DUPLICATION DISTRIBUTION PROHIBBITED AND. Utilizing Economic and Clinical Outcomes to Eliminate Health Disparities and Improve Health Equity

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1 General Session IV Utilizing Economic and Clinical Outcomes to Eliminate Health Disparities and Improve Health Equity Accreditation UAN L04-P Participation in this activity earns 2.0 contact hours. To receive credit, participants must complete an evaluation form at the conclusion of this session. 1

2 General Session IV At the completion of this activity, participants will be able to: Identify opportunities for research funding to address issues of health disparities; and Describe the use of economic and clinical outcomes to improve health equity. Kathleen B. Kennedy, PharmD OPENING REMARKS John Ruffin, PhD NIMHD DIRECTOR S ADDRESS 2

3 Aisha Morris Moultry, PharmD PRESENTATION Aisha Morris Moultry, Pharm.D., M.S. President, Association of Black Health-System Pharmacists Associate Professor of Pharmacy Practice, Texas Southern University Fifth Health Disparities Conference, New Orleans, LA Objectives Discuss core components, institutional supports, and barriers to providing patient-centered care in underserved populations p Discuss strategies that have been effective in managing minority populations with diabetes and hypertension 3

4 Trends in Healthcare Shift from a professionally driven approach toward one that is patient centered or consumer centered Recognition that incorporating an individual patient s perspectives and greater involvement in his/her care results in better health outcomes and satisfaction. Underserved Populations Low-income Uninsured Immigrants Racial and ethnic minorities iti Elderly Core Components of Patient- Centered Care for Underserved Welcoming environment Respect for patients values and expressed needs Patient empowerment or activation Socio-cultural competence 4

5 Core Components of Patient- Centered Care for Underserved Coordination and integration of care Comfort and support Access and navigation skills Community outreach Key Institutional Supports for Patient-Centered Care Feedback and measurement Patient/family involvement Workforce development Leadership Involvement in collaboratives/pilots Barriers to Patient Centered Care Difficulty recruiting and retaining underrepresented minority healthcare professionals Lack of defined boundaries for outreach staff Lack of tools to gauge and reward PCC performance 5

6 Barriers to Patient Centered Care Financial constraints Traditional attitudes among staff unwilling to change the old school provider/patient relationship Fatigue and competing priorities Prevalence of Hypertension Target Populations Hypertension Total population 30.5% US 58.0% TX (65+) African Americans 31.8% US 41.4% TX Asian Americans 21% US - Hispanics/ Latinos 26.1% US 21.7% TX 6

7 Prevalence of Diabetes Target Populations Total population African Americans Asian Americans Hispanics/ Latinos Demographics Target Populations Diabetes 8.3% US 22.7% TX (65+) % US 33.5% TX (65+) 16.9% HOU 8.4% US % US 34.8% TX (65+) 8.6% HOU City of Houston Population (n= 2,024,379) African Americans 24% (n=487,666) Asian Americans 5% (n=108,015) Hispanics/ Latinos 42% (n=849,226) Impact of Hypertension 65+ Years Houston Population (n=180,008) 25% (n=44,204) 5% (n=9,548) 18% (n=33,206) In 2007, it was reported that 47.6% of individuals with high blood pressure also had cardiovascular diseases In 2006, there were 25,980 first-listed hospital discharges for diagnoses for hypertension The average cost of providing care in a hospital to a patient with hypertension in 2007 was $2,

8 Impact of Diabetes The risk of hospitalization from cardiovascular disease is two to four times higher for women with diabetes as compared to women without diabetes. Health care costs three times higher for diabetes patients with multiple hospitalizations as compared to those with a single stay in a given year Patients with diabetes who are racial/ethnic minorities, enrolled in public insurance programs, or living in low-income communities are more likely to experience multiple hospitalizations and have higher hospital costs than their counterparts Medication Adherence Statistics ~75% of adults are non-adherent to medication regimens ~30% of adults stop taking their meds before it runs out ~33% of adults do not get prescription orders filled ~50% of people 65 years and older receive an average of >5 medications Office visits involving polypharmacy estimated to quadruple from 10mil in 1990 to 37.5mil in 2000 Linear relationship to number of drugs taken to the incidence of new hospital admissions per year due to adverse drug reactions and inappropriate medication use Significance of Research Provides a model to reconcile medication regimen for a population that often sees multiple providers who prescribe without knowing patient s complete medication history 8

9 Patient Centered Care Collaboration to Improve Minority Health Initiative Program funded by HHS-OMH Targets African Americans, Asian Americans, Hispanics, Native Americans with chronic disease states t Based out of two locations Houston Hub Texas Southern University Chicago Hub University of Illinois-Chicago Houston Hub Intervention Goal To evaluate the effectiveness of evidencebased practices used to improve rates of medication adherence through information dissemination among diabetic and hypertensive African-American, Asian American, and Hispanic residents housed in senior living facilities located in the Greater Houston Area. Inclusion Criteria Age 55 and older Member of one of the targeted ethnic groups Resident of the targeted facilities Taking at least one medication for diabetes/hypertension at the time of recruitment Access to a telephone at home 9

