DESIGN: A formal affiliation between a managed care organization (MCO) and a school of pharmacy. The collaborative activities are extensive and include student and residency training, didactic instruction, research, and patient care.

CONCLUSIONS: Colleges of pharmacy must develop innovative alliances with practice environments outside the traditional institution. Collaboration with managed care settings is critical to the development of student skills. Colleges of pharmacy and MCOs need to develop collaborative arrangements to jointly fulfill their missions. If appropriately constructed and managed, these affiliations can benefit both organizations.

KEYWORDS: Managed care, Residency, Student education, School of pharmacy

J Managed Care Pharm 1999:425-428

The Academy of Managed Care Pharmacy (AMCP) has worked to design coursework that can be incorporated into curricula at individual colleges of pharmacy. AMCP also has developed the diplomat program, in which liaison relationships between AMCP members and colleges of pharmacy have been established. The American Association of Colleges of Pharmacy and AMCP have appointed a joint task force to design training programs and workshops to educate faculty about managed care principles.

Despite these efforts, incorporation of managed care principles into didactic curricula or experiential programs has been limited. Some colleges of pharmacy offer rotations in managed care settings. Often the number of these experiences is limited, and many students do not have the opportunity to participate. In addition, rotations in managed care have great diversity between sites. Some are administrative or deal with population-based strategies to alter prescribing behavior; others are similar to traditional community externships, primary care, drug information, or medical specialty clerkships, but with a cost/quality/satisfaction focus.

AFFILIATION AGREEMENTS

University of Colorado Health Sciences Center policies prevent the School from paying preceptors or health systems for student clerkships. Therefore, innovative alternatives had to be considered to offset the time Kaiser personnel spend teaching students. In 1996, the School needed additional managed care clinical rotations in light of the expansion of its Pharm.D. program. Therefore, under another formal agreement, the School provided funds designed for residency training within the Kaiser Pharmacy Department, which has in turn received administrative approval to fund a residency. This mechanism has successfully served the School and Kaiser as a method to offset Kaiser's costs for providing clerkship education.

Finally, in 1996 an agreement to jointly and equally fund a faculty position was completed. This full-time faculty member spent approximately 75% of his or her time in one of the large hub Kaiser medical office facilities where primary care pharmacy services are provided.

SELECTED SCHOOL OF PHARMACY PROGRAMS

At the time of this writing, the Department of Pharmacy Practice employed 21 full-time faculty. This includes nonpractice faculty in pharmacoeconomics, pharmacoepidemiology, and pharmacy administration. Full-time faculty members are paid 100% through the School, even though they may receive partial funding from another source such as University Hospital, where most of the School's full-time clinical faculty practice. The School and the University Hospital operate a pharmacy practice residency and specialized residencies in critical care, nutrition support, drug information, oncology, neurology, and primary care.

The Department of Pharmacy Practice also has approximately 50 adjoint faculty (nonpaid) who are appointed within the department. These faculty are clinical pharmacy specialists in Denver-area hospitals, clinics, or health systems. They either provide direct patient care or are pharmacy administrators. Most adjoint faculty members have completed specialized residencies or fellowships or have equivalent experience and many are board certified in a specialty such as pharmacotherapy, nutrition support, oncology, or psychiatry. To maintain adjoint faculty status, individuals must provide a consistent level of didactic, clerkship, and other services to the School. These adjoint faculty are distinct from the preceptors who provide externship training for traditional hospital or community pharmacy (outpatient pharmacy) rotations.

Prior to 1995, the School had limited numbers of faculty who practiced in ambulatory or primary care settings. A strategic objective to expand in this area is underway. Several ambulatory care clinical faculty have been hired to practice in University Hospital-affiliated clinics. Because Kaiser had established extensive clinical pharmacy services in primary care clinics, the affiliation between the two programs helped the School meet its goal of increasing primary care experiences.

As a result of the formal agreement 19 Kaiser clinical specialists and administrators are appointed within the School. This includes one adjoint professor, one adjoint associate professor, and 17 adjoint assistant professors. The adjoint professor and the adjoint associate professor were appointed because they held professor and associate professor titles, respectively, at academic institutions prior to joining Kaiser. New policies established by the School in 1997 allow Kaiser faculty to be promoted through the ranks from adjoint assistant professor to adjoint associate professor and eventually to adjoint professor.

