Healthy Heart Healthy Heart Initiative and the Initiative and the

Role of the Role of the PharmacistPharmacist

Alexis Beyer, PharmD, NCPSAlexis Beyer, PharmD, NCPSCherokee Indian HospitalCherokee Indian HospitalHealthy Heart PharmacistHealthy Heart Pharmacist

ObjectivesObjectives Understand the Healthy Heart Initiative grant Understand the Healthy Heart Initiative grant

program and the benefits of risk reduction.program and the benefits of risk reduction. Assess the need and value of pharmacist Assess the need and value of pharmacist

participation in the Healthy Heart Initiative participation in the Healthy Heart Initiative grant program.grant program.

Understand the outcome measures for Understand the outcome measures for tracking cardiovascular health.tracking cardiovascular health.

Compare patient outcomes of Eastern Band Compare patient outcomes of Eastern Band Cherokee Indian (EBCI) Healthy Heart Cherokee Indian (EBCI) Healthy Heart participants with that of EBCI patients participants with that of EBCI patients diagnosed with diabetes but NOT enrolled in diagnosed with diabetes but NOT enrolled in the Healthy Heart Program. the Healthy Heart Program.

Facts At a GlanceFacts At a Glance

3.3 Million: Number of American Indians & 3.3 Million: Number of American Indians & Alaska Natives (AI & AN) according to 2007 Alaska Natives (AI & AN) according to 2007 U.S. CensusU.S. Census

16.3%: Number of AI & AN adults diagnosed 16.3%: Number of AI & AN adults diagnosed with DM compared with 8.7% of non-Hispanic with DM compared with 8.7% of non-Hispanic CaucasiansCaucasians

68%: Percent increase in DM from 1994 to 68%: Percent increase in DM from 1994 to 2004 in AI & AN youth aged 15-19 years2004 in AI & AN youth aged 15-19 years

~ 2 times higher: Likelihood of AI & AN to ~ 2 times higher: Likelihood of AI & AN to have diabetes compared with non-Hispanic have diabetes compared with non-Hispanic CaucasiansCaucasians

Facts At a Glance (cont.)Facts At a Glance (cont.) 58%: Increase in diabetes prevalence among 58%: Increase in diabetes prevalence among

AI & AN aged 20-29 from 1990 to 1998, AI & AN aged 20-29 from 1990 to 1998, compared to 9.1% of general U.S. population compared to 9.1% of general U.S. population

3 times higher: Death rate due to diabetes for 3 times higher: Death rate due to diabetes for AI & AN compared with general U.S. AI & AN compared with general U.S. population population

3 – 4 times higher: The risk for developing 3 – 4 times higher: The risk for developing cardiovascular disease in AI & AN with cardiovascular disease in AI & AN with diabetes compared with AI & AN without diabetes compared with AI & AN without diabetesdiabetes

66%: Percent of AI & AN with cardiovascular 66%: Percent of AI & AN with cardiovascular disease that had prior history of diabetesdisease that had prior history of diabetes

Data from DHHS: http://www.ihs.gov/medicalprograms/diabetes/ Data from DHHS: http://www.ihs.gov/medicalprograms/diabetes/

Healthy Heart InitiativeHealthy Heart Initiative

Indian Health Service (IHS) Grant ProgramIndian Health Service (IHS) Grant Program Targets individuals with DiabetesTargets individuals with Diabetes Clinical, team-based, intensive case-Clinical, team-based, intensive case-

management approach using current clinical management approach using current clinical guidelinesguidelines

Goal: Reduce the risk of cardiovascular diseaseGoal: Reduce the risk of cardiovascular disease Funded by IHS Special Diabetes Program Funded by IHS Special Diabetes Program

for Indians (SDPI)for Indians (SDPI) Division of Diabetes Treatment and PreventionDivision of Diabetes Treatment and Prevention

Participation CriteriaParticipation Criteria

Inclusion Inclusion CriteriaCriteria Diagnosis of Diagnosis of

diabetesdiabetes

Exclusion CriteriaExclusion Criteria PrediabetesPrediabetes Pregnancy or postpartum Pregnancy or postpartum

< 1yr < 1yr DialysisDialysis Age < 18Age < 18 Current substance abuse Current substance abuse Unstable chronic Unstable chronic

conditions conditions Diagnosis of cancer & on Diagnosis of cancer & on

chemo or radiationchemo or radiation

Cherokee HHI StaffCherokee HHI Staff

Full TimeFull Time Certified Nursing AssistantCertified Nursing Assistant Registered NurseRegistered Nurse Exercise PhysiologistExercise Physiologist

