Prepping Pharmacist Preceptors on the Pharmacists’ Patient Care Process (PPCP)

INTRODUCTION: A PATIENT CASE

JM, an 8-year-old white male presents to your clinic. It’s a pediatric care clinic located in an area where many financially challenged families live. After talking with his parents, you learn he was recently diagnosed with central precocious puberty (CPP). His endocrinologist recommends initiating therapy and would like to know what treatment you recommend. His parents also have questions.

Your spry pharmacy student jumps at the opportunity to write a SOAP note using the “PPCP.” To you, PPCP sounds like an illegal drug that was abused in the 1980s. She explains that the Pharmacists’ Patient Care Process (PPCP) is a standardized model for collaborative medication management. She clarifies what it entails and how to apply the process in a clinical setting.

PPCP’s Importance

Schools of pharmacy have taught the PPCP for the past few years. Preceptors who are unfamiliar with the process may find it helpful to review the PPCP as many students will take this approach when addressing clinical problems in the workplace.

PPCP: THE DETAILS

Teamwork in healthcare has achieved major goals for many patients (although we have room for improvement): accessible, affordable, and high-quality care. In addition to the many healthcare team members, pharmacists are critical contributors to care plans. Medication expertise equips pharmacists with the knowledge to reduce drug adverse events, prevent medication errors, and provide invaluable input for decision-making.¹

In 2014, the Joint Commission of Pharmacy Practitioners (JCPP) developed a standardized process for medication management that could be used across interdisciplinary teams and dubbed it PPCP. JCPP’s members developed the approach using principles of evidence-based practice. The five steps—collect, assess, plan, implement, and follow-up—are tied together with careful communication and documentation.² Pharmacists can remember the steps as the pneumonic “CAP-IF.”

SOAP Notes

The subjective, objective, assessment, and plan (SOAP) note provides a method of documentation for the collect, assess, and plan steps of the PPCP. SOAP notes are probably familiar to most preceptors, as clinicians have used them for roughly 50 years.³ Table 1 highlights the key components of SOAP notes.

Table 1. Components of a SOAP Note¹

Collect

Thorough collection of the right information supplies pharmacists with tools to make safe, effective decisions. A combination of objective and subjective information paints a more complete picture of a patient’s clinical status. If possible, pharmacists should obtain and verify their information across multiple sources. Past medical records, active medication lists, and laboratory results are great places to start.

When soliciting subjective information, pharmacists should use open-ended questions. Prompting patients with questions formatted to avoid “yes” or “no” answers allow providers to obtain more information in less time, prioritize chief complaints better, and minimize implicit assumptions.⁴

Back to the Case

Your head is spinning trying to sort all the “P’s” in PPCP, CPP, and JCPP, but your student assures you that she will start with collecting relevant clinical information. First, you and your student perform a physical assessment of JM including taking his height and weight. JM takes no medication except an occasional antihistamine, but if he took other chronic medications, this would be the time to direct your student to perform a medication reconciliation. Next, you prompt JM’s parents with open ended questions, and they recall JM’s past medical history. You should ask your student if JM needs to be involved in the discussion (see SIDEBAR). After meeting with JM and his parents, here is the relevant information your student jots down:

Subjective information

• At age 5, JM frequently soaked through his underarm clothing with pungent perspiration, so since then, he uses a strong deodorant
• He is starting to develop pubic and underarm hair
• He has some acne on his face and upper back
• JM occasionally tells his parents he feels “different” than his classmates because he is so much bigger and taller
• He has no past surgeries or hospitalizations
• Takes OTC multivitamins daily and loratadine for allergies in the spring

Objective Information

• Height = 4’8” inches
• Weight = 102 pounds
• DHEA Sulfate = Tanner stage III - 60 ug/dL (N = < 28 ug/dL)
• Clinical exam findings = testicle size indicates puberty
• X-ray bone age hand and wrist = greater than 2 standard deviations, 156 months (expected = 108.9 months)
• Luteinizing hormone (LH) = 0.4 units/L (N = < 0.3 units/L)

SIDEBAR: Pediatric Involvement in Healthcare Decisions^5,6

In pediatric cases, clinicians may choose to consult only parents when making decisions regarding their child’s medical care. However, this practice, which is rooted in legal precedence, should shift to involve affected children to some extent. The American Academy of Pediatrics advocates that adolescents actively participate in decisions based on their ability and maturity. ⁵ While research is lacking on how exactly to assess a child’s aptitude to participate in decision making, some studies show that children can participate as young as age 5.⁶ Regardless, it doesn’t hurt to ask children if they have questions or concerns. In the case, JM is 8 and has voiced his concern previously about his height and size. Therefore, including him in the conversation is a possibility if his parents agree.

