attachment 5b
myrx participant first home visit form:
diabetes/hypertension/diabetes and hypertension
First Home Visit Form: Hypertension
TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE
MINORITY HEALTH (PCCC) INITIATIVE
Date:
Participant name (Last name, First initial):
Client ID #:
Pharmacist Conducting Home Visit:
Home Visit Date:
Section I. Participant Demographics
Pharmacist Step #1: Introduction and collect baseline information.
1. On eligibility form
2. On eligibility form
3. Baseline blood pressure screening:
4. Wt: |___|___|__|
lbs.
5. Ht: |__| – |__|__|
feet inches
6. How long have you had high blood pressure?
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 40 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
7. What is your current household income per year?
$0 to $24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000 or more
Section II. Hypertension Knowledge
Pharmacist Step #2: Ask the participant the following questions and mark their answers.
1. If someone’s blood pressure is 120/80, it is…
High
Low
Normal
Don’t know
2. If someone’s blood pressure is 160/100, it is…
High
Low
Normal
Don’t know
3. Once someone has high blood pressure, it usually lasts for …
A few years
5–10 years
The rest of their life
Don’t know
4. People with high blood pressure should take their medicine…
Everyday
At least a few times a week
Only when they feel sick
5. Losing weight usually makes blood pressure…
Go up
Go down
Stay the same
6. Eating less salt usually makes blood pressure…
Go up
Go down
Stay the same
7. High blood pressure can cause heart attacks.
Yes
No
Don’t know
8. High blood pressure can cause cancer.
Yes
No
Don’t know
9. High blood pressure can cause kidney problems.
Yes
No
Don’t know
10. High blood pressure can cause strokes.
Yes
No
Don’t know
Section III. PCCC Survey
Pharmacist Step #3: Ask the participant the following questions and mark their answers.
The statements below describe attitudes and beliefs you may have about the health program you signed up for and your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box.
Strongly Somewhat Somewhat Strongly
disagree disagree Neutral agree agree
1. I will learn new information to help me to manage my health condition
2. I will get useful information about my health condition
3. I expect to put what I learn from this program into practice
4. I expect to see positive changes in myself if I do what they teach me
5. I can do something to improve my health condition
6. It is very important to take care of your health
7. I am ready to improve my health
Section IV. Medication Use and Adherence
Pharmacist Step #4: Review the medications that the participant has OR has been prescribed. Create a medication chart with the participant. Fill out attached Appendix A Medication List with the participant.
Questions to ask:
What medication are you taking including OTC and dietary supplement?
Why are you taking the medication?
When do you take this medication?
When was your last dose?
Do you have any special instructions for this medication?
11. Medication History:
Medication |
Purpose |
Schedule |
Date of Last Dose |
Special Instructions |
1.
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16.
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Hypertension
12. How often have you forgotten to take your medicine for blood pressure in the past week?
Always
Very Often
Sometimes
Rarely
Never
13. How often do you stop taking your medicine for high blood pressure because you were careless?
Always
Very Often
Sometimes
Rarely
Never
14. How often do you stop taking your blood pressure medicine because you feel better?
Always
Very Often
Sometimes
Rarely
Never
15. How often do you stop taking your medicine for blood pressure when you experience side effects?
Always
Very Often
Sometimes
Rarely
Never
16. Please find the statement that best describes the way you feel right now about taking your high blood pressure medication as directed.
A. No, I do not take and right now am not considering taking my high blood pressure medication as directed. (Precontemplation)
B. No, I do not take but right now am considering taking my high blood pressure medication as directed. (Contemplation)
C. No, I do not take but am planning to start taking my high blood pressure medication as directed. (Preparation)
D. Yes, right now I consistently take my high blood pressure medication as directed.
17. If the answer to question 16 is D, then ask: How long have you been taking your high blood pressure medication as directed?
A. ≤3 months
B. >3 months to 6 months
C. >6 months to 12 months
D. >12 months
Section V. Pharmacist Step #5: Pharmacist Assessment
If the answer to question 16 is D and the answer to question 17 is A or B, then the stage of change is action. If the answer to question 16 is D and the answer to question 17 is C or D, then the stage of change is maintenance.
Area/Stage |
Precontemplation |
Contemplation |
Prepare |
Action |
Maintenance |
Adhere to medication |
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Blood pressure goal is: |________|/|_________|
Today blood pressure is / is not (circle one) at goal.
