Learning Objectives. 1. Identify medications which may increase risk of injury to farmers or those in agriculture

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2 Learning Objectives 1. Identify medications which may increase risk of injury to farmers or those in agriculture 2. Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers 3. Recognize opportunities for pharmacists to fill the healthcare gaps in rural areas and serve as partners in agricultural health and safety

3 In your pharmacy 0 RJ is a 67 year old Missouri farmer 0 Hobby farm on roughly 300 acres which includes: hay, corn, and 95 head of beef cattle 0 Medical conditions: 0 Parkinson s disease 0 Arthritis pain 0 Hypertension 0 Diabetes 0 Constipation 0 Depression 0 Seasonal Allergies 0 Past surgical history: 0 Hip replacement 1 year ago

4 Agriculture in the U.S. 0 Farming is consistently one of the most dangerous occupations in the United States 1 0 Fatality rate among the 2,166,000 agricultural workers is 642 deaths or 29.2 per 100, One in 20 farm injuries each day result in permanent impairment and lost work. 2 0 Taking a medication increases risk of agricultural injury by 2-4 fold 3 1. National Safety Council (2006). Injury Facts, Edition. 2. National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention. Agricultural safety. Workplace Safety and Health Topics. Available at: Accessed on August 4, Am. J. Ind. Med.2009;52:

5 Survey Data from Quick Stats

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7 Knowing Your Population 0 58% of Missouri hospitals 0 Majority with fewer than 25 beds 0 18% of Missouri s primary care physicians Rural Missouri

8 Leading cause of death in 0 Rural heart disease death rate: vs urban 235 Missouri. 0 92% of counties with death rate higher than state rate are rural

9 Graphic from:

10 Stroke: Cause of disability & death 0 The stroke mortality rate for Missouri s rural counties (58.4) significantly higher than the rate for Missouri s urban counties (52.5) 0 Rural counties make up 88% of the counties that have a stroke mortality rate significantly higher than the state rate

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12 Needs Assessment 0 COPD: 0 4 th leading cause of death in Missouri 0 Diabetes: 0 6 th leading cause of death in Missouri 0 Rural death rate (53.2) due to COPD significantly higher than urban rate (45.6) 0 Rural Missouri counties make up 82% of the Missouri counties with significantly higher rate of diabetes deaths than the state rate

13 0 Retrospective examination of Veterans Health Administration database in n=3,040,635 of which 23.4% received CPS at various locations: 0 Medical center: 25.9% 0 Urban clinic: 22.5% 0 Rural clinic: 17.6% 0 Nearly 50% of CPS encounters via telehealth, in particular video telehealth services among rural clinic patients was substantially higher than among medical center patients (OR = 9.7; 95%CI ) 0 Rural patients 35% less likely to receive CPS J Am Pharm Assoc. 2014;54:

14 Agriculture in the U.S. 0 Farming is consistently one of the most dangerous occupations in the United States 1 0 Fatality rate among the 2,166,000 agricultural workers is 642 deaths or 29.2 per 100, One in 20 farm injuries each day result in permanent impairment and lost work. 2 0 Taking a medication increases risk of agricultural injury by 2-4 fold 3 1. National Safety Council (2006). Injury Facts, Edition. 2. National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention. Agricultural safety. Workplace Safety and Health Topics. Available at: Accessed on August 4, Am. J. Ind. Med.2009;52:

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16 Medication-Related Agricultural Injury 0 Use of medications alone and in combination 0 Regular medication use increases risk times Stomach, laxative medicines increase risk 2.8 times 4 0 Heart, circulatory medicines increase risk 4.2 times 4 0 Narcotic pain relievers increase risk 9.3 times 5 0 Non-narcotic pain relievers increase risk 2.4 times 5 0 Incontinence therapy increases risk 2.95 times 5 0 Sleep agents increase risk 2.11 times 6 1. Risk factors for agricultural injury: a case-control analysis of Iowa farmers in the Agricultural Health Study. J Agric Saf Health 2003;9(1): Risk factors for falls among Iowa farmers: a case-control study nested in the Agricultural Health Study. Am. J. Ind. Med 2003;44: Nonfatal agricultural injuries among Colorado older male farmers. J Aging Health 1999;11(1): Medications as risk factors for farm injury. Accid. Anal. and Prev. 1996;28(4): Pain, medication and injury in older farmers. Am. J. Int. Med2006;49: Sleep deprivation and injuries in part-time Kentucky farmers: impact of self reported sleep habits and sleep problems on injury risk. AAOHN J Sep;52(9):