10 Intervention Design Will utilize a pre-post intervention study design that will involve a series of data collection points by providers Baseline A1C and blood pressure screenings, medication and disease state knowledge, current behavior Monthly phone calls to measure knowledge obtained from educational sessions and behavior changes Final data collection of A1C and blood pressure screenings, medication and disease state knowledge, behavior changes Pharmacist Home Visit Individual home visit for each participant (~1 hour) by a pharmacist who speaks the preferred language Assess the participant s baseline knowledge Collect baseline clinical data (i.e., hemoglobin A1c and blood pressure) Educate the patient Information about the participant s disease state Role of medication adherence How to read prescription labels and packaging Over-the-counter medication use as it relates to the targeted disease state Group Health Education Classes Two one-hour classes on lifestyle modifications will be held at each facility in preferred languages Exercising and reducing stress Healthy Eating Health educators will facilitate the classes Pharmacists will be present at the classes to answer any clinical questions 10

11 Pharmacist Telephone Counseling Will occur by pharmacists one to two weeks following each education session Same pharmacist who conducted home visit Assess and reinforce concepts taught in the classes Offer individualized consultations on their medication Physician Connection Participants will provide contact information and sign agreement to allow program to communicate information Initial contact provided to inform physician of patient s participation in program Any unusual findings during consultations with providers will be reported to physician Physician will receive overview of patient s information at the end of the study Cultural Adaptation Language preference Information tailored to culture Culture of facility 11

12 Pharmacists Training Human subjects certification Motivational interviewing/health coaching Health literacy Cultural competency Current therapy in hypertension and diabetes Community Engagement Residents at each facility Harris County Hospital District Community Outreach Services Department of Pharmacy San Jose Clinic Boat People SOS Houston Housing Authority African American Health Coalition Hispanic Health Coalition MD Anderson Cancer Center American Diabetes Association Managing Medication Adherence in Elderly Hypertensive Patients through Pharmacists Home Visits The purpose of the study is to reduce health disparities in blood pressure control by improving medication adherence among the African American Medicare beneficiary population age 65 years and older The objectives of the program are to: 1) achieve blood pressure control rate of 50% among patients 2) achieve patient medication adherence rate of 90%; 3) obtain a 95% patient usage of the blood pressure monitor at home; 4) improve hypertension awareness and knowledge among patients by 10% Program funded by Centers for Medicare and Medicaid Services 12

13 Inclusion Criteria To be eligible, an individual must be: African American 65 years or older during the period of study On antihypertensive medications Medicare enrollee Resident of Harris County or Greater Houston Area Methodology O1: Collection of baseline data X1: Initial in home pharmacy consultation X2: Series of biweekly telephone consultations X3: Follow-up in home pharmacy consultation O2: Data collection and analysis Initial Home Visit Introduction and collection of demographic information Hypertension knowledge assessment Education on self-monitoring information Pharmacist assessment

14 Telephone Follow Ups Pharmacy interns will be responsible for telephone follow up Review medication use and adherence Report blood pressure reading Review self-monitoring techniques 6 month Follow Up Visit Pharmacist will: Re-check blood pressure Review medication adherence Ask the patients to complete a hypertension awareness survey Review the patient s medications to determine if there have been any changes Document all findings in a standardized 6 month documentation form Preliminary Results As of 8/1/2011: # patients recruited 321 # patients receiving services 149 # patients waiting for services 74 # patients assigned to pharmacist 97 and waiting for services # patient withdrew (1) Number of Patients Total # patients enrolled

15 Preliminary Results Characteristics (N=321) Age, Mean (range) 74.7 (65-100) Female, no. (%) 257 (80%) BMI, Mean (range) 30.3 (21-46) Years of Hypertension, Mean 16.3 Recruitment Sites Distribution No. of Patients Community Senior Assisted Living Groups Facilty/ Apartments Faith-based organizations Preliminary Result Primary Outcome % controlled blood pressure (n=59) 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Referral by patient First Home Visit Telephone f/u #1 Telephone f/u #

16 Challenges Lack of trust Pharmacist recruitment and training Blood pressure cuff size Patient t availability Acknowledgements Ivy Chui-Poon, Pharm.D., BCPS (TSU) Principal Investigator CMS Co-Investigator for Houston Hub PCCC Kimberly Pounds, DrPH (TSU) Co-Investigator CMS Co-Investigator for Houston Hub PCCC Brenda Leath, MHSA, PMP (Westat) Principal Lead Investigator PCCC References 1. Economic and Social Research Institute. Patient-centered care for underserved populations: definition and best practices. January U.S. Census Bureau, American Community Survey. 3. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Houston Department of Health and Human Services. City of Houston Health Disparities Data Report Texas Diabetes Council. Texas Diabetes Fact Sheet, Fryar CD, Hirsch R, Eberhardt MS, et al. Hypertension, high serum cholesterol, and diabetes: Racial and ethnic prevalence differences in U.S. adults, , NCHS data brief, no 36. Hyattsville, MD: National Center for Health Statistics Texas Behavioral Risk Factor Surveillance System, Center for Health Statistics. High blood pressure prevalence in Texas Texas State Department of Health. Behavioral Risk Factor Surveillance System Available at: Accessed September 15, American Heart Association. Statistics you need to know: Statistics on medication. Accessed at on March 23,

17 Michael T. Robinson, PharmD CALL TO ACTION Cleared for Take Off.. Tools needed for the journey 17

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19 Case Study 78 year old African American male presents to the E.R. with a 20 year hx of smoking and emphysema. Past medical history is significant for cardiovascular disease, diabetes and unsteady ygait. Upon admission patients family explains that J.R. attempted to get out of bed several times but stumbled each time. He tried at 1 pm and stumbled. He tried at 2 pm and stumbled. He tried at 3 pm and stumbled. But each time he stumbled he never fell because the family caught him every single time. 19

20 You have been cleared for take off.. Thank you for your participation! 20