from pharmaceutical care to cmm: what’s next?• enrolled 6,000 patients since oct 2012 •...

From Pharmaceutical Care to CMM: What’s Next?

Steven W. Chen PharmD, FASHP, FCSHP, FNAP Associate Professor and Chair

Titus Family Department of Clinical Pharmacy and Pharmacoeconomics and Policy William A. Heeres and Josephine A. Heeres Endowed Chair in Community Pharmacy Co-Chair Emeritus, HRSA Patient Safety & Clinical Pharmacy Services Collaborative

Question to Run on…

How can the profession of pharmacy achieve broad recognition and acceptance of the role as medication

management experts on the healthcare team?

Outline • USC / AltaMed CMMI Healthcare Innovation Award

– Overview – Results – Medical leadership and patient perspectives – Abbreviated “change package” for CMM

• Partnerships to spread CMMI program results and CMM

Medication-Related Problems in U.S.

• $290 billion of avoidable spending annually due to misuse of medications (NEHI)

• Adverse effects from medications ~ 4th leading cause of death in U.S. (FDA)

• 75% of hospital readmissions among seniors are avoidable, primarily through better use of medications (James J., Health Affairs 2013)

• ½ of prescription medications taken every year in the US are used improperly (CDC, 2013)

• 90% of chronic diseases require medications as first-line therapy (Medco, 2010)

USC Personnel: Geoffrey Joyce, PhD- CoPI

Steven Chen, PharmD Kathleen Johnson, PhD, PharmD

R. Pete Vanderveen, Ph.D.

USC / AltaMed CMMI Project: Specific Aims

UNIVERSITY OF SOUTHERN CALIFORNIA

National Conference on Best Practices and Collaborations to Improve Medication Safety and

Healthcare Quality

Feb 20-21, 2014

Resident and technician training

for expansion

Web-based pharmacist training and credentialing

OUTCOME MEASURES Healthcare Quality Safety Total Cost / ROI Patient & provider

satisfaction Patient access

Telehealth clinical pharmacy 10 teams

Pharmacist + Resident + Clinical Pharmacy Technician

USC Patient Targeting and Management Strategy

Clinical Pharmacy

Comprehensive Medication

Management

Clinical pharmacy tech “check-ins” every 2 months

Yes

Unstable

No

Treatment Goal Reached?

High cost patients

Frequent and recent acute care utilizers

48 EHR-embedded triggers to detect high risk patients

MD referrals

Comprehensive Medication Management Programs: Responsibilities

Identify potential drug-related prob’s

Consult w/ primary provider

if needed

Order labs, drugs, consults as needed per collaborative

practice agreement Promote patient

self-management, Document activities

Provide follow-up care to ensure

successful outcome

High-risk patient with

chronic medical conditions

Interview patient, apply assessment skills as needed

History and scope of clinical pharmacy services

Presenter

Presentation Notes

First, we established inclusion and exclusion criteria for abnormal labs. Over a 2 month period abnormal labs were collected and reviewed. Then, a chart and medication profile review was done to assess the need for patient enrollment. Subsequently the Primary Care Physician was consulted regarding enrollment. Then, I interviewed and evaluated the patient and made recommendations and interventions accordingly.


– Overview – Results

Outcome: Recruit high risk patients

• Enrolled 6,000 patients since Oct 2012

• Predominantly Hispanic, non-elderly women

• 3/4ths have hypertension, 36% uncontrolled

• 2/3rds have diabetes, 60% uncontrolled

• High rates of hospitalizations

Outcome: Improvement in Clinical Markers

125

130

135

140

145

150

155

Baseline 3 Months MostRecent

Systolic Blood Pressure

72

74

76

78

80

82

84

86

88

Baseline 3 Months MostRecent

Diastolic Blood Pressure

* Among those with uncontrolled hypertension at baseline

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Less than 7 7 to 8 8 to 9 9 to 10 Greater than 10

A1C Levels

Baseline 6 months Most Recent

Outcome: Improvement in Clinical Markers

Outcome: Hospitalizations are declining

Control Group Selection Propensity scoring to match CPS enrollees (treatments) to similar patients receiving care at non-treatment clinics (controls) in three steps:

