Houston- Participant,Provider, Facility Administrator, Local Hub. Steering Committee Members

Attachment 5C

MYRX PARTICIPANT Telephone Follow-Up:
Being Active and Managing Stress

Telephone Follow-Up: Being Active and Managing Stress

TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE

MINORITY HEALTH (PCCC) INITIATIVE

Date:

Participant name (Last name, First initial):

Client ID #:

Date of Birth:

Study diagnosis (circle all that apply):  Hypertension   Diabetes

Date of the First Home Visit:

Pharmacist:

• Blood pressure at first home visit: ____________________

• Hemoglobin A1C at first home visit: ___________________

Script:

Intern: Hello, my name is __________________. I am with the medication therapy management program at Texas Southern University College of Pharmacy. On ____________(date of first home visit), a pharmacist visited with you to discuss your blood pressure/diabetes and medications. Your blood pressure/hemoglobin A1C at that time was _____________. Do you have about 20 minutes to talk to me about your blood pressure/diabetes?

Participant answer: No (then proceed with the following question)

1. “When is a good time to contact you?”

Record time and date:

“Okay, thank you very much Mr./Ms. (say participant’s last name.) We will definitely try calling you back at this more convenient time and look forward to speaking with you. Have a good day.”

OR

Participant answer: Yes (then proceed with the following questions)

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 20 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

2. Medication Adherence

Medication (Name/Strength)	Purpose	Schedule	Date of Last Dose	Special Instructions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

Has the participant missed any doses in the past two weeks?

Yes

No

If answer is yes, explain why.

Knowledge Questions Exercise: Ask the participant the following questions and mark their answers (refer to appropriate section below based on participant’s diagnosis)

I. Hypertension:

1. Exercise can lower your blood pressure.

True

False

2. How much physical activity is enough?

20 minutes everyday

90 minutes a day once you are in shape

150 minutes a week

It depends on the size of your heart

3. People who have hypertension can do any kind of exercise they want.

True

False

4. Exercise can be dangerous if it increases your heart rate too fast.

True

False

5. Serious depression is common in people with hypertension, but treatment can help.

True

False

II. Diabetes:

1. For a person in good control of their diabetes, exercise lowers blood glucose.

True

False

2. Examples of aerobic exercise include which of the following activities?

Brisk walking

Swimming

Dancing

All of the above

3. Exercise can cause low blood glucose levels.

True

False

4. When you’re stressed, it’s hard to keep your blood glucose on track because:

Your body makes hormones that affect your blood glucose

It’s hard to pay attention to your diabetes

Both of the above are correct

5. Serious depression is common in people with diabetes, but treatment can help.

True

False

For office use only:

1st attempt: Date ______ Time: ________ Outcome: _______

2nd attempt: Date______ Time: ________ Outcome: _______

3rd attempt: Date ______ Time: ________ Outcome: _______

After three failed attempts, the participant is dropped from program.