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To assess the train-the-trainer component of an initiative (Partners in D) to train pharmacy students to facilitate patient enrollment in the best Medicare Part D prescription drug plan (Part D).
Faculty members from 6 California colleges or schools of pharmacy were taught how to train pharmacy students about Medicare Part D and how to conduct outreach events targeting underserved patient populations. A preintervention and postintervention survey instrument was administered to determine participants' (1) knowledge of the Part D program; (2) skill using the Medicare Prescription Drug Plan Finder tool; and (3) confidence in their ability to train pharmacy students. Implementation of the Partners in D curriculum in faculty members' colleges or schools of pharmacy was also determined.
Participants' knowledge of Part D, mastery of the Plan Finder, and confidence in teaching the material to pharmacy students all significantly improved. Within 8 weeks following the program, 5 of 6 colleges or schools of pharmacy adopted Partners in D coursework and initiated teaching the Partners-in-D curriculum. Four months afterwards, 21 outreach events reaching 186 Medicare beneficiaries had been completed.
The train-the-trainer component of the Partners in D program is practical and effective, and merits serious consideration as a national model for educating patients about Medicare Part D.
The passage of the Medicare Prescription Drug Improvement and Modernization Act (MMA) in 2003, and the implementation of its Part D prescription drug benefit provision in 2006, marked the largest expansion of the Medicare program since its inception in 1965. Despite a large-scale educational campaign by the Centers for Medicare and Medicaid Services (CMS), many Medicare beneficiaries lack sufficient knowledge and skills to navigate this complex and confusing Part D benefit.1,2 Specifically, those with low income, multiple co-morbidities, widows, racial and ethnic minorities, and residents of rural communities experience the most difficulty maximizing the Part D benefit.1-3 Furthermore, today's healthcare workforce is ill-equipped to assist the Medicare population in the enrollment in, and selection of, the most appropriate Part D plan.4
Because of their awareness of pharmacy benefit design, understanding of medication therapy management services (MTMS), and accessibility to the public in the community setting, pharmacists are in a unique position to act as patient advocates in this area. As patient advocates, pharmacists and pharmacy students can demystify the Part D program, ensure that therapeutic outcomes are optimized, reduce the risk of adverse events, and enroll beneficiaries in the lowest-cost prescription drug plan, based on their current drug regimen and financial circumstances.
In 2006, faculty members from University of California, San Francisco (UCSF) developed and implemented Partners in D, a statewide outreach and research project designed to help underserved Medicare beneficiaries in California, and non-pharmacist health care professionals, improve their understanding and use of the Medicare prescription drug benefit. Partners in D, a multi-site research collaborative project involving 7 colleges or schools of pharmacy across California, under the direction of UCSF faculty, consists of 3 major interventions: (1) Part D community outreach events targeting the underserved in the places where they live and congregate; (2) specially trained pharmacy students give Part D lectures in the classroom and educate their health professional peers in medical, dental, and nursing schools across the state; and (3) medication therapy management interventions in clinical practice sites.
The Part D community outreach component, the focus of this paper, specifically targeted the underserved elderly (eg, those eligible for both Medicare and Medicaid, those with low incomes, and those with limited or no English-speaking proficiency). The outreach curriculum, which has been described elsewhere, improves pharmacy student knowledge, skill mastery, and confidence in performing Part D outreach. 5 Early success with the program, coupled with interest from other schools of pharmacy in California, led to the development of a faculty training program with the goal of promoting broad-scale dissemination using a train-the-trainer approach.5 Here we present evaluation data from our initial statewide faculty train-the-trainer program for the Part D community outreach component of the Partners in D program.
A lead faculty member was identified at each of 6 California colleges or schools of pharmacy participating in the Partners in D project. The following criteria were applied to select the appropriate faculty member from partner schools: (1) an interest in attending a train-the-trainer program on the use of a shared Part D curriculum; (2) current teaching responsibilities for Part D-related content in the curriculum and/or involvement in community outreach efforts targeting underserved populations; and (3) ability to integrate a Part D curriculum into an existing course or develop a new course at their college or school of pharmacy. As the program encourages team-teaching methods, faculty members were asked to identify other participants from their college or school who met the above criteria. Seventeen faculty members from 6 colleges or schools of pharmacy in California participated in the program, which is comparable to the sample size of other regional train-the-trainer programs.6-8 All program materials were provided to participants at no charge. Study procedures and instruments were approved by the Committee on Human Research at UCSF.