• Wave 1 treatment patients

• PACE treatment patients from Wave 2

• Non-PACE treatment patients from Wave 2

Covariates used to model the propensity score: • Demographics • Health status • Utilization • Other

Changes in Clinical Measures (% of Patients with Uncontrolled Disease)

Condition % Uncontrolled Managed Patients Unmanaged Patients

Baseline 6 months Baseline 6 months

High blood pressure (SBP/DBP) 100 39% 100 48%

Elevated cholesterol (LDL) 100 38% 100 52%

Elevated Blood Sugar (HgA1c) 100 34% 100 57%

15

Sample restricted to patients with uncontrolled condition at baseline. Unmanaged patients received usual care from AltaMed primary care physicians. Interpretation: Program reduced rates of uncontrolled blood sugar (diabetes) by 23 percentage points relative to the unmanaged group (34% vs. 57%).

Summary of Difference-in-Differences Results for Utilization (Treatment – Control, Probit Analysis)

At 6 month follow-up: Readmissons per year per patient -16% Readmissions per year per patient primarily attributed to medications -33%

Untreated (Cohort) Versus Treated Patients, USC CMMI Program

Mortality rates

- 25.7% absolute

difference

0.01

0.009

0.008

0.007

0.006

0.005

0.004

0.003

0.002

0.001

0 1 2 3 6 9 12

Months after enrollment

Untreated Treated

1. Chen SW, et al. Webinar presented at: 2016 UCLA Clinical and Translational Science Institute. April 6, 2016. http://www.slideshare.net/jebyrne/improving-healthcare-quality-and-safety-while-reducing-costs-through-clinical-pharmacy-service-integration. Accessed April 14, 2016.

Presenter

Presentation Notes

Speak to slide.

Medication-Related Problems Identified Through CMMI Clinical Pharmacy Program 67,169 problems among 5,775 patients (Avg 11.6 per patient)

9,222, 14%

22,229, 33%

13,352, 20%

14,059, 21%

8,267, 12%

Medication Nonadherence

Safety Issues

Appropriateness / Effectiveness

Misc Insufficient Patient Self-Management

Top Actions Taken by Pharmacists to Resolve Medication-Related Problems (excluding education)

2,665

3,847

4,230

5,554

14,981

Substitute Medication

Discontinue Medication

Order test

Add Medication

Change Dose or Drug Interval

Presenter

Presentation Notes

31% (chg dose/drug interval); 31% add new med; 12% education; 11% sub med; 10% d/c med;

Physician Satisfaction

Unsolicited letter from AltaMed Physician

”I am writing to you today of my own accord, I have offered to make my opinion known about the excellent work that USC pharmacy team is doing without solicitation because I think pharmacy team has done an extraordinary job.”

“Both Dr. Oh and Dr. Lin are extremely diligent and knowledgeable professionals, with very good rapport with their patients. I know that most of my patients actually look forward to having their sessions with the pharmacy team and have learned a great deal regarding their chronic disease self-management. Improving patient clinical parameters are an excellent proof of that.”

“Dr. Oh in particular has been an integral part of the work that we do here, as a resident she goes above and beyond to make sure the patient are well care for. We have had some really mutually beneficial academic discussions and she has helped changed my practice on a few occasions while bringing in new research to my knowledge. I am really grateful to have the opportunity to work with Dr. Oh and Dr. Lin and look forward to their continued mutually beneficial relationship with us.”

Clinical Pharmacy Impact

Average score = 9.6

Average score = 9.7

Patient Satisfaction

Unsolicited letter from AltaMed patient

• I wanted to take this time to commend and congratulate Alta Med Healthcare in implementing such a vital and useful program for their patients. The Clinical Pharmacy Service is a benchmark that all other Health Care providers could learn from and try to emulate. And in an era where severe cuts are the norm at the State and Local levels, I can’t begin to express how fortunate I feel to be a benefactor of this program. It is well staffed with professionals who seem to want to make a positive difference in their community outreach. I was made aware that the Clinical Pharmacy Service was established through a grant to maintain a more efficient protocol between Dr. and patient. In reflective thought I can’t think of money better spent.

