IMPLEMENTATION AND OUTCOMES OF NEBRASKA PHARMACISTS … · IMPLEMENTATION AND OUTCOMES OF NEBRASKA PHARMACISTS CHRONIC DISEASE, PREVENTION AND MANAGEMENT CONTROL PROGRAM 2016 4 Payments

IMPLEMENTATION AND

OUTCOMES OF NEBRASKA

PHARMACISTS CHRONIC

DISEASE, PREVENTION AND

MANAGEMENT CONTROL

PROGRAM 2016

12/31/2016 FINAL REPORT on 29918-Y3 SUB AWARD

Award Name: Nebraska’s Public Health Actions to Prevent and Control Chronic Diseases Submitted by: Kimberly Galt Submitted to: Danielle Wing Term: January 1, 2016 through September 29, 2016

IMPLEMENTATION AND OUTCOMES OF NEBRASKA PHARMACISTS CHRONIC DISEASE, PREVENTION AND

MANAGEMENT CONTROL PROGRAM 2016

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Table of Contents

PURPOSE ................................................................................................................................................................................... 3

CONTRACTED SERVICES ........................................................................................................................................................ 3

SELECTION OF PHARMACIES ............................................................................................................................................... 4

SELECTION OF CLINICAL AND COMMUNITY PARTNERS ............................................................................................... 5

Determination of Stipends ................................................................................................................................................. 5

Participating Pharmacies and Partners in Bi-directional Referral ............................................................................ 6

EXPECTED OUTCOMES .......................................................................................................................................................... 7

BENCHMARKS AND EARLY ACHIEVEMENT IN START UP OF PROGRAM ................................................................... 7

OUTCOMES ACHIEVED .......................................................................................................................................................... 9

Pharmacy Case Stories ...................................................................................................................................................... 9

Patient Care Outcomes ...................................................................................................................................................... 9

Fedback from Patients and Providers ........................................................................................................................... 10

LESSONS LEARNED ............................................................................................................................................................. 10

Determine what services to provide ............................................................................................................................. 10

Determine the population size anticipated to receive services ............................................................................... 10

Determine how to offer the service .............................................................................................................................. 11

Track the impact of offering the services .................................................................................................................... 12

Renovate the physical facilities and reform the infrastructure support you need to offer services.................. 12

Disseminate information about the program to other care professionals to encourage referrals and the community to encourage self referrals ........................................................................................................................ 13

DISSEMINATION ACTIVITIES TO PROMOTE TRANSLATION ACROSS NEBRASKA ................................................ 13

PHARMACY CASE STORIES ................................................................................................................................................. 14

Mark’s Pharmacy ............................................................................................................................................................... 14

Sutton Pharmacy .............................................................................................................................................................. 17

Weaver Pharmacy ........................................................................................................................................................... 20

OneWorld Community Health Centers ......................................................................................................................... 21

OneWorld Community Pharmacy .......................................................................................................................... 21

OneWorld Outpatient Clinics ................................................................................................................................. 21

Hy-Vee Community Pharmacy ....................................................................................................................................... 25

Arbor State Pharmacy .................................................................................................................................................... 26

Deines Pharmacy .............................................................................................................................................................. 27

TABLES ....................................................................................................................................................................................... 6

Table 1. Participants ......................................................................................................................................................... 6

Table 2. Initial Benchmarks in Pharmacies During Program Start Up ...................................................................... 8

Table 3. Outcomes Achieved in Pharmacies During the Initial Start Up Period .................................................... 9

FIGURES .................................................................................................................................................................................... 4



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Figure 1. Services ideally present in pharmacies being considered for participation ........................................ 4

Figure 2. Stipend model for pharmacies. .................................................................................................................... 6

APPENDICES ........................................................................................................................................................................... 29

Appendix A Overview for medical champions ........................................................................................................... 29

Appendix B Hypertension: pharmacists service and patient self management .................................................... 30

Appendix C Creighton Magazine ................................................................................................................................. 33

Appendix D Marks Pharmacy – BP monitoing agreement and intervention sheet............................................... 34

Appendix E Marks Pharmacy – patient education ..................................................................................................... 35

Appendix F Marks Pharmacy – BP monitor data download .................................................................................... 36

Appendix G Marks Pharmacy – bag stuffer .............................................................................................................. 38

Appendix H Marks Pharmacy – Cambridge newspaper reprints ........................................................................... 39

Appendix I Sutton Pharmacy – patient log ................................................................................................................ 40

Appendix J Sutton Pharmacy – patient flow sheet ................................................................................................... 41

Appendix K Sutton Pharmacy – bag stuffer .............................................................................................................. 43

Appendix L OneWorld CHC – patient assesssment for suitability to receive home BP monitor ....................... 44

Appendix M OneWorld CHC – monitoring form ....................................................................................................... 45

Appendix N OneWorld CHC – collaborative practice agreement ........................................................................ 46

Appendix O OneWorld CHC – clinical pharmacist protocol ................................................................................... 49

Appendix P OneWorld CHC – patient education sheet ........................................................................................... 52



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IMPLEMENTATION AND

OUTCOMES OF NEBRASKA

PHARMACISTS CHRONIC DISEASE,

PREVENTION AND MANAGEMENT

CONTROL PROGRAM 2016 F I N A L R E P O R T O N 2 9 9 1 8 - Y 3 S U B A W A R D

PURPOSE

This project explores the structure, process and outcomes of community pharmacies/ pharmacists and

their associated clinical and community partners to: (a) Determine how to improve chronic disease

management models; (b) Identify critical aspects to scale high functioning/high performing models in

additional communities throughout the state of Nebraska, while providing support for selected pharmacies

and medical practices to engage in Nebraska Pharmacists Chronic Disease Prevention, Management and

Control Program aimed at improving chronic disease care for patients, particularly around hypertension and

diabetes, through the integration of pharmacists’ services; and (c) Aid in the sharing of best practices among

pharmacists, providers, and organizations.

CONTRACTED SERVICES

Upon completion of this contract period finalized agreements were to be reached with up to 10

Pharmacists, Pharmacies, Providers and/or Clinical sites in Nebraska in partnership with DHHS, Creighton

University Center for Health Services Research and Patient Safety and the University of Nebraska Medical

Center. Absence of key leaders in the employment positions required at the University of Nebraska Medical

Center made for unfortunate timing during this period, so this aspect of the relationship will be developed

more fully in the coming year’s plans. Each participating pharmacist had to allow for: (a) Conducting site

visits, interviews, and directly observing activities at each site; (b) Conducting interviews with entities that

pharmacists work with to accomplish bi-directional referral; (c) Review artifacts and documents describing

structure, process and outcome components that affect medication management and chronic disease

management activities; (d) Determine the factors that influence pharmacists conduct of medication

management and chronic disease management activities; (e) Train and guide sites in how to participate in the

project, including describing and outlining bi-directional referral, determining factors that influence referral,

and recommending and working through changes to bi-directional referral approaches with each

participating site; (f) Establishing a project time line and quarterly benchmarks for these efforts with DHHS

staff; and (g) Monitoring site progress to determine if sites have met benchmark obligations and issue

payments to sites for participation.



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Payments to participating Pharmacists, Pharmacies, Providers and/or Clinical sites in Nebraska

Pharmacists Chronic Disease Prevention, Management, and Control Program were managed by Kim Galt

under this contract. She (a) Oversaw financial administration of the Nebraska Pharmacists Chronic Disease

Prevention, Management, and Control Program, and issued participation payments to participating

pharmacies and medical practices, upon receipt of an invoice; (b) Provided an accounting report for the

distribution of funds for the program; and (c) Participated in regular communications with DHHS about

progress from each site via telephone, email or in-person meetings.

A dissemination plan was developed and implemented for the professionals in the state of Nebraska

with input from key stakeholders, such as but not limited to, the schools/colleges of pharmacy, professional

associations, employers, consumers, and government personnel. This included supporting and facilitating in-

person, web-based or remote learning and/or connections between Pharmacists and Providers to aid in best

practice sharing across organizations.

SELECTION OF PHARMACIES

Pharmacy sites were selected based upon the following criteria: (1) services identified in Figure 1 already being provided, (2) bidirectional referral processes taking place on these services between pharmacist and other clinical partners in the community, (3) bidirectional referral processes between other community entities and the pharmacist, (4) collaborative practice agreement in place for at least one clinical activity (e.g., immunizations), and (3) desire to advance their scope of service to patients in their communities related to care delivery in hypertension (HTN) management, and other chronic diseases. Pharmacies of interest might also have indicated a relationship, either with an Accountable Care Organization (ACO), or as part of a Patient-Centered Medical Home (PCMH). Pharmacies were identified in each public health district within the state based upon the 2015 Nebraska Community Pharmacy Demographics study led by Dr. Kim Galt (full access available from Ne DHHS). A total of 501 community pharmacies were surveyed (68% response rate) about the services they offer in chronic disease management that emphasize self-care and the ability of the patient to interact with the pharmacist to improve self-care. We used these survey results to identify potential pharmacies for inclusion.

Figure1. Services ideally present in pharmacies being considered for participation

Participants in this project were required to do one or more of these strategies to improve patient care services and connections to the larger health care community:

Expand Medication Therapy Management Services (MTMS) services to include HTN referrals

Develop educational marketing materials to inform community of HTN management services

Blood pressure checks, including self-service blood pressure machine

Hypertension self-management education, formal to individuals or groups

Diabetes self-management, formal to individuals or groups

Comprehensive drug therapy review (e.g., brown bag review)

Medication adherence assistance (e.g. telephone/text reminder refill, counseling, pill organizers)

Home delivery of medications and supplies

Medication Therapy Management Services



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Obtain additional training to enhance quality/scope of HTN management services

Present findings of case experience to other pharmacists in region/state/nation

Implement expanded scope of practice within an existing Collaborative Practice Agreement (CPA) for HTN management

Implement formal referral processes within community

Implement documentation of services

Implement tracking of referrals

Engage Community Health Workers with patient referral opportunities in the community1

Engage Community Health Workers in care delivery services (transportation, obtaining medication refills, other daily services needed by patients). A breadth of community pharmacy types was of interest in this initial launch. Program implementation

successes and challenges may be dependent upon the extent of autonomy possible at the local pharmacy level, and the extent of resource allocation decision making that takes place locally. So we tried to select pharmacies that included independent community pharmacy ownership, small chain community pharmacy ownership, a federally qualified health center model, a large chain pharmacy, and a grocery chain pharmacy or mass merchandising pharmacy.

