Volume 04, Number 3, 2013

Persistent link for this collectionhttps://hdl.handle.net/11299/170648

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Student Scientific Inquiry in the Core Doctor of Pharmacy Curriculum: Critical Issues in Designing and Implementing a Student Research Program
(University of Minnesota, College of Pharmacy, 2013) Vaidean, Georgeta D.; Vansai, Sandeep S.; Moore, Ronnie J.; Feldman, Stuart
While student-driven research has been credited with many learning benefits, few schools of pharmacy require such activities. Professional organizations repeatedly urge for incorporating research content in schools’ curricula, yet no guiding principles or recommendations currently exist to guide such implementation efforts. This paper provides an overview of the critical issues, guiding principles, benefits and challenges encountered in designing and implementing a required, research program in the Pharm.D. curriculum. Several critical issues are reviewed: goals, unitary focus and expectations, structure and deliverables, time and curricular integration, monitoring and institutional oversight, outcomes measurement, resources, students and faculty response, and dissemination. These general critical issues are then discussed as implemented in the student research program at Touro College of Pharmacy-New York. Different schools can address these core issues, based on their academic milieu. This paper invites an inter-institutional dialogue for the pursuit of successful incorporation of student scientific inquiry in the core curriculum.
Student Self-Ratings of Skill Acquisition from a Clinical Controversy Debate in a Third Year Pharmaceutical Care Lab
(University of Minnesota, College of Pharmacy, 2013) McNamara, Anusha; Janke, Kristin; Conway, Jeannine; Schweiss, Sarah
Objectives: To evaluate student perspectives of a clinical controversy debate activity designed to improve their skills to effectively approach and communicate complex therapeutic dilemmas. Design: A clinical controversy debate activity was implemented in the fall semester of the third year pharmaceutical care laboratory curriculum. Topics were chosen based on controversies encountered in practice. Students were assigned to groups of 5-6 and subdivided to the pro or con of the topic. Each debate lasted 25 minutes. Students completed a self-assessment asking them to rate eight skills (e.g. selecting appropriate references, analysis of literature, defending and predicting arguments, composing and delivering the presentation, and persuading the audience) before and after the debate as: novice, developing, skilled, facilitating/leading, or educating. Results were analyzed descriptively and the pre-post ratings were compared using a Wilcoxon Signed Rank Test. Results: 140 (84.8%) students responded to the self-assessment survey. The skill that students rated most highly prior to the debate was selecting appropriate resources and primary literature, with only 7.1% rating themselves as novice. After completing the debate, the skill rated with the greatest improvement was predicting opposing arguments with 47.1% rating as developing and 40% rating as skilled. All eight skills had statistically significant improvements pre- and post- assignment (p < 0.001). Implications: Preparing arguments for and against treatment options is an important clinical skill, used regularly by pharmacists. A clinical controversy debate activity resulted in reports of improvement on eight measures of evidence based medicine-related skills.
Leadership: Three Key Employee-Centered Elements with Case Studies – Editor’s Commentary
(University of Minnesota, College of Pharmacy, 2013)
Design and Implementation of Acute Emergency Decision Making Tools to Aid Case Managers: A Focus Group Study
(University of Minnesota, College of Pharmacy, 2013) Bradshaw, Marquita D.; Washington, Nicole B.; Munoz, Ricky; Brahm, Nancy C.
Objectives: To evaluate and determine if use of specific reference cards for diabetes, stroke, and heat stroke [1] heightened understanding of the signs and symptoms of these conditions and [2] helped case managers (CMs) on the community-based integrated multidisciplinary program of assertive community treatment (IMPACT) team better evaluate patients. Background: Healthcare professionals who service those with a severe mental illness (SMI) diagnosis face many unique challenges. One particular challenge is medical assessment of patients with a SMI diagnosis. Often CMs do not have a background or work experience differentiating medical concerns from psychiatric signs and symptoms. Methods: Reference cards were developed at the request of the IMPACT team. Feedback was elicited through a one-time focus group session conducted by an independent party on the use of the reference cards as an educational tool. Anonymity was maintained. The responses were evaluated for themes. The moderator asked questions regarding the reference cards in each of the following areas: usability when answering questions about hypo- and hyperglycemia, stroke and heat stroke, understanding key points, recommendations for enhancement, and presentation of information. Results: Of the 8 CMs on the IMPACT team, 5 participated. Identified themes were quick reference and easily identifiable information. The use of pictures to illustrate the concepts was helpful. The language was appropriate for the cards and readily understandable. Suggestions for changes to the existing cards included use of a larger font, lighter background color, and moving medication information to the same side of the card. The limited availability of the heat stroke card in the summer was an identified limitation. Conclusions: The use of reference cards as an educational tool for CMs has not been extensively reviewed. Although data are limited from this pilot project, the CMs are enthusiastic about this resource and requested cards on additional topics.