• However when I was first introduced to this program I was quite leery to say the least… I’m quite busy and after seeing my primary care physician the last thing I wanted to do is spend more time with a clinical pharmacist… But after my first visit with Dr. Hamai I became a true believer. I was so taken back and impressed with her immeasurable knowledge and seasoned professionalism.

Clinical Pharmacy Impact


– Overview – Results – Abbreviated “change package” for CMM

CMM Abbreviated “Change Package”

1- Secure support from senior medical leadership 2- Align program with partnering organization’s

financial incentives • High cost (acute care utilization, readmission

penalties) • High value (value-based payments, STAR

ratings, ACO shared savings measures, etc.) • 340B program


3- Identify high-risk populations with the greatest potential benefit from CMM (Drives ROI) – Consider pre-program data audit

4- Find resources to pilot / expand program – Full or PT pharmacist from organization or college

of pharmacy faculty – Residency program – Local foundation grants – 340B contribution – Local foundation grants (fdo.foundationcenter.org)


5- Develop clinical pharmacy collaborative practice agreements for targeted patient populations and integrate program processes into existing workflow – Flow diagram – Disrupt support staff workflow → Unhappy staff

6- Ensure that reliable data is available for evaluating program impact

7- Drive Quality: Host frequent team + leadership calls / meetings, integrate into key committees

8- Manage hazardous or misaligned partnerships

9- Maximize efficiency and productivity- telehealth, technicians

Clinical Pharmacy Tech Competencies

1. Collect accurate information about medications from patients (Rx, OTC, supplements, herbals)

2. Prepare medication adherence tools (pill boxs, charts, etc.) 3. Solicit participation of targeted patients in pharmacy

program 4. Perform appointment support functions (scheduling

appointments, lab orders, etc.) 5. Manage a Patient Assistance Program (PAP) including 6. Provide education reinforcement / support 7. Conduct follow-up check-ins with patients after reaching

treatment goals

Impact of Clinical Pharmacy Technician on Team Efficiency

Med Rec

CMM Appointment with Clinical Pharmacist

Orders &

Chart

Clinical Teaching Reinforcement &

Sched f/u Appt

5 min 15-30 min 5-10 min 5-15 min

Time of visit: 20 - 40 minutes Dependent on initial vs. follow up visit

40-50% more patients seen each day

Presenter

Presentation Notes

Cut down anywhere from 10-20 minutes

10. Patient Engagement / Retention Keys

Engagement Retention Daily availability for walk-ins / “warm hand-offs” PCP endorsement to targeted / enrolled patients Match team member language skills Clinical pharmacy technicians Engage family and caregivers Consider selective home visits Extended hours / weekend availability Flyers / media explaining program in lay terms Consider peer-led group appointments Continuity of pharmacist / tech provider


11- Share impact results and powerful stories • Total healthcare costs (driven by hospitalizations / readmissions) • Healthcare quality measures (NQF-aligned focusing as much as

possible on pay for performance, shared savings, etc.) • Medication-related problems including a highlight on safety

(distinguishing role of pharmacists) • Provider access (PCMH measure) • Physician satisfaction (survey, possibly less turnover) • Patient satisfaction (survey, patient retention) • Powerful patient stories • Mortality (if level of risk and numbers are high enough)

12- Seek opportunities for sustained funding

• Alternative Payment Models • CMS / CMMI programs • Medicaid plans • Self-insured employers • CMS 1115 waiver • SB493

Target percentage of payments in ‘FFS linked to quality’ and ‘alternative payment models’ by 2016 and 2018

2016

30%

85%

2018

50%

90%

2014

~20%

>80%

2011 0%

68%

Goals Historical Performance

All Medicare FFS (Categories 1-4) FFS linked to quality (Categories 2-4) Alternative payment models (Categories 3-4)

Framework for Progression of Payment to Clinicians and Organizations in Payment Reform