Final determination. Site visits were made to each pharmacy under consideration. The expected

outcomes were discussed. The willingness, preparedness and enthusiasm were evaluated and if compatible, a mutual agreement reached. Each pharmacy signed a Memorandum of Understanding (MOU) as a mechanism for agreement of responsibilities.

SELECTION OF CLINICAL AND COMMUNITY PARTNERS Pharmacies described where partnerships were already strong and naturally occurring in patient care. Each was asked to identify the partners and partner model that would best fit the pharmacy’s program offerings.

Determination of stipends

Pharmacy stipends. Each pharmacy is provided stipend monies to support the activities related to program implementation. Stipends have been agreed to as shown in Figure 2. Pharmacies could use these resources to hire additional help to carry out infrastructure support of the pharmacy, use funds to educate/train pharmacists and technicians on skills required, or support the dissemination of program availability through community relations, media outlets and promotional and educational materials for distribution.

Partner stipends. Pharmacies were encouraged to discuss possible stipends for their clinical partners

and community partners. These stipends could range from $3,000 to $5,000, based upon the extent of engagement and activity the pharmacist could expect from the partner participation. Talking points were prepared for the pharmacists for the conversation (Appendix A). The establishment of more formal

1 Community Health Workers (CHW) is a trusted member of and/or has a good understanding of the community and serves as a liaison/link to the health

system and community to facilitate access to services and improve the quality and cultural competence of service delivery. Other names for this type of health care provider include promotor(a) de salud, community health representative, lay health ambassador, community health advocate, outreach worker and lay health advisor.



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partnerships and possible stipends is in process. We left the possible offer of a stipend up to the pharmacists based upon what the needs and desires are between the entities.

Figure 2. Stipend model for pharmacies.

Participating Pharmacies and Partners in Bi-directional Referral

Pharmacies have been gradually enrolled, as have their partners. Table 1 displays the sites engaged to date. Expansion of engagement is planned for the coming year. Table 1. Participants

Stipend Scope and Level of Participation $7,500 Pharmacy concentrating on blood pressure care program by implementing a

pre-existing model in the state with a selected patient population and has one clinical partner responsible to the program. When multiple sites involved within the same health care system, each location qualifies for a stipend.

$10,000 Pharmacy is part of a consortium across a community, concentrating on blood pressure care program development requiring some innovation but it is shared across the pharmacies; and may have one or two clinical partners responsible to the program.

$15,000 Pharmacy developing comprehensive blood pressure care program by developing local model that best serves the full population of the pharmacy and the greater area. No assistance through a larger pharmacy consortium is taking place, and the pharmacy is taking full responsibility for advancing their

services across one or more clinical partners and community partners.



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EXPECTED OUTCOMES Expected Outcomes. To determine how to improve chronic disease management models, participants were expected to provide (a) open disclosure and description by each participating pharmacy and pharmacists service model operations and (b) pharmacy site specific metrics describing the operations and services within the site. To identify critical aspects to scale high functioning/high performing models in additional communities throughout the state of Nebraska, while providing support for selected pharmacies and medical practices aimed at improving chronic disease care for patients, particularly around hypertension and diabetes, through the integration of pharmacists’ services, participants were expected to (a) assess the potential amongst the population served locally in the pharmacy to participate in this program, (b) assess the modifications needed to add this program offering in the pharmacy workflow and load, (c) provide staff education and training, (d) prepare policies, procedures, and patient care program materials for use in the program offering, and (e) begin patient engagement and enrollment in the program. To aid in the sharing of best practices among pharmacists, providers, and organizations, participants were expected to (a) provide their opinions about what works well, (b) what does not work well, and (c) share materials, procedures and findings for cross sharing with other pharmacists for future program development in other pharmacies.

Patient care outcomes expected include reporting the number of patients who self-monitor their blood

pressure (BP) and return to the pharmacists for assessment, and the number of consultative reports/feedback the medical practices receive from pharmacists involved in chronic management of patients with hypertension. Community linkages are reflected in the number of referrals that occur. Eventually, we expect to see an increase in the number of health care clinics/systems that are integrating pharmacists into care provision for blood pressure and diabetes management, and an increase in the number of health care clinics/systems that integrate management of blood pressure through engagement of the pharmacist in patient therapy plans, including self-management, lifestyle changes, and medication management.

BENCHMARKS AND EARLY ACHIEVEMENT IN START UP OF PROGRAM

Table 2 describes the initial benchmarks and progress made during this program start up. Most

pharmacies did not count benchmark standards to assess their own progress and programmatic outcomes prior

to this program being initiated. This first year of the project involved identification of sites to involve,

conducting a baseline assessment of the pharmacies current services and opportunities for further service

integration. Overall, progress was excellent and set the stage for pharmacies to continue to develop and

provide services indefinitely. Considerations about processes and lessons learned are summarized later in the

report, and in the individual pharmacy case stories included. The cases described in this initial year include:

Independent solo owned community pharmacy (Mark’s Pharmacy) serving greater Cambridge and

surrounding areas.

Independent solo owned community pharmacies serving the same geographic community of the

greater Beatrice area (Arbor State Pharmacy and Deines Pharmacy).

Small community chain pharmacies serving difference communities of Sutton and Geneva and have

same primary owner with co-owners) (Sutton Pharmacy and Weaver Pharmacy).



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Grocery chain pharmacy working in cooperation with federally qualified health center patients

residing in the Plattsmouth area (HyVee Corporation and One World Health Community Health

Center in Plattsmouth).

Federally qualified health center community pharmacy in the South Omaha area serving all patients

who choose to select the pharmacy (One World Health Community Center).

Federally qualified health center pharmacist network serving with one pharmacist in the primary care

clinic (One World Health Community Center in South Omaha) and one working with patients in the

outreach clinic sites (One World Health Community Health center in Plattsmouth; Northwest Omaha

and Southwest Omaha).

Table 2. Initial Benchmarks in Pharmacies During Program Start Up

Benchmark Activity

(C = complete; I – in process; NA = not

applicable)

Name of Pharmacy

(Month started in program)

Ma

rk’s P

harm

acy

(A

pri

l 2

016

)

Sut

ton

Pha

rma

cy

(M

ay 2

01

6)

One

World H

ealth

Pha

rmacy

(Ma

y 2

01

6)

One

World H

ealth

Prim

ary

Clini

cs

(Jun

e 2

01

6)

Hy-V

ee P

harm

acy

(Ju

ne 2

016

)

Dein

es

Pha

rma

cy

(Jul

y 2

016

)

Arb

or

Sta

te P

harm

acy

(Ju

ly

20

16

)

Wea

ver

Pha

rmacy

(J

uly 2

01

6)

Assess pharmacy capability (work force, space, environment, population served) to expand services to include greater contact time with the patient and the patient’s pharmacy records.

C C C C C C C C

Determine readiness of pharmacy – provider relationships to support expanded services resulting in information exchange and referral with providers (exchange can take place in any communication format).

C C C C C C C C

Determine potential amongst population served to receive these services.

C C C C C C C C

Determine program(s) offering that is sustainable with the pharmacy business model.

C C C C C C C C

Provide staff training prior to program launch. C C C C C C C C

Prepare policies, procedures and protocols prior to program launch.

C C C C C C C C

Prepare patient education materials. C C C C C C C C

Prepare systematic method for documenting patient care in the pharmacy.

C C C C C C C C

Patient tracking system developed. C C C C C C C C

Prepare procedures for bi-directional referral for services. C C C C C I I C



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OUTCOMES ACHIEVED

Pharmacy Case Stories

Each pharmacy has characteristics about itself, the community served and the approach the

pharmacists offer services with. Case stories are written for each of the pharmacies and follow this summary

report. From these case stories and metrics reporting, we have generated quantifiable outcomes and lessons

learned.

Patient Care Outcomes

Patient care outcomes related to this program are summarized in table 3. While the goal of this first

year was to understand how pharmacists can deliver systematic and bi-directional chronic disease

management care with hypertension as the primary condition to anchor this from, services were initiated and a

substantial amount of care provided. Outcomes related to blood pressure and hypertension care achieved

through the sites studied are shown. Self-care through encouraging self BP measurement and monitoring to

patients is as clear activity relatively unique to pharmacies – a ready outlet for self-care monitoring devices in

the community. Quantitative findings reflect various start up time periods for each individual pharmacy. This

data demonstrates the extent of engagement achieved by each pharmacy within the context of the local

community served, with each pharmacy being enrolled and started up asynchronously. Some of the

pharmacies had 6 months to get started and enroll patients while others only 6 weeks of enrollment.

Regardless, initial success was outstanding given the startup efforts required to formalize many activities.

