Asthma MTM Pilot Checklist

Transcription

1 Asthma MTM Pilot Checklist Patient Identifier: This Checklist is intended to guide you as you conduct the MTM process for the indicated patient. It is suggested that you keep this packet on file for the patient throughout the entire pilot program. Enrollment Meeting/Phone Call (5 min) Date: Completed by: Description of study and participation agreement Schedule Initial Visit (must be a LIVE meeting) o Inform patient to bring in ALL medications, both non-prescription and prescription. o Advise patient to arrive 15 minutes early to fill out paperwork Notify Kim Roberson of the scheduled Initial Visit Initial Visit Comprehensive Medication Review (CMR) Date: Completed by:,rph Enrollment may be performed by technician (15 minutes) Enrollment application form and consent forms Health Attitudes Typing Tool and summary guide (adherence survey) (optional) > General Patient Assessment Tools MTR Patient Health and Lifestyle ionnaire (highlight questions that are critical to complete) Asthma Control Test Score: Pharmacist meeting with patient (20 minutes) Assess patient adherence. Have they missed any doses? o If so, educate the patient on the importance of adherence and follow up in about 2 weeks to determine if compliance has improved. After follow-up, document the Encounter claim in the Outcomes system. Talk with patient about medical, family, social history, problems with medications, health status Complete the CMR and Personal Medication Record and provide a copy to the patient Counsel patient on smoking cessation and refer if necessary using the Quitline Fax Referral Form Counsel patient on allergen testing if necessary using the Allergy Testing Referral Form Provide patient with an Asthma Care Kit and instruct them to record their peak flow meter readings daily until the next appointment o Provide patient with the Peak Flow Meter Patient Log Page 1 of 4

2 Asthma MTM Pilot Checklist Patient Identifier: After patient leaves Screen for adverse drug reactions, drug interactions, clinical appropriateness, and cost effectiveness of therapy Develop Medication Action Plan and obtain physician approval for any recommended changes. o Fax the Asthma Action Plan and Prescription Approval Letter to the physician Fax Quitline Fax Referral Form to if applicable o Note: Use your pharmacy s name under the Clinic Name field. Fax Allergen Testing Referral Form to physician if applicable Document CMR and bill through OutcomesMTM o If additional MTM services were provided (drug therapy problems were found), document these as a CMR with Encounter. Additional claims may be created and saved at this time in the OutcomesMTM system until you have determined the result(s). o If the visit is a CMR with follow-up Encounter where additional patient training is needed, discuss needed follow-up visit where peak flow meter and holding chamber training will be provided. Recommend this be scheduled AFTER physician approves recommended Asthma Action Plan. Schedule Second Live Visit after receiving physician approval of the Asthma Action Plan and any changes to drug therapy Second Live Visit (20 25 min) Date: Completed by:,rph Prior to meeting may be completed by technician Complete Asthma Control Test Score: Pharmacist meeting with patient Assess if patient has experienced adverse events since initial visit o If so, work with patient and/or physician to resolve the new issue. Upon response from the patient / physician, document the Encounter claim in the Outcomes system. Assess patient adherence. Have they missed any doses? o If so, educate the patient on the importance of adherence and follow up in about 2 weeks to determine if compliance has improved. After follow-up, document the Encounter claim in the Outcomes system. Provide Peak Flow Meter and Holding Chamber training if necessary Discuss Asthma Action Plan approved by the physician. Counsel patient on any drug therapy changes made regarding drug therapy problems found as a result of the CMR. (new prescriptions, etc) Counsel on health and lifestyle changes. Schedule Telephone Follow-Up (two weeks if DTP identified; four weeks if not) Page 2 of 4