Category 1: Fee for Service – No Link to Quality

Category 2: Fee for Service – Link to Quality

Category 3: Alternative Payment Models on Fee-for Service Architecture

Category 4: Population-Based Payment

Description Payments are based on volume of services and not linked to quality or efficiency

At least a portion of payments vary based on the quality or efficiency of health care delivery

• Some payment is linked to the effective management of a population or an episode of care

• Payments still triggered by delivery of services, but, opportunities for shared savings or 2-sided risk

• Payment is not directly triggered by service delivery so volume is not linked to payment

• Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (eg, >1 yr)

Examples

Medicare • Limited in Medicare fee-for-service

• Majority of Medicare payments now are linked to quality

• Hospital value-based purchasing

• Physician Value-Based Modifier

• Readmissions/Hospital Acquired Condition Reduction Program

• Accountable Care Organizations

• Medical Homes • Bundled Payments

• Eligible Pioneer accountable care organizations in years 3 – 5

• Some Medicare Advantage plan payments to clinicians and organizations

• Some Medicare-Medicaid (duals) plan payments to clinicians and organizations

Medicaid Varies by state • Primary Care Case Management

• Some managed care models

• Integrated care models under fee for service

• Managed fee-for-service models for Medicare-Medicaid beneficiaries

• Medicaid Health Homes • Medicaid shared savings

models

• Some Medicaid managed care plan payments to clinicians and organizations

• Some Medicare-Medicaid (duals) plan payments to clinicians and organizations

Rajkumar R, Conway PH, Tavenner M. The CMS—Engaging Multiple Payers in Risk-Sharing Models. JAMA. Doi:10.1001/jama.2014.3703

• Two-way risk in Medicare Shared Savings Programs including medical and pharmaceutical costs

• State Innovations Model (SIMs) as a payment taxonomy accelerator

• Partnership for Patients & 11th Statement of Work assault on Adverse Drug Events

• CMS Innovation Center Awards • Hospital Readmission penalties

• Evaluation & Management Services (E&M) “Incident-To” billing model

• Transitional Care Management (TCM) coding • Chronic Care Management (CCM) coding • Evaluation of a new pharmacy payment

schematic (Community Care of No. Carolina) • Transforming Clinical Practices Initiative (TCPI) • Enhanced MTM Model

Pharmacist Impact on Performance Measures

• Over one-half of the 33 ACO performance measures are impacted by the effective and safe use of drugs

• At least half of 12 ACO patient experience measures impacted by patients’ managing their medications

• Medicare Part D Ratings for health plan performance in the Drug Benefit Program (Star & Display ratings)

• Medicare Advantage Programs provide a glimpse of relationships between ACO and Part D measures

• 22/51 HEDIS-2016 measures impacted by drugs

37


– Overview – Results – Abbreviated “change package” for CMM

• Partnerships to spread CMMI program results and CMM

USC School of Pharmacy Collaborations to Develop High-Impact, Sustainable Results

Modes of CMM Delivery 1. Medical Groups (Pay for Performance,

Chronic Disease Management)

– Cedars-Sinai, Sharp, USC

2. Integrated into Medical Homes

– VA, Kaiser, safety net clinics including AltaMed, QueenCare, LA Christian

3. Community Pharmacies

– Ralphs, Walgreens, independents

4. Video Telehealth- VA, USC

5. Telephonic

– MEDCO, SinfoniaRx, Kaiser Permanente, USC, Heritage ACO

http://www.pcpcc.net/files/medmanagepub.pdf http://www.cdc.gov/dhdsp/programs/nhdsp_program/docs/pharmacist_guide.pdf

Higher complexity

Lower complexity

Limited scale

Broader scale

Background: The California Wellness Plan May 2012: Governor Brown issues

executive order calling for the development of a ten-year plan improve the wellbeing of Californians by controlling costs, improving quality, advancing health equity, and identifying obstacles to improve care

2014: California Department of Public Health (CDPH) drafts the California Wellness Plan (CWP), California’s chronic disease prevention and health promotion plan

http://www.cdph.ca.gov/programs/cdcb/Documents/CDPH-CAWellnessPlan2014%20(Agency%20Approved).FINAL.2-27-14(Protected).pdf

