During her last year of pharmacy school at the University of Oklahoma, Stephanie Manning, PharmD, did a clinical rotation at the Oklahoma City branch of a specialty infusion provider. “I had never heard about home infusion before, and my preceptor there introduced me to all the basics of how it works and the pharmacist’s role in home infusion.”

Prior to that, Dr. Manning had already decided that she wanted to do a pharmacy residency after completing her degree, but she had been undecided about her focus. Her experience with home infusion during her clinical rotation made her wonder whether such a thing as a home infusion residency even existed.

“I was looking through residency programs on the ASHP [American Society of Health-System Pharmacists] Web site and found that Critical Care Systems [CCS] had a home infusion residency,” Dr. Manning said. After speaking with some of CCS’ previous residents at the ASHP Midyear meeting, she settled on CCS as her first choice for a residency.

Dr. Manning had stumbled on what was, at the time, the only active pharmacy residency specifically devoted to home infusion pharmacy. Since then, Coram Specialty Infusion Services, where she pursued the clinical rotation that sparked her interest in the field, also has launched a similar residency, and Walgreens has reinstated a postgraduate year (PGY)-1 residency program in home infusion that was on hiatus when Dr. Manning was looking for a program.

CCS’ home infusion residency first got its start in 2007, when three of the organization’s pharmacists—Barbara Prosser, RPh, Caryn Dellamorte Bing, RPh, MS, and Donald Filibeck, PharmD, MBA—began discussing the growth of pharmacy residency programs in the wake of ASHP’s new pharmacy residency accreditation standards. “We were all acutely aware of the number of residencies out there; they were all primarily hospital and academic-type residencies,” said Ms. Bing. “But more and more schools were starting to recognize that there were other sites of practice besides hospital or community settings. We had a wealth of experience with home infusion and saw the opportunity to build on that with a residency.”

Dr. Filibeck noted, “We struggle for pharmacists, just like every other major segment of pharmacy. The schools don’t seem to be educating people for non-hospital, nonambulatory-type positions, and the move by ASHP and other professional associations to push for residency as a requirement for direct patient care gave us an opportunity to structure a residency and groom future pharmacists for our locations.”

Building Momentum

In August 2007, CCS launched its PGY-1 home infusion residency program at five of its locations: Chicago; Houston; Philadelphia; Boston; and Tempe, Ariz. “At the time, the company was structured in five regions, and the company leadership supported putting a residency training program in each of our regions,” said Ms. Bing.

During that first year, they were able to recruit only two residents—one in Philadelphia and one in Boston. During that year, both sites successfully went through ASHP’s accreditation process for PGY-1 pharmacy residencies, and the following year, CCS was able to recruit home infusion pharmacy residents for all five sites. By the program’s third and fourth years, they were able to fill the five residencies through the ASHP’s Residency Matching program. “We’ve gone from just a handful of applicants to having the high-class headache of being selective in screening potential applicants,” Dr. Filibeck said.

The residency is set up as a hub-and-spoke model, with central management of program design, standardized learning and policies. In addition to a primary corporate preceptor, there is at least one preceptor, and preferably more, working at each branch location where the resident is located.

Pointing to some of the benefits of the program, Ms. Bing said that the home infusion residency offers pharmacy residents unique learning experiences. “We have an on-call component with 24/7 services to our patients, involving more ongoing clinical monitoring, I believe, than what you would see in many hospital rotations. That experience is very acute—a patient is there for a couple of days and then discharged,” she noted. In contrast, she added, “our residents experience the continuum of care with the patients as they come out of hospital. We have the highest-intensity, highest-acuity patients, and the residents in our program learn how to respond to all facets of patient care.”

On a typical day, CCS home infusion residents do many of the same activities CCS pharmacists do, such as taking referrals and managing patients through the care process. “The rest of the learning experiences are geared to give them exposure to things that they might not see in other programs, such as the opportunity to provide drug information and clinical information support, not just at their own location but across our entire network of home infusion branches,” said Cindy Kunzendorf, RPh, MBA, general manager of Accredo’s CCS locations.

Residents can specialize in individual areas of home infusion, such as heart failure or nutrition. “My resident [Dr. Manning] is currently doing an extra rotation in nutrition, so that she can be more confident as a practicing clinician in managing home parenteral nutrition patients,” said Ms. Kunzendorf.

Noting that the residency has exposed her to areas of pharmacy practice she had never experienced in school, Dr. Manning said, “I never learned about extended stability issues during my education. We’re dispensing a week’s worth of parenteral medication at a time and have to make sure it’s safe and will be effective for that patient in their home. Pharmacy school’s focus is either on the retail aspect or on the clinical aspect of hospital pharmacy. But in the hospital, you’re monitoring labs on a daily or every-other-day basis; with home infusion, it’s weekly, if that.”