A Description of Medication Decision-Making, Dispensing, and Utilization for Hypertensive Patients in Nishtar Hospital Multan, Pakistan
(University of Minnesota, College of Pharmacy, 2013) Saeed, Hafiz Muhammad Khawar; Nasar, Naveera; Batool, Sonia; Ghauri, Rabia; Rauf, Aquula
Hypertension is a worldwide health problem affecting developed and developing countries, and Pakistan is no exception. Nishtar Hospital Multan is categorized as one of the biggest hospitals in South Asia. The objective for this study was to describe medication decision-making, dispensing, and utilization for patients diagnosed with hypertension at this patient care facility. The study was conducted by 5 trained pharmacists working in collaboration with prescribers who met with study participants when they visited the hospital. All interview questions were asked in Urdu during the hospital visit. Data were summarized using descriptive statistics. A total of 301 patients who visited the hospital agreed to participate in the study. The findings showed that prescribers spend little time with patients and rarely follow guidelines for decision-making. Regarding the dispensing of medications for the treatment of hypertension, none of the dispensing was completed by a pharmacist and none of the patients received counseling about medications at the time of dispensing. Most patients reportedly do not take their medication as prescribed. Regarding outcomes, 20% of the patients had pre-hypertension, 47% stage 1 hypertension, and 33% stage 2 hypertension. Great improvements are possible in the treatment of hypertension at the hospital we studied through application of standard treatment guidelines, patient education, and adjustments to work system processes so that alignment of provider’s skills with opportunities in improving the patient care process can be achieved.
The Healthcare Future for the iGeneration: Integrating the Patient and the Healthcare System
(University of Minnesota, College of Pharmacy, 2013) Wood, Kristina D.; Greene, Elisa M.; Franks, Rachel B.; Poole, Traci M.; Ficzere, Cathy H.; Johnston, Philip E.
Objective: To propose a vision to integrate patients, their health-related data, and their wellness plans into the healthcare system using smartphone and tablet computer technology. Setting: Ambulatory care and community practice Practice Innovation: Utilization of smartphone and tablet computer technology to assess health care conditions, educate and involve patients, and facilitate seamless communication between the patient, electronic health record, pharmacy system, third-party payers, point-of-care testing, and all health-care providers. Main Outcome Measures: By providing integrated and customized information at the point of use, medication adherence and access to care will be increased and patients will engage in healthy behaviors more often resulting in an improved level of care for patients. Results: In the future, the authors believe if the vision is achieved, the health care system and patients will see improved health outcomes and more efficient utilization of the healthcare system. Conclusions: Our proposed use of technology provides an opportunity to empower patients to positively improve their own health which could be a vital advancement in health care, especially in the areas of medication adherence, improving access to care, and health behavior support. As pharmacists, we may also embrace technology opportunities to expand our roles as health care professionals as we continue to partner with patients and the health care team to improve outcomes.
Individualized Dosing of Children’s Liquid Medications in the Community Pharmacy Setting: A Survey of Parents and Guardians
(University of Minnesota, College of Pharmacy, 2013) Shelly, Jamie; Hiller, Debbie; Zhai, Lingxiao; Ferreri, Stefanie; Marciniak, Macary Weck
Objectives: 1) To determine parents’ and/or guardians’ interest in having pharmacists provide children’s liquid medications in a pre-measured, individualized dosing device 2) To assess parents’ and/or guardians’ perception of dosing liquid medications for a child. Design: Observational survey Setting: Regional chain pharmacy in North Carolina Participants: > 18 years old, parent/guardian of a child <13 who had prescription filled for liquid medication within the pharmacy chain, responsible for administering child’s liquid medication Intervention: 14 item questionnaire Main Outcome Measure: Interest in pharmacists providing children’s liquid medications in pre-measured, individualized dosing devices Results: 250 questionnaires were mailed; 42 were marked “return to sender” (16.8%), 22 were returned completed (10.6%), and 20 of the 22 met inclusion criteria (9.6%). 95% of study participants reported being interested in having pharmacists provide children’s liquid medications in the proposed dosing device, and 40% were willing to pay for such a service. 90% of respondents reported it is “not at all difficult” to understand the amount of dose a child is to receive, while 55% reported it is “not at all difficult” to measure doses. 25% of respondents reported sometimes using a kitchen spoon to measure a child’s medication. Conclusion: Community pharmacists should explore providing children’s liquid medications in an individualized dosing device, as study results determined parents are interested in and willing to pay for the theoretical device. Further large-scale studies would be beneficial in determining interest in and willingness to pay for the dosing device in various pharmacy settings nationwide.