CWP Goal 2 Optimal health systems linked with community prevention (From 2014 Calif Wellness Plan)

Priority 2.2 Increase Access to Primary and Specialty Care Objective 2.2.1I By 2022, increase the percentage of patients receiving

care in a timely manner from primary care physicians and specialists (Developmental)

Priority 2.3 Increase Coordinated Outpatient Care/Increase People Receiving Care in an Integrated System

Objective 2.3.1L By 2022, increase the percentage of patients whose doctor’s office helps coordinate their care with other providers or services

CWP Goal 2 Optimal health systems linked with community prevention (From 2014 Calif Wellness Plan)

Priority 2.6 Increase Controlled High Blood Pressure and High Cholesterol

Objective 2.6.2L By 2022, increase the percentage of adults diagnosed with hypertension that have controlled high blood pressure

Objective 2.6.4L By 2022, increase the percentage of adults diagnosed with high cholesterol who are managing the condition

Objective 2.6.8L By 2020, decrease stroke mortality rate Objective 2.6.9L By 2020, decrease heart disease mortality rate

Objective 2.6.10L By 2020, decrease heart failure mortality rate Priority 2.7 Decrease Adult and Childhood Asthma

Objective 2.7.2L By 2022, reduce the asthma emergency department visit rate

Priority 2.12 Increase Hospital Safety and Quality of Care Objective 2.12.1L By 2022, decrease the 30-day all-cause unplanned

readmission rate

Impact of Comprehensive Medication Management

CMM for high-risk patients: Lowers total healthcare costs, e.g., reducing

hospitalizations, readmissions- up to 12:1 ROI Improves health care quality, pay for performance Improves medication safety, patient satisfaction;

provider satisfaction Improves provider access, pharmacist responsible

for CMM HOW?? http://www.usphs.gov/corpslinks/pharmacy/comms/pdf/2011advancedpharmacypracticereporttotheussg.pdf

https://www.pcpcc.org/sites/default/files/media/medmanagement.pdf

CA Wellness Plan Goal 2: Comprehensive Medication Therapy Management - Statewide Implementation Work Group

Jessica Nunez de Ybarra, MD, MPH, Medical Director, CDPH Mary Fermazin, MD, Medical Director, HSAG Steven Chen, PharmD, Dept Chair, USC School of Pharmacy Liz Helms, CEO, Chronic Care Coalition Ashley Butler, P4 student, Touro College of Pharmacy Alexandria Simpson, CDPH

Karen Mark, CDPH Janet Bates, CDPH Matthew Lincoln, HSAG

Shirley Shelton, CDPH Loriann DeMartini, PharmD, MPH, CDPH Patricia Shane, PharmD, Touro College of Pharmacy Charles Magruder, MD, Indian Health Service Hattie Hanley, MPA, Right Care Initiative

Terri Trotter, HSAG

Work Group Focus / Recommendation

Whether through direct staffing structures, consultation

arrangements, virtual or shared providers, or other types

of community linkages, CMM should be recognized,

incorporated and appropriately compensated within

health systems for high-risk patients.

Presenter

Presentation Notes

Pharmaceuticals are the most common medical intervention and their potential for both health and harm is enormous.

https://www.cdph.ca.gov/programs/cdcb/Documents/CMMWhitePaperCDPH2015Dec23FINALrev.pdf

Contents 1. Executive Summary

2. Introduction (Definition of CMM)

3. Background 4. Implementation

5. Methods

6. So. California Case Studies 7. Challenges

8. Appendices / Resources

Characteristic MTM CMM Conduct a comprehensive medication therapy review to identify all medication-related problems ✓ ✓ Confirm medication-related problems including assessment, point-of-care testing, medication-related labs ✓ ✓ Assess ALL medications and medical conditions ✓ Develop individualized medication care plan to address medication-related problems and ensure attainment of treatment goals

✓ ✓

Add, substitute, discontinue, or modify medication doses ✓ ✓ Generate complete medication record ✓ ✓ Document care delivered and communicate to health care team ✓ ✓ Ensure care is coordinated with other health care providers ✓ ✓ Provide follow-up care in accordance with treatment-related goals ✓ Requires collaborative practice agreement between pharmacist and physician ✓

Flashback: Pharmaceutical Care

Pharmaceutical Care is a patient-centered, outcomes oriented pharmacy practice that requires the pharmacist to work in concert with the patient and the patient's other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use to assure that drug therapy regimens are safe and effective.