3 Asthma MTM Pilot Checklist Patient Identifier: Post-Meeting Document information in Medication Action Plan and/or progress notes. If any, fax recommendations for medication changes to physician Recurring Telephone Follow Up Date: Completed by:,rph If a Drug Therapy Problem is identified at any follow-up, the next follow-up should occur at two weeks. Otherwise, all follow-ups are at four-week intervals until the 6-month observation period has ended. Document information in Medication Action Plan and/or progress notes. Follow-up Log: Assess if patient has experienced adverse events since last visit o If so, work with patient and/or physician to resolve issue. Upon response from patient/physician, document MTM claim in Outcomes system Assess patient adherence. Have they missed any doses? o If so, educate the patient on the importance of adherence and follow up in about 2 weeks to determine if compliance has improved. After follow up- document MTM claim in Outcomes system. If any, fax recommendations for medication changes to physician o Notify patient to pick up new prescriptions if necessary Complete Asthma Control Test Obtain any hospitalization or Emergency Room visit information since last contact Record ACT score and hospitalization / ER visit information in OutcomesMTM and in the form below (for each follow-up) Date ACT Score Hospitalization since last visit? (Y/N) Page 3 of 4

4 Asthma MTM Pilot Checklist Patient Identifier: Final Visit (preferred Live) Document information in Medication Action Plan and/or progress notes. Date: Completed by:,rph Complete Asthma Control Test o Score: Obtain any hospitalization or Emergency Room visit information since last contact Record ACT score and hospitalization / ER visit information in OutcomesMTM Have patient complete the Patient Satisfaction Survey No further meetings required Page 4 of 4

5 Pre- Visit 1. Identify patients with Asthma/COPD taking 4 or more chronic medications who are receiving pharmacy services at the study location sites. 2. Contact patients who have expressed interest in participating in the pilot program. Telephone Contact 1. Provide description of study 2. Schedule first visit 3. Remind patient to avoid food, smoking & caffeine at least 30 minutes prior to appointment 4. Remind patient to arrive 15 minutes early to complete enrollment forms Live Contact 1. Provide description of study 2. Complete enrollment forms if time permits, otherwise, remind patient to arrive 15 minutes early to Initial Visit 3. Schedule first visit 4. Remind patient to avoid food, smoking & caffeine at least 30 minutes prior to appointment Initial Visit Comprehensive Medication Review (CMR) When patient arrives prior to Initial Visit: Pharmacist Tasks: 1. Obtain a complete list of medications (Prescription and Over- the- Counter), any available clinical data 2. Obtain a brief patient history using appropriate forms from the MTM Guide Packet Technician Tasks: 1. Confirm patient meets pilot criteria and has completed all forms in the Patient Enrollment Packet 2. Health Attitudes Typing Tool (optional) 3. MTR Patient Health and Lifestyle ionnaire 4. Asthma Control Test During Initial Visit: 1. Assess patient adherence 2. Discuss patient s medical history, social history, family history, health status, etc. 3. Complete CMR. 4. Fill out Personal Medication Record and provide a copy to the patient. 5. Counsel patient on smoking cessation and refer using the Quitline FAX Referral Form if necessary 6. Counsel patient on allergen testing and refer to physician using the Allergen Testing Referral Form if necessary 7. Provide patient with an Asthma Care Kit and instruct them on the proper use of a Peak Flow Meter ask patient to record their twice- daily readings on the Peak Flow Meter Patient Log After Initial Visit: 1. Screen for adverse drug reactions, drug interactions, clinical appropriateness, cost effectiveness, and other drug therapy problems 2. Fax Asthma Action Plan, Prescription Approval Letter, Allergen Testing Referral Form, and other recommendations to the physician 3. Send Quitline FAX Referral Form to if applicable. 4. Document CMR and bill through OutcomesMTM After Physician Approval/Denial is received, schedule the Second Live Visit. Second Live Visit (Approx. 2 weeks later) Prior to meeting with patient: 1. Complete Asthma Control Test During Second Live Visit: 1. Assess if patient has experienced adverse events since initial visit. 2. Assess patient adherence. 3. Provide Peak Flow Meter and Holding Chamber training if necessary. 4. Discuss Asthma Action Plan that was approved by physician fill in any missing information 5. Counsel patients on any changes to drug therapy as a result of the CMR. 6. Counsel on health and lifestyle changes if necessary After Second Live Visit: 1. Document the encounter in OutcomesMTM 2. Document information in progress notes if necessary. 3. If any, fax recommendations for medication changes to the physician. 2- Week Telephone Follow- Up 1. Contact the patient to notify them of any changes to therapy 2. Encourage them to pick up new prescriptions 3. Reiterate key discussion topics (adherence, adverse events, etc.) 4. Complete Asthma Control Test and document information 5. Continue to document in OutcomesMTM 6. Identify any drug therapy problems. Yes Were any drug therapy problems found? No Final Live Visit (6 months after enrollment) 1. Complete ACT and obtain hospitalization information 2. Document in OutcomesMTM 3. Have patient complete the Patient Satisfaction Survey 4- Week Telephone Follow- Up 1. Reiterate key discussion topics (adherence, adverse events, etc.) 2. Complete Asthma Control Test and document information 3. Continue to document in OutcomesMTM 4. Identify any drug therapy problems

