmacists can offer patients. If you have a patient who smokes, he suggested, but that person is homeless and unsure where he or she will sleep that night, smoking may be a coping mechanism. Focusing on getting that patient to quit smoking might not be the best starting point. “[Hotspotting teaches students to] meet the patients where they are and figure out what they are motivated and able to do,” he said. “It’s giving them a much better sense of the gritty reality.” Working on an interprofessional team gives students who aren’t in the same program the opportunity to learn to function effectively to achieve a common goal, he added. “You’re dealing with people from multiple professions. You have to acknowledge the barriers and deal with them. Most health systems aren’t readily set up to operate these programs. Students have to navigate bureaucratic challenges. That’s the reality. It’s teaching the students the importance of grit and perseverance.”

Building Relationships With Providers and Patients

For some of the hubs, hotspotting activities are woven into the curriculum. At the Jefferson College of Pharmacy at Thomas Jefferson University, P3 students who apply to participate can get independent study credits, while hotspotting is a co-curricular activity for P4 students who apply and are accepted. Dr. Amber King, associate professor, said the university is right across the river from Camden, is in close proximity to underserved populations and has a center for interprofessional education, which made it an ideal candidate to become a hub. “This is a great win-win in that it helps students, patients and potentially the health system if we find that these interventions are actually saving money and preventing people from going to the emergency room so often,” she said.

This year, two additional faculty from the college of pharmacy who work in ambulatory care clinics will be joining teams as advisers. “A physician approached each of them in their clinics and asked if they would help precept a team,” King explained. “It’s great to see providers asking for a pharmacist on the team.” She said the opportunity for students to work on these teams is unique because it has the potential to have a real impact on individual patients and the health system.

“We talk so much about the social determinants of health and how they impact someone’s ability to care for their health, but that’s really not something you can learn in the classroom,” she continued. “Working with these individuals who have so many barriers to healthcare and other things going on making it hard for them to care about their health is really eye-opening for students. Someone might not care about having hypertension at that moment because he or she is worried about where to sleep that night or how to pay the rent. It really opens students’ eyes and gives them insight and empathy. We need to respect our patients and their experiences and understand how at some points in time, those other things are more urgent than health.”

King said this interprofessional education experience helps student pharmacists see the value that they provide to the healthcare team early on in their education and careers. “It helps them advocate for the profession, and see the benefits they can provide to patients and the unique things they can bring to the table,” she said. “When you know that as a student, that just makes you a better clinician and gives you a more solid foundation to build upon.”

At the Southern Illinois University hub site, student hotspotting is an elective experience for P3 and P4 students. Somewhere between 60-80 students participate on hotspotting teams each year, with about four to eight of those being student pharmacists, according to Dr. Janice Frueh, clinical associate professor at the Southern Illinois University Edwardsville School of Pharmacy. Frueh has been collaborating with SIU’s School of Medicine since 2009, working with underserved patient populations in the area. Her colleagues at the SIU School of Medicine became aware of the hotspotting program through that work and suggested putting teams together. The program allows student pharmacists to build on their skills around patient-centered care.

“Camden’s curriculum provides the students with background evidence and tools related to working with medically and socially complex patients,” she noted. “Student pharmacists learn some new concepts they are not getting from the required curriculum. Motivational interviewing is in our curriculum but trauma-informed care is not. The student pharmacist works with the patient and also coaches the other team members to be able to help with setting up access to financial resources that would be more sustainable for the patient. All students on the team support patients in accessing all of their benefits and accompanying them to primary care doctor visits. Students help work with the primary care provider in terms of establishing patient-specific goals, and then provide additional support to the patient between visits to help the patient achieve those goals, which might mean getting lab results completed or accessing transportation services.”

Frueh added that the student hotspotting program was also appealing because it meets the school’s interprofessional education objectives. “Within our curriculum, we’ve really focused those IPE experiences on the four core competencies from IPEC,” she said. “It’s not just about doing something together, it’s about really building students who can practice together. Student hotspotting fits all four of those competencies that IPEC has put out.”

Camden compiled data to share this fall regarding student satisfaction with the program and how it’s helped prepare participants for healthcare careers. In terms of patient clinical outcomes, the program has been an obvious success for the Springfield area. Frueh said that in the past two years, the hotspotting program has saved the two local hospital systems about $2 million.

Frueh received feedback from student pharmacists indicating that this experience has been the most challenging aspect of their training but has also helped them feel more connected to other healthcare professionals and made them more resilient. “In order for healthcare to transform, to be more sustainable financially and also to be seen as more of a partner by patients, we will need to find solutions together,” she pointed out. “The way student hotspotting is designed, it touches on all the things that are going to be important in healthcare transformation. Many community pharmacy practices are in a silo of healthcare delivery. Student hotspotting allows student pharmacists to experience how to build relationships with colleagues, how to work together and how to face challenges they will face in practice. If they’re able to do that together now, with the toughest patient population they have experienced, even if they end up in a practice that looks like a silo, it will better prepare student pharmacists for how healthcare delivery can be simply redesigned or how to work collaboratively with others in their communities.”

A New Approach to Care

The University of Utah College of Pharmacy is making student hotspotting a curricular component after offering it as an extracurricular activity last year. About 10–15 P3 students signed up for the elective course this year. Dr. Kyle Turner, clinical assistant professor, was faculty adviser during a pilot phase of Camden’s program and then applied to have the university become a hub. Turner appreciates the interprofessional aspect of the student hotspotting program and that it represents value-added education. “It’s giving back to the healthcare system. We are making an impact at the same time that our students are learning,” he pointed out. “It’s a shift toward value-based healthcare. The way we practice is really in a value-based manner where we’re looking at saving costs and improving outcomes.”

Turner also thinks it’s important that all of the students bring their professional lens to the experience and run the patient’s experience through their own professional filter. “When they come back together as a team, they can connect patients to the right services,” he said. “They get the benefits of a broad array of connections and skill sets. One of the goals of this program is to establish authentic relationships. Many of these patients [in underserved communities] have had very negative experiences with the healthcare system. Now they are developing deep relationships with healthcare providers that will regain their trust in healthcare again. That’s one of the biggest benefits for everyone involved.”

As other hub leaders mentioned, the program provides insight into what a patient’s life really looks like. “Some of these principles—trauma-informed care, the social determinants of health and the role we play in that—are nearly nonexistent in pharmacy education,” Turner noted. “I hope the students recognize some of the things that drive poor health outcomes and they see some of the manifestations of these things. I hope they remember that we need to take a different approach and focus in on what the patient really needs.” He thinks the student hotspotting experience opens students’ eyes to a new way of providing care for the future. “They have a really meaningful experience with other professions and a better understanding of where they fit in the care continuum. It’s a real team experience and figuring out that dynamic and how you navigate that.”

The ultimate goal, he continued, is to change practice. “As we educate students in this way, they will come into their professional spheres with a different perspective that we hope will begin to drive changes in the way we practice,” he said. “How can we work together with actual practitioners and be a bridge for students? We’re educating and preparing students for a different kind of healthcare system. We’re influencing the student but also influencing the system as well.”

Jane E. Rooney is managing editor of Academic Pharmacy Now.