The goal of Pharmaceutical Care is to optimize the patient's health-related quality of life, and achieve positive clinical outcomes, within realistic economic expenditures.

3. Background: Burden of Chronic Disease

Accounts for 86 cents of every health care dollar spent in 2011 in the U.S.

>14 million individuals in California suffer from chronic illnesses

California spent ~$98 billion in 2010 in the medical treatment of the six most common chronic conditions in the state: arthritis, asthma, cancer, depression, diabetes, heart disease

Most chronic diseases require medication use first-line based on clinical trial evidence

http://www.cdc.gov/chronicdisease/ http://almanac.fightchronicdisease.org/Chapters/AnOverview Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012. Brown PM, Gonzalez ME, Sandhu R, Conroy SM, Wirtz S, Peck C, Nunez de Ybarra JM. 2015. California

Department of Public Health. Economic Burden of Chronic Disease in California 2015. Sacramento, California. New England Healthcare Institute http://www.nehi.net/writable/publication_files/file/pa_issue_brief_final.pdf

3. Background: Fragmented Health Care Delivery System

Shortage and misaligned distribution of primary care and specialty care physicians in many regions → reduced patient access to healthcare services in California ◦ 45 % of reside in regions with limited primary care physicians

>130,000 new physicians will be needed in U.S. by 2025

CMS incentivizing improvement by shifting towards value-based payment models, but transition is slow

Distractions and time required to navigate EHRs may reduce the time physicians spend providing patient care services

A J Manag Care. 2009. 15:S284-S290. http://innovation.cms.gov/initiatives/map/index.html#model=incentives-for-the-prevention-of-chronic-disease-in-

medicaid-demonstration CSRHA Policy Brief. California State Rural Health Association; Sacramento, CA; August 2007. http://www.dhcs.ca.gov/provgovpart/Documents/BodenheimerWebinar3.pdf How Pharmacists Can Improve Our Nation’s Health. CDC Public Health Grand Rounds. Atlanta, GA: Centers for

Disease Control and Prevention. Farm Med. 2001; 33(70): 528-532. N Engl J Med. 2001. 344(3): 198-204.

3. Other Background Elements

Provider status for pharmacists in California Practice types / settings Patient targeting Implementation costs / payment and Return

on Investment Outcomes / Quality measures

4. Implementation: Role of Pharmacists

Half-century history of pharmacist-provided MTM and CMM

CPA required, physician remains in leadership role in medical home / healthcare team

Scope of practice, communication and QA requirements, etc. dictated by CPA Patient targeting / recruitment Evaluation Evidence-based plan (more than meds) Follow-up

Example of range of services performed during CMM

Growing CMM practices in community pharmacy

4. Implementation: Role of Patients

Patient and family engagement Shared Decision-Making Beyond adherence Breaking through stereotype pharmacist image

4. Implementation: Role of Public Health

Identifying community needs and chronic disease surveillance Facilitate dissemination of knowledge regarding pharmacist

intervention to stakeholders: ◦ Government ◦ Health plans ◦ Self-insured employers ◦ Providers

Identify partners and advocates Identify pharmacist- and physician-champions Promote co-locating community health programs with clinical

pharmacists Support health information exchange Promoting policy changes to ensure continuity of care

CMM White Paper: Next Steps Dissemination to: CMA CPCA CAPG Government healthcare agencies Legislators National organizations

Increase awareness and utilization

Some Next Steps for Workgroup CDC Lifetime of Wellness and Prevention First grantees

workshop Engagement and collaboration conferences with community

pharmacy leadership Patient advocacy leaders

CMM briefing at state capitol Chronic Care Coalition, American Heart Association

partnerships, Right Care Initiative (health plans), CAPG Statewide medical leadership meeting, May 17, 2017