Table 3. Outcomes Achieved in Pharmacies During the Initial Start Up Period

Outcomes to Date Since Start of Program

Ma

rk’s P

harm

acy

Sut

ton

Pha

rma

cy

OW

H P

harm

acy

OW

H L

ivest

ock

Exch

ang

e

OW

H W

est

Clini

cs

OW

H N

ort

hwest

Clini

cs

OW

H C

ass

Clini

cs

Hy-V

ee P

harm

acy

Dein

es

Pha

rma

cy

Arb

or

Sta

te

Pha

rmacy

Wea

ver

Pha

rmacy

TOTA

L A

CRO

SS

SIT

ES

Number of Patients with pressures recorded 54 40 26 78 17 12 4 12 51 45 63 494

Number of Patients issued/sold BP monitors 50 1 8 30 11 8 1 0 3 0 5 106

Number of patients continuing to be monitored 46 8 7 7 6 4 3 4 6 3 16 89

Number of patients lost to follow-up 6 NT 1 17 2 2 2 NT NT 0 0 30

Number of reports sent to prescribers (bi-direct referral)

108 NT 56 157 28 22 6 12 0 7 79 463

Number of prescribers who have receive reports 23 4 26 78 17 12 4 12 0 2 6 31

Number of patients that achieved therapeutic goal

-- 30 18 54 10 7 2 NT 45 NT NT 136

Number of undiagnosed patients enrolled in care

6 0 NT NT NT NT NT NT 0 3 NT 9

Number of patients referred from prescribers 5 0 NT NT NT NT NT NT NT NT 0 5

NT = “not tracked”



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Feedback from Patients and Providers

Patient feedback has been positive. This is evident from the high rate of early enrollment and

participation and low rate of patients lost to follow up (drop out or don’t enroll). Self-care and

empowerment are observed through the high use and purchase of BP monitors by patients who enroll.

Patients’ disenrollment (low rate) has occurred for these reasons: transfer to nursing or assisted living facilities

from home, have intolerance of cuff pressure on their arm (elderly) or choose to refuse treatment because

they ignore their condition. Provider (prescriber) feedback is positive. Prescribers cite trust in the data and

appreciate the ease of patient access to care as prime advantages. Bi-directional referral is common

already in local communities between pharmacists and primary providers. However, almost all of this activity

is done through telephone calls. Providers like receiving the information in a form that can be included as

documentation in the patient’s medical record. Pharmacists were able to create documentation within the

pharmacy record in some systems.

LESSONS LEARNED

Successful program implementation has unique aspects in each pharmacy, primarily driven by what is

already in place, and what needs to be developed. Common lessons did predominate, however. These may

be valuable to other pharmacists who are going to implement such programs. These were gleaned from

observations and interviews of the pharmacists who participated in this initial launch program.

Determine what services to provide

Pharmacists need to determine the level of services they can offer that are sustainable and packaged in a program. A guideline was developed to help pharmacists evaluate the scope of services possible and determine what they are ready to offer. This guideline is attached as Appendix B. Services may be blood pressure screenings, blood pressure self-management education – including sale and use of BP monitoring device, blood pressure monitoring and patient care assessment with recommendations made via telephone at time patient is cared for or referral to primary provider when medical attention required, and finally, blood pressure treatment under a collaborative practice agreement with one or more primary providers. Determine the population size anticipated to receive services

Estimate the potential number of persons who your services can be provided to in order to assess

workload. Estimate the number of persons who need BP checks based upon their use of antihypertensive

therapies through your prescription database. You may be able to search and find the number of persons

who have active prescriptions filled for antihypertensive therapy.

Reach out to existing patients who are highly likely to benefit. Not all patients will accept community

pharmacy blood pressure monitoring. It is observed throughout these case studies that a small proportion of

patients do not accept any blood pressure monitoring and do not want to participate. Most patients welcome

services and have expressed appreciation to the pharmacists for having this relationship formed.

Sent personalized letter about enrollment.

Patient recruitment and case management are a constant work-in-progress



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Determine how to offer the service General findings regardless of the services pharmacists decide to provide:

Flag all hypertension patients in your pharmacy records for screening. This identifies for you what your potential population numbers are and helps to predict workload you might anticipate once you start this program systematically

A combination of both a walk in model of care and appointment model of care is optimal, if pharmacist is offering more than drop in BP screenings.

o “Walk in” (without an appointment) model of care has led to increased numbers of persons initiating care themselves and often the desire to self-monitor BP.

o “Appointment model” appreciated by patients with multiple medications where BP monitoring and MTM is combined who are able to travel to the pharmacy and do not find this a barrier.

Home BP monitors have been found useful and desirable by patients who have the capacity to use them. Make sure to assess this with a simple screening tool.

Home BP monitors are also useful to those patients in these programs when the patient experiences episodes of hypotension, is known to have white-coat hypertension and those with scheduling or transportation difficulties.

Home BP monitors with downloadable results has high value for pharmacist and patient self-monitoring. Consider having these monitors as the preferred ones to recommend and teach patients to use. Use this approach to retrieve results from at-home devices through visits or have devices brought in to pharmacy for download.

Uses validated monitors and ensure patient technique is appropriate.

If you limit your service to Blood Pressure screenings:

Offering a free, anytime reliable service with results recorded in the pharmacy record and sent to the patient’s doctor at the time of requesting refills/renewals has been received extremely well by both patients and providers.

Contact primary physician immediately for critical results (per JNC 8 standards)

Write down the results for the patient on a wallet/BP monitoring card

Consider the possibility and recommendation of a home BP monitoring device, if it seems a good fit with the patient’s situation.

If you limit your service to screening Blood Pressure and Blood pressure self-management education – including sale and use of BP monitoring device:

Offer your screening service as described above. Then consider drop in education sessions, appointment times, or group education classes for your patients.

Counsel patient and provide materials. Providing written and video education materials to supplement pharmacist provided training to patients has made this well received by patients.

Input results into the patient’s pharmacy record in your pharmacy computer system if you can do so in an easily accessible format. Based on the type of pharmacy record system you have; this may be readily available as a software feature already. If not, create this feature in your computer clinical notes area for tracking patients’ progress. If no computer system option is available, maintain a log of blood pressure results manually using a tracking system for patients so that the information is readily available for use on revisit.

Downloadable BP devices have a large impact on reducing workload.



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Technicians can be trained to make reminder phone calls to have patients bring BP devices in for

downloading and interpretation.

Invest in patient lifestyle modification education and encouragement of self-monitoring blood pressure

measurement.

If you offer Blood pressure monitoring and patient care assessment with recommendations made via telephone at time patient is cared for or referral to primary provider when medical attention required:

Offer your screening service as described above.

Offer drop in and scheduled appointment options to patients.

Program enrollment involves 3 different patient types as a result of screening and monitoring activities: (a) through BP screening and drop in activities previously undiagnosed cases are identified – so newly diagnosed hypertensive, (b) patients on antihypertensive medications and benefit from monitoring for effectiveness, and (c) patients referred to the program by prescribers or other organizations – a bi-directional referral.

This program offers comprehensive medication therapy management focused on hypertension as the primary condition that brought the patient to your program. However, these patients are likely to need a complete medication review and to receive an MTM service model from the pharmacist. Patient should either be coming periodically for the pharmacist to check the patient’s blood pressure or be provided and taught how to use the BP self monitoring device.

Maintain a clinical pharmacy care record on each patient.

Relay information gathered to patient’s physician with refill requests or when care is needed more urgently.

Technicians can be trained to make reminder phone calls to have patients bring BP devices in for

downloading and interpretation.

Blood pressure treatment under collaborative practice agreement with one or more primary providers:

Establish a collaborative practice agreement with the prescribers that are willing to support your services. Take the initiative to develop the practice protocol and set up the arrangement individually with each prescriber or prescribing group commonly prescribing medications for the patients whose prescriptions you fill.

Track results, monitor progress, adjust therapies in conjunction with prescriber within the collaborative practice agreement protocol.

Record findings in the pharmacy care record and report findings to the prescriber as suggested in the other services.

Track the impact of offering the services

Tracking patient participation, clinical outcomes, referral activity, and financial impact provide the needed facts to maintain the program successfully. Each pharmacy case story identifies the tracking outcomes at the time each site initiated services. Further development at each site will be part of the coming year’s work.

Renovate the physical facilities and reform the infrastructure support you need to offer services

Physical modification of pharmacy is needed to provide privacy and professional environment, and is worth the investment and effort.



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Find the best way to accommodate your work flow, each pharmacy operates differently.

Disseminate information about the program to other care professionals to encourage referrals and the community to encourage self referrals

Physician clinics, hospital discharge planner, county health organizations and other professionals are important to detail about the program. Prescribers support this program – improved patient outcomes is beneficial for their practice success as well.

Newspaper articles and radio “appearances” to inform the public

Bag stuffers to inform the community who frequents the pharmacy.

Consider providing a continuing education presentation to physicians in your community about the program.

Provide professionals in your community with flyers and brochures for their own use and to share with their patients.

Consider reaching out to the community to provide screenings for pre-diabetes and pre-hypertensive patients. This can be particularly successful if you partner with your local health department.

DISSEMINATION ACTIVITIES TO PROMOTE TRANSLATION ACROSS

NEBRASKA

Dissemination of progress has been targeted at several groups: (a) local residents in the participating

pharmacy areas about the services available, (b) other pharmacists and health professionals who can

facilitate connecting patients to these services, (c) other pharmacists who may desire to expand services in a

similar way, and (d) local health departments. To date the following dissemination activities have taken

place:

1. A presentation about the program and funding was made to the Nebraska State Board of

Pharmacy. This presentation was made by Dr. Kim Galt and Ms. Danielle Wing.

2. A presentation was provided at the University of Nebraska Medical Center Pharmacy Preceptor

Program in fall of 2016. This program reaches over 100 pharmacists who precept pharmacy

students across the state of Nebraska in community and hospital settings. Mark McCurdy (Mark’s

Pharmacy), Dana Griess and Bill Weaver (Sutton Pharmacy/Weaver Pharmacy), and Thea Ramos

and Jennifer Hickman (One World Health Centers) presented about these services they are offering

at the Preceptor Program. This meeting was co-hosted by Ms. Danielle Wing.