SELECTED KAISER PERMANENTE PROGRAMS

For five years, Kaiser has increased the number of ambulatory care clinical pharmacy specialists who practice in the primary care clinics. All these specialists have Pharm.D. degrees with specialty residencies or fellowships in ambulatory care. Most are board-certified pharmacotherapy specialists who practice in primary care clinics and provide direct patient care. In addition, these specialists provide academic detailing, target drug programs focusing on quality and cost issues, and provide drug information services to the providers in their clinics.

Kaiser clinical pharmacy specialists are responsible for a centralized clinical pharmacist-managed anticoagulation service for Kaiser members in the Denver-Boulder area (approximately 4,000 patients). Pharmacists also manage a cardiac risk clinic for high-risk patients throughout the region. Kaiser clinical pharmacy services operates an international travel clinic for members in three Kaiser regions (about 900,000 KP members). This service, which is open to the general public, provides immunization recommendations and preventive drug therapy for foreign travel. Specialty clinical pharmacy services are provided in infectious diseases, oncology, and drug information. The latter service is enhanced through sharing with the much larger California division of Kaiser, via a cofunded drug information specialist based there, as well as having a full-time clinical pharmacy specialist in Denver.

Kaiser also operates a centralized Call Center staffed by more than 100 registered nurses (RNs) and appointment clerks who provide advice to patients and make medical office appointments. A team of clinical pharmacists has been immensely successful in the Kaiser Call Center answering drug-related questions from the RNs and members.

In addition to the residency covered by the formal memorandum of understanding, Kaiser provides funding (excluding benefits) for a jointly administered primary care specialty residency. This resident equally splits time between the School and Kaiser. This joint residency was first funded by Kaiser in 1994 as a demonstration of support for the new Pharm.D. program and to enhance pharmacy practice in the community. The clinic coverage provided by the resident is an overall benefit to the school because the resident can extend primary care clinical activity provided by the faculty. Kaiser also operates another primary care specialty residency and one managed care administrative residency. The Kaiser residents conduct nearly all of their rotations within the Kaiser integrated system.

SERVICES PROVIDED BY KAISER TO THE SCHOOL

Classroom Teaching
Since 1997, Kaiser clinical pharmacy specialists have provided approximately 100 hours of didactic instruction in courses such as therapeutics (both B.S. and Pharm.D.), nonprescription drugs (B.S.), and clinical services leadership (Pharm.D.). These pharmacists also served as facilitators for problem-based learning and clinical skills sessions. The Clinical Services Leadership course is coordinated by a Kaiser clinical administrator. Administrators from Kaiser and other health care institutions shared in teaching this course.

Experiential Training
Kaiser participates in the School's externship program and the Pharm.D. clerkship program. During the 1996-1997 academic year, Kaiser's pharmacists precepted 36 B.S. and 11 Pharm.D. students for a total of 53 six-week rotations. During the 1997- 1998 academic year, 11 Pharm.D. students were precepted on five different rotations for 17 six-week rotations.

The B.S. pharmacy students were each assigned to a Kaiser clinic pharmacy location with a pharmacist preceptor to complete a general community/ambulatory rotation. Each week of the rotation included specific assignments that focused on the issues of pharmacy and managed care, including discussions on disease state management (diabetes and asthma) and drug interaction cases; evaluating journal articles; counseling patients; and advising and dosage selection for patients receiving nonprescription drugs. Students also were scheduled to visit specialty practice areas within Kaiser such as home care, ambulatory care, oncology clinic, travel clinic, and the emergency care unit.

The Pharm.D. students were assigned to a clinical pharmacy specialist in a specific practice site who was also an adjoint faculty member at the School. These rotations included ambulatory care, general medicine, surgery, managed care administration, mental health, infectious disease, drug information, and emergency medicine. As the programs of Kaiser evolve, future clerkships may be offered in home care, prevention, research, and disease management.

All clerkship and externship experiences are coordinated at Kaiser by an internal Externship Committee, also monitors and provides feedback to preceptors on their performance.

Other Services

The School has included adjoint faculty from the community in strategic planning efforts. In particular, the Department of Pharmacy Practice involved Kaiser faculty when developing its current strategic plan.

