Post Intervention: Diabetes or Hpertension or Hperteension and Diabetes

Post Intervention Follow-Up Form: Hypertension

TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE

MINORITY HEALTH (PCCC) INITIATIVE

Date: ___________________

Patient Name (Last name, First initial): _________________________________________________

Client ID: ________________________

Pharmacist Conducting Post-Intervention Home Visit: ________________________________

Post-Intervention Home Visit Date: ______________________

Section I. Patient Demographics:

Pharmacist Step #1: Introduction and collect baseline information.

1. Blood pressure screening: _________________
   
   

2. Wt: ________________ lbs
   
   

3. Ht: _______ feet ________ inches
   
   

4. How long have you been diagnosed with high blood pressure? _______________
   
   

5. What is your current household income per year?

• $0 to $24,999

• $25,000 to $49,999

• $50,000 to $74,999

• $75,000 or more

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

Section II: Hypertension Knowledge:

Pharmacist Step #2: Ask the patient the following questions and mark their answers.

1. If someone’s blood pressure is 120/80, it is…

• High

• Low

• Normal

• Don’t know

2. If someone’s blood pressure is 160/100, it is…

• High

• Low

• Normal

• Don’t know

3. Once someone has high blood pressure, it usually lasts for …

• a few years

• 5–10 years

• The rest of their life

• Don’t know

4. People with high blood pressure should take their medicine…

• Everyday

• at least a few times a week

• only when they feel sick

5. Losing weight usually makes blood pressure…

• go up

• go down

• stay the same

6. Eating less salt usually makes blood pressure…

• go up

• go down

• stay the same

7. High blood pressure can cause heart attacks.

• Yes

• No

• don’t know

8. High blood pressure can cause cancer.

• Yes

• No

• Don’t know

9. High blood pressure can cause kidney problems.

• Yes

• No

• Don’t know

10. High blood pressure can cause strokes.

• Yes

• No

• Don’t know

Section III. Medication Use and Adherence

Pharmacist Step #3: Review the medications that the patient has OR has been prescribed. Create a medication chart with the patient. Fill out attached Appendix A Medication List with the patient.

Questions to ask:

• What medication are you taking including OTC and dietary supplement?

• Why are you taking the medication?

• When do you take this medication?

• When was your last dose?

• Do you have any special instructions for this medication?

11. Medication History:

Medication (Name/Strength)	Purpose	Schedule	Date of Last Dose	Special Instructions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

HYPERTENSION	Always	Very Often	Sometimes	Rarely	Never
12. How often have you forgotten to take your medicine for blood pressure in the past week?
13. How often do you stop taking your medicine for high blood pressure because you were careless?
14. How often do you stop taking your blood pressure medicine because you feel better?
15. How often do you stop taking your medicine for blood pressure when you experience side effects?

16. Please find the statement that best describes the way you feel right now about taking your high blood pressure medication as directed.

1. No, I do not take and right now am not considering taking my high blood pressure medication as directed. (Precontemplation)

2. No, I do not take but right now am considering taking my high blood pressure medication as directed. (Contemplation)

3. No, I do not take but am planning to start taking my high blood pressure medication as directed. (Preparation)

4. Yes, right now I consistently take my high blood pressure medication as directed.

17. If the answer to question 16 is D, then ask: How long have you been taking your high blood pressure medication as directed?

1. ≤3 months

2. >3 months to 6 months

3. >6 months to 12 months

4. >12 months

Section IV. Pharmacist Step #4: Pharmacist Assessment:

If the answer to question 16 is D and the answer to question 17 is A or B, then the stage of change is

action. If the answer to question 16 is D and the answer to question 17 is C or D, then the stage of

change is maintenance.

Check the most appropriate stage according to the readiness to change:

Area/ Stage	Precontemplation	Contemplation	Prepare	Action	Maintenance
Adhere to medication

Blood pressure goal is: ____/___ Today blood pressure is/ is not (circle one) at goal.

Assessment Notes: _____________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Section V. Pharmacist Step #5: Patient Satisfactory Survey:

Pharmacist Step #5: Ask the patient the following survey questions and mark their answers.

The statements below describe attitudes and beliefs you may have about the health program you participated in and about your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box.	1 = I strongly disagree 2 = I somewhat disagree 3 = I’m neutral 4 = I somewhat agree 5 = I strongly agree
	1	2		3	4			5
I learned new information that helped me to better manage my health condition
I received useful information from this program
I am putting what I learned from this program into practice
I see positive changes in myself already from being in this program
I am doing something to improve my health condition
It is very important to take care of your health
I’m ready to improve my health
What was important to you about this program?
Information was easy to understand
Materials were easy to use
Materials were written in my language
The classes were taught by a trained professional (community health worker, health educator, pharmacist)
The person who talked with me spoke in my language
The curriculum took my cultural practices into consideration
Someone called me to follow-up on what I learned and remind me of what I should do to manage my health
Group classes
One-on-one sessions at my home
The statements below describe attitudes and beliefs you may have about the best ways for you to learn about your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box.	1 = I strongly disagree 2 = I somewhat disagree 3 = I’m neutral 4 = I somewhat agree 5= I strongly agree
	1		2	3		4	5
9. The best way for me to learn about my health condition is from a:
Brochure or pamphlet
Direct mail
Toolkit of materials with a CD
Email
Telephone text message
Facebook posting
Webinar
Group classes
One-on-one sessions at my home

Please rate how satisfied or dissatisfied you are with these statements about this program by placing a check mark in the appropriate box.	1 = Very dissatisfied 2 = Dissatisfied 3 = Neutral 4 = Satisfied 5 = Very satisfied
	1	2	3	4	5
How satisfied are you that what you learned helps you to make good decisions about improving your health?
Overall, how satisfied are you with the program?