The train-the-trainer program was conducted over a 3-day period. The opening session included introductions and presentations describing the history and vision of the Partners in D program. The remainder of the training program focused on presenting the Partners in D community outreach material with an emphasis on its delivery and implementation. Faculty members who had been involved in the Part D curriculum at UCSF taught all train-the-trainer sessions. Presentations included the core elements of the community outreach curriculum, including lectures describing the details of the Part D benefit, and principles of geriatrics, health literacy, and culturally competent care. The latter 2 subjects were considered especially important, given that the target audience was comprised of poor, multi-ethnic patients with limited or no English-speaking proficiency. An interactive, hands-on, Web-based workshop allowed participants to develop skills using the Medicare Part D Plan Finder tool, an online resource which Medicare beneficiaries may use to enroll in a Part D prescription drug plan.9 The second day concluded with role playing, “trigger tape” exercises (taped patient encounters designed to stimulate discussion of pertinent topics), and case scenario discussions. The third day of the program included presentations on the evaluation component of the Partners in D community outreach program and developing effective outreach partnerships with vulnerable Medicare beneficiaries in their communities. The majority of the afternoon was dedicated to individual school brainstorming sessions to assess how the program could be integrated into existing curricula at each school and to identify any possible barriers to adoption. At the end of the program, through a group debriefing session, participants explored and shared possible methods for implementation at each participating school. At the conclusion of the program, participants completed a posttraining survey instrument.
A pretest-posttest research design was used to measure change in 3 domains: knowledge of Part D, skill mastery of the Medicare Plan Finder tool, and confidence in ability to teach participants the Part D outreach material. The pretest survey instrument and Medicare Part D Plan Finder tool case study exercise were administered before any instruction was given, and the posttest survey instrument and a second case study were administered at the conclusion of the program. Our study measures were adapted from assessment materials used in Rx for Change: Clinician-Assisted Tobacco Cessation, a national train-the-trainer program for health professional students, educators and practitioners.10 Sociodemographic factors that were assessed included: age, academic level, area of expertise, years in current position, prior experience with Part D (including teaching responsibilities), and years of teaching experience.
A 12-item multiple-choice examination was used to assess the participants' knowledge of the Part D prescription drug benefit. This examination (previously described by Cutler, et al5) was administered at baseline and repeated at the end of the program. To measure faculty members' mastery of how to navigate the Part D benefit, participants also completed a case-based, 4-item, short-answer questionnaire, using the online Medicare Part D Plan Finder tool. In this exercise, participants were presented with a hypothetical case of a Medicare beneficiary, including current prescription drug coverage, and were asked to apply the Plan Finder tool in helping the patient determine: (1) the 3 least-expensive prescription drug plans and their annual costs to the patient; (2) if the patient would reach the coverage gap; (3) the estimated month the patient might reach the coverage gap; and (4) the rank order and cost of the patient's current prescription plan if no change was made. A member of the UCSF research team documented the time (in minutes) it took for each participant to complete the Plan Finder portion of the survey.
Before and after the train-the-trainer program, participants were asked to rate their confidence in teaching the following components of the Partners in D community outreach curriculum: overview and application of the Medicare Part D Plan Finder tool; precepting students at a Part D outreach event; Part D advocacy skills/knowledge; geriatrics (related to Part D); Part D counseling skills/knowledge (including health literacy and cultural competence); Part D education of non-pharmacist health professional students and other healthcare professionals; and evaluation of the impact of the outreach program on pharmacy students and patients. Response options included: 1 = not at all, 2 = a little, 3 = moderately, 4 = very, 5 = extremely.