6 Patient Health and Lifestyle ionnaire This questionnaire is based on the information available to the pharmacist as provided by the patient. This questionnaire is to remain in the patient s chart in the pharmacy and can be used as a reference when communicating with other healthcare providers. Patient Identifier: Date of Birth: Race: Gender : M / F Pharmacist/Student Intern: Date Prepared: Patient Height: Primary Pharmacy and Phone Number: Type of MTM visit: Initial Visit Follow- up Visit Blood Glucose: HgA1c: Lipids: Total Cholesterol: LDL: HDL: Triglycerides: What questions does the patient have about his/her medications or disease states? Medication Allergies and Adverse Drug Reactions (if known): Patient Weight: Waist Circumference: Today s Blood Pressure (in the pharmacy): If so, list at home blood pressure readings here: Does the patient drink alcoholic beverages? Y / N Does the patient drink caffeinated beverages? Y / N Does the patient smoke or use tobacco products? Y / N For how long? Does the patient take at- home blood pressure readings? Y / N If so, what type and how often? If so, what type and how often? If so, what type? How much per day? Does the patient salt their food? Y / N If so, how often and how. Does the patient exercise? Y / N does the patient exercise? Medical Conditions (Check all that apply): Does the patient want to lose weight? Y / N Alcoholism Breastfeeding Depression Heart failure Obesity Chest pain Cancer Diabetes High cholesterol Osteoporosis Arthritis Headache GI disorder High blood pressure Pregnancy Asthma Pain Glaucoma Kidney disease Seizure disorder Bleeding disorder COPD Heart disease Liver disease Thyroid disease Other:

7 Immunizations: Tdap Y / N Date: / Meningococcal Y / N Date: / Zostavax/Shingles Y / N Date: / Influenza Y / N Date: / Hepatitis A Y / N Date: / Pneumococcal Y / N Date: / Hepatitis B Y / N Date: / Additional Patient Information: Is the home heated/cooled by central heat and air? Y / N Is a swamp cooler used to cool any room in the house? Y / N Is the patient s room carpeted? Y / N Does the home have a basement? Y / N Is the patient s room located in the basement? Y / N How many people live in the home? Do any of them smoke? Y / N Are the patient s mattress and pillow encased in anti- allergenic dust covers? Y / N Do any of the patient s siblings or birth parents suffer from Asthma? Y / N If so, who? Are any rooms in the house heated by a kerosene heater or fireplace? Y / N Is the house carpeted? Y / N Are there any stuffed animals in the patient s room? Y / N Are there pets in the home? Y / N If so, what type and how many? Does the home have a problem with leaks in the ceiling, windows, or plumbing that may lead to mold? Y / N Does the home have a problem with cockroaches? Y / N Are any rooms in the house or attached to the house used to store/use varnishes, thinner, patients, petroleum products, or other chemicals? Y / N Dose the patient routinely use any of the following medications? (Select all that apply) Visine (or other OTC eye drops) Acetaminophen (Tylenol) Aspirin Cold medications that contain acetaminophen Does the patient routinely consume any of the following foods? (Select all that apply) Beer Wine Grape Juice Wine vinegar Pickles Sauerkraut Lemon Juice Lime Juice Shrimp Molasses Dried fruit other than raisins or prunes Processed potatoes (French fries, tator tots, etc.) Relevant Family History (1 st degree relatives, Marital Status, Children, etc.): Relevant Social History (use of illicit drugs):

