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: ___________________

Patient 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?

Patient 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 patient’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

Patient 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
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• Has the patient missed any doses in the past two weeks?  Yes  No

If answer is yes, explain why. __________________________________________________

___________________________________________________________________________

___________________________________________________________________________

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

I. Hypertension:

1. Exercise can lower your blood pressure.

1. _____ True

2. _____ False

2. How much physical activity is enough?

a) _____ 20 minutes everyday

b) _____ 90 minutes a day once you are in shape

c) _____ 150 minutes a week

d) _____ It depends on the size of your heart

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

1. _____ True

2. _____ False

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

a) _____ True

b) _____ False

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

1. _____ True

2. _____ False

II. Diabetes:

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

a) _____ True

b) _____ False

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

a) _____ Brisk walking

b) _____ Swimming

c) _____ Dancing

d) _____ All of the above

3. Exercise can cause low blood glucose levels.

a) _____ True

b) _____ False

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

1. _____ Your body makes hormones that affect your blood glucose

2. _____ It’s hard to pay attention to your diabetes

3. _____ Both of the above are correct

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

a) _____ True

b) _____ False

For office use only:

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

2^nd attempt: Date______ Time: ________ Outcome: _______

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

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