The impact of a community pharmacist conducted comprehensive medication review (CMR) on 30-day re-admission rates and increased patient satisfaction scores: A pilot study
(University of Minnesota, College of Pharmacy, 2013) Snodgrass, Brittany; Babcock, Charles K.; Teichman, Anne
Objective: To determine the impact of pharmacist conducted Comprehensive Medication Review (CMR) follow-up within seven days after discharge on (1) readmission rates, (2) detection of drug related problems, (3) and changes in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Design: Rates of re-admission for pneumonia, congestive heart failure (CHF), or myocardial infarction (MI), within 30 days of discharge are compared between patients receiving a CMR from the pharmacist to a historical control group not receiving the service. The CMR documentation is reviewed to classify any detected drug related problems. Overall HCAHPS scores for the hospital are compared for the three months prior to instituting this service and the three months during the service. Setting: Patients were discharged from a 101-bed acute care hospital located in rural West Virginia. The community pharmacist worked with the hospital to contact patients after discharge to demonstrate a partnership between inpatient and outpatient care. Patients: Patients were included if they had a discharge diagnosis of pneumonia, congestive heart failure (CHF), or myocardial infarction (MI), and were returning to self-care or family-care. If discharged between 10/12/2012 and 12/11/2012 they were included in the historical control group. If discharged between 12/12/2012 and 2/12/2012 they were offered the CMR service and included in the intervention group. Intervention: Patients received a telephone call two to seven days following discharge from a pharmacist who conducted the Comprehensive Medication Review (CMR). Results: Patients who participated in a CMR via the telephone had decreased 30-day readmission rates compared to the historical control group (16% v 33%). Overall 22 significant drug therapy problems were identified among patients. HCAHPS scores for the questions “Did you receive communication regarding your medications” increased during the study time period (65% vs 72%). Conclusion: The mixed results of available data from previous studies on pharmacist inclusion in the discharge process focuses heavily on counseling before the patient is discharged. Results of this study show community pharmacist partnership in discharge follow-up can also assist in decreasing readmissions, detecting drug related problems, and increasing patient satisfaction.
http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3, Article 121 INNOVATIONS in pharmacy 1 Design and Implementation of an Interdisciplinary Elective Course in Drug Discovery, Development, and Commercialization
(University of Minnesota, College of Pharmacy, 2013) Ettouati, William S.; Hirsch, Jan D.; Ma, Joseph D.
Objective: To describe the design and implementation of an elective course in drug discovery, development, and commercialization for pharmacy, medical, biomedical graduate, business, and law students. Case Study: This course included didactic lectures, student group discussions, a longitudinal assignment, and a question and answer panel session. A 9-item instrument using a 5-point response scale was used for course evaluation. The longitudinal assignment was the creation and presentation of a product lifecycle strategic plan (PLSP). Respondents rated ‘agree’ and ‘strongly agree’ in the course providing useful information on drug discovery (39% and 53%), drug development (39% and 60%), and drug commercialization (33% and 60%). The majority of student-reported overall understanding of the drug discovery and drug development process was rated ‘very good’ (49% and 46%), while the drug commercialization process was rated ‘good’ (46%). Conclusions: An elective course on drug discovery, development, and commercialization included enrollment of students with diverse educational training. The course provided useful information and improved overall student understanding.
Development and implementation of a community pharmacy medication therapy management-based transition of care program in the managed Medicaid population
(University of Minnesota, College of Pharmacy, 2013) Kelling, Sarah E.; Bright, David R.; Ulbrich, Timothy R.; Sullivan, Donald L.; Gartner, James; Cornelius, Douglas C.