SERVICES AND PROGRAMS PROVIDED BY THE SCHOOL TO KAISER

The School recently added another academic title, that of clinical instructor, for preceptors who teach students on traditional community pharmacy and outpatient pharmacy rotations. This rank may include Kaiser pharmacists in the outpatient pharmacies. In order to maintain this title, this faculty will need to routinely precept students, obtain 15 hours per year of continuing education (CE is not mandatory in Colorado), and attend an School program to improve teaching methods at least once every two years.

Residency Stipends and Support
The joint primary care specialty residency discussed above is funded by Kaiser. However, benefits are paid by the School. In addition, the School and University Hospital recently received accreditation by the American Society of Health System Pharmacists (ASHP) for all of the residencies operated by the hospital and the School. One of these specialty residencies is in primary care. As part of the accreditation process, the School included the joint Kaiser/School primary care residency. The School paid all of the accreditation fees and costs associated with the ASHP site team visit.

Education and Training
Adjoint faculty receive reduced registration fees at School-sponsored CE programs. Many adjoint faculty from Kaiser have been paid speakers at the major CE programs provided by the School. A major event for the School is the winter CE program. At each of the past three winter programs, Kaiser faculty have presented lectures and conducted workshops in their areas of expertise in primary care. Kaiser faculty are very involved in the "didactic" portion of the nontraditional Pharm.D. program offered over the Internet.

The School currently has a program in pharmaceutical economics and outcomes and plans to develop official Center of Excellence status in the near future. This program provides training and education in pharmacoeconomic principles, formulary management, development of guidelines for formulary submission, management of prescription databases, and related topics. The first training program was a Certificate Program in Pharmaceutical Economics offered to pharmacy practitioners in the community in March and April 1998. Five Kaiser pharmacists completed this 7.5-day certificate program. Kaiser pharmacists also will be invited to participate in future programs. When the program in pharmaceutical economics and outcomes becomes an official Center, Kaiser faculty will be invited to join.

Research
Several collaborative research projects have been conducted by Kaiser faculty and School faculty. Some of these have evolved from required residency projects; one such example was published in the medical literature.⁵ Kaiser faculty also have utilized faculty with pharmacoeconomics expertise from the School as collaborators.

To stimulate collaborative research, the Department of Pharmacy Practice initiated a seed-grant program to promote research collaboration between adjoint faculty and full-time School faculty. This $5,000 competitive award requires that the principal investigator be an adjoint faculty member and that a full-time School faculty member serve as a coinvestigator. Kaiser faculty have successfully competed for this award.

BENEFITS TO THE SCHOOL AND KAISER

The affiliation provides additional residencies that increase the opportunities for the school's graduates. While not a direct benefit to the school, Kaiser also hires numerous pharmacy student interns who provide a unique perspective to their classmates who practice in other environments.

Finally, the inclusion of this large core of highly skilled practitioners and administrators enriches the overall program by providing high-quality input into committees, faculty meetings, and strategic planning efforts.

One of the major benefits to Kaiser is the academic affiliation provided to its pharmacy staff. All the clinical pharmacy specialists are highly trained and qualified to serve as clinical faculty members in colleges of pharmacy. Their activities for the School serve to enrich their professional careers.

The increased residency training provided by the affiliation has benefited Kaiser in several ways. First, it has provided additional staffing for important clinical pharmacy service activities. Second, the residencies have served as a source of potential employees who are familiar with the Kaiser system.

The loss of experiential training sites witnessed by many colleges of pharmacy suggests that sites that provide clerkships view students as a cost or liability.^6,7 However, studies have found that when Pharm.D. students are given responsibility for making patient-specific recommendations, 90% of their recommendations are accepted by physicians,^8-10 and that more than 90% of these recommendations were considered somewhat significant. Sauer and colleagues¹¹ determined that Pharm.D. students were responsible for 43% of initial patient work-ups, 34% of the patient information and education episodes, and 25% of the inservice programs to physicians. Abel¹² recently described Pharm.D. student activities that were documented to save his institution $7,000 per student rotation. The clerkship program was documented to be worth four full-time equivalents.

Academic health centers, and colleges of pharmacy in particular, will need to develop innovative alliances with practice environments to maintain their relevance. Most importantly, colleges of pharmacy and MCOs will need to develop collaborative arrangements to jointly fulfill their missions. If appropriately constructed and managed, these affiliations can offer major benefits to both organizations.

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