Assessment Notes:
Section VI. Pharmacist Step #6: Pharmacist Education Checklist
Education Points
**Please make sure you have discussed the following items with the participant by initialing in the next column** |
Pharmacist’s Initials |
I have reviewed all of the participant’s medications with the participant. |
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I have discussed all potential drug interactions with the participant. |
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I have provided disease state education on blood pressure to the participant. |
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I have discussed in detail the medications for blood pressure with the participant. |
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I have discussed the importance of medication adherence with the participant. |
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I have discussed over-the-counter medication use as it relates to blood pressure with the participant. |
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I have discussed how to read and understand prescription labels/packaging with the participant. |
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I have showed the participant how to use a pillbox for medication maintenance. |
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I have discussed when to call in for refills with the participant. |
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I have discussed blood pressure goals with the participant. |
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Section VII. Pharmacist Step #7: Interventions/Recommendations Made (check appropriate box per intervention and list each intervention)
Education on hypertension awareness
Diet:
Exercise:
Medication duplication:
Condition not treated:
Drug-disease interaction:
Drug-food interaction:
Drug-drug interaction:
Inappropriate Dose:
Therapeutic suggestion/alternatives:
Noncompliant:
Adverse drug event:
Other (SPECIFY):
Section VIII. Pharmacist Step #8: Follow-up Plan
18. Remind the participant about the upcoming education session. Ask the participant when is a good time for your follow-up telephone call after your education class next month?
Day:
Date:
Time:
19. Participant will need more education in the following areas (by phone):
Medication management
Blood pressure self-monitoring
Other (SPECIFY):
20. Does participant’s PCP need to be notified?
Yes
No
Why?
SERVICE DELIVERY FORM
TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE MINORITY HEALTH (PCCC) INITIATIVE
Directions: Complete this form at the end of the home visit. Pharmacist will send the completed form to the program coordinator.
Participant Name:
Pharmacist Name:
Visit Date:
The following service(s) have been provided to me today:
Baseline Blood Pressure Screening
Baseline Knowledge Survey
Disease State/Monitoring Education
Medication Management Education
Other (SPECIFY):
Participant Signature Date
Pharmacist Signature Date
TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE
MINORITY HEALTH (PCCC) INITIATIVE
First Home Visit Form: Diabetes
Date:
Participant name (Last name, First initial):
Client ID #:
Pharmacist Conducting Home Visit:
Home Visit Date:
Section I. Participant Demographics
Pharmacist Step #1: Introduction and collect baseline information.
1. On eligibility form
2. On eligibility form
3. Baseline A1C screening:
4. Wt: |___|___|__|
lbs.
5. Ht: |__| – |__|__|
feet inches
6. How long have you had diabetes?
7. What is your current household income per year?
$0 to $24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000 or more
Section II. Diabetes Knowledge
Pharmacist Step #2: Ask the participant the following questions and mark their answers.
1. People with diabetes have a higher risk for heart disease and stroke, compared with people who do not have diabetes.
True
False
2. Warning signs of eye problems include which of the following:
Having double vision
Seeing floating spots
Having trouble seeing
All of the above
3. You can help lower your risk for kidney problems by making the efforts to reach your targeted blood glucose level and blood pressure level.
True
False
4. Exercise can lower your blood glucose, blood pressure, and cholesterol levels.
True
False
5. Carbohydrate counting is a method that helps you know what to eat and how much to eat.
True
False
6. These foods are high in carbohydrates
Bread, biscuits, cornbread, tortillas, and crackers
Corn, peas, potatoes, and sweet potatoes
All of the above are correct
7. The A1C check:
Tells you what your blood glucose has been over the last two to three months
Tells you how well your diabetes treatment plan is working
All of the above are correct
8. If your A1C is 7 or higher:
You may need a change in your treatment plan
Your diabetes plan is working well
All of the above are correct
9. Blood glucose is too high when it is:
Higher than 130 before meals
180 and higher 2 hours after meals
All of the above are correct
10. Blood glucose is too low when it’s below 70.
True
False
Section III. Baseline PCCC Survey
Pharmacist Step #3: Ask the participant the following questions and mark their answers.
The statements below describe attitudes and beliefs you may have about the health program you signed up for and your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box.
Strongly Somewhat Somewhat Strongly
disagree disagree Neutral agree agree
1. I will learn new information to help me to manage my health condition
2. I will get useful information about my health condition
3. I expect to put what I learn from this program into practice
4. I expect to see positive changes in myself if I do what they teach me
5. I can do something to improve my health condition
6. It is very important to take care of your health
7. I am ready to improve my health
Section IV. Medication Use and Adherence
Pharmacist Step #4: Review the medications that the participant has OR has been prescribed. Create a medication chart with the participant. Fill out attached Appendix A Medication List with the participant.