Objective: To describe successes and barriers with the development and implementation of a community pharmacy medication therapy management-based transition of care program in the managed Medicaid population. Setting: A single supermarket chain pharmacy Practice description: Community pharmacists provide dispensing and non-dispensing pharmacy services including medication therapy management, biometric wellness screenings, and immunizations. Practice innovation: Developed and implemented a community pharmacy medication therapy management-based transition of care program for patients with managed Medicaid Main outcome measures: Feasibility of developing and implementing a transition of care service in a community pharmacy Results: During the first six months, a total of 17 patients were seen as part of the program. Study pharmacists identified successes and potential strategies for overcoming barriers. Conclusion: Developing and implementing a community pharmacy transition of care program for patients with managed Medicaid was logistically feasible.
Acceptance Rates for Pharmacist-Initiated Interventions in Long-Term Care Facilities
(University of Minnesota, College of Pharmacy, 2013) Carson, Gina L.; Crosby, Kimberly; Huxall, Garrett R.; Brahm, Nancy C.
Objectives: Describe individualized medication interventions, categorize intervention types, and report acceptance rates by prescribers following a pilot medication intervention program in which a pharmacist rounded with the patient care team in long-term care facilities in addition to their traditional medication regimen review (MRR) process. Design: Prospective Chart review Setting: Two primary long-term care (LTC) facilities Participants: Fifty randomly selected patient charts. Inclusion criteria were adult patients (18 years old or older) residing in one of the LTC facilities receiving consultant pharmacist services. Patient charts not meeting inclusion criteria were excluded from the review. Interventions: Recommendations made according to the needs of each patient and categorically reported. Main Outcome Measures: Intervention acceptance rates by prescribers and aggregate reporting for type of medication interventions. Results: For 50 patient charts (68% female, 32% male) 66 interventions were reported. The average patient age was 81.5 years. Approximately 45% of the interventions pertained to drug utilization concerns, and 21% involved pain management. Additional categories included treatment of eye and skin conditions and pharmacotherapy for mental health. A ‘nonpharmacotherapy’ designation was given to individual interventions not fitting into a larger category. New medications and regimen changes were the most common medication therapy outcomes (42% and 32%, respectively). Overall 92% of all pharmacist interventions were either fully or partially accepted by the prescriber where partial acceptance was defined as implementation of the recommendation with an adjustment. Interventions related to drug utilization or pain management each approached a 93% acceptance rate. Conclusions: The consultant pharmacist provided personalized recommendations following extensive chart review and patient assessment. Our chart review suggests that high prescriber acceptance rates along with medication therapy optimization may produce similar benefits in other LTC facilities.
Leadership: Three Key Employee-Centered Elements With Case Studies
(University of Minnesota, College of Pharmacy, 2013) Summerfield, Marc
Social Media and Unprofessional Pharmacist Conduct: A Cross-Sectional Survey of Boards of Pharmacy
(University of Minnesota, College of Pharmacy, 2014) Skelley, Jessica; Hughes, Peter; Elmore, Lindsey
Purpose: To determine how often boards of pharmacy (BOPs) receive complaints related to licensee’s online behavior, and what types online behaviors may prompt an investigation of a licensee. Methods: A survey (consisting of questions related to BOP’s management of complaints against licensee online behavior and 10 case vignettes) was adapted from a previous survey of United States medical boards. Vignettes encompassed themes such as patient confidentiality, derogatory language, alcohol use, false or misleading product claims, and others. Following institutional review board approval, survey materials were distributed via email by the National Association of Boards of Pharmacy to 63 domestic and international boards of pharmacy. Completed surveys were analyzed using descriptive statistics. The proportion of respondents who indicated that the vignette would “very likely” or “likely” result in an investigation was used to determine consensus. Proportions of >75%, 50%-75% and <50% were classified as high, moderate and low consensus, respectively. Results: Fourteen completed surveys (22.2%) were received. Sixty percent of respondents stated that their board has been involved in managing a complaint regarding the online behavior of a licensee, and that disciplinary actions including revocation or suspension of license, letter of reprimand, and monetary fines have been enacted. While 79% of responding BOPs have a policy regarding Internet usage, 36% are unsure whether the policies are sufficient to cover online professionalism. One vignette, where a pharmacist made misleading claims regarding a compounded product, achieved high consensus for likelihood to prompt an investigation. Moderate consensus was achieved for a breach of patient confidentiality, inappropriate alcohol use, and misrepresentation of professional credentials. Conclusion: Boards of pharmacy are widely varied in what types of online behaviors may prompt an investigation. Additional dialogue is needed among pharmacy leaders to determine best practices.
