First Home Visit Form: Diabetes or Hypertension or Hypertension and Diabetes

First Home Visit Form: Hypertension

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

First Home Visit Form: Hypertension

TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE

MINORITY HEALTH (PCCC) INITIATIVE

Date:_____________________

Patient name (Last name, First initial): _________________________________

Client ID #: ____________________________

Pharmacist Conducting Home Visit: ________________________________

Home Visit Date: ______________________

Section I. Patient Demographics:

Pharmacist Step #1: Introduction and collect baseline information.

1. On eligibility form
   
   

2. On eligibility form
   
   

3. Baseline blood pressure screening: _________________
   
   

4. Wt: ________________ lbs
   

5. Ht: _______ feet ________ inches
   
   

6. How long have you had high blood pressure? _______________
   
   

7. 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 40 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. PCCC Survey:

Pharmacist Step #3: Ask the patient the following questions and mark their answers.

The statements below describe attitudes and beliefs you may have about the health program you signed up for and 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
1. I will learn new information to help me to manage my health condition
2. I will get useful information about my health condition
3. I expect to put what I learn from this program into practice
4. I expect to see positive changes in myself if I do what they teach me
5. I can do something to improve my health condition
6. It is very important to take care of your health
7. I am ready to improve my health

Section IV. Medication Use and Adherence

Pharmacist Step #4: 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