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Improving Health Outcomes of Residents of Public Housing: Integrating Clinical Pharmacy
Services
Rina Ramirez, MD, FACP Terry Lawson, RPh, CDE
Learning Objectives
List three ways in which Clinical Pharmacy Services (CPS) can help identify patient barriers to improved health
Name two tools that the pharmacist and the patient use
to improve adherence
Describe two ways in which CPS can help control polypharmacy
Zufall Health Center Dover, Morristown, Hackettstown, Mobile Van
Established in 1990 in church basement in Dover by Dr. Zufall and volunteer physicians
FQHC since 2004; dental services since 2002
Expanded to three sites and a mobile van
Serving 4 counties in NW NJ Serving uninsured, underinsured,
homeless, residents of public housing, farm workers
Open 7 days a week, extended hours
Services Open 7 days/week - 24/7
bilingual call coverage Services provided: ◦ Pediatrics ◦ Adult Medicine ◦ Women’s Health ◦ Ryan White Part A, C & F ◦ Dental ◦ Podiatry ◦ Behavioral Health ◦ Neurology ◦ Clinical Pharmacy Services ◦ Outreach and Support Services ◦ 340B Pharmacy ◦ Reach Out and Read ◦ Patient Navigation ◦ Senior Empowerment ◦ Health Literacy Program
ZHC 2012 Data
Served over 16,500 patients with over 50,000 visits 94% of patients are at or below 200% of FPL 72% of patients have no insurance 80% of patients in racial/ethnic minority groups, the majority being
Hispanic 58% of patients best served in language other than English Children – 22%, Adults – 72%, Seniors – 6%
48% of children and 79% of adults are uninsured 20% of patients have Medicaid/NJ Family Care; 3% have Medicare
540 are residents of public housing
Clinical Pharmacy Services (CPS) at ZHC
Joined HRSA Patient Safety and Pharmacy Services Collaborative in 2008
First PDSA involved contract pharmacy and the use of “Brown Bags” at health center
Hired a part time clinical pharmacist in 2009 Target population Diabetes, HTN, Hyperlipidemia, Obesity, HIV and CVD
Have served over 1,000 patients with improvements in health and safety by 67% or more
Evolved with our participation in Project IMPACT-Diabetes Engaged the patient in self-management
How we provide CPS
High risk patients referred by provider or team
Pharmacist sees patient one on one
Frequent follow up visits
20 hours a week one on one encounters and also coordinates QA projects
Some of the Components of CPS
Prospective Chart Review The Big Picture
Medication Reconciliation Patient engagement through use of interactive
tools
Medication Therapy Management Individualized medication assessment
Disease State Management Self management
Prospective Chart Review The Big Picture - Getting to
Know Your Patient
Medication Reconciliation Polypharmacy Patient History ADEs/pADEs Lab Review Cultural Competency Health literacy
Medication Reconciliation Use of Interactive
Tools – Engage the Patient
Brown Bag Adherence Sheet Pill Box Communication
techniques
Tools: Brown Bag Helps assess: Barriers Adherence Literacy Attitudes towards the
pharmacy Actual medications being
taken Physical disabilities Patient safety
Tools: Adherence Sheet
Tools: The Pill Box
Works well with Adherence Sheet
Memory helper
Simplifies regimen
Tools: “Teach Back” Reminders to Staff
Practice “Teach back” or
“Show me” Method
Ask This Question
Ask This Question
Watch Verbal and Non-Verbal
CommunicationUse Open-Ended
Questions
Goal: Patients know their health conditions and how to manage
them.
History of Medication Therapy Management (MTM) 2003 – CMS coined term – Part D recipients 2005 – Joint Commission – National Patient Safety Goal- Med
Reconciliation had 17 elements 2010 - ACA – provides grants for implementation of MTM
services 2011 – Joint Commission – revised NSPG - now consists of 5
elements 2011 – NCQA PCMH – incorporates comprehensive
medication management within its standards
Medication Therapy Management (MTM)
Each medication is looked at
Helps to determine that every medication is appropriate effective safe acceptable
for the patient.
MTM – How does it help our patients? Patient centered process
Improves outcomes
Comprehensive approach
Specific medication related needs identified
Collaboration with the team
On going assessments to create a care plan
Disease State Management (AADE 7 Self Care Behaviors)
Pathology explained with focus on medications “What’s in it for Them” – patient empowerment Self Management – improves with patient comprehension –
gives patient the whys behind other aspects of self management:
1. Healthy Eating 2. Exercise/Physical Activity 3. Problem Solving 4. Healthy Coping 5. Monitoring 6. Medications 7. Reducing Risks
Patient Comprehension = Adherence to all aspects of self management
In a Nutshell: Problems with Polypharmacy
Multiple medications – 5 or more Most common in older adults; 40% of those >65 Increase in rate and severity of ADEs Drug-drug interactions Poor adherence- complicated regimens Decrease in cognition and mobility– often from side effects
Increase in costs Lead to poor patient outcomes
Project IMPACT-Diabetes (APhA Foundation) Resulted in significant
improvements N=84, average 4.2 visits HbA1c dropped by 0.9 BP systolic dropped by 3 LDL dropped by 4.8 Triglycerides dropped by 24
points
Improved rates of recommended screenings
Patient JO
63 year old Hispanic male First visit in 2011 Taking 5 meds + additional
medications not on list Multiple conditions-DM,
Lipids, Glaucoma, Physical Disability
Non-adherent
Referral to CPS/MTM HbA1c = 7.9% LDL >130 Pain-uncontrolled
10 Steps for MTM-Addressed: Culture Barriers- Respect Home Environment Stressors-
Healthy Coping Fear/Denial- Education Confusion about medications-
Medication Reconciliation Health Literacy- Education
UPDATE: On 3/2013, JO’s HbA1c level is at 6.5%, LDL at 78
Patient MJ 47 year old white male First visit in Jan 2011 Taking 6 medications
Multiple conditions - DM, Lipids, Schizophrenia, Schizoaffective disorder, smoker, recovering alcoholic
Recently released from prison, lives in single room
Non-adherent
Referral to CPS/MTM HbA1c = 10.2%, Tgs = 865
Addressed barriers and stressors Meal preparation Adherence
April 2011 – alcohol-free, compliant HbA1c – 6.1%, Tgs = 202
May 2011 – quit smoking, DM meds d/c’d
UPDATE: HbA1c level is at 5.2%, has follow up visit on 8/2013
Questions? Teresita Lawson, RPh, CDE [email protected] (973) 328-9100 ext. 354
Rina Ramirez, MD
[email protected] (973) 328-9100 ext. 311