Accessibility to Essential Medicines in New York City by Zip Code Income Levels and Boroughs
(University of Minnesota, College of Pharmacy, 2014) Aronson, Yan; Addo-Atuah, Joyce
Access to essential medicines is fundamental to medication adherence, continuity of care and hence population health outcomes and overall quality of life. Disparities in the availability and the cost of these medications in New York City, especially for low income neighborhoods, would compound the underlying health disparities in these neighborhoods. This study examined the physical and financial accessibility to 8 of the 150 Most Frequently Prescribed Drugs in New York, 2 each for Asthma, Diabetes, Hypertension, and Hyperlipidemia, 4 conditions that are among the top 10 most costly conditions in the United States. The study did not find any significant differences in mean drug prices between the high, medium, and low income neighborhoods in the City. However, the significantly different income levels and uninsured rates across neighborhood income strata in the City (p<0.001 for both), coupled with the high disease burden and other underlying disparities in low income neighborhoods, would point to potential affordability challenges for needed medications in these neighborhoods. On the other hand, significant differences in mean prices between the 5 City boroughs were found for 3 of the study drugs: Advair® , p=0.009; Amlodipine 10mg, p<0.001; and Lisinopril 10mg, p=0.046. No such significant differences were observed for the mean prices of the other 5 study drugs-Proventil HFA,® Metformin HCL 500mg, Glipizide ER 5mg, Simvastatin 20mg, and Atorvastatin 10mg. The study findings did not also suggest that drug prices are dictated by the number of pharmacies in a neighborhood. Further studies would be needed to better understand the complexities associated with the accessibility of essential medicines in New York City. These studies could include qualitative ones which would examine the perceptions and experiences of City residents with respect to the accessibility of prescribed medications as the basis for targeted interventions directed at promoting access to needed medications for all New Yorkers.
An Elective Course in Women’s Health Issues
(University of Minnesota, College of Pharmacy, 2014) DiPietro, Natalie A.
Purpose: To develop, implement, and evaluate an elective course for the Doctor of Pharmacy (PharmD) curriculum that provides students with a comprehensive overview of women’s health across the lifespan and exposes them to social and economic issues that impact women’s health. Case Study: At the time of this writing, the class has been delivered 3 times to a total of 56 students. Students read and discussed (both in-class and online) timely articles in women’s health issues on topics including sex-based biology; women in clinical trials; maternal and child health; women’s health coverage and access to care in the United States; gender and health communication; abuse and the role of healthcare professionals; and international issues in women’s health and women’s rights. Students completed a pre- and post-test; developed seminar presentations regarding women’s health issues; wrote reflective essays about the course; and designed and implemented health promotion projects for National Women’s Health Week (NWHW). At the end of the course, the number of correct answers on the post-test significantly improved from the pre-test (p<0.001). Through anonymous course evaluations, students indicated that the assignments fulfilled the learning objectives (mean 4.68 on a 5-point Likert scale) and the exercises were useful in helping their understanding of the material (mean 4.66 on a 5-point Likert scale). Over 500 women from the campus and community participated in the NWHW projects. Implications: An elective course was designed to educate pharmacy students regarding women’s health issues and to provide students with an opportunity to perform community outreach.
Project ImPACT: Hypertension Outcomes of a Pharmacist-Provided Hypertension Service
(University of Minnesota, College of Pharmacy, 2014) Nemerovski, Carrie Wentz; Young, Maria; Mariani, Nicholas; Bugdalski-Stutrud, Carol; Moser, Lynette R.