Invaluable Guidance

Dr. Manning praises CCS’ willingness to give residents the freedom to pursue their areas of interest. “They’ve let me take over the TPN [total parenteral nutrition] patients and work closely with one of the dietitians,” she said. “I have guidance from both Caryn [Bing] and Don [Filibeck], who are my corporate preceptors, and then I also have the branch preceptors. I think I’m being molded into a good, solid clinical pharmacist in home infusion.”

“It’s so exciting to see that CCS has done this,” said Phil Hagerman, RPh, president and CEO of Diplomat Specialty Pharmacy, in Flint, Mich., the nation’s largest privately owned specialty pharmacy. “I think every small to mid-sized specialty pharmacy should be figuring out how to hire a resident. At this year’s Armada summit, I spoke quite a bit about the need for specialty pharmacy to get involved in education and training of residents.”

That’s not easy, conceded Jennifer Hagerman, PharmD, Diplomat’s director of education. “Your curriculum needs to be well defined, with clear goals and objectives and qualified preceptors. Residents need to be able to rotate through a number of different areas, such as operations, business development and managed care.”

But the rewards can be substantial. Of the four residents Diplomat has had so far (three in its prior community pharmacy residency and one in its new specialty pharmacy residency), three have been hired long-term, two in management roles. “It’s always about trying to find talented people to take your company to the next level,” Mr. Hagerman said.

Given the lack of a stand-alone specialty pharmacy residency (sidebar), Mr. Hagerman thinks specialty pharmacy needs its own accreditation category. “Specialty pharmacy is a $100 billion segment of our industry,” he said. “It needs its own specific, accredited program.”

Dr. Filibeck wouldn’t argue with that. “There has been a true lack of good, experienced home infusion pharmacists, and creating a residency has empowered all of us to share our experience as the industry is growing and changing, and impart our knowledge to future leaders. When I look at these people, I know they will do something incredible with their careers, because they had such a good start.”

Specialty Pharmacy: A Pharmacy School Unknown?

CCS’ home infusion pharmacy resident Stephanie Manning, PharmD, said she got virtually no exposure to specialty pharmacy issues—such as the extended stability that is so important in home infusion—during her pharmacy school training.

She’s not alone, said Diplomat Specialty Pharmacy’s President and CEO Phil Hagerman, RPh. “There is no college of pharmacy with a reputation for any focus on specialty pharmacy. And with more and more drugs, such as oncology and rheumatoid arthritis medications, being channeled through specialty pharmacy, we have to start challenging academia to aggressively instill this specialty coursework,” stressed Mr. Hagerman.

The Accreditation Council for Pharmacy Education (ACPE) does not keep track of specialty pharmacy coursework at colleges of pharmacy, according to Lindsay M. Antikainen, MS, accreditation facilitator for professional degree program accreditation. “The ACPE’s standards are really focused on developing a generalist curriculum, so the curricular content required by our standards is aimed at that,” she said. “Specialty coursework is really up to the individual programs to develop, both in terms of didactic and experiential curricula. That’s not something we track, as it varies widely from institution to institution.”

Jennifer Hagerman, PharmD, who was an associate professor of pharmacy at Ferris State University College of Pharmacy, in Big Rapids, Mich., before becoming Diplomat’s director of education, said that students taking electives in specialty pharmacy or managed care will get basic introductions to the field. “But if you want to truly delve into specialty pharmacy, you have to do a residency.”

Currently, there are only three ASHP categories for accrediting PGY-1 pharmacy residencies: community-based, managed care and pharmacy practice. Specialty pharmacy residencies, like CCS’ home infusion program, are accredited under the pharmacy practice section, but Mr. Hagerman said that he thinks specialty pharmacy needs its own PGY-1 accreditation category.

But that’s unlikely to happen, according to Janet Teeters, RPh, MS, ASHP’s director of accreditation services, because the group is aiming for fewer PGY-1 categories, not more. “We’re trying to merge community, managed care and pharmacy practice so that instead of three sets of standards for a residency you just have one,” she said. “Regardless of where your setting is, your residency should give all pharmacists these basic skills.”

Other efforts to address the learning opportunities in specialty pharmacy also are moving forward. A new specialty pharmacy certification program, offered through the Specialty Pharma Education Center, will begin offering courses in September. To achieve certification as a certified specialty pharmacist, participants will be required to complete 30 hours of educational programs within a 12-month period.

For its part, Diplomat has established an internal training program, called Diplomat University. “We partner with Ferris State University to provide specialty pharmacy continuing education programs for both our pharmacists and our technicians,” noted Dr. Hagerman. “This is in an effort to address the lack of time devoted to specialty pharmacy in the pharmacy school curriculum and in educational CE [continuing education] opportunities as a whole and to keep our pharmacists and technicians current in this rapidly growing industry.”