Part TimePart Time Physician’s AssistantPhysician’s Assistant PharmacistPharmacist

Participation Requirements

Baseline visit Labs

Monthly case management visits Completion of Course: Balancing Balancing

Your Life and Diabetes: Honoring Your Life and Diabetes: Honoring the Gift of Heart Healththe Gift of Heart Health

Monthly activitiesMonthly activities Encouraged but not required

Incentives for Participation Incentives for Participation in Cherokee’s HHI programin Cherokee’s HHI program Medication alignmentMedication alignment Medication pick-up at clinic visits; no Medication pick-up at clinic visits; no

wait timewait time Prizes & healthy meals provided at Prizes & healthy meals provided at

activitiesactivities Points for all visits and activity Points for all visits and activity

participation; grocery voucherparticipation; grocery voucher INCREASED CONTROL OF CV INCREASED CONTROL OF CV

RISK!!!RISK!!!

Pharmacist’s RolePharmacist’s Role

Baseline patient visitBaseline patient visit Follow-up case management visitsFollow-up case management visits Medication fills for Medication fills for

Nurse case management visitsNurse case management visits Provider medical visitsProvider medical visits Pharmacy case management visitsPharmacy case management visits Dose changes and/or new medicationsDose changes and/or new medications

Participate in all team activities Participate in all team activities Prepare and teach group classesPrepare and teach group classes

Baseline Pharmacist Baseline Pharmacist VisitVisit

Full MTM reviewFull MTM review DM SOCDM SOC ImmunizationsImmunizations Labs/VitalsLabs/Vitals MedicationsMedications Education Education Recommendations for providerRecommendations for provider

Count/align all medicationsCount/align all medications

Pharmacist Involvement in Pharmacist Involvement in Case Management & Goal Case Management & Goal

SettingSetting

IntensiveIntensive Monthly individual Monthly individual

visitsvisits Quarterly f/u with Quarterly f/u with

providerprovider

Goal SettingGoal Setting SpecificSpecific AttainableAttainable

Tobacco Cessation Tobacco Cessation EducationEducation

Patient ClassesPatient Classes

Balancing Your Life and Diabetes: Balancing Your Life and Diabetes: Honoring the Gift of Heart HealthHonoring the Gift of Heart Health

Group classGroup class Meets weekly for five weeksMeets weekly for five weeks Pharmacist leads class on diabetes Pharmacist leads class on diabetes

medicationsmedications

Cherokee HHI ActivitiesCherokee HHI Activities Family InvolvementFamily Involvement Walks/Easy hikesWalks/Easy hikes Healthy Tips CookoutHealthy Tips Cookout Exercise classes Exercise classes

Ti-chiTi-chi YogaYoga ZumbaZumba

Stress ManagementStress Management Healthy Holiday Healthy Holiday

PartiesParties Gardening TipsGardening Tips

Treatment Treatment Targets/Outcome MeasuresTargets/Outcome Measures

Glucose ControlGlucose Control A1c < 7%A1c < 7%

BP ControlBP Control <130/80<130/80

Lipid ControlLipid Control Primary target: LDL < 100 (< 70 Primary target: LDL < 100 (< 70

with CVD)with CVD) Secondary: TG <150Secondary: TG <150

Cherokee Healthy Heart Cherokee Healthy Heart Participant ResultsParticipant Results

81 Total Participants81 Total Participants Patient measures at Patient measures at

day zeroday zero A1c at goal: 32A1c at goal: 32 BP at goal: 36BP at goal: 36 LDL at goal: 49LDL at goal: 49 TG at goal: 33TG at goal: 33 HDL at goal: 23HDL at goal: 23

Current patient Current patient measuresmeasures A1c at goal: 34A1c at goal: 34 BP at goal: 55BP at goal: 55 LDL at goal: 57 LDL at goal: 57 TG at goal: 41TG at goal: 41 HDL at goal: 32HDL at goal: 32

Cherokee Healthy Heart Participants

0

10

20

30

40

50

60

A1c atgoal

BP atgoal

LDL atgoal

TG atgoal

HDL atgoal

Day Zero

Current

Cherokee Healthy Heart Cherokee Healthy Heart Participant Results Since Participant Results Since

Baseline HHI VisitBaseline HHI Visit

78 of 81 78 of 81 patients patients enrolled in Cherokee’s enrolled in Cherokee’s Healthy Heart Initiative Healthy Heart Initiative Program have improved Program have improved in at least one area since in at least one area since their baseline visittheir baseline visit