8 Asthma Control Test The ASTHMA CONTROL TEST is a quick test for people with asthma 12 years and older. It provides a numerical score to help assess asthma control. Name: Today s Date: INSTRUCTIONS: 1. Write the number of each answer in the score box provided. 2. Add up the score boxes to get the TOTAL. 3. Discuss your results with your doctor. 1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? SCORE All of the time [1] Most of the time [2] Some of the time [3] A little of the time [4] None of the time [5] 2. During the past 4 weeks, how often have you had shortness of breath? More than once a day [1] Once a day [2] 3 to 6 times a week [3] Once or twice a week [4] Not at all [5] 3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? 4 or more nights a week [1] 2 or 3 nights a week [2] Once a week [3] Once or twice [4] Not at all [5] 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 3 or more times per day [1] 1 or 2 times per day [2] 2 or 3 times per week [3] Once a week or less [4] Not at all [5] 5. How would you rate your asthma control during the past 4 weeks? Not controlled at all [1] Poorly controlled [2] Somewhat controlled [3] Well controlled [4] Completely controlled [5] If your score is 19 or less, your asthma may not be as well controlled as it could be. No matter what your score is, share the results with your healthcare provider. TOTAL: Copyright 2002, by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated. This material was developed by GlaxoSmithKline The GlaxoSmithKline Group of Companies All rights reserved. Produced in USA. AD5863R0 June 2012

9 Peak Flow Meter Patient Log Please bring this form with you to your follow-up appointment at the pharmacy. Name: DOB: / / Date Peak Flow Meter Reading Date Peak Flow Meter Reading Date Peak Flow Meter Reading Date Peak Flow Meter Reading Date Peak Flow Meter Reading Date Peak Flow Meter Reading

10 Personal Medication Record Patient Name: Date of Birth: Pharmacist/Intern/Technician: Date Prepared: Pharmacy: Pharmacy Phone: Emergency Contact Name/Number: Physician Contact Name/Number: Prescription Medications: Medication Name Dose Route Frequency Indication Duration of Therapy Physician/Comments Over-the-Counter Medications: Herbal Supplements: Dietary Supplements: MEDICATION ALLERGIES AND REACTIONS: This sample Medication-Related Action Plan (MAP) is provided only for general informational purposes and does not constitute professional health care advice or treatment. The patient (or other user) should not, under any circumstances, solely rely on, or act on the basis of, the MAP or the information therein. If he or she does so, then he or she does so at his or her own risk. While intended to serve as a communication aid between patient (or other user) and health care provider, the MAP is not a substitute for obtaining professional healthcare advice or treatment. This MAP may not be appropriate for all patients (or other users). TPA assumes no responsibility for the accuracy, currentness, or completeness of any information provided or recorded herein.

11 This sample Medication-Related Action Plan (MAP) is provided only for general informational purposes and does not constitute professional health care advice or treatment. The patient (or other user) should not, under any circumstances, solely rely on, or act on the basis of, the MAP or the information therein. If he or she does so, then he or she does so at his or her own risk. While intended to serve as a communication aid between patient (or other user) and health care provider, the MAP is not a substitute for obtaining professional healthcare advice or treatment. This MAP may not be appropriate for all patients (or other users). TPA assumes no responsibility for the accuracy, currentness, or completeness of any information provided or recorded herein.