Preceptors can and should provide tangential learning when working with special populations. Reminding students that adolescents, older adults, people who have cognitive decline or dementia, and people for whom English is a second language will need careful counseling. Pharmacists and pharmacy staff will also need to select their words carefully and accommodate these patients’ needs. Assigning students to do some research on the various needs in these populations is an excellent way to help them develop skills and a professional identity.

Upon looking at your student’s notes so far, you assure her she has done well. However, you still have some questions. You remind her that sometimes information like height and weight requires additional evaluation and ask her to calculate JM’s BMI; she finds that it’s 22.9. You ask your student, “How does JM’s height and weight compare to the expected height and weight of boys his age?” To which she replies, “Pediatric growth charts will give us a better idea!” After consulting the growth charts, she determined and documented that JM falls within the 112th percentile for both measurements.

To make learning comprehensive, you could ask the student if the only kind of precocious puberty is central in nature. This will help your student learn to differentiate among different forms of similar diagnoses.

Assessment

An assessment of comprehensive patient information helps prioritize the problems that require attention. Pharmacists should consider all information when identifying the problem, the rationale, and the goals of therapy. Some example questions pharmacists can consider include¹

Medication appropriateness

• What is the indication for each medication?
• What is the correct dosing?
• What are the common adverse effects?
• What are the possible drug interactions?

Factors that impact access to care

• What cultural factors create barriers to care?
• What socioeconomic factors impact the patient?
• What is the patient’s level of healthcare literacy?
• What goals does the patient or his parents have?
• What barriers impact patient adherence?

Additional services

• What preventive care measures does the patient qualify for?
• Which immunizations has the patient received?
• What other concerns does the patient have?

THE CASE RESUMED...

After compiling the objective and subjective information on JM, the student finds guidelines in the Journal of Clinical Endocrinology for the management of CPP.⁷ Due to JM’s symptoms and lab values showing consistencies with CPP, the guidelines recommend initiating a gonadotropin releasing hormone (GnRH) analog. Depending on JM’s and his parents' preferences, the endocrinologist can choose either an injectable (leuprolide) or long-acting implantable device (histrelin) provided the insurance covers it or the cost is manageable.

Once again, you should have some questions for your student. For example, asking the student to list the search terms and search engines she employed can shed light on her process. Another question might be, “Are these the only guidelines available?” You can show her that you used PubMed, as she did, but when you used Google Scholar, you found an excellent review article that lists five other publications. You suggest she look at them since expert recommendations can vary. She might also contact the endocrinologist and ask if he plans to follow the guidelines she identified, and if not, why not.

The endocrinologist messages back saying he agrees leuprolide and histrelin are both reasonable options to consider for first-line therapy. However, he also cites a 2019 update published on Hormone Research in Paediatrics. These guidelines recommend a third U.S. Food and Drug Administration (FDA)-approved option for the treatment of CPP, triptorelin.⁸ He says the student should consider this choice as a potential treatment for JM as well.

After reading the endocrinologist’s note, you emphasize to your student the importance of citing multiple guidelines when drafting an assessment. In this case, the FDA approved an additional treatment, triptorelin, in 2022. You walk through your student’s process of finding clinical information to identify more ways she can improve next time. Furthermore, you point out how the endocrinologist’s insight exemplifies the importance of interdisciplinary care.