At the conclusion of the program, participants were surveyed about the following issues: (1) whether their Part D knowledge and confidence in teaching others had increased; (2) the overall usefulness of the Partners in D training program; and (3) whether participants would recommend the train-the-trainer program to other pharmacy faculty members and/or health professional faculty members outside of pharmacy who might be interested in teaching Part D outreach to their students. Response options included: 1 = definitely yes, 2 = probably yes, 3 = probably not, 4 = definitely not. Finally, participants were asked to estimate the percentage of the program content that was: (1) completely new; (2) taught before but a necessary review; and (3) an unnecessary review (with 1 through 3 summing to 100%).
The participants were asked to assess the overall usefulness of each of the following components (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent), and the overall likelihood that each component would be used (1 = not at all, 2 = a little, 3 = moderately, 4 = very, 5 = extremely likely): PowerPoint lecture slides, instructor notes that accompany the PowerPoint lecture slides, case scenarios for role playing, instructor guidelines that accompany case scenarios, trigger tapes, and ancillary student handouts.
Participants assessed their perceptions regarding the adoptability of the Partners in D community outreach program: (a) compatibility for integration into the existing curriculum structure; (b) comprehensiveness of content; (c) appropriateness of teaching methodologies used; (d) clarity of the Faculty Coordinator's Guide in terms of its ability to facilitate program implementation; (e) confidence in their skills for teaching the Partners in D materials; and (f) likelihood of adoption of Partners in D community outreach program during the 2007-08 academic year. Response options included 0 = none, 1 = low, 2 = moderate, 3 = high. Rogers' diffusion of innovation theory was used as a framework guiding development of study measures.11
Using a 5-point scale (1 = not at all, 2 = a little, 3 = moderately, 4 = very, 5 = extremely important), participants assessed a series of perceived potential barriers to program adoption. These included: lack of available curriculum time, financial resources, available faculty expertise in Part D, faculty member interest in Part D-related issues, faculty's perceived importance of Part D issues as applicable to a pharmacist's practice, lack of institutional support for Part D outreach events, and the availability of community sites that are appropriate for Part D outreach events.
The Principal Investigator from each of the 6 participating colleges or schools of pharmacy was contacted by the Partners in D Evaluation Coordinator in January 2008 to determine the status of incorporating/integrating the Partners in D curriculum at their respective schools. They were asked the same series of questions relating to the type of course, if any, where Partners in D material was integrated; time devoted to teaching the didactic portion of the Partners in D curriculum; number of students trained (and which year they were in pharmacy school); and how many hours of community outreach (if any) were required of the students.
Schools were asked to complete an online survey instrument every time they completed an outreach event where the student participants had received training with the Partners in D curricular material. This survey asked general descriptive questions about the outreach event (location, date, and number of attendees) and demographic characteristics of the attendees (ie, languages spoken, ethnic/racial background, and socioeconomic status).
Descriptive statistics were used to summarize demographic characteristics of the participants and where participants' responses had no comparator group (ie, questions only appearing on the posttest). Paired t test (for continuous variables), McNemar's test (for nominal variables), or Wilcoxon signed rank test (for ordinal variables) was used to compare responses before and after the train-the-trainer program. Due to the small sample size, we did not complete any subanalyses on participant responses stratified by demographic characteristics. All significance calculations were based on a 95% confidence interval at an alpha of <0.05. Data analyses were performed using SPSS, version 15.0 (Chicago, IL).
Seventeen participants from the 6 colleges or schools of pharmacy attended the train-the-trainer program. Of the participants, 1 was a professor, 2 were associate professors, 11 were assistant professors, 1 was a clinical instructor, 1 was a resident, and 1 was a community pharmacist and PhD candidate. The average age of the participants was 39 ± 13 years. The average length of time in their current position was 5 ± 7 years, and their average length of teaching experience was 10 ± 11 years. When asked about their prior experience with Part D, 9 had read or heard about Part D through the media or peer-reviewed journals, 5 had personal experience with it through friends or family members, 4 had clinical experience with Part D, 3 had received prior instruction in Part D, 2 had participated in Part D outreach activities, and 2 had teaching experience with Part D. Importantly, 3 participants stated they had no experience with Part D prior to the train-the-trainer program.