3. Newspaper articles and radio announcements were produced and released for a couple of the sites

in local rural communities in Nebraska. These announcements focused on getting persons in the news

catchment area aware of services available at their local pharmacies. A kit for helping local

pharmacies promote services via the media is under development.

4. A feature article about the pharmacies and their programs was published in the

November/December issue of Creighton Magazine (see Appendix C). Creighton Magazine reaches

a readership of 60,000 people. A good portion of the readership are alumni from the health

professions programs of Creighton University – including medicine, pharmacy, nursing (and nurse

practitioner), dentistry, occupational therapy, physical therapy and emergency medical services.



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PHARMACY CASE STORY

Mark’s Pharmacy PO Box 117 624 Patterson St. Cambridge, NE 69022

Mark’s pharmacy provides local services to the greater Cambridge area, provides a daily delivery service to the Oxford community area (about 70 miles round trip), and also serves the nursing home daily in Beaver city. Mark and Cheryl McCurdy have been invested in the community of Cambridge for 27 years. Cheryl is originally from Cambridge and Mark served as the Director of Pharmacy in the local hospital health system for several years. Eventually, he decided to become an independent pharmacy owner when the former pharmacist and owner decided to retire. Services provided prior to blood pressure management program participation Mark’s Pharmacy was already providing: (a) Medication fill/refill synchronization, (b) Adherence follow up through telephone reminder calls made by his pharmacists and technical staff, )c) Initiating medication refill requests to the physicians/clinicians serving the pharmacy patients, (d) Medication adherence packaging for personalized fills/refills, (e) Home delivery of medications, supplies, and devices – traveling 70 miles round trip

MARK’S PHARMACY INDEPENDENTLY OWNED COMMUNITY PHARMACY, INCLUDES, DAILY OUTREACH DELIVERY TO SMALLER COMMUNITIES, LONG TERM CARE PHARMACY AND

LOCAL COFFEE SHOP AND RESTAURANT

IMPLEMENTATION AND OUTCOMES OF NEBRASKA PHARMACISTS CHRONIC DISEASE, PREVENTION AND MANAGEMENT

CONTROL PROGRAM 2016

15

each day, (f) Medication Therapy Management Services to patients served by this local pharmacy through both Outcomes and Mirixa generated patient lists, (g) Medicare Part D prescription program selection and assistance, (h) Long term care medication reviews, (i) Durable Medical Equipment supplies, and (k) drop in blood pressure checks upon a patient’s request. Pharmacists on Mark’s staff have also been active in the community work of participating and promoting local health fairs, serving on the local public health department board, and serving emergency medical services. Blood Pressure Self-Management Program started as a Service Enhancement for Patients and Community Guiding Plan

Challenge met was to develop a program that can meet the needs of persons who come to the pharmacy, as well as, those who live 30 miles away and depend upon our services

Referral requests of physicians and other care providers in the service area sought. Requests for services sought from existing patients and persons in community interested in more self-care.

Promotion visits made with support materials developed/provided to area health care professionals.

News media/ local paper article released about these activities. How Program Works

Program enrolls 3 different patient groups: (a) undiagnosed who are identified through BP checks, (b) on antihypertensive medications, or (c) patients referred to the program by prescribers or other organizations. Since the program was started there were 7 persons identified who had no prior diagnosis of hypertension. They have identified 90 patients likely to be eligible for this program and after a few months had already enrolled 54 of them. Five are new within the last couple weeks of the project period and all of these were referred by prescribers.

Walk in model of care. If patients agree to ongoing monitoring they sign a simple agreement with the pharmacist (see Appendix D)

Free, anytime reliable service with results sent to their doctors to complete the patients care loop. At the outset, 108 reports to 23 prescribers and 1 Veterans Affairs clinic, some requiring medication adjustments.

Provide written and video education materials to supplement pharmacist provided training. Patients indicate they appreciate and value the personal attention. They are also curious about the results and what they mean (see Appendix E).

BP cuffs with downloadable results are sold to patients who are a good fit for self-monitoring. Downloadable BP devices huge impact on reducing workload. Examples of the downloadable results are shown in Appendix F.

Track results, monitor progress, adjust therapies in conjunction with prescriber works well. Use of EQuIPP as a platform to assist with monitoring overall performance progress is a valuable tool.

Monitoring Medicare Star Ratings Performance is part of this effort for overall fiscal assessment and improvement.



16

Prescriber feedback continues to be extremely positive. They cite trust in data and ease of patient access as prime advantages. They also point out that it is beneficial to their own practices to have improved patient outcomes.

Anticipate able to carry 200 patients in this program model so they continue to reach out to existing patients who are highly likely to benefit. Ways this is done include:

o Sent personalized letter about enrollment and awaiting response. o Technician makes reminder phone calls to bring BP device in for download.

Investments in People, the Pharmacy and the Community A software program for recording and reporting results in pharmacy was established. Physician clinics, hospital discharge planner and other professionals have been detailed about program;

working on county health organizations. Bag-stuffers to inform community are now used (see Appendix G). Newspaper articles and radio “appearances” to inform the public (see Appendix H). Physical modification of pharmacy to assure privacy for patients and pharmacist interaction was done.



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PHARMACY CASE STORY

Sutton Pharmacy 210 N. Saunders Ave. PO Box 445 Sutton, NE 68979

Sutton Pharmacy provides local services to the greater Sutton area, also serves the local nursing home daily. Dana Griess, PharmD is originally from Sutton and decided to become a co-owner of an independent chain pharmacy when given the opportunity by pharmacist Bill Weaver. Bill is the owner of Weaver Pharmacy in Geneva – our next Pharmacy Case Story. Sutton Pharmacy has a comprehensive self-care already in place, with outstanding

over the counter product selection, comprehensive durable medical equipment supporting an active practice of an in town physical therapist routinely interacting with the pharmacist for patient self-care recommendations and patient referral when needed. Sutton Pharmacy also supports a shared location for an in town optometry practice and massage therapy service. Dr. Griess completed an ambulatory care residency at Nishna Valley Pharmacy during which she had previously developed a blood pressure management program. This offered the program guidance for starting up the program at Sutton Pharmacy. Dr. Griess and Bill Weaver both are active in the Nebraska Pharmacists association and Dr. Griess is serving on the State Board of Pharmacy. Services provided prior to blood pressure management program participation

Sutton Pharmacy was already providing: (a) Medication fill/refill synchronization, (b) Adherence follow up through telephone reminder calls made by his pharmacists and technical staff, )c) Initiating medication refill requests to the physicians/clinicians serving the pharmacy patients, (d) Medication adherence packaging for

SUTTON PHARMACY SMALL CHAIN COMMUNITY PHARMACY

INCLUDES LONG TERM CARE PHARMACY, OPTOMETRY AND MASSAGE THERAPY SERVICES



18

personalized fills/refills, (e) Home delivery of medications, supplies, and devices, (f) dedicated appointment time for Medication Therapy Management Services to patients one day a week and also telephone MTMS through both Outcomes and Mirixa generated patient lists, (g) Medicare Part D prescription program selection and assistance, (h) Long term care medication reviews done daily at the local facility, (i) Durable Medical Equipment supplies, and (k) drop in blood pressure checks upon a patient’s request. Blood Pressure Self-Management Program started as a Service Enhancement for Patients and Community

Guiding Plan The Sutton Pharmacy program is designed to achieve hypertension control and adherence to medication use through community pharmacy intervention. The goals are to: (a) Improve patient awareness of hypertension and self-management, (b) Improve adherence to anti-hypertensive medication regimens, (c) Increase blood pressure monitoring, and (d) Continue to build treatment models using the triad of

patient, pharmacy, and provider. The pharmacy staff offers free screening during all normal business hours in addition to during special events (sidewalk sale, health fairs, etc.) Physical Facility Sutton Pharmacy has a private counseling area to support patients who participate. This room is currently used for administering immunizations and conducting scheduled Medication Therapy Management visits with patients. Sutton Pharmacy follows a program designed in two parts:

Part 1: Adherence (focus on least compliant to most compliant). In this first part, the pharmacist makes phone calls to all patients who are identified as being <80% adherent. The pharmacist (a) Assesses barriers to adherence (ex: forgetfulness, difficult regimen, do not see value in taking, cost, side effects, etc), (b) Offers solutions to problems identified, (c) Offers Med Synchronization program, Auto

Refill program with “text” notification that prescription are ready, and (d) Follows up to determine if needs have been met and therapy adherence has improved. Sutton Pharmacy evaluates the Prescribe Wellness data every 4 weeks. The baseline prescribe wellness database revealed there were 188 patients on antihypertensives with the adherence proportions estimated as: Adherence 0-50% - 16 patients, 50-70% - 8 patients, 70-80% - 8 patients, 80-90% - 20 patients, and 90%+ estimated at 136 patients. Part 2: Hypertension Screening/Monitoring (all patients receiving treatment for hypertension and any referred by primary care provider). In this part of the program,

the pharmacists identify patients with hypertension. These patients are flagged in the pharmacy computer system and



19

when they call in for a refill request or come in to pick up refills, they are invited to have the pharmacy technician or pharmacist take their blood pressure. Blood pressure measurements are provided to both the patient and provider to collaborate in care. Time is used when with patient to reinforce educational components to empower self-management and engagement in care. Care is documented in the Computer-RX under the Chart Tab. Then the pharmacist/technician Copy/Paste Blood pressure readings into the notes on refill request for antihypertensive medications. Patients are tracked in a card index for easy tracking as well (Appendix I). Continued Development of the “Team” It is important to share this plan with local providers so they can know what to expect from us and their patients. We plan to explore opportunities to collaborate through educational sessions in the community. The local public health department has met with community partner, Quality Healthcare, to develop additional programs. Sutton Pharmacy is also reading out to Sutton Family Practice to determine how to strengthen the integrated care model this is starting. Other program development actions Screening/Monitoring is being developed by training pharmacy technicians to take blood pressure. We are using the Welch Allyn Spot Vital Signs for measurements by technicians. If blood pressure is above the normal cutoff the pharmacist would follow with a manual measurement or repeat digital measurement as determined by practitioner. If blood pressure is more than 20mmHg higher than the last reading the pharmacist follows up with evaluation. If blood pressure is in the normal range or consistent with previous readings the results are shared with the provider at next refill request. Readings are forwarded to healthcare providers at anytime the pharmacist determines there is a need. Patients are given a pocket card with the readings. Use of the 5 minute rest period to recheck the patient’s blood pressure provides an opportunity for patient education. Items Needed for Successful Implementation

Proper equipment- manual and professional digital was purchased. Training of pharmacy technicians. The MCD Public Health online blood

pressure training module developed by the Nebraska Department of Health and Human Services was completed by all staff members

Flow sheets to standardize interventions between pharmacists and to train technicians were developed and the local clinics informed about the protocol (See Appendix J).