Simultaneously, you and your student read through all three monographs and discuss the major differences you’d like to share with his parents. You ask the student to practice her delivery of the information, and she says, “Leuprolide is a long acting injectable administered intramuscularly (IM) or subcutaneously. Your doctor will administer the IM formulation every month, three months, or six months. “Triptorelin is similar to leuprolide, but is only available as a six month IM formulation. The other option is for your doctor to administer the subcutaneous formulation every six-months.⁹ On the other hand, histrelin comes as a long-acting 1¼ inch implant surgically placed into the upper arm every 12 to 24 months. For the first 24 hours after the surgery, JM should avoid swimming or bathing. As long as JM avoids heavy play or exercise for the first week, he will not have to worry about any further restrictions after that. The implant also requires surgical removal.”¹⁰

Now, you prompt the student to recall that JM’s parents expressed concern about what would happen if JM experienced an adverse reaction to the long-acting implantable device. They asked, “What is the procedure like?” and “If JM has a reaction to the implant, must he continue to wear it for 12 months or can the doctor remove it easily before then?”

The student does more research and says she will assure JM’s parents that this outpatient procedure lasts only 10 minutes, though the appointment may last 60 to 90 minutes. Most surgeons will just numb the area; however, children may undergo sedation if necessary. The surgeon will insert the narrow implant into a small approximately 5 mm opening made in the skin on the inner surface of the arm. With this option, JM can return to school the same day. The student plans to mention that complications don’t commonly occur, but minor discomfort and bruising may.¹¹ The student plans to continue, “The implant may be removed immediately if JM presents at any time a severe allergic reaction or adverse effect. However, this is not common.”

Before you and the student document the assessment section of your SOAP note, the student indicates she will ask JM if he has questions. He shares that he “HATES needles” but is also scared of the surgery hurting.” The student plans to tell him not to worry because he won’t feel any pain during the operation. He can also choose to sleep during the surgery if he prefers.

Here, the preceptor should step in with gentle corrections about patient-appropriate language. First, most Americans have no idea what a 5 mm incision will look like. You ask her to calculate its length in inches and explain it by comparing it to something the child will recognize, like the size of small dice or a stack of 20 playing cards. Next, it’s critical to remind the student that we must never tell patients that something won’t hurt. This is a lesson students should learn during immunization training and creates an opportunity for cross training (applying this principle to other areas of pharmacy) that applies regardless of patient age. Healthcare professionals should never say, “This will not hurt a bit!” or anything similar. People have different pain thresholds making it impossible to predict whether it will hurt. Student pharmacists need to develop language they are comfortable with and use it. A good response if people ask if it will hurt is, “It may hurt or sting a little but just for a minute or two.” In this case, the preceptor suggests saying, “The doctor will numb the area.”

Finally, the preceptor may point out that “operation” can be a scary word for children. The student needs to use a word like “procedure” or find a way to avoid either of those words.

The preceptor should also point out that JM’s parents had also said they were worried about two things: (1) potential side effects and (2) the cost of care. They heard on the news that expenses associated with these medications can add up quickly. The cost of care and determining what the patient’s insurance will cover is probably foremost in the endocrinologist’s mind, too.

In terms of potential side effects, your student says that both GnRH analogs have similar side effect profiles. From the pediatric studies she read on GnRH adverse effects, she shares that signs of puberty may increase transiently with therapy before growth velocity eventually slows down. Some children experience weight gain, changes in appetite, body aches, headaches, gastrointestinal (GI) symptoms, or signs of a common cold. Parameters like physical growth and bone mass density may decrease during treatment but usually return to normal one year after treatment discontinuation.^{9, 10}

Before selecting JM’s treatment option, it’s critical to evaluate insurance coverage since it’s on the forefront of everyone’s concerns. The student needs to determine if they have insurance and what the plan covers. She starts by finding information on ballpark cost. She reports a histrelin implant costs around $40,000. If the patient requires mild sedation when the doctor inserts the implant, the cost may increase. However, in some cases, the implant may be used for up to two years. Leuprolide’s median annual cost ranges from $20,000-$40,000 depending on the formulation.¹² A single injection of triptorelin costs roughly $19,000, making the annual cost nearly $40,000 as well. Then says she will remind JM’s parents that while this may give them an idea, the cost may vary outside of that range.