17 Assess for Side Effects Dizziness Confusion Lightheadedness Drowsiness Blurred vision Gait disturbance

18 Objective 1: Identify medications which may increase risk of injury to farmers or those in agriculture Condition 0 Arthritis/Chronic pain 0 Heart disease 0 Stroke 0 High blood pressure 0 Diabetes 0 Seizure disorders 0 Osteoporosis 0 Parkinson s disease 0 Depression 0 Alzheimer s disease 0 Dementia 0 Psychosis 0 Spasms Treatment 0 Narcotics 0 Diuretics 0 Antihypertensives 0 Antiarrhythmics 0 Oral diabetes agents 0 Insulin 0 Anticonvulsants 0 Antidepressants 0 Anti-anxiety agents 0 Antipsychotics 0 Anti-nausea agents 0 Allergy medicine 0 Anti-spasm medicine 0 Bladder medicine 0 Sedatives

19 In your community pharmacy 0 RJ is a 67 year old Missouri farmer 0 Hobby farm on roughly 300 acres which includes: hay, corn, and 95 head of beef cattle 0 Medical conditions: 0 Parkinson s disease 0 Arthritis pain 0 Hypertension 0 Diabetes 0 Constipation 0 Depression 0 Seasonal Allergies 0 Past surgical history: 0 Hip replacement 1 year ago

20 Why Pharmacists as Partners in Agricultural Health and Safety? 0 most accessible healthcare profession 0 among most trusted healthcare professionals 0 medication expert 0 Knowledge and Training 0 Assessment 0 Safe medication use 0 Communication skills 0 Health literacy 0 Adherence 0 Counseling 0 Education 0 Patient advocate

21 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers 0Minimize jargon 0PAR technique 0APPLE principle 0 Accessible 0 Personal 0 Professional 0 Linked 0 Empathetic 0Respect 0Patient-centered plan of care 0Motivation linked to continued productivity Beeson, Peter G Farm Crisis and Mental Health Summit: A summary of findings. In Party-line, ed. Peter G. Beeson, St. Cloud: National Association for Rural Mental Health.

22 Culture of Agriculture 0Solid family values 0Hard work 0Commitment to community 0Strong religious beliefs 0Self-sufficiency WK Kellogg Foundation Report: Perceptions of Rural America, 2004.

23 Identify Characteristics and Needs 0 Can do and must do attitude 0Independent 0Proud 0Realistic 0Thrifty 0Private 0Stoic 0Skeptical

24 Identify Barriers 0 Long working hours and seasonal deadlines 0 Fatigue 0 Isolation 0 Worry about survival of the family farm 0 Tensions of handling on-farm and off-farm work 0 Inability to control external factors

25 Identify Barriers 0Work still has to get done 0Reluctance to enter a sick role 0Access to health care limited by resources and insurance as well as demands of farming 0Rehabilitation must result in their ability to get work done

26 "We need to feed our cows, to continue to produce the milk which is our livelihood, and how do you choose between that and paying for the health insurance for your family?" --Sandi Cihlar, a third-generation dairy farmer with her husband for 30 years.

27 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers Recognize that farming is a chosen way of life Respect and listen to what the farmer wants for his/her life As appropriate, help return safely the farmer to farm life and work Rural Tele-pharmacy

28 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers Identify risk Advocate React Empower Connect with resources

29 Identifying Potential Risks 0Sedation 0Dizziness 0Confusion 0Lightheadedness 0Blurred vision 0Gait disturbance

30 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers 0 During the past 12 months were you injured seriously enough that you got medical advice or treatment? 0 Do you visit a primary care provider regularly? 0 Predisposing conditions 0 Do you take medicine for a condition? 0 Multiple physicians 0 Decreased alertness 0 Onsite Farmstead Assessment Identify risk

31 Red Flags 0 Balance impairment 0 Changes in sensorimotor function/skills 0 Recent falls 0 Recent hospitalization 0 Altered confidence in ability to work on the farm 0 Changes to farm management 0 Changes to family involvement 0 Determine if changes to farm work 0 Recognize that medication side effects could be contributing 0 Recognize that chronic conditions could be contributing 0 Express concern for potential risks

32 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers Identify risk Advocate React Empower Connect with resources

33 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers 0 Determine if there have been changes to farm work 0 Recognize that medication side effects could be contributing 0 Recognize that chronic conditions could be contributing 0 Express concern for potential risks React

34 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers Identify risk Advocate React Empower Connect with resources

35 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers 0 Missouri Extension 0 Comprehensive medication review especially at Transitions of Care! 0 Telehealth Networks 0 Health fair screenings 0 Falls Prevention Resources Connect with resources

36 Venues 0 Considerations 0 target population 0 proximity 0 access 0 services offered 0 feasibility 0 cost 0 awareness 0 advertising 0 Accessible locations employed: 0 Public health & wellness events 0 County and state fairs 0 Community centers 0 Farm safety days 0 Western Farm Show 0 Pharm to Farm On-site Farmstead Medication Assessments