Educational handouts for patient education. Monitoring parameters. Bag stuffers explaining the service for use daily in the pharmacy (see Appendix K).



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PHARMACY CASE STORY

Weaver Pharmacy 1014 G Street Geneva NE 68361

Weaver Pharmacy provides local services to the greater Geneva area. Bill is the owner of Weaver Pharmacy in Geneva – our next Pharmacy Case Story. Weaver Pharmacy has a comprehensive self-care approach in place already, with outstanding over the counter product selection, and fairly comprehensive home medical equipment. All of the pharmacists offer diabetes care management, administer immunizations, and offer the same pharmacy programs as Sutton. As this opportunity developed, Bill Weaver saw the value in having the community pharmacies of Sutton and Weaver be participants. With Dana Griess’s expertise in place, he emulated the program developed at Sutton. Holly Mussman, PharmD, has taken the lead at Weaver Pharmacy. They enrolled late in the implementation year, but patients “have been excited about the program” and she has received great feedback. They had 43 patients enrolled in September and intend to grow. Weaver pharmacy has a strong interest in lifestyle modification education and encouragement of self-monitoring blood pressure measurement. Weaver Pharmacy is reaching out to the community to provide screenings for pre-diabetes and pre-hypertensive patients.

WEAVER PHARMACY

SMALL CHAIN COMMUNITY PHARMACY



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PHARMACY CASE STORY

OneWorld Community Health Centers, Inc. 4920 S. 30th St. Omaha, NE 68107

One World Community Health Centers established a pharmacy/provider team-based care initiative in 2012 in the OneWorld Community Outpatient Pharmacy with the primary clinic in the Livestock Exchange location. The program purpose is to improve safety and quality health-related outcomes of patients with hypertension by improving blood pressure control when treatment includes antihypertensive medications, without increasing patient or provider costs. The program has already been deemed a success within OneWorld Community Health Center, resulting in program continuation. The pharmacy is located on the first floor of the Livestock Exchange Building and through contract with other pharmacies, provides affordable medications and pharmacist’s services. One World’s status as a federally qualified health center

enables (340B) discount prescription pricing. In addition, many drug companies offer discount medication assistance programs to income-eligible patients and the One World pharmacy staff offers assistance with enrollment in these programs. Growth in pharmacy service use from 2013 to 2014 was 5.3% as measured by the number of pharmacy prescriptions. The pharmacy is the central site for this program.

The opportunity in this current project is to expand blood pressure self-management and monitoring programs led by pharmacists throughout the OneWorld Community Health Centers system of primary care clinics, outreach clinics, community pharmacy owned by OneWorld and an external community pharmacy (Hy-Vee Pharmacy in Plattsmouth) where many OneWorld patients live. Beginning in 2014, One World also employed a clinical pharmacist that collaborates with physicians and patients in the medical clinics to ensure that the

ONE WORLD HEALTH COMMUNITY HEALTH CENTERS COMMUNITY PHARMACY

FEDERALLY QUALIFIED HEALTH CENTER OUTPATIENT PHARMACY

OUTPATIENT CLINICs

FEDERALLY QUALIFIED HEALTH CENTER CLINIC



22

highest quality care is provided. This was expanded to two pharmacists so that the primary clinic and remote clinics could all have patient visits with pharmacists. EXPANSION OF ONE WORLD COMMUNITY HEALTH CENTERS PROGRAM DESCRIPTION

Program objective: To improve patient access, self-involvement in care and hypertension control through

pharmacist interaction in clinic and in the community pharmacy collaboration.

Patient Eligibility: OneWorld patients with diagnosed hypertension and uncontrolled blood pressure according to

their most recent visit. Diagram A provides a general overview of how the patient participates in care.

Diagram A

Participating Sites within One World:

OneWorld Pharmacy (4920 S. 30th St)

Livestock Exchange OneWorld Clinic (4920 S. 30th St)

West Omaha OneWorld Clinic (4101 S. 120th St)

Northwest Omaha OneWorld Clinic (4229 N. 90th St)

Cass Family Medicine (122 S. 6th St Plattsmouth, NE)



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One World collaboration with HyVee grocery chain pharmacy in Plattsmouth:

Cass Family Medicine (122 S. 6th St Plattsmouth, NE) in collaboration with Hy-Vee Pharmacy (Plattsmouth, NE) for patients who use One World as their primary medical care providers.

Four service models designed to deliver comprehensive program via pharmacists by site:

Site Patient Care Flow Options by Site Number of Family

Practice Providers

Livestock Exchange

OneWorld Clinic (4920

S. 30th St)

Self-monitoring 13

Face-to-face visits

Bi-directional referral with OneWorld Community

pharmacy and communication with other pharmacies based

on patient’s selection.

OneWorld Community

Pharmacy (4920 S. 30th

St)

Self-monitoring Many in several

sites Face-to-face visits

Bi-directional referral with Livestock Exchange OneWorld

Clinic clinical pharmacists and providers.

Cass Family Medicine

(122 S. 6th St

Plattsmouth, NE)

Collaboration with HyVee Community pharmacy

Plattsmouth

1

West Omaha


S. 120th St)

Self-monitoring 3

Face-to-face visits

Northwest Omaha


N. 90th St)

Self-monitoring 2

Face-to-face visits

Description of Services and Patient Care Flow at Sites

1. Self-monitoring promoted at all sites (including the collaboration site in Plattsmouth) a. Recommend home blood pressure monitoring device (see Appendix L for patient assessment) b. Provide training and education on device c. Report home readings to clinical pharmacists via secure electronic methods d. Clinical pharmacists titrates medications as per collaborative practice agreement. All interventions involve

recording and communicating to primary care provider via electronic health record and use of clinical practice agreement (see Appendices M, N, O).



24

Patient care flow: At an initial appointment with the OneWorld clinical pharmacist in any of the OneWorld

locations, patients screened for appropriateness of self-monitoring of blood pressure at home. If they

elect to self-monitor, the clinical pharmacist will provide a monitor as well as education on technique of

home blood pressure monitor use (see Appendix P). Blood pressure values taken outside of clinic by the

patient are relayed back to the clinical pharmacist via text, e-mail, or telephone by patient’s preference.

Clinical pharmacists act upon the self-reported measurements in accordance with the hypertension

collaborative practice agreement and protocol at OneWorld.

2. OneWorld collaboration with Plattsmouth HyVee community pharmacy a. Blood pressure check at time of refill or as needed at HyVee community pharmacy b. HyVee Community pharmacy to report blood pressure results to clinical pharmacists of OneWorld via

secure electronic methods c. Clinical pharmacists to titrate medications as per collaborative practice agreement

Patient care flow is a bi-directional referral model: For patients of Cass Family Medicine in Plattsmouth, we

will enter into an agreement with HyVee pharmacy at which the patient may present for a blood pressure

check outside of clinic. Blood pressure measurements taken at this community pharmacy will be relayed

back to the clinical pharmacist at OneWorld via secure email or fax (see sample form attached). Clinical

pharmacists will act upon the pharmacy-reported information in accordance with the hypertension

collaborative practice agreement and protocol at OneWorld.

3. OneWorld pharmacy a. Usual care of offering free blood pressure measurements employed. b. Pharmacists and technicians will utilize an electronic generated report via the pharmacy platform to

identify patients who are overdue to refill their anithypertensive medications. These patients are contacted via telephone or other secure electronic methods to remind them to refill their medications.

Patient care flow and bi-directional referral: For patients at OneWorld pharmacy, usual care continues free

blood pressure measurements and titration of medications via current collaborative practice agreement.

As an additional way to target uncontrolled patients, pharmacists and technicians use an electronic-

generated report via the pharmacy platform to identify patients who are overdue to refill their

antihypertensive medications and suggesting possible non-adherence. Patients contacted via telephone or

other secure electronic methods to remind them to refill their medications and potentially identify any

barriers to their non-adherence.Bi-directional referral takes place between the community pharmacy and

the clinic pharmacists and providers.

4. Clinical pharmacist visits a. Blood pressure check in the office (via walk-in or scheduled free appointments) b. Clinical pharmacists to titrate medications as per collaborative practice agreement

Patient care flow: If the patient elects not to self-monitor, he/she may continue seeing the clinical

pharmacist in our current model of face-to-face visits. Clinical pharmacists will act in accordance with the

hypertension collaborative practice agreement and protocol at OneWorld. Bi-directional referral takes

place between the clinic pharmacists and providers, and the community pharmacy.