The participants demonstrated a significant increase in their knowledge of the Part D benefit as indicated by improved accuracy of responses to 8 of the 12 questions (Table (Table1).1). Of the 4 questions that did not show a significant increase, 3 had been answered correctly by the majority of participants (77% to 82%) at baseline.
We observed significant increases in participants' proficiency with the Medicare Prescription Drug Plan Finder tool. Fourteen of the 17 participants achieved perfect scores on all the Plan Finder questions after the train-the-trainer program, compared to none at baseline (Table (Table2).2). Additionally, the duration of time necessary to complete the case study was reduced by 51%, from 18.9 minutes to 9.2 minutes.
The participants experienced significant increases in their confidence in teaching every component of the Partners in D outreach material to pharmacy students (Table (Table3).3). Eligibility requirements for the low-income subsidy showed the lowest confidence at baseline (mean = 1.6). On the posttest, the lowest confidence items were those on the financing of Part D (mean = 3.4) and geriatrics (ranged from 3.4 - 3.6).
Participants were asked to rate the overall usefulness and likelihood of adoption of 6 curriculum material components: lecture slides, instructor notes, case scenarios for role playing, instructor guidelines accompanying the case scenarios, the trigger tapes (patient video clips), and the ancillary student handouts. All components were well-received and appeared likely to be adopted by the 6 schools. The lecture slides and instructor notes received the highest ratings for usefulness, with all 17 participants rating them either very good or excellent. Both the lecture slides and instructor notes also were rated the highest for likelihood of adoption. Twelve participants rated them as extremely likely to be adopted, and 4 rated them as very likely to be adopted.
The participants were most concerned about the lack of available community sites that are appropriate for Part D outreach and the lack of available curriculum time. As for potential barriers to implementation of evaluation tools, 4 participants expressed concern about the patient evaluations and 3 participants were concerned about Internet access issues during outreach events.
When asked about their perception of the train-the-trainer program, all participants reported that their knowledge, skill mastery, and confidence improved. Additionally, all participants found the program useful and would recommend it to other pharmacy faculty members. All but 1 of the participants would recommend this program to faculty members from other health professional schools.
Eight weeks after the conclusion of the training, 5 of the 6 schools were able to integrate some aspects of the Partners in D curriculum into the fall 2007 quarter/semester (Table (Table4),4), and the sixth school adopted the curriculum change in the fall 2008 semester. Two schools were able to create entirely new elective courses that focused exclusively on Partners in D curriculum and community outreach. Student interest in these 2 new courses was so great that enrollment had to be limited to 20 students. The remaining 4 schools integrated Partners in D curriculum into existing courses. Across the 6 schools, 742 students were trained in the didactic component of the curriculum, with the amount of time dedicated to didactic instruction ranging from 2 hours to 19 hours. Of these students, 240 students from 5 of the schools received additional training in the outreach component and were required to conduct Part D–related outreach activities.
Community outreach events were completed by 5 of the 6 schools, starting with the first event on November 3, 2007, and continuing through the end of December 2007, which marked the end of the Part D open enrollment period (Table (Table5).5). Twenty-one events were conducted throughout the state of California, targeted specifically at underserved populations (eg, low or no English literacy, low educational level, low socioeconomic status), and 186 seniors were individually counseled by pharmacy students about Part D.
The train-the-trainer model appears to be an effective method for disseminating health care educational interventions as suggested by documented improvements in faculty knowledge and confidence in teaching the content areas, in addition to assessments of curricular adoption and impact on trainees. 6-8;12-19 The sharing of evidence-based, comprehensive, and “turnkey” curricula via the train-the-trainer method has been cited as a faculty development approach that benefits faculty members, students, institutions, and ultimately society.20 In this study, we found that targeted training of faculty members with a Part D community outreach program resulted in significant improvements in knowledge of Part D, skill mastery of the Medicare Plan Finder tool, and increased confidence in teaching the materials to other learners. Faculty members participating in the Partners in D train-the-trainer program did not begin the training with high levels of confidence or experience in teaching Part D material. Despite this initial lack of confidence and experience, faculty members were able to significantly improve over the course of the training. Perhaps most striking was the significant improvement in applying the information learned in a simulated patient scenario (as demonstrated by the improvements in the accurate assessment of plan choices for a patient case, using the Medicare Plan Finder tool). Further, participants' confidence and perceived ability to teach the material increased by the end of the training. While the perceived likelihood of adoption and confidence in abilities to teach train-the-trainer material at the faculties' home institution is an important finding, the ability to implement the curricular material in 5 of the 6 schools within 8 weeks of the training is even more significant.