81 Patient 81 Patient ParticipantsParticipants

Reduction in A1cReduction in A1c 40 (49.38%)40 (49.38%)

Reduction in BPReduction in BP 37 (45.68%)37 (45.68%)

Reduction in LDLReduction in LDL 29 (35.80%)29 (35.80%)

Reduction in TGReduction in TG 36 (44.44%)36 (44.44%)

Increase in HDL Increase in HDL 39 (48.15%)39 (48.15%)

Diagnosed with DM; Why Diagnosed with DM; Why Participate in the HHI Participate in the HHI

Program?Program?Non-HHI ptsNon-HHI pts HHI ptsHHI pts

Total # PtsTotal # Pts 31603160 8181

A1c at goalA1c at goal 886 (28.04%)886 (28.04%) 34 (41.98%)34 (41.98%)

BP at goalBP at goal 976 (30.89%)976 (30.89%) 55 (67.90%)55 (67.90%)

LDL at goalLDL at goal 1523 1523 (48.20%)(48.20%)

57 (70.37%)57 (70.37%)

TG at goalTG at goal 206 (6.52%)206 (6.52%) 41 (50.62%)41 (50.62%)

HDL at goal HDL at goal (F)(F)

504504 20 20

HDL at goal HDL at goal (M)(M)

476476 1212

Comparison of EBCI HHI Comparison of EBCI HHI Patients vs. EBCI Patients Patients vs. EBCI Patients with Diagnosis of DM, Not with Diagnosis of DM, Not

Enrolled in HHIEnrolled in HHI

SummarySummary

Healthy Heart Initiative grant Healthy Heart Initiative grant program program

Reduce CVD through targeted risk Reduce CVD through targeted risk reductionreduction

Pharmacists are valuable assets in Pharmacists are valuable assets in disease state management disease state management

Intensive case-management Intensive case-management improves patient outcomesimproves patient outcomes

Interested in HHI Grant Interested in HHI Grant Program?Program?

Division of Diabetes Treatment and Prevention  

www.ihs.gov/MedicalPrograms/www.ihs.gov/MedicalPrograms/Diabetes/ Diabetes/

diabetesprogram@ihs.gov

ContributionsContributions

Special thanks:Special thanks: LT Janet Dudley, PharmDLT Janet Dudley, PharmD

Pharmacy Resident for CIHAPharmacy Resident for CIHA Non-HHI pt data collectionNon-HHI pt data collection

Chenoa Gass, RNChenoa Gass, RN

Cherokee Healthy Heart Nurse Case Cherokee Healthy Heart Nurse Case ManagerManager HHI pt data collectionHHI pt data collection

ReferencesReferences Cherokee Indian Hospital Electronic Health Record, 2012.Cherokee Indian Hospital Electronic Health Record, 2012. Colorado School of Public Health (n.d.), Healthy Heart Colorado School of Public Health (n.d.), Healthy Heart

Initiate Program. Retrieved on January 21, 2012 from: Initiate Program. Retrieved on January 21, 2012 from: http://www.ucdenver.edu/academics/colleges/PublicHealthhttp://www.ucdenver.edu/academics/colleges/PublicHealth/research/centers/CAIANH/sdpi/Pages/sdpi.aspx/research/centers/CAIANH/sdpi/Pages/sdpi.aspx

Indian Health Service (n.d.), Diabetes in American Indians Indian Health Service (n.d.), Diabetes in American Indians and Alaska Natives. Retrieved on May 3, 2012 from: and Alaska Natives. Retrieved on May 3, 2012 from: http://www.ihs.gov/medicalprograms/diabetes/ http://www.ihs.gov/medicalprograms/diabetes/

National Institutes of Health (n.d.). National Diabetes National Institutes of Health (n.d.). National Diabetes Information Clearinghouse. Retrieved on May 3, 2012 Information Clearinghouse. Retrieved on May 3, 2012 from: http://diabetes.niddk.nih.gov/ from: http://diabetes.niddk.nih.gov/

QuestionsQuestions

Alexis Beyer, PharmD, NCPSAlexis Beyer, PharmD, NCPS

Cherokee Indian HospitalCherokee Indian Hospital

alexis.beyer@cherokeehospital.orgalexis.beyer@cherokeehospital.org

alexisrosebeyer@gmail.com alexisrosebeyer@gmail.com