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Outcomes planned for assessment:

1. Change in pre-intervention vs. post-intervention systolic blood pressure (sBP), diastolic blood pressure (dBP) for each patient

2. Percent of population with hypertension in-control (<140/90) in trailing 12 months pre-intervention and post-intervention (including patients not involved in project)

3. Number of patients involved in each intervention at each site 4. Number of patients identified as being overdue to fill at least one antihypertensive medication at

OneWorld pharmacy, number of patients contacted, and number of patients who picked-up their medication within 1 week of pharmacy contact

5. For each intervention arm identify change in population pre- vs. post-intervention sBP, dBP and compare among each approach

Progress Made Across All Care Delivery Models

Eighty-two patients were seen by clinical pharmacists across all clinics/sites for a total of 157 encounters (range 1 – 5+/patient). Forty patients were at goal at the end of this initial project period and 24 patients are being actively followed. There were 18 patients “lost to follow-up”/need appointments. Thirty home blood pressure monitors were distributed across all sites and patients received comprehensive education for follow up. Development of case management strategies to recall patients was occurring at the end of this first period of project initiation.

Troy Ruffner, PharmD, is the supervising pharmacist in charge at the Hy-Vee Community Pharmacy in Plattsmouth. He has worked with the OneWorld Community Health Center pharmacists in the on-going care of persons in his local community who see their medical providers at OneWorld in Omaha. The goal of this relationship is to make BP self-care monitoring for the patient convenient and supported by the pharmacist the patient is likely to see most often, one near their home. Blood Pressure Self-Management Program started as a Service Enhancement for Patients and Community

The design of this program is to replicate the activities of the OneWorld pharmacist, or refer the patient to obtaining this care at the Plattsmouth OneWorld Clinic. This is one of the last pharmacies to join the project. The program has been set up between the pharmacist at OneWorld and the pharmacist at Hy-Vee, however, only a handful of patients have been piloted through this effort. We expect growth and results in the upcoming year.

HY VEE COMMUNITY PHARMACY

GROCERY CHAIN COMMUNITY PHARMACY Plattsmouth, NE



26

PHARMACY CASE STORY

Arbor State Pharmacy 203 South 7th Street Wymore, NE 68466

Jeremy Waltke, PharmD, is a relatively new pharmacy owner who manages and

staffs the pharmacy. This pharmacy serves the greater Wymore area. Arbor State

Pharmacy provides important local services and is building a comprehensive self-

care approach. Currently, Arbor State Pharmacy offers: (a) medication refill

reminder phone call or automated service, (b) immunizations, (c) some diabetes

education and glucometer training, and (d) blood pressure checks on request.

Before starting this program, the pharmacy was identifying a couple of days a

month to check blood pressures on request.

Blood Pressure Self-Management Program started as a Service Enhancement for Patients and Community

The design of this program is to start having the general community participates in blood pressure self-management. This program was just started, and the pharmacy now has a blood pressure kiosk. A blood pressure machine was purchased added for patient use with pharmacist education. In the meantime the pharmacy staff, including technicians, is obtaining training on proper BP measurement. The pharmacist has screened over 70 patients and is monitoring 45 of these. Seven reports have been sent to prescribers about drug therapy and hypertension needs. The program has been received well and appreciated by the local primary care practice and the patients. Public Health Solutions has worked closely and successfully with Arbor State Pharmacy, providing a professional sign and banner for blood pressure screening for the window of the pharmacy. They are also providing the pharmacy with Million Hearts support materials and tracking sheets to start monitoring the number of patients serviced. The pharmacy reports remaining challenged by not having enough staffing and time, however, next phases will include looking for systems and efficiencies for sustainability. This has added value to the pharmacy services in the community.

ARBOR STATE PHARMACY

INDEPENDENTLY OWNED COMMUNITY PHARMACY



27

PHARMACY CASE STORY

Deines Pharmacy 910 Court Street Beatrice, Nebraska 68310

Mitch Deines, PharmD, and Colleen Deines, RN started Deines Pharmacy in 1991. Deines Pharmacy is a comprehensive pharmacy and health center. Home medical equipment, orthopedic braces, urology, ostomy and incontinence supplies, post-mastectomy products, durable medical equipment, a Diabetes Shoppe for comprehensive diabetes care supplies, and a “closed door” long term care consulting and dispensing service. The pharmacy provides traditional prescription and over the counter medications with pharmacist counseling, and administers immunizations. Deines Pharmacy has a strong relationship with Public Health solutions, the local health department and also with the Beatrice Community Hospital and associated clinic practices. Deines has three licensed practical nurses engaged in home care and support of patients in the pharmacy. The LPNs have been doing blood pressure checks on request for patients. All three LPNs have completed the state of Nebraska sponsored blood pressure training modules. Track results, monitor progress, adjust therapies in conjunction with prescriber. Blood Pressure Self-Management Program started as a Service Enhancement for Patients and Community

The design of this program is to start having the general community participates in blood pressure self-management and to establish a bi-directional monitoring and referral system with the primary internal medicine clinic associated with Beatrice Community Hospital. This program was just started, and the LPNs have an active

DEINES PHARMACY

INDEPENDENTLY OWNED COMMUNITY PHARMACY



28

protocol between the clinic and the pharmacy. The physical facilities for conducting a more comprehensive blood pressure self-management program are outstanding. The major challenge is to take the next step and have the LPNs work directly with the pharmacists in the pharmacy to review the BP findings, review the drug therapy comprehensively, and to communicate with the primary prescribers about the medication adjustment needs. This is currently a larger challenge at Deines as the pharmacy has not routinely implement MTM services, a natural vehicle for establishing this next step. Public Health Solutions has worked closely and successfully with Deines, providing a professional sign and banner for blood pressure screening for the window of the pharmacy. They are also providing the pharmacy with Million

Hearts support materials and tracking sheets to start monitoring the number of patients serviced, and working collaboratively with the bi-directional referral process with the clinic.

This coming year, the goal is to integrate the self-management program between the pharmacists and LPNs to maximize drug therapy outcomes related to hypertension management.



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APPENDIX A

NEBRASKA PHARMACISTS CHRONIC DISEASE PREVENTION, MANAGEMENT AND CONTROL PROGRAM

Overview for Medical / Clinical Champions Working with A Pharmacy

The state of Nebraska has secured Dr. Kim Galt to administer a funding program for selected pharmacies and selected medical practices to facilitate chronic disease care for patients, especially hypertension, through integration of pharmacist’s services using community linking, referral and other strategies.

_________________ at _____________________Pharmacy has recommended you as a champion to work with.

The pharmacist’s services focus on improving outcomes in hypertensive patients through advancing patient self-care through improving medication adherence, assessing BP control in response to medications prescribed (and other self-care behaviors), self-care BP monitoring, and referrals and communication that improves continuity of care for the patient. Pharmacists will implement care models from their pharmacies.

Medical champions will:

Share information with the practice professionals and staff about the availability of the services the pharmacist is offering to patients,

Share information with other medical professionals in the community (e.g., hospital medical staff meetings, peers in practice office, etc.) about the availability of the pharmacist’s services.

Generally inform their patients requiring BP control about the availability of the service,

Receive information from the pharmacist about how the patient BP control is going when the patient visits with the pharmacist for BP checks, medication refills, or when the pharmacist learns of a need in the patient’s care to work directly with the medical champion to adjust the patient’s drug therapies (e.g., potential side effects or ineffectiveness of current drug regimen requiring modification to improve patient’s response to care).

Keep track of the patients who are receiving the pharmacist’s services and provide a summary of the number of patients who are participating through the pharmacist referral and communication process.

Provide Dr. Kim Galt with impressions about how the program is being received by other members of the medical community and clinic staff.

The pharmacy is expected to provide the medical champion with information materials to share and promote to others (e.g., flyer with outline of services and how patients can participate, contact information).

In order to participate, the medical/clinical champion will sign a Memorandum of Understanding (MOU).

The program is offering a stipend of $5,000 to offset time, effort and any modest expenses associated with performing these duties as a part of this program.

To receive the stipend, please provide me your contact information, including, the named clinical champion, the contact information of the organization to receive the stipend, including your email address to send formal communications to and a phone number.

Medical champion name: Organization name and contact information:

Email address:

Appendix B

HYPERTENSION: PHARMACISTS SERVICES AND PATIENT SELF-MANAGEMENT

Program of Services Description of Support Needs for Services Methods to Assess Impact

Health and Wellness Screening

Services for Hypertension

Blood pressure screenings Approach Option 1

Pharmacist him/herself or properly trained support staff who

conduct BP checks on patients:

At time of anti-hypertensive medication refills,

Upon patient request.

Approach Option 2

Pharmacist him/herself or properly trained support staff who

conduct BP checks on patients:

At posted times each week (e.g., Tuesday and Thursday mornings, Wednesday afternoons) where patients may drop in.

Approach Option 3:

Pharmacist makes available a self-care BP machine for persons to

take their own BP:

Pharmacist posts sign next to machine to invite patient to bring the results to him/her for interpretation.

Approach 1, 2 and 3:

Number of patients who have their BP checked – tallied monthly.

Describe changes made to pharmacy staffing/workflow to accomplish service delivery.

Blood pressure self-management

education

Approach Number of patients who have their BP checked – tallied monthly.

IMPLEMENTATION AND OUTCOMES OF NEBRASKA PHARMACISTS CHRONIC DISEASE, PREVENTION AND MANAGEMENT CONTROL PROGRAM 2016

31

Pharmacist him/herself or properly trained support staff

sell/dispense blood pressure monitoring devices to patients and:

Teach proper use of device with teach back techniques (patient demonstrates can do)

Conducts BP check on patient

By scheduled appointments each week, or

Hosting an evening, morning or afternoon every other week where patients come for this activity – small group or individual learning.

Number of BP monitoring devices sold – tallied monthly.

Number of patient appointments made.

Number of class sessions offered.

Actions Taken by Pharmacist to

Support Patient’s Care

Physical Environment

Pharmacy provides a proper place to facilitate BP screening and self-management education activities.

Education of Staff

Pharmacy provides education for proper BP assessment to pharmacy staff.

Properly trained staff member or pharmacist takes patient’s blood pressure.

Interpretation of BP and Patient Care Assessment

The pharmacist interprets the BP finding, assesses the effectiveness of medication.

