USPHS Deployment and Pharmacy Forms

1. USPHS Deployment and Pharmacy Forms LCDR Binh T. Nguyen, Pharm.D., M.S. LCDR Connie T. Jung, RPh, Ph.D. Food and Drug Administration PharmPAC 04/04/07

2. Objectives • How can Medication Therapy Management (MTM) be applied towards emergency health response/preparedness (USPHS deployment)? • Purpose of implementing USPHS Pharmacy MTM forms • Other pharmacy deployment forms

3. USNS COMFORT Mission to Latin America and the Caribbean • 1 ER/FP Physician • 1 Preventive Medicine Physician • 1 Infectious Disease Physician • 1 Internal Medicine Physician • 2 Dentists • 4 Dental Hygienists • 2 Medical-Surgical Nurses (comfortable with patients of all ages, in both in-patient and out-patient environments) • 1 Environmental Engineer • 1 Environmental Health Officer • 1 Veterinarian (primarily large animal focus)

4. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 • MMA 2003, Congress stipulated that Part D sponsors (i.e. plans) must establish an MTM program that is designed “to optimize therapeutic outcomes (for targeted beneficiaries) through improved medication use, and to reduce the risks of ADE and drug interactions. MMA 2003 also said MTM program elements should promote these goals: • Counsel patients for appropriate use of medications and risk of ADE • Increase adherence to prescription drug regimens through medication refill reminders, special packaging, and other means • Detection of ADE and pattern of drug overuse and under-use

5. MMA 2003 • If properly implemented in community pharmacy, the provision of MTM services will lead to: • Improved care for patients • Higher patient and customer satisfaction • Lower overall health care expenditures • New profit centers in community pharmacies • Greater professional fulfillment for pharmacists • Unprecedented national recognition of pharmacist’s value

6. What is Medication Therapy Management? • MTM includes services not limited to • Performing patient health status assessments • Formulating prescription drug treatment plans • Managing high-cost specialty medications • Evaluating and monitoring patient response to drug therapy • Providing education and training • Coordinating MTM with other care management services • Participating in state-permitted drug therapy management

7. How will MTM be developed? • The final rule states that: “MTM must be developed in cooperation with licensed and practicing pharmacists and physicians.”

8. Medication Therapy Management: Components • Medication therapy review (MTR) • Monitor ongoing therapy • Review of all meds: Rx, OTC, herbal, DS at least annually • Outcome: to optimize drug therapies • Personal medication record • List of patient’s own meds, strength, dosing directions, and other info • RPh encourages patients to share this list with all of their health care providers • Medication Action Plan (MAP) • A MAP contains info to help patient improve their medication management • Intervention on medication therapy problems and/or referral • RPh intervenes to address med related problems • RPh refers patients to other health care providers • Documentation of services and follow-up

9. Applicability to USPHS Emergency Health Response • Standardized forms for screening • Standardized flyers for different types of services: Immunization (influenza, hepatitis…), Diabetes, Cholesterol, Hypertension, Osteoporosis, Hepatitis B, Food Pyramid, Exercise, Heartburn, Asthma, Depression, Generalized Anxiety Disorder • Consent forms • Electronic prescribing and dispensing • PharmPAC health work group • Use MTM model to support USPHS pharmacy response to public health emergencies

10. Disease management Hypertension (26%) Arthritis (20%) Respiratory disease (19%) Cholesterol disorders (13%) Chronic Mental conditions (13%) Heart disease (11%) – Cardiac risk / CHF Eye disorders (10%) Asthma (10%) - COPD Diabetes (10%) Oncology Anticoagulant therapy Women’s health Nephrology AIDS Osteoporosis Pediatric services Hormone replacement therapy (bioidentical therapies) Depression Generalized Anxiety Disoder Hepatitis Lab Testing/Screening Blood lipids Bone density A1C Blood glucose Blood pressure Streptococci Helicobacter pylori Pulse oximetry Prothrombin time test Peak flow monitoring / education Wellness Program Diet/nutrition Smoking cessation Health status assessment Immunizations Travel health clinics Emergency contraception Weight loss management Patient services pharmacists may provide:

11. Diabetes Adherence with healthy eating and physical activity Adherence with drug therapy (i.e. insulin, oral antidiabetes medications) Percentage of patients with A1C < 7%* Percentage of patients with blood pressure of < 130/80 mm Hg Percentage of patients who: Self-monitor blood glucose Receive annual eye exam, lipid panel, flu shot, and comprehensive foot exam Hypertension Adherence with healthy eating and physical activity Adherence with antihypertensive drugs Percentage of patients who reach target blood pressure goals*. For example: <140/90 mmHg in those with hypertension <130/80 mmHg in those with hypertension and diabetes or renal disease Quality’s indicators for pharmacists’ services

12. key scientific based references 1) lifestyle modifications with regard to obesity, exercise, healthy eating and smoking. http://www.medscape.com/viewarticle/438855 2) reducing health disparity, specifically as it relates to the very young and the very old. http://www.uspharmacist.com/index.asp?show=article&page=hhc_award/hhcAward5/FifthAnnualhhcAwardArticle2.htm 3) emergency preparedness and response readiness to chemical, biological, and other terrorist threats http://www.hhs.gov/pharmacy/ccrf.html 4) reduction and prevention of medication errors http://cdernet/ods/Error%20Resource%20Page/resource.html 5) misuse and abuse of drugs (Rx, OTC, herbal, alcohol, tobacco) http://www.drugabuse.gov/ResearchReports/Prescription/prescription6.html http://arthritis.about.com/od/prescriptionabuse/a/abuseofdrugs.htm pharmacist involvement and intervention 1) pharmacist role as Medication Therapy Management specialists, in terms of providing the public with important clinical drug and health information relating to different disease states; http://www.medscape.com/viewarticle/406783 2) pharmacists as immunization specialists - being able to give vaccinations; 3) pharmacist's role in providing good IT support/communication technology to make sure drug and health information for patients are known and can be addressed during disaster relief; http://www.uspharmacist.com/index.asp?show=article&page=8_1217.htm 4) pharmacy response at the community and local level, during any emergency, including distribution of drugs where they are most needed, including the National Stockpile; http://www.hhs.gov/pharmacy/ccrf/html 5) pharmacists as pharmacogenomic specialists, in terms of knowledge of pharmacokinetics and factors affecting drug metabolism. SG Health Priorities: Healthy People 2010 &Guide to Public Health Research Needs, 2006

13. MTM forms Patient OTC Medication, Usage, and Family History form Pharmaceutical Care Drug Assessment & Diagnosis form Patient’s Question / Concern and Pharmacist’s Assessment / Response form Patient Proper Medication Use form Pharmacist Communication to Physician form Health Clinic Health passport Screening Diabetes Cholesterol Hypertension Others Diet and Exercise Depression Hospital Practice Immunization form http://www.psc.gov/forms/IHS/ihs.html MTM forms, VAPSA and Hospital Practice

14. Other deployment forms • Narcotic inventory CII and CIII-V log • Controlled substance dispensing log • Immunization log • Pharmacist’s record • Temperature log form (Freezer/Refrigerator) • Prescription form • Important contacts

15. Thank you • PharmPAC • All officers who provided comments and feedbacks • Pharmacy Work Group members • RDF Pharmacy Team Leadership