12 Asthma Action Plan Prescriber Authorization: For: Doctor: Date: Doctor s Phone Number Hospital/Emergency Department Phone Number GREEN ZONE YELLOW ZONE RED ZONE Doing Well No cough, wheeze, chest tightness, or shortness of breath during the day or night Can do usual activities And, if a peak flow meter is used, Peak flow: more than (80 percent or more of my best peak flow) My best peak flow is: Before exercise Asthma Is Getting Worse Cough, wheeze, chest tightness, or shortness of breath, or Waking at night due to asthma, or Can do some, but not all, usual activities 2 or 4 puffs, every 20 minutes for up to 1 hour (short-acting beta 2 -agonist) Nebulizer, once If your symptoms (and peak flow, if used) return to GREEN ZONE after 1 hour of above treatment: Continue monitoring to be sure you stay in the green zone. -Or- If your symptoms (and peak flow, if used) do not return to GREEN ZONE after 1 hour of above treatment: Take: 2 or 4 puffs or Nebulizer (short-acting beta 2 -agonist) Add: mg per day For (3 10) days (oral steroid) Call the doctor before/ within hours after taking the oral steroid. -Or- Peak flow: to (50 to 79 percent of my best peak flow) Medical Alert! Very short of breath, or Quick-relief medicines have not helped, or Cannot do usual activities, or Symptoms are same or get worse after 24 hours in Yellow Zone -Or- Peak flow: less than (50 percent of my best peak flow) Take these long-term control medicines each day (include an anti-inflammatory). Medicine How much to take When to take it 2 or 4 puffs 5 minutes before exercise First Second Take this medicine: Add: quick-relief medicine and keep taking your GREEN ZONE medicine. (short-acting beta 2 -agonist) (oral steroid) Then call your doctor NOW. Go to the hospital or call an ambulance if: You are still in the red zone after 15 minutes AND You have not reached your doctor. 4 or 6 puffs or Nebulizer mg DANGER SIGNS Trouble walking and talking due to shortness of breath Take 4 or 6 puffs of your quick-relief medicine AND Lips or fingernails are blue Go to the hospital or call for an ambulance NOW! (phone) See the reverse side for things you can do to avoid your asthma triggers.

13 Prescription Approval Letter Dr., Date: I am pleased to inform you that our mutual patient,, has chosen to participate in the Texas Pharmacy Association Medication Therapy Management Pilot Project. This program provides self care education, frequent monitoring, and structured patient accountability in a multi collaborative setting consisting of the patient, pharmacist, and practitioner, with the goal of coordinating guideline based 1 asthma care to improve patient outcomes. As part of the project, a Comprehensive Medication Review (CMR) and Medication Therapy Management (MTM) Session was recently performed here at. The purpose of this MTM Session was to help our mutual patient manage complex drug therapies used for asthma. During this session, several items were addressed regarding our patient s asthma, including the frequency, severity, and nature of our patient s symptoms, the amount of exacerbations within the past year, and the amount of asthma related hospitalizations within the past year. We also discussed the development of an Asthma Action Plan based on symptoms and peak flow meter results, and education was provided regarding when and how to implement the Asthma Action Plan. Based on this information, I would like to recommend for your approval the following drug therapies for our patient s Asthma Action Plan. Our patient understands that these drug therapies at these doses are to be used solely for acute asthma exacerbations and are based on severity of symptoms and peak flow meter results (see below). Furthermore, our patient has been educated on identifying and recognizing the current status of their asthma during an acute exacerbation, as well as what steps should be taken. GREEN ZONE: No symptoms of exacerbation; Peak flow 80% of personal best Continue long term control medicines each day YELLOW ZONE: Moderate symptoms of exacerbation; Peak flow 50 79% of personal best Albuterol for quick relief; Prednisone regimen if necessary RED ZONE: Severe symptoms of exacerbation; Peak flow < 50% of personal best Quick relief Albuterol AND Prednisone regimen; Seek medical attention On page 2 of this fax, you will find our patient s information, as well as a few drug therapy options and dosages for your selection. Please select ONE Albuterol dosing regimen and ONE Prednisone dosing regimen for our patient, and I will ensure that our patient receives additional counseling regarding the use of these medications for the treatment of an acute asthma exacerbation. Thank you for your support of the Texas Medicaid Medication Therapy Management Pilot Project and our efforts to coordinate guideline based 1 asthma care. Sincerely,, R.Ph. ¹ National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma: Summary Report Bethesda, MD: National Institutes of Health, US Dept of Health and Human Services, National Heart, Lung, and Blood Institute; Page 1 of 2