As previously discussed, the purpose of the Partners in D curriculum was to train pharmacy students as experts in Part D who could perform community outreach for underserved populations. As a result of the Partners in D curriculum, 6 schools participated in 21 Part D community outreach events across California. Thus, the Partners in D train-the-trainer program achieved its goal to train pharmacy students to provide outreach in the community within 4 months following completion of the program. We are unaware of any studies that have evaluated the impact of a train-the-trainer program on the target patient population. This impact on our target population was evaluated as a cost minimization study and found that outreach interventions performed by trained student pharmacists reduced the out-of-pocket drug expenditures by Medicare beneficiaries. 21
The primary concerns expressed by train-the-trainer participants centered around 3 key areas. The first concern related to the technology needed to perform an outreach in the community (ie, Internet access to use the Medicare Plan Finder tool, computer access, printers, etc). Many faculty members did not feel that their target communities would have ready Internet or computer access. Since most students owned a laptop, it was determined that Internet access was the larger concern. As a result, the research team secured mobile broadband cards, routers, and network printers for each institution to provide readily available Internet access at all sites where a cellular phone signal could be detected.
The second concern related to the faculty involvement necessary at each institution to ensure appropriate preceptorship of pharmacy students at each outreach event. Although this was a concern at the train-the-trainer program, 5 of the 6 colleges and schools were able to perform outreach with pharmacist faculty supervision. The new Accreditation Council for Pharmacy Education (ACPE) standards that require pharmacy students to participate in introductory pharmacy practice experiences (IPPEs) may have helped secure more faculty preceptors. This IPPE requirement is uniform across all colleges or schools of pharmacy, and because the Part D outreach activity involved direct patient encounters, it was recognized as an appropriate IPPE at participating schools.
Third, the faculty members expressed concerns related to the patient evaluation form that was used to collect patient knowledge and attitudinal and behavioral changes as a result of the Part D encounter with a pharmacy student. As a result of this concern, an evaluation subcommittee was formed to improve the evaluation tool, broader pretesting was conducted at multiple sites, and the tool was translated into multiple languages.
There were 2 key limitations to this study. First, the 6 schools received funding as subcontracted institutions under the Partners in D program. This funding was discussed with the dean and chair of each college or school of pharmacy, thus providing school “buy-in” before the train-the-trainer program was initiated. However, the rapid implementation of the curriculum speaks to the ease of integration and highlights the improvements in faculty abilities to teach the Partners in D material. Second, we did not re-test the knowledge of the participants after the posttest was administered on the second day of the program; thus, longitudinal knowledge retention cannot be reported.
There is a need to provide Part D outreach services to Medicare beneficiaries throughout California and across the country, particularly to those patients with low incomes and those with little or no English proficiency. The Partners in D outreach curriculum is an innovative train-the-trainer program that could help train pharmacy students and faculty to provide Part D outreach to underserved communities across the United States.
Funding of the Partners in D program was received from the Amgen Foundation. The authors would like to acknowledge Karen Hudmon and Christine Fenlon for their mentorship in helping us develop the train-the-trainer program and Tara Allen, Eric Davila, Susan Haley, Eric Lai, Susan Levings, Thomas Yi, and Sharon Youmans for their assistance during the train-the-trainer program. The authors would also like to acknowledge Mitra Assemi, Bree Johnston, and Sharon Youmans for Partners in D outreach material development, as well as the faculty participants for their feedback, enthusiasm, and assistance in implementing the outreach curriculum throughout the state.