Telephone Follow-up: Healthy Eating

Exp. Date XX/XX/20XX

Telephone Follow-Up: Healthy Eating

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 (hours)(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

1. 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. People with hypertension can still eat the foods they like.

a) _____ True

b) _____ False

2. The Nutritional Facts label can help you make better food choices when you’re shopping.

a) _____ True

b) _____ False

3. How much sodium does the body need daily.

a) _____ 1000 mg

b) _____ 2300 mg

c) _____ 200 mg

d) _____ None of the above

4. Eating less salt usually makes blood pressure…

a) _____ Go Up

b) _____ Go Down

c) _____ Stay the Same

5. Carbohydrate counting is a method that helps you know what to eat and how much to eat.

a) _____ True

b) _____ False

II. Diabetes:

1. People with diabetes can still eat the foods they like.

a) _____ True

b) _____ False

2. The diabetic diet is a healthy diet for most people.

a) _____ True

b) _____ False

3. What effect does unsweetened fruit juice have on blood sugar?

a) _____ Lowers it

b) _____ Raises it

c) _____ Has no effect

4. You and your healthcare team can design a meal plan that takes into account.

a) _____ Your favorite foods

b) _____ A variety of foods

c) _____ Your like and dislikes

d) _____ Your daily routine

e) _____ All the above are correct

5. The Nutritional Facts label can help you make better food choices when you’re shopping.

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