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 tlawson@zufallhealth.org (973) 328-9100 ext. 354

Rina Ramirez, MD

rramirez@zufallhealth.org (973) 328-9100 ext. 311