Questions to ask:
What medication are you taking including OTC and dietary supplement?
Why are you taking the medication?
When do you take this medication?
When was your last dose?
Do you have any special instructions for this medication?
11. Medication History:
Medication |
Purpose |
Schedule |
Date of Last Dose |
Special Instructions |
1.
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15.
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16.
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Diabetes
12. How often have you forgotten to take your medicine for diabetes in the past week?
Always
Very Often
Sometimes
Rarely
Never
13. How often do you stop taking your medicine for diabetes because you were careless?
Always
Very Often
Sometimes
Rarely
Never
14. How often do you stop taking/injecting your medicine for diabetes because you feel better?
Always
Very Often
Sometimes
Rarely
Never
15. How often do you stop taking your medicine for diabetes when you experience side effects?
Always
Very Often
Sometimes
Rarely
Never
16. Please find the statement that best describes the way you feel right now about taking your diabetes medication as directed.
A. No, I do not take and right now am not considering taking my diabetes medication as directed. (Precontemplation)
B. No, I do not take but right now am considering taking my diabetes medication as directed. (Contemplation)
C. No, I do not take but am planning to start taking my diabetes medication as directed. (Preparation)
D. Yes, right now I consistently take my diabetes medication as directed.
17. If the answer to question 16 is D, then ask: How long have you been taking your diabetes medication as directed?
A. ≤3 months
B. >3 months to 6 months
C. >6 months to 12 months
D. >12 months
Section V. Pharmacist Step #5: Pharmacist Assessment
If the answer to question 16 is D and the answer to question 17 is A or B, then the stage of change is action. If the answer to question 16 is D and the answer to question 17 is C or D, then the stage of change is maintenance.
Check the most appropriate stage according to the readiness to change:
Area/Stage |
Precontemplation |
Contemplation |
Prepare |
Action |
Maintenance |
Adhere to medication |
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Hemoglobin A1C goal is: |________|/|_________|
Today hemoglobin A1C is / is not (circle one) at goal.
Assessment Notes:
Section VI. Pharmacist Step #6: Pharmacist Education Checklist
Education Points
**Please make sure you have discussed the following items with the participant by initialing in the next column** |
Pharmacist’s Initials |
I have reviewed all of the participant’s medications with the participant. |
|
I have discussed all potential drug interactions with the participant. |
|
I have provided disease state education on diabetes to the participant. |
|
I have discussed in detail the medications for diabetes with the participant. |
|
I have discussed the importance of medication adherence with the participant. |
|
I have discussed over-the-counter medication use as it relates to diabetes with the participant. |
|
I have discussed how to read and understand prescription labels/packaging with the participant. |
|
I have showed the participant how to use a pillbox for medication maintenance. |
|
I have discussed when to call in for refills with the participant. |
|
I have discussed hemoglobin A1C goals with the participant. |
|
Section VII. Pharmacist Step #7: Interventions/Recommendations Made (check appropriate box per intervention and list each intervention)
Education on diabetes awareness
Diet:
Exercise:
Medication duplication:
Condition not treated:
Drug-disease interaction:
Drug-food interaction:
Drug-drug interaction:
Inappropriate Dose:
Therapeutic suggestion/alternatives:
Noncompliant:
Adverse drug event:
Other (SPECIFY):
Section VIII. Step #8: Follow-up Plan
18. Remind the participant about the upcoming education session. Ask the participant when is a good time for your follow-up telephone call after your education class next month?
Day:
Date:
Time:
19. Participant will need more education in the following areas (by phone):
Medication management
Diabetes self-monitoring
Other (SPECIFY):
20. Does participant’s PCP need to be notified?
Yes
No
Why?
SERVICE DELIVERY FORM
TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE MINORITY HEALTH (PCCC) INITIATIVE PROGRAM
Pharmacist will complete.
Directions: Complete this form at the end of the home visit. Pharmacist will send the completed form to the program coordinator.
Participant Name:
Pharmacist Name:
Visit Date:
The following service(s) have been provided to me today:
Baseline Diabetes Screening
Baseline Knowledge Survey
Disease State/Monitoring Education
Medication Management Education
Other (SPECIFY):
Participant Signature Date
Pharmacist Signature Date
First Home Visit Form: Hypertension and Diabetes
TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE
MINORITY HEALTH (PCCC) INITIATIVE
Date:
Participant name (Last name, First initial):
Client ID #:
Pharmacist Conducting Home Visit:
Home Visit Date:
Section I. Participant Demographics
Pharmacist Step #1: Introduction and collect baseline information.