Plan

Following the assessment, pharmacists work to develop a personalized patient care plan in collaboration with other healthcare professionals. The plan should reflect recommendations from the most recent evidence-based clinical practice guidelines. Pharmacists should focus on optimization of care in a safe, effective, and cost-effective manner.

1. Address medication-related problems and optimize medication therapy
2. Set specific, measurable, achievable, realistic, and timed (SMART) goals in the context of the patient’s healthcare goals and access to care
3. Involve patients to engage in education, empowerment, and self-management
4. Support non-pharmacologic interventions as appropriate

SMART Goals. When creating an action plan for patients, pharmacists should aim to set goals that are SMART.

• Specific instructions provide other clinicians with accurate information about the patient.
• Measurable outcomes provide clinicians the ability to evaluate the patient’s progress and whether the plan requires adjustments
• Achievable and realistic goals
• A timeline for the plan ensures healthcare providers routinely follow up with their patient

A PLAN FOR JM

After you document JM’s main problem, rationale, and goals for care in the assessment section, you move on to create his plan. Following careful consideration of the assessment, you and your student decide to recommend starting histrelin to treat his CPP since his insurance will cover it once the endocrinologist completes prior authorization forms. (Here, you suggest that the student find the prior authorization forms and volunteer to complete as many sections as she can for the endocrinologist. You explain that she can expedite the process and this is a skill she can apply to many different pharmacy practice locations.) Choosing histrelin is also a needle-free option, which may make JM happy. You remind your student that the plan should also include scheduling necessary appointments and follow-ups with JM’s other providers in addition to counseling on the specific adverse effects of the medication detailed in Table 2.

Table 2. Example SOAP note for JM ⁷

Implement

During the implementation phase, pharmacists set the action plan into motion. This may include the administration of vaccines, initiating or discontinuing a medication, or scheduling the next follow-up appointment. Pharmacists, primary care physicians, or caregivers work together to provide care based on the goals made in the planning step.¹

Follow-up and Monitor

The pharmacist in collaboration with other health care providers should follow-up with the patient as recommended in practice guidelines and referring back to the SOAP note. Continuous monitoring of medication appropriateness, adherence, safety, laboratory results, and patient concerns will indicate if the plan requires revision. Routine medication reconciliations, check-ups, or conversations with patients improve outcomes and help to achieve goals of therapy.

Putting it All Together

Upon completion of the SOAP note, you send the endocrinologist your recommendations. You contact JM’s parents to discuss scheduling a follow-up appointment in three months with the endocrinologist and counsel on histrelin.

IMPLICATIONS FOR PRECEPTORS

The Benefits. The PPCP model creates a reproducible framework that demonstrates clinical pharmacists’ contributions to medication-related outcomes.¹³ In addition to improving the quality and completeness of patient medical records, SOAP notes give pharmacists a place to start when working up a new patient. As students practice developing SOAP notes, preceptors should emphasize how the lessons they learn in one case can apply to future cases.

The Drawbacks. As more pharmacy programs integrate PPCP into their curriculum, new students will have access to courses that teach the model. But because the PPCP model is relatively new, many licensed pharmacists have not yet familiarized themselves with the process. Extracting the necessary information to write quality SOAP notes can also be time consuming. Depending on the setting, pharmacists may not have enough time to walk through every step with students. Finally, the PPCP method does not encompass all clinical situations. The framework relies on pharmacists to exercise clinical judgment and reasoning to modify the model as needed.

Uncomfortable Topics. Students often have little exposure to difficult topics. These may include end-of-life issues, psychiatric diagnoses, cultural or ethnic differences, drug abuse/misuse, and gender-related topics. In this case, students may feel strong discomfort in discussing matters related to sex and sexual development. Preceptors need to help students reduce their hesitancy when communicating with you and the patient because improper communication can lead to poor collection of relevant information. Keep in mind strong note-writing skills facilitate good care. Two things help: (1) practice, and (2) finding resources designed to help with difficult topics. The Conversation Project (https://theconversationproject.org/resources/healthcare/) is one such resource that can help students become more comfortable with difficult topics.