Option: referral to the prescriber

The prescriber is contacted if there is a need to change the

medication care plan for the patient.

Prescriber provided BP findings and pharmacist’s assessment and recommendations.

Observe presence of semi private, clean, properly furnished area to check BP.

Documentation of training of pharmacists and/or staff with new or renewed skills.

Number of patient assessments performed by pharmacist – tallied monthly.

Number of patient referral calls made to prescribers – tallied monthly.

Number of patient care plans prepared by pharmacist – tallied monthly.

Number of BP monitoring cards distributed by pharmacy staff – tallied monthly.

IMPLEMENTATION AND OUTCOMES OF NEBRASKA PHARMACISTS CHRONIC DISEASE, PREVENTION AND MANAGEMENT CONTROL PROGRAM 2016

32

Pharmacist records BP on pharmacy record and documents care changes implemented with patient.

Patient Education

Provides patient with wallet card size note with date and BP reading with interpretation.

Actions Taken with Provider

Agreement to Support Patient’s

Care through Collaborative

Practice Agreement

Prescriptive Authority Actions

Pharmacist completes all steps as above through interpreting BP and conducting patient assessment.

FOR HYPERTENSION ONLY CASES: Pharmacist completes targeted drug therapy review on medications to control blood pressure.

FOR MULTIPLE CONDITION/CHRONIC CONDITION MANAGEMENT CASES: Pharmacist completes comprehensive drug therapy review on all medications, and evaluates impact of drug therapy changes needed to control blood pressure.

Pharmacist modifies drug therapy prescription within agreement protocol guidelines.

Pharmacist notifies prescriber of changes with update on patient’s status, and follow up care plan.

As above

APPENDIX C

Published in Creighton Magazine, Fall issue, 2016, page 11.



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APPENDIX D

MARK’S PHARMACY

Blood Pressure Monitoring Agreement and Intervention Sheet

Name: ___________________________ Doc/PA #1: ______________________________

Address: _________________________ Doc/PA #2: ______________________________

_________________________ Doc/PA #3: ______________________________

City/St/Zip: _______________________

Phone: ___________________________ Best time to call: _________________________

email: ____________________________ Notes: _________________________________

Pharmacies used: __________________________________________________________________

I agree to routinely monitor my blood pressure and provide the results to Mark's Pharmacy. No

protected health information will be released.

Signature: _______________________________________ Date: __________________________

Pharmacist Interventions and Notes:



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APPENDIX E MARK’S PHARMACY

What is blood pressure?

Blood pressure (BP) is the force or pressure that blood puts on the walls of your arteries as it goes through your

body. BP readings are usually written as 2 numbers. The first or top number is called systolic BP. The second or

bottom number is called diastolic BP. The goal for blood pressure is less than 120/80.

How do I take my BP? • Sit and rest for 5 minutes before you take your BP. Roll up your sleeve or remove any tight-sleeved clothing.

Extend your arm and support it on a flat surface. Your arm should be at the same level as your heart. Both of

your feet should be flat on the floor. Sit up straight with your back against the chair, legs uncrossed.

• The device has a built-in pump that inflates the cuff. Put the cuff about 1 inch (2.5 cm) above your elbow.

Wrap the cuff snugly around your arm but leave enough space to slide two fingers comfortably inside the cuff.

The BP reading may not be correct if the cuff is too loose or too tight.

• Turn on the BP monitor and follow the directions.

How often should I take my BP?

It is recommend that you record your BP three times two times a day. Take your BP at the same times each day,

such as the morning and evening. You should record at least one reading per week as a minimum.

What else do I need to know?

• Take your medicines as directed. Do not stop taking your medicines without talking to your caregiver first.

• Do not check your blood pressure within 30 minutes of smoking, drinking coffee, or exercising. These may

affect your BP reading.

• Do not take a BP reading in an arm that is injured or has an IV or a shunt.

When should I seek immediate care?

Seek care immediately or call 911 if:

• You have a severe headache, accompanied by confusion and blurred vision

• You have chest pain or pressure.

• You have trouble breathing.

• You have trouble thinking or speaking clearly, have memory loss or become unresponsive.

• You have nausea and vomiting

• You have seizures.

• You have numbness or weakness

These symptoms indicate that your high blood pressure is damaging your organs. This is a life-threatening

situation and must be addressed immediately!

What should I do if my BP is high (top number over 180 or bottom number over 120) and I have do not

symptoms?

• Don't make a decision based on one BP reading alone.

• Rest for at least 5 minutes in a quiet area. During that time review if you have missed any medications in

the last 24 hours or have recently used an item that may cause an increase in BP (such as caffeine, cold

medication, nicotine, illicit drugs or physical activity.)

• When you feel calm, test again. If the reading is still elevated, wait for 5 minutes and test your other arm.

• If your readings are still elevated, call your doctor, report the steps you have taken and ask if you should

be seen immediately. If your doctor isn't available, contact the emergency room for directions.

If you have questions about the machine (ex. Accuracy of readings, etc.), please contact the maker of the machine

(Microlife) at 1-800-568-4147



36

APPENDIX F MARK’S PHARMACY



37

APPENDIX F - continued MARK’S PHARMACY



38

APPENDIX G MARK’S PHARMACY

We're here to help!

Blood pressure testing is available during regular pharmacy hours.

No appointment necessary – and it's FREE!

It's important to get your blood pressure checked. High blood pressure is one of the leading causes of

heart disease. People with high blood pressure are at greater risk of heart attack, stroke, kidney failure

and even death. 1 in 3 adults in the U.S. has high blood pressure but many are unaware or undertreated

because there are no real signs or symptoms.

A member of our trained pharmacy staff will take your blood pressure, provide immediate results,

answer your questions and educate you on what everything means at a time that is convenient for you.

Your result will be explained to you and you will be offered any advice and support needed to manage

your blood pressure.

Importantly, we will send a copy of your visit records to your primary provider so that he or she knows

how you're doing. If you are interested, we will teach you how to check your own blood pressure at

home.

Free

Blood

Pressure

Tests



39

APPENDIX H MARK’S PHARMACY



40

APPENDIX H - continued MARK’S PHARMACY



41

APPENDIX I SUTTON PHARMACY

Hypertension Patient Interaction

Name:___________________________ Primary Provider: ___________________

Date: Blood Pressure Initials Education Given Pharmacist



42

APPENDIX J SUTTON PHARMACY

Date: ___________________

Name: ___________________________________________ DOB: __________________

Current Antihypertensive Perscriptions:

_____________________________________________________ ___ yes ___ no

_____________________________________________________ ___ yes ___ no

_____________________________________________________ ___ yes ___ no

_____________________________________________________ ___ yes ___ no

Prescribe Wellness RDC Hypertension _______________

Notes from refill history

____________________________________________________________________________________

__________________________________________________________________________________

Barriers to adherence

___ Forget to take medications ___ Too many medications ___ Side effects

___ Cost too much ___ Do not see a need ___ Other

___ Inconvenient dosing ___ Forget to order or pick up when out

Interest in the following

Med Synchronization (single day of month to refill all prescriptions) ____ yes ___ no

Automatic Refills with Text notification when ready ____ yes ___ no

Text notification only when ready ____ yes ____ no

Remind we have an app to help with medication management, request refills, and other health tools.

“My GNP”

Self monitoring

Do you monitor your blood pressure at home? __ yes __ no If yes, how often? ________________

Do you recall your most recent blood pressure either from home or doctor visit? __________________

What did we do for the patient?

___ Educate on Adherence ___ Help implement new strategy for adherence

___ Address side effects from medications ___ Calibrate Blood Pressure Monitor

___ Teach patient to use home monitor ___ Educate patient on meaning of blood pressure numbers

___ Educate on disease process (ex increased risk of stroke, MI, etc)

___ Educate on lifestyle modifications (salt, caffeine, alcohol, etc)

___ Attempt to find lower cost alternative



43

APPENDIX K SUTTON PHARMACY



44

APPENDIX L ` ONEWORLD COMMUNITY HEALTH CENTERS

Identifying self-monitoring blood pressure candidates

Screening items Yes No

Physically capable (i.e. does not have impaired dexterity, vision, or

mobilization required for self-monitoring)

Cognitively capable (i.e. does not have a diagnosis suggestive of cognitive

impairment)

Motivated – patient states he/she is interested in self-monitoring blood

pressure at home

Reliable – patient has been seen by clinical pharmacist in at least 1 previous

visit and is committed to regular follow-ups and engaged with care

Other

Self-monitoring patient education check list

Education Completed

Provide blood pressure monitor with appropriate size cuff

Watch demonstration video of home monitoring

Provide handout for self-monitoring and review verbally

Educate on proper blood pressure technique

Review goal blood pressure and reasons for seeking medical attention

immediately

Patient demonstration of taking accurate blood pressure

Compare at least 1 reading with home monitor to 1 reading in-clinic

Determine method and time of follow-up with clinical pharmacist

Other:



45

APPENDIX M ONEWORLD COMMUNITY HEALTH CENTERS

Sample Blood Pressure Monitoring Form

Name (last, first)

DOB (mm/dd/yyyy)

Today’s Date (mm/dd/yyyy)

Sitting blood pressure

Measurement #1: Measurement #2: Average:

Pulse: _______ bpm Standing blood pressure (if ≥ 65 years old or complaints of orthostasis)

Measurement #1: Measurement #2: Average:

Technique: (circle all that apply)

Automatic Manual Right arm Left arm Pediatric cuff Adult Regular cuff Adult Large cuff

Current antihypertensives Date of last refill/day supply

# of missed doses in the past month

Needs refills on current rx (yes or no)

1.

2.

3.

4.

5.