Objective: To evaluate the impact of pharmacists, working collaboratively with patients, on blood pressure control, lifestyle goal setting, adherence to antihypertensive therapy, patient knowledge and satisfaction, and modification of cardiovascular risk factors. Methods: Self-declared hypertensive patients met with the pharmacist for blood pressure monitoring, lifestyle goal setting, and education about medications and disease state on four occasions over a 6–month period. Practice innovation: A community pharmacy partnered with an employer wellness plan to provide education and monitoring for patients with hypertension based on home blood pressure readings obtained using monitors that wirelessly transmit information to the pharmacist. Main outcome measure(s): Percentage of patients at blood pressure goal, mean blood pressure, percentage of patients with lifestyle goals, medication adherence, patient knowledge and satisfaction, and modification of cardiovascular risk factors. Results: Patients not at their goal blood pressure at baseline had a significant decrease in blood pressure and a significant increase in achievement of their blood pressure goals. Across the population, no significant changes were seen in the primary outcome, lifestyle goals, medication adherence or modification of cardiovascular risk factors. Patient knowledge increased from baseline and satisfaction with the service was high. Conclusion: Blood pressure control improved in patients not at their treatment goal. All patients increased their knowledge about hypertension and reported high satisfaction with the pharmacy service. Pharmacy services should be offered to patients who are more likely to reap a benefit. Home blood pressure readings are useful to inform clinical decision making and supplement patient consultation within the pharmacy setting.
Impact of Antibiotic Shortage on H. Pylori Treatment: A Step-Wise Approach for Pharmacist Management
(University of Minnesota, College of Pharmacy, 2014) Lamb, Michelle M.; Wu, Weiwei; Lloyd, Ann
The current drug shortage crisis involving multiple oral antibiotics has significantly impacted preferred therapeutic options for treatment of H.pylori infection. Pharmacists may help alleviate the impact of this shortage through a proposed step-wise approach which includes proper inventory management, verification of indication, evaluation of regimen, therapeutic monitoring, and communication with patients and providers regarding alternative therapy or symptomatic relief.
The Healthcare Future for the iGeneration: Integrating the Patient and the Healthcare System
(University of Minnesota, College of Pharmacy, 2014) Simard, Tim
Developing a Respiratory Depression Scorecard for Capnography Monitoring
(University of Minnesota, College of Pharmacy, 2014) Felhofer, Katie
Pulse oximetry is the most common way to measure a patient’s respiratory status in the hospital setting; however, capnography monitoring is a more accurate and sensitive technique which can more comprehensively measure respiratory function. Due to the limited number of capnography monitoring equipment at the University of Minnesota Medical Center-Fairview (UMMC-Fairview), we analyzed which patients should preferentially be chosen for capnography monitoring over pulse oximetry based on risk of respiratory depression. We conducted a retrospective chart review of all serious opioid-induced over-sedation events that occurred at UMMCFairview between January 1, 2008 and June 30, 2012. Thirteen risk factors were identified which predispose patients to respiratory depression. The average patient demonstrated 3.75 risk factors. The most commonly occurring risk factor was the concomitant use of multiple opioids or an opioid and a CNS-active sedative, followed by an ASA score ≥ 3. Based on this data, we developed a scorecard for choosing patients at the most risk of developing respiratory depression; these patients are the best candidates for capnography. Although further studies are necessary to corroborate this research, at this time giving extra consideration to patients demonstrating the previously stated risk factors is prudent when assessing those patients most in need of capnography.
Cultivation and Implementation of Community-Engaged Pharmacy Services in a Free Clinic to Enhance Care for the Medically Underserved
(University of Minnesota, College of Pharmacy, 2014) Tran, Emmeline; Jennings, Brandon T.
Partnerships between community free clinics and academic medical centers improve patient outcomes and enhance learning opportunities for students. A community-academic partnership between the Maliheh Free Clinic and the University of Utah College of Pharmacy was formed to fulfill a community need for pharmacy services, to promote interdisciplinary patient care, and to provide an experiential opportunity for students. The Maliheh Free Clinic based in Salt Lake City, Utah provides free primary health care to uninsured individuals who live 150% below federal poverty guidelines. Three pharmacy services were developed and implemented. These include: 1) clinic chart reviews which involve written recommendations following a comprehensive assessment of the patient’s chart examining his or her disease states and the appropriateness of his or her medications; 2) medication reconciliations and discussion of pharmacy-related recommendations with patients during Diabetes Day, an inclusive interdisciplinary patient appointment that addresses important aspects of diabetes care; and 3) an insulin dose adjustment service through a collaborative practice agreement with the clinic to monitor a patient’s blood glucose levels and adjust his or her medications accordingly on a weekly basis.

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