USC CMM Certification and Collaborative Learning Network

• Certification aligned with APP recognition through program developed with CMMI funding

• Enrollment in collaborative learning network to accelerate programs and impact aligned with payer and provider priorities / incentives

• Two major payers as partners

Collaborations to Identify and Manage High Blood Pressure

• AHA Check, Change, Control- Los Angeles County Task Force

• California Right Care Initiative- Dedicated to reducing heart attacks and strokes for all Californians

• Health Services Advisory Group • The Los Angeles Blood Pressure Barber Shop Study

Can barbers cut BP too? Ron Victor, M.D. Burns & Allen Chair in Cardiology Research Professor of Medicine, UCLA Director, Hypertension Center Associate Director, Cedars-Sinai Heart Institute

Presenter

Presentation Notes

It’s a real honor to join team Cedars and I want to thank everyone for making me feel so welcome. I’m going to tell you about the barbershop HTN study I started in Dallas and, with your help, will re-invent in LA. But first some back ground about HTN in AA.

AHA 2009 Update: (NCHS, 2005)

Blacks

Deaths per

100,000

0

10

20

30

40

50

Men Women

Whites Blacks

AHA 2009 Update: (NCHS, 2005)

Disparity in death rates from HTN

Presenter

Presentation Notes

Non-Hispanic Black men have the highest death rates from HTN and the shortest life expectancy of any race/gender group in the US. These are age-adjusted death rates and they underestimate the magnitude of the disparity because HTN starts at an earlier age in Blacks.

CDC: MMWR, 2000

0

2

4

1

3 Relative

Risk

Age, y

Whites

Disparity in stroke deaths

Presenter

Presentation Notes

The disparity in stroke deaths is greatest in young adults. A case in point is Barry White, one of the greatest R&B artists, who died of a stroke in his 50s.

Pharmacists?

Physician inertia

Barber fidelity Patron acceptance

BARBER-2 Trial (in Los Angeles): How to optimize intervention potency?

Non- Adherence

Better medical treatment

Presenter

Presentation Notes

Of the 10M US black htvs, currrently 30% are untreated and 60% uncontrolled. The barriers to better HTN control include psychosocial factors, loss of health insurance, physician inertia, and non-adherence. Most previous work has considered AA men and women as a group and not considered gender specific upstream pyschosocial factors.

The LA Blood Pressure Barbershop Study

PI: Ronald Victor, MD NIH-funded R01 grant 2015-2019 ClinicalTrials.gov Identifier NCT 02321618

40 Barbershops randomized (500 patrons)

Baseline 20 barbershops 15 patrons/shop

Baseline 20 barbershops 15 patrons/shop

Enhanced Intervention Barber-pharmacist BP mgt.

Active Comparator Barber health educator

6 Month Follow up

Extension Study

12 Month Follow up

6 Month Follow up

Extension Study

12 Month Follow up

Presenter

Presentation Notes

BARBER-1 was a cluster randomized trial conducted on 1300 HTV male patrons of 17 AA-owned barbers in Dallas county Texas

Enhanced Intervention Barber‘s Blood Pressure

Work Station

Cohort member card with barcode

Wireless transmission

Pharmacist visits

Presenter

Presentation Notes

Also Both groups will get results of their BP readings by independent survey staff at baseline and at 6- and 12- month follow-up.

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.vinyl-decals.com/mortar_and_pestle_pharmacy_symbol-CD-CGS04848.php?cat=15&ei=qcTsVJn4EIzjoAT2zICoBA&bvm=bv.86475890,d.cGU&psig=AFQjCNGWs0QeNz0iAiJd_NOmXWaXLQmWOg&ust=1424889330576123

Value Proposition- CMM Services

Integration of CMM services for high-risk patients:

• Lowers total healthcare costs (↓hospitalizations / readmits)

• Improves healthcare quality measures (value-based $)

• Improves medication safety (priority for CMS, others)

• Improves provider access (PCMH measure) and satisfaction (less staff turnover)

• Improves patient satisfaction (retention)

• Saves lives!