1. On eligibility form
2. On eligibility form
3. Baseline blood pressure screening:
4. Baseline A1C screening:
5. Wt: |___|___|__|
lbs.
6. Ht: |__| – |__|__|
feet inches
7. How long have you had high blood pressure?
8. How long have you had diabetes?
9. What is your current household income per year?
$0 to $24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000 or more
Section II. Hypertension Knowledge
Pharmacist Step #2: Ask the participant the following questions and mark their answers.
Hypertension
1. If someone’s blood pressure is 120/80, it is…
High
Low
Normal
Don’t know
2. If someone’s blood pressure is 160/100, it is…
High
Low
Normal
Don’t know
3. Once someone has high blood pressure, it usually lasts for …
A few years
5–10 years
The rest of their life
Don’t know
4. People with high blood pressure should take their medicine…
Everyday
At least a few times a week
Only when they feel sick
5. Losing weight usually makes blood pressure…
Go up
Go down
Stay the same
6. Eating less salt usually makes blood pressure…
Go up
Go down
Stay the same
7. High blood pressure can cause heart attacks.
Yes
No
Don’t know
8. High blood pressure can cause cancer.
Yes
No
Don’t know
9. High blood pressure can cause kidney problems.
Yes
No
Don’t know
10. High blood pressure can cause strokes.
Yes
No
Don’t know
Diabetes
1. People with diabetes have a higher risk for heart disease and stroke, compared with people who do not have diabetes.
True
False
2. Warning signs of eye problems include which of the following:
Having double vision
Seeing floating spots
Having trouble seeing
All of the above
3. You can help lower your risk for kidney problems by making the efforts to reach your targeted blood glucose level and blood pressure level.
True
False
4. Exercise can lower your blood glucose, blood pressure, and cholesterol levels.
True
False
5. Carbohydrate counting is a method that helps you know what to eat and how much to eat.
True
False
6. These foods are high in carbohydrates
Bread, biscuits, cornbread, tortillas, and crackers
Corn, peas, potatoes, and sweet potatoes
All of the above are correct
7. The A1C check:
Tells you what your blood glucose has been over the last two to three months
Tells you how well your diabetes treatment plan is working
All of the above are correct
8. If your A1C is 7 or higher:
You may need a change in your treatment plan
Your diabetes plan is working well
All of the above are correct
9. Blood glucose is too high when it is:
Higher than 130 before meals
180 and higher 2 hours after meals
All of the above are correct
10. Blood glucose is too low when it’s below 70.
True
False
Section III. PCCC Items
Pharmacist Step #3: Ask the participant the following questions and mark their answers.
The statements below describe attitudes and beliefs you may have about the health program you signed up for and your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box.
Strongly Somewhat Somewhat Strongly
disagree disagree Neutral agree agree
1. I will learn new information to help me to manage my health condition
2. I will get useful information about my health condition
3. I expect to put what I learn from this program into practice
4. I expect to see positive changes in myself if I do what they teach me
5. I can do something to improve my health condition
6. It is very important to take care of your health
7. I am ready to improve my health
Section IV. Medication Use and Adherence
Pharmacist Step #4: Review the medications that the participant has OR has been prescribed. Create a medication chart with the participant. Fill out attached Appendix A Medication List with the participant.
Questions to ask:
What medication are you taking including OTC and dietary supplement?
Why are you taking the medication?
When do you take this medication?
When was your last dose?
Do you have any special instructions for this medication?
11. Medication History:
Medication |
Purpose |
Schedule |
Date of Last Dose |
Special Instructions |
1.
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2.
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12. Medication Adherence
Very
Hypertension Always Often Sometimes Rarely Never
a. How often have you forgotten to take your medicine for blood pressure in the past week?
b. How often do you stop taking your medicine for high blood pressure because you were careless?
c. How often do you stop taking your blood pressure medicine because you feel better?
d. How often do you stop taking your medicine for blood pressure when you experience side effects?
Diabetes
a. How often have you forgotten to take your medicine for diabetes in the past week?
b. How often do you stop taking your medicine for diabetes because you were careless?
c. How often do you stop taking/injecting your medicine for diabetes because you feel better?
d. How often do you stop taking you medicine for diabetes when you experience side effects?
Hypertension
13. Please find the statement that best describes the way you feel right now about taking your high blood pressure medication as directed.
A. No, I do not take and right now am not considering taking my high blood pressure medication as directed. (Precontemplation)
B. No, I do not take but right now am considering taking my high blood pressure medication as directed. (Contemplation)
C. No, I do not take but am planning to start taking my high blood pressure medication as directed. (Preparation)
D. Yes, right now I consistently take my high blood pressure medication as directed.
14. If the answer to question 13 is D, then ask: How long have you been taking your high blood pressure medication as directed?