Symptoms: (circle all that apply) Dizziness Headache Chest pain Palpitations Shortness of breath Edema Pharmacist signature: _____________________________________ Date: _____________

FAX to: 402-734-xxxx Attention: XXXXX



46

APPENDIX N



47

OneWorld Community Health Centers

COLLABORATIVE PRACTICE AGREEMENT FOR DRUG THERAPY

MODIFICATION & MONITORING OF HYPERTENSION MEDICATIONS

Description of Agreement: This collaborative practice agreement is established between One World

Community Health Center physicians and the undersigned pharmacist for the pharmacist to provide drug

therapy modification and monitoring of hypertension therapy according to the JNC-7 (The Seventh Report of

the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure)

guidelines. The goal of this program is to help patients more quickly achieve clinical goals of therapy,

improve team-based collaboration, and improve patient satisfaction. The intent is not to replace regularly

scheduled exams with the patient’s primary care provider.

PHYSICIANS/PROVIDERS OF PHYSICIAN(S) CLINICS MAY: 1. Refer patients requiring therapy modification or dosing adjustments for hypertension to a clinical

pharmacist with respect to the following referral criteria:

a. Diagnosis of hypertension

b. Age: 18-85 y/o

c. Examples of these patients include, but are not limited to:

i. Patients with most recent blood pressure of 140/90 or greater

ii. Patients not meeting blood pressure goals with diet and exercise alone

iii. Patients not meeting blood pressure goals on current drug therapy

iv. Patients not tolerating medications

CLINICAL PHARMACIST WILL:

1. Meet with patient (face-to-face) to check blood pressure; appointsments are available under “Clinical Pharmacy” in the electronic health record or for walk-ins if times allows

2. Provide instruction and education as needed to the patient, including but not limited to:

a. Lifestyle modification as indicated.

b. Blood pressure stage and goal based on current blood pressure and co-morbidities.

1. < 140/90 mmHg without diabetes

2. < 130/80 mmHg with diabetes and/or renal disease

c. Special considerations will be made for patients with co-morbidities according to JNC 7 guidelines

(i.e. ischemic heart disease, heart failure, chronic kidney disease, cerebrovascular disease, recurrent

stroke, etc).

3. Assess the indication for, effectiveness, tolerability, and adherence to prescribed medications.

4. Adjust doses of medications, discontinue medications or add medications, through this agreement, as

needed (in accordance with JNC-7) to achieve blood pressure control.

5. Authorize refills to initiate, change doses and/or discontinue the anti-hypertensive medications as listed in

this CPA. The prescription will be sent under the referring provider.

6. May order lab work associated with assessment parameters affected by blood pressure medications..

7. Blood pressure and pulse will be reviewed and/or checked at every patient encounter.

8. Document encounters and actions taken in patient’s electronic medical record. These notes will be tasked

to the referring provider as necessary.



48

OneWorld Community Health Centers

REFERRAL BACK TO PRIMARY CARE PROVIDER: Patients will be advised to schedule an appointment with their primary provider if:

1. The patient’s blood pressure is at goal and documented in the EHR.

2. The patient no longer desires to continue care with the pharmacist.

3. The provider decides to manage patient’s blood pressure.

4. The pharmacist determines the primary care provider’s care is needed.

5. Previously mentioned monitoring parameters are out of range.

6. The patient’s blood pressure at the visit is ≥180/110 mmHg (stage 3 HTN per JNC-7),the patient will be

seen by a provider (preferably the referring physician) in the clinic for further work-up of end-organ damage

and implementation into a hypertensive urgency protocol where applicable.

7. The patient complains of any new associated cardiac symptoms (i.e. chest pain, shortness of breath,

palpitations) or new irregular pulse.

U:\Hypertension\Documents to BOP\HTN Clinical Pharmacist policy_Downes Jan 2015.docx Updated 5-09

Revised 7/12, 1/15, 4/15 2



49

APPENDIX O

Clinical pharmacist hypertension management

I. Visit protocol a. Referrals will originate from any provider at OneWorld CHC who has previously evaluated the patient for hypertension within the past year

b. Patients will also be recruited via mail if uncontrolled hypertension in the last 2 years and more than (1) month has elapsed since their previous visit

c. Appointments will be scheduled under the Clinical Pharmacy appointment book and will be scheduled for 20 minutes increments

d. At the visit, the clinical pharmacist will: i. Review the medical record and interview the patient to determine:

1. History of hypertension, PMH, family history, social history, allergies, current medications, and laboratory values

2. Current medication list will be updated at each visit ii. Assess the patient for:

1. level of motivation and ability to implement changes

2. barriers for communicating, retaining, or understanding information related to health literacy

3. individual health goals iii. Review risk stratification for blood pressure and corresponding goal for patient (see Appendix A)

iv. Perform limited physical exam and evaluate the patient for signs or symptoms of target organ damage including: increased SOB, peripheral edema, mental status changes, increased chest pain, or signs/symptoms of stroke/TIA

v. Assess blood pressure and pulse 1. Resting at least 5 minutes

2. No caffeine, tobacco, or exercise in the past 30 minutes

3. Proper technique

4. Assess orthostatic blood pressures if orthostasis is suspected vi. Assess adherence to medications

1. Identify causes of non-compliance

2. Evaluate for the presence of adverse effects from medications

3. Review medication list for drugs that may elevate blood pressure vii. Order additional tests as needed:

1. BMP to assess baseline renal function and serum potassium prior to starting ACEIs, ARBS, or diuretics

2. Repeat BMP within 1-4 weeks after initiation of medications and annually thereafter

3. EKGs can be completed and reviewed by provider prior to starting beta-blocker therapy or non-dihydropyridine calcium channel blockers

4. At-home blood pressure monitoring viii. Provide education as it relates to hypertension management including:



50

1. Risks of uncontrolled hypertension

2. Importance of medication compliance

3. Antihypertensive medications

4. Weight loss

5. DASH diet

6. Lower sodium intake (< 2,400 mg/day)

7. Exercise recommendations

8. Tobacco cessation

9. Moderation of alcohol consumption ix. Adjust antihypertensive therapy based on current guidelines (JNC7, JNC8, and ADA) and compelling indications if:

1. adequate trial of medication(s) has been given and blood pressure goal has not been achieved

2. unacceptable adverse effects occur x. Electronically refill antihypertensive medications as appropriate under referring provider’s name

xi. Recommend follow-up appointments with Clinical Pharmacist: 1. 1-4 weeks if blood pressure not at goal or medication adjustments

2. 4-8 weeks if at goal

3. The pharmacist will refer the patient back to provider once blood pressure stabilizes and remains at goal for 2 consecutive months

xii. Referral back to primary care provider: 1. at least annually

2. blood pressure at goal after 2 consecutive months

3. if patient no longer desires to continue care with the pharmacist

4. two consecutive no-shows with clinical pharmacist

5. the provider decides to manage the patient’s blood pressure

6. as requested by clinical pharmacist xiii. The clinical pharmacist will immediately notify the referring provider or supervising physician in the event of any potentially serious or life-threatening hypertension-related complications including:

1. SBP > 180 mmHg or DBP >110 mmHg

2. New onset or increasing chest pain

3. Symptoms of cerebral infarct or thrombosis

4. Mental status changes

5. Acute decrease in renal function

6. New cardiac arrhythmias

7. Pulse < 55 or > 120 bpm

8. Potassium < 3.0 (if on digoxin < 3.5) or > 6.0 xiv. If resistant hypertension is suspected, the clinical pharmacist will contact the referring provider to collaborate on further management



51

Appendix A: Treatment Goals

Indication Goal Guideline

Adults without compelling indications

<140/90 mmHg JNC VII1

Adults > 60 years <150/90* JNC 8

Diabetes or CKD < 140/90 mmHg or (optional: < 130/80)

JNC VII1 ADA 20152 JNC 83

Appendix B: Medications to treat hypertension with compelling indications1-3

Compelling Indication Recommendations

Diabetes ACE-I or ARB

Coronary artery disease/post-MI

BB and ACE-I/ARB Angina symptoms: CCB

Heart failure with reduced EF

ACE-I or ARB BB (metoprolol succinate, bisoprolol or carvedilol) Aldosterone antagonist Diuretic Black: hydralazine/isosorbide dinitrate

Heart failure with preserved EF

ACE-I or ARB BB (metoprolol succinate, bisoprolol or carvedilol) Diuretic

Chronic Kidney Disease ACE-I or ARB

Ischemic Stroke or TIA Thiazide diuretic, ACE-I

No compelling indications Black: thiazide-type diuretic or CCB Non-black: thiazide-type diuretic, CCB, ACE-I, or ARB

References: 1. National High Blood Pressure Education Program coordinating Committee. The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. 2003. NIH Publication No. 03-5233. Washington, D.C. 2. Standards of Medical Care in Diabetes –2014. Diabetes Care. 2015;38(1):S1-S93. 3. 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eight Joint National Committee (JNC 8). JAMA. 2014; 311(5):507-20.



52

APPENDIX P

Home Monitoring to Help Control Blood Pressure

What you can do to make sure that your readings are accurate

DO:

Sit comfortably with both feet on the floor for at least five minutes before taking a measurement

Rest your arm on a table so that your elbow is at the level of your heart

Write down blood pressure results and bring these with you to all OneWorld appointments.

Your provider may also ask you to bring your cuff to appointments.

Place the cuff on bare skin, not over clothing. Rolling up a sleeve until it tightens around your arm

can result in an inaccurate reading

Ask your doctor, pharmacist, or nurse to watch you use your monitor to see if you’re doing it

properly

Call the clinic or your clinical pharmacist if you have readings of greater than 180 systolic (top

number) or 110 diastolic (bottom number) and you have taken your medications as prescribed.

DO NOT:

Exercise, eat food, or have caffeine, tobacco or alcohol for 30 minutes before taking a

measurement

Talk while taking your blood pressure

Measure your blood pressure when you are cold, stressed, uncomfortable, or in pain.

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