Houston- Participant,Provider, Facility Administrator, Local Hub. Steering Committee Members

Attachment 5D

MYRX PARTICIPANT Telephone Follow-Up: Healthy Eating

Telephone Follow-Up: Healthy Eating

TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE

MINORITY HEALTH (PCCC) INITIATIVE

Date:

Participant 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?

Participant 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 participant’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

Participant 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 20 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

2. Medication Adherence

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.

Has the participant missed any doses in the past two weeks?

Yes

No

If answer is yes, explain why.

Knowledge Questions Exercise: Ask the participant the following questions and mark their answers (refer to appropriate section below based on participant’s diagnosis)

I. Hypertension:

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

True

False

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

True

False

3. How much sodium does the body need daily.

1000 mg

2300 mg

200 mg

None of the above

4. Eating less salt usually makes blood pressure…

Go Up

Go Down

Stay the Same

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

True

False

II. Diabetes:

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

True

False

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

True

False

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

Lowers it

Raises it

Has no effect

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

Your favorite foods

A variety of foods

Your like and dislikes

Your daily routine

All the above are correct

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

True

False

1st attempt: Date ______ Time: ________ Outcome: _______

2nd attempt: Date______ Time: ________ Outcome: _______

3rd attempt: Date ______ Time: ________ Outcome: _______

After three failed attempts, the participant is dropped from program.