In addition, students may have implicit and explicit biases for uncomfortable topics such as the use of hormone blockers, which may bring to mind their use in transgender children. Creating a safe place for your student to share opinions provides a great opportunity for you to teach students how to avoid these biases. Preceptors need to remember that learning—especially if it changes a student's perspective or points out a student's mistake—can be threatening, and students can feel vulnerable while learning. It’s an emotional experience.⁶

To help guide students through these experiences, the SIDEBAR provides 10 additional tips preceptors can use when supervising the PPCP.

SIDEBAR: PRO TIPS for Preceptors Who Supervise the PPCP

(1) Don't let the acronym scare you! This is a new name for a process you've probably used knowingly or unknowingly for years.

(2) Encourage independence. Hand over the problem to the student once you've described the problem and fielded the student's questions. Establish a time for the student to be prepared to discuss it but check in periodically to see if the student is having trouble.

(3) Rescue when necessary. Some students will need more support than others. If a student is clearly flummoxed, spend more time and provide more direction.

(4) Promote interdisciplinary communication. Having students discuss a clinical problem with another clinician, either with you or on their own, fosters interdisciplinary care. Students will also learn from the other clinicians, which will lighten your load!

(5) When students present findings, always ask them to describe things like the search terms and search engines they used or the obstacles they encountered. Help them refine their processes to reduce barriers or find more appropriate resources.

(6) Consistently prompt students to determine if the case is typical or unusual. Asking questions based on a modification of the case can help students learn more globally.

(7) Don't "stay in your lane"! In this CE, the practice site is an ambulatory care location specific to pediatrics. The lessons a student learns in this rotation, if they go beyond pediatrics, will be invaluable. Helping students develop communication skills or analyze how disease states present or are treated in adults or other special populations will increase their clinical acumen in future rotations.

(8) Address implicit biases or misconceptions. Students may not know that an attitude or opinion is biased, incorrect, or simply rude.

(9) Debrief. After the PPCP is done, provide feedback, ask others who may have been involved to provide feedback, and ask the student to perform a self-assessment.

(10) Appreciate reverse mentoring. Remember that students often teach us new things!

Common Sources of Error

Collecting too little information. Not all the information pharmacists need to collect will be obvious. In the patient case, the student collected important objective information like height and weight. However, without something like growth charts to evaluate JM’s height/weight compared to other kids his age, the information does not help in the assessment. Preceptors can aid students who are new to documenting SOAP notes when they are required to dive deeper into collected information. Students should not make assumptions as to what other clinicians know off the top of their heads. In this case, other areas where the preceptor helped the student included directing her to seek other expert opinions like the endocrinologist. That puts the “inter” in “interdisciplinary” care!

Collecting too much information. Pharmacists and students should collect information worthy of appraisal. In other words, only collect the necessary information that will contribute to the identification, prevention, and resolution of either the chief complaint or medication-related problems. If pharmacists/students do not actively use collected information to make the assessment or plan, they should omit it in the note. Documenting more information does not equate to better information. This leads to overly lengthy or confusing SOAP notes. Here, as in the previous error, preceptors should ask students to examine and explain their processes.

Not verifying information. All information should be verified across multiple sources like when performing traditional medication reconciliations. This prevents possible errors in note-taking that may arise from outdated documentation.

Sourcing one guideline. Depending on the disease state, the frequency in which guidelines are updated can vary. Preceptors should emphasize the importance of looking for multiple guidelines and paying attention to their publication dates. Occasionally, the FDA may approve new treatment options after the release of clinical guidelines or updates. In this case, the student completely missed an additional treatment option as a result of sourcing a single guideline from 2013. Similar to how preceptors should encourage students to verify collected information across multiple sources, preceptors should also encourage students to cross-check sources that aid in their assessment.

The assessment lacks evidence. As mentioned above, the assessment should communicate the assessor’s thought process. The information collected by the pharmacist/student should justify why the problem is a problem. If there is no subjective or objective information to back up the assessment, the assessment has no basis.

Forgetting recommendations on current medications. Pharmacists/students should not forget to include instructions for the patient’s current medications, not just the newly prescribed medications.

Forgetting non-pharmacologic recommendations. The plan section also encompasses non-pharmacologic interventions such as referral to another provider, ordering additional laboratory tests, education, or counseling on lifestyle interventions. Pharmacists/students should remember that not all patients require initiation of a new medication.