A. ≤3 months
B. >3 months to 6 months
C. >6 months to 12 months
D. >12 months
Diabetes
15. Please find the statement that best describes the way you feel right now about taking your diabetes medication as directed.
A. No, I do not take and right now am not considering taking my diabetes medication as directed. (Precontemplation)
B. No, I do not take but right now am considering taking my diabetes medication as directed. (Contemplation)
C. No, I do not take but am planning to start taking my diabetes medication as directed. (Preparation)
D. Yes, right now I consistently take my diabetes medication as directed.
16. If the answer to question 15 is D, then ask: How long have you been taking your diabetes medication as directed?
A. ≤3 months
B. >3 months to 6 months
C. >6 months to 12 months
D. >12 months
Section V. Pharmacist Step #5: Pharmacist Assessment
Hypertension
If the answer to question 13 is D and the answer to question 14 is A or B, then the stage of change is
action. If the answer to question 13 is D and the answer to question 14 is C or D, then the stage of
change is maintenance.
Diabetes
If the answer to question 15 is D and the answer to question 16 is A or B, then the stage of change is
action. If the answer to question 15 is D and the answer to question 16 is C or D, then the stage of
change is maintenance.
Check the most appropriate stage according to the readiness to change:
Area/Stage |
Precontemplation |
Contemplation |
Prepare |
Action |
Maintenance |
Hypertension Adhere to hypertension medication |
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Diabetes Adhere to diabetes medication |
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Blood pressure goal is: |________|/|_________|
Today blood pressure is / is not (circle one) at goal.
Hemoglobin A1C goal is: |________|/|_________|
Today hemoglobin A1C is / is not (circle one) at goal.
Assessment Notes:
Section VI. Pharmacist Step #6: Pharmacist Education Checklist
Education Points
**Please make sure you have discussed the following items with the participant by initialing in the next column** |
Pharmacist’s Initials |
I have reviewed all of the participant’s blood pressure medications with the participant. |
|
I have reviewed all of the participant’s diabetes medications with the participant. |
|
I have discussed all potential drug interactions for blood pressure with the participant. |
|
I have discussed all potential drug interactions for diabetes with the participant. |
|
I have provided disease state education on blood pressure/diabetes to the participant. |
|
I have discussed in detail the medications for blood pressure/diabetes with the participant. |
|
I have discussed the importance of medication adherence with the participant. |
|
I have discussed over-the-counter medication use as it relates to blood pressure/diabetes with the participant. |
|
I have discussed how to read and understand prescription labels/packaging with the participant. |
|
I have showed the participant how to use a pillbox for medication maintenance. |
|
I have discussed when to call in for refills with the participant. |
|
I have discussed blood pressure/diabetes goals with the participant. |
|
Section VII. Pharmacist Step #7: Interventions/Recommendations Made (check appropriate box per intervention and list each intervention)
Education on hypertension awareness
Education on diabetes awareness
Diet:
Exercise:
Medication duplication:
Condition not treated:
Drug-disease interaction:
Drug-food interaction:
Drug-drug interaction:
Inappropriate Dose:
Therapeutic suggestion/alternatives:
Noncompliant:
Adverse drug event:
Other (SPECIFY):
Section VIII. Pharmacist Step #8: Follow-up Plan
17. Remind the participant about the upcoming education session. Ask the participant when is a good time for your follow-up telephone call after your education class next month?
Day:
Date:
Time:
18. Participant will need more education in the following areas (by phone):
Medication management
Blood pressure self-monitoring
Diabetes self-monitoring
Other (SPECIFY):
19. Does participant’s PCP need to be notified?
Yes
No
Why?
SERVICE DELIVERY FORM
TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE MINORITY HEALTH (PCCC) INITIATIVE
Directions: Complete this form at the end of the home visit. Pharmacist will send the completed form to the program coordinator.
Participant Name:
Pharmacist Name:
Visit Date:
The following service(s) have been provided to me today:
Baseline Blood Pressure Screening
Blood Pressure
Diabetes
Baseline Knowledge Survey
Blood Pressure
Diabetes
Disease State/Monitoring Education
Blood Pressure
Diabetes
Medication Management Education
Blood Pressure
Diabetes
Other (SPECIFY):
Participant Signature Date
Pharmacist Signature Date
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Attachment 5. Houston Participant Surveys |
| Author | Linda Markovich |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |