Layered Learning Models

By Jazmin Turner, PGY2 Geriatric Pharmacy Resident, University of Maryland School of Pharmacy

Overview

As pharmacy practice has shifted from a traditional dispensing role to a more clinical role, existing models of care have not always adapted to facilitate and accommodate these changes. A layered learning model (LLM) is comprised of a team of pharmacists and pharmacy learners; it is led by an attending pharmacist and incorporates PGY1 and PGY2 residents and pharmacy students. Members of the team are responsible for precepting learners on the level below them. The attending pharmacist is responsible for all levels of pharmacotherapeutic care and resident/student education. LLMs allow for an expansion of clinical pharmacy services through the use of pharmacist extenders.¹ Various studies have shown that LLMs decrease medication costs, improve medication education for patients, and facilitate the resolution of medication-related problems.^{1, 2, 3} Additionally, by incorporating residents and students, institutions are able to provide enhanced patient care at a lower cost.² This model also allows pharmacy residents to practice and improve upon their teaching skills.

Parallels can be drawn with medical residents who participate in teaching and precepting medical students. In a qualitative study, medical residents stated that teaching students helped them become better clinicians by causing them to think critically, evaluate their knowledge, and keep abreast of current literature.⁴ As there are many parallels between post graduate pharmacy and medical education, it may be reasonable to extrapolate these findings to pharmacy residents and state that through layered learning models, pharmacy residents can enhance their clinical skills. However, additional studies on LLM need to be conducted in order to validate this hypothesis.

Implementation Considerations and Barriers

The limited literature available that details the implementation of LLMs has focused primarily on inpatient clinical pharmacy services. There is currently a wide variance at different institutions in terms of overall clinical pharmacy services. According to a 2013 national ASHP survey, less than 45% of hospitals with fewer than 200 beds had pharmacists that regularly attended rounds versus 100% of hospitals with greater than 600 beds. Despite these numbers, over 70% of hospitals have fewer than 200 beds. Therefore, there are large disparities when it comes to clinical pharmacy services and this shows that there are a multitude of opportunities for expansion, especially with the use of LLMs.²

In order to establish a LLM, there needs to be collaboration and shared leadership between the institution and the school of pharmacy in order to define student goals and outcomes as well as a shared teaching philosophy. There has to be a systematic approach so that the clinician is adequately prepared for this model and so that the learners are properly trained to provide high quality patient care. Adequate resources, such as office space and access to the electronic medical record, for example, are also a key component to implementation so that patient care activities can be executed and documented efficiently. Finally, it is important to continually evaluate the program and obtain feedback from various groups in order to facilitate improvement.^{1, 3}

Time is a large barrier to providing patient care using a LLM.¹ This is especially true in an ambulatory care setting where, for example, a student may take a patient history and conduct a patient assessment, present their findings to the resident, and then both the student and resident present the findings and the plan to the attending pharmacist. Patients often do not want to spend the additional time at the clinic in order for these various steps to occur when it would be faster to interact with the attending pharmacist only. It also can be difficult to accommodate the learners’ abilities¹; for example, if a student is struggling and is unable to see patients independently, the attending pharmacist may have the resident directly oversee the student. This can take away from the residents’ time for their own patient care activities.

My Experience with Layered Learning Models

Over the course of my residency training, I have had the opportunity to participate in various LLMs across mainly ambulatory care and home health care settings. During my PGY1, I was typically responsible for helping to co-precept 3-4 APPE students per rotation and during my PGY2 I helped co-precept 2-3 APPE students throughout the week during the course of my longitudinal rotations. This enhanced responsibility helped me build upon my leadership skills, especially during times when I was starting a rotation at the same time as the student and they looked to me for guidance and support. Similar to what the medical residents stated in the Busari et al article, I feel that LLMs have helped me develop as a clinician because I had to critically evaluate my knowledge while helping students cultivate their own knowledge.

Additionally, by holding topic discussions and journal clubs, I had to stay abreast of current literature and study about certain disease states or clinical problems that I may not have under other circumstances. Student feedback helped me evaluate my approach to precepting and identify the best ways for me to coach and model for my students. One disadvantage to LLMs, in my experience, is that in some scenarios, it decreased my exposure to direct patient care. For example, if only one patient came to their appointment in clinic, the student would be the one to see the patient to ensure that they were meeting their various outcomes. However, my preceptors did not always have students with them on rotation so that was not always a barrier.

Summary

The LLM can help with ASHP's Practice Advancement Initiative by enabling pharmacists to interface with a greater number of patients, provide additional pharmacy services, enhance patient care and patient satisfaction, and promote integration into the care team.⁵ LLMs are beneficial to pharmacy residents because they can cultivate skills that can help them develop into better practitioners. However, there should be a balance so that both residents and students have equal opportunities. Overall, it is a model that will likely expand as more residency programs are created across the country and the need for expanded pharmacy services increases.

References:

1.    Pinelli NR, Eckel SF, Vu MB, et al. The layered learning practice model: Lessons learned from implementation. Am J Health-Syst Pharm 2016; 73:2077-82. Available at: http://www.ajhp.org/content/73/24/2077.

2.    Soric MM, Glowczewski JE, Lerman RM. Economic and patient satisfaction outcomes of a layered learning model in a small community hospital. Am J Health-Syst Pharm 2016; 73:456-62. Available at: http://www.ajhp.org/content/73/7/456.

3.    Bates JS, Buie LW, Amerine LB, et al. Expanding care through a layered learning practice model. Am J Health-Syst Pharm 2016; 73:1869-75. Available at: http://www.ajhp.org/content/73/22/1869.long.

4.    Busari JO, Scherpbier AJJA. Why residents should teach: a literature review. J Postgrad Med 2004;50(3):205-10. Available at: http://www.jpgmonline.com/article.asp?issn=0022-3859;year=2004;volume=50;issue=3;spage=205;epage=210;aulast=Busari.

5.    American Society of Health-System Pharmacists. Practice Advancement Initiative. Overview. Available at: http://www.ashpmedia.org/pai/overview.html. Accessed April 16, 2017.