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39 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers 0 Missouri AgrAbility Project:

40 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers 0 Pharm to Farm: 0 Missouri Association of Rural Health Clinics: 0 Rural Health Information Hub: 0 National Rural Health Association: 0 International Society for Agricultural Safety and Health: 0 AgriSafe Network Healthcare Provider Resources: 0 Federally Funded NIOSH Ag Centers: 0 Great Plains Center for Agricultural Health, University of Iowa 0 Upper Midwest Agricultural Safety and Health Center, University of Minnesota 0 Central States Center for Agricultural Safety and Health, University of Nebraska 0 National Farm Medicine Center and National Children s Center for Rural and Agricultural Health and Safety, Marshfield WI

41 AgroMedicine Courses

42 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers 0Encourage overall health 0Motivate client to: 0 Place value on seeking care 0 Ask questions of their healthcare providers 0 Voice concerns about injuries or medicine Empower

43 Objective 2: Describe techniques pharmacists can incorporate into practice and resources available to meet the healthcare needs of Missouri farmers 0Services & resources to resource-poor areas 0Missouri Extension 0Access to care Advocate

44 Objective 3: Recognize opportunities for pharmacists to fill the healthcare gaps in rural areas and serve as partners in agricultural health and safety 0 Application of skills, identification of drug-related problems 0 Environment: 0 Medication Therapy Services collaboration with rural physicians 0 Rural Health Clinics 0 Federally Qualified Health Centers 0 Senate Bill 716 signed July 2014 creating new medical license for assistant physicians to engaged in limited practice in underserved areas 0 Rules pending Board of Healing Arts

45 Pharmacists as Partners in Agricultural Health and Safety 0 Safe medication use practices 0 Assess drug interactions 0 Prevent adverse effects 0 Individualized evaluation 0 Educate and empower patients

46 Interested in partnering? 0 Please drop your business card in a basket OR 0 Fill out this Google Form:

47 Posttest Question #1 0 Which of the following medication classes is known to cause the highest potential risk of medication-related agricultural injury? a. Antihypertensives b. NSAIDs c. Sedatives d. Narcotics

48 Posttest Question #1 0 Which of the following medication classes is known to cause the highest potential risk of medication-related agricultural injury? a. Antihypertensives b. NSAIDs c. Sedatives d. Narcotics

49 Posttest Question #2 0 RJ is a 67 year old Missouri farmer of roughly 300 acres which includes: hay, corn, and 95 head of beef cattle 0 Medical conditions: 0 Parkinson s disease 0 Arthritis pain 0 Hypertension 0 Diabetes 0 Constipation 0 Depression 0 Seasonal Allergies 0 Past surgical history: 0 Hip replacement 1 year ago How can you, as his community pharmacist, assess RJ to prevent farm injury? a. Ask about recent falls b. Recognize changes to farm management c. Evaluate medication history for drug-related problems d. All of the above

50 Posttest Question #2 0 RJ is a 67 year old Missouri farmer of roughly 300 acres which includes: hay, corn, and 95 head of beef cattle 0 Medical conditions: 0 Parkinson s disease 0 Arthritis pain 0 Hypertension 0 Diabetes 0 Constipation 0 Depression 0 Seasonal Allergies 0 Past surgical history: 0 Hip replacement 1 year ago How can you, as his community pharmacist, assess RJ to prevent farm injury? a. Ask about recent falls b. Recognize changes to farm management c. Evaluate medication history for drug-related problems d. All of the above

51 Posttest Question #3 Pharmacists can incorporate the APPLE principle into practice to meet the healthcare needs of Missouri farmers by being: a. Admirable, Public, Professional, Local, Engage b. Accessible, Personal, Professional, Linked, Empathic c. Accessible, Public, Professional, Local, Engage d. Admirable, Personal, Poised, Local, Empathetic

52 Posttest Question #3 Pharmacists can incorporate the APPLE principle into practice to meet the healthcare needs of Missouri farmers by being: a. Admirable, Public, Professional, Local, Engage b. Accessible, Personal, Professional, Linked, Empathic c. Accessible, Public, Professional, Local, Engage d. Admirable, Personal, Poised, Local, Empathetic

53 Posttest Question #4 Opportunities for pharmacists to fill the healthcare gaps in rural areas and serve as partners in agricultural health and safety exist through: a. Telehealth b. Rural outreach and wellness initiatives c. MTS with rural providers d. All of the above

54 Posttest Question #4 Opportunities for pharmacists to fill the healthcare gaps in rural areas and serve as partners in agricultural health and safety exist through: a. Telehealth b. Rural outreach and wellness initiatives c. MTS with rural providers d. All of the above

55 Questions? Kelly Cochran, PharmD, BCPS