Being vague. When initiating new therapy appropriately, pharmacists/students should always provide specific recommendations with the drug name, dose, and frequency. Vague instructions such as “Initiate hormone blocker therapy” are unhelpful. Similarly, instead of “monitor for side effects,” pharmacists/students can list the specific symptoms that present most commonly.

Poor communication. Errors due to poor communication directly hinder the PPCP. Furthermore, clinicians with experience are not necessarily better communicators. Therefore, pharmacists should engage in education/training to constantly improve communication skills. SOAP notes should effectively communicate the pertinent information used to create a plan and document important details for the patient’s medical record.

Setting it and forgetting it. The PPCP is not a linear process. While this framework provides clinicians a place to start and a checklist of sections to complete in order, pharmacists should remember to review and revise all sections at any given time. For example, pharmacists may identify new information they should go back to collect as they work on their assessments. Preceptors should encourage their students to occasionally step back and evaluate the completeness and coherence of the SOAP note. Sometimes patient cases will require students to revise sections of the SOAP note they already completed.

And a New Case

Just before the end of the month, the endocrinologist sends yet another patient with precocious puberty to you. The patient LD is a 9-year old Hispanic female. Her endocrinologist recently diagnosed her with idiopathic precocious puberty and wants to know which treatment you recommend. Her parents also want to know why this is happening to their daughter. Before taking LD’s family from the clinic waiting room, you decide to let your student take charge of this case while you supervise. You ask your student “Now that you have practiced writing SOAP notes and know a little about this disease state, how will you approach the PPCP this time?”

The student says to you...

“I stored all my notes from the last case on precocious puberty from earlier this month. I have a document containing the guidelines from the Journal of Clinical Endocrinology along with several updated publications that cite all additional first-line medications approved after the original guideline’s release. I will start with the collection of subjective information such as LD’s symptoms and medical history followed by objective information, specifically pertaining to her growth statistics. I should calculate BMI and her height/weight percentiles since precocious puberty is usually associated with accelerated growth. Next, I will examine her relevant lab values. Since the patient is female, I will be looking out for progesterone levels this time. If possible, I shall cross-reference all of the information I collect across multiple sources.”

“Before I move onto making an assessment, I understand LD’s parents may feel very concerned about their daughter's condition. I don’t want to forget to address their question. I will explain that idiopathic precocious puberty does not have a definitive cause. To help them better understand, I’ll mention that idiopathic cases may result from anything ranging from a head injury in childhood to exposure to certain chemicals. Regardless of the cause, I will assure them there are several treatment options that may be appropriate for LD at this time. I can walk them through the pros and cons of all the available options.”

“Next, I would prompt LD’s parents with open-ended questions to learn more about their major concerns, potential barriers to medication therapy, and insurance eligibility. I know these are important considerations for my assessment. It would also be appropriate for me to engage with LD using appropriate language for a 9-year-old girl. I realize the topic may be uncomfortable to discuss, but without taking initiative of the discussion I may forget to include pertinent details in my SOAP note.”

“Finally, using the information I collected about the family’s preferences and LD’s medical history, I will draft the chief complaint, rationale for treatment, goals of therapy, and eventually a completed plan. The plan will include which treatment I recommend along with the dose, frequency, and which adverse effects are most common. I will write when I recommend a follow-up with her endocrinologist and make note of which lifestyle modifications may support her specific treatment. If the endocrinologist is on board, then we can collaboratively implement and follow-up with the patient as appropriate.”

You are overjoyed to hear that your student has taken what she learned from the previous case and applied it to this case as well. Although some of the parameters were different, such as the patient’s sex, she was able to anticipate how the changes may impact her SOAP note this time. While you identify a few areas in which she can improve, you are happy that she is continuing to expand her clinical pharmacy knowledge.

Conclusion

The PPCP model can be applied to any healthcare setting in which pharmacists practice. This comprehensive approach to patient-centered care has established a streamlined method of documenting patient information to be shared among healthcare teams. As the PPCP continues to grow in clinical settings, practicing pharmacists should become familiar with its methods and applications.

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