14 Prescription Approval Letter PATIENT NAME: ADDRESS: DOB: PHONE: NUMBER OF ASTHMA EXACERBATIONS / HOSPITALIZATIONS IN THE PAST YEAR: PHARMACY: PHARMACY PHONE: PHARMACY FAX: PRESCRIPTION (PLEASE SELECT ONE): Albuterol MDI (90 mcg/puff): Inhale 4 8 puffs by mouth every 20 minutes up to 4 hours, then every 1 4 hours as needed Albuterol nebulizer solution 0.083% (2.5 mg/3 ml): Use 1 2 vials via nebulizer every 20 minutes for 3 doses, then every 1 4 hours as needed Other: (Please write here) PRESCRIPTION (PLEASE SELECT ONE): Prednisone 40 mg by mouth once daily for days (please circle one) Prednisone 30 mg by mouth twice daily for days (please circle one) Prednisone 60 mg by mouth once daily for days (please circle one) Other: (Please write here) PHYSICIAN NAME: ADDRESS: PHONE: SIGNATURE: DATE: ***A physician s signature indicates that this form has been approved as a VALID PRESCRIPTION to be dispensed by the pharmacy Page 2 of 2

15 Allergen Testing Referral Form Date: / / Dr., Our records indicate that your patient,, has not been tested for common respiratory inhalant allergens that may be contributing to their asthma symptoms. The NIH Guidelines for the Management of Asthma recommends the assessment of allergic triggers in all patients diagnosed with persistent asthma. Specifically, all patients prescribed a daily medication to control their symptoms should be tested to reliably determine their sensitivity to inhaled allergens. In vitro IgE testing has recently been approved to be paid for by several Texas Managed Medicaid Plans (listed below). Typically, Asthma Action Plans for adults and children include a checklist of asthma triggers, both allergic and non-allergic. However, without information gained from IgE testing, documentation of a patient's specific allergic triggers is limited to qualitative information provided by the patient. Elevated specific IgE test results, when consistent with patient history, symptoms, and clinical exam, support the diagnosis of allergy and allow for more effective management of the allergy, including pharmacotherapy. If you have not done so, you may order the IgE testing from the lab corresponding to the patient's Texas Managed Medicaid Plan as indicated below. If you have any questions or concerns, please contact me using the contact information provided below. Thank you for your commitment to improve the care of your patient with persistent asthma. Sincerely, Phone: Fax: 1 of 2

16 Texas Managed Medicaid Plans and corresponding lab providers (Pharmacist: Please indicate the plan in which the patient is enrolled by checking the corresponding box) Plan Aetna Aetna Better Health Amerigroup BCBS TX CHRISTUS Health Plan Community First Health Plans Community Health Choice Cook Children s Health Plan Driscoll Children s Health Plan El Paso First Premier FirstCare STAR HealthSpring Molina Healthcare Parkland Healthfirst Right Care from Scott and White Health Plan Sendero Seton Superior Health Plan Texas Children s Health Plan United Healthcare Community Lab Provider, CPL CPL LabCorp Other: Information is current as of 1/8/14; please verify coverage before referring patient to lab. This is not an exhaustive list. 2 of 2

17 Quitline FAX Referral Form Fax Number: PROVIDER INFORMATION: Fax Sent Date: / / Clinic Name: Health Care Provider: Contact Name: I am a HIPAA-Covered Entity (Please check one) Yes No I Don t Know Fax: ( ) Phone ( ) Comments: PATIENT INFORMATION: Gender: male / female Pregnant? Y N Patient Name: DOB: / / Address: City: Zip: Primary #:( ) Type: HM WK CELL OTHER Secondary #:( ) Type: HM WK CELL OTHER Language Preference (check one): English Spanish Other Tobacco Type (check ALL that apply): Cigarettes Smokeless Tobacco Cigar Pipe I am ready to quit tobacco and request the Quitline contact me to help me with my quit plan. (Initial) I DO NOT give my permission to the Quitline to leave a message when contacting me. (Initial) Patient Signature: Date: / / The Quitline will call you. Please check the BEST 3-hour time frame for them to reach you. NOTE: The Quitline is open 7 days a week; call attempts over a weekend may be made at times other than during this 3-hour time frame. 6am - 9am 9am - 12pm 12pm - 3pm 3pm - 6pm 6pm - 9pm Within this 3-hour time frame, please contact me at (check one): Primary Secondary 2005 Free & Clear, Inc. All rights reserved. Confidentiality Notice: This facsimile contains confidential information. If you have received this facsimile in error, please notify the sender immediately by telephone and confidentially dispose of the material. Do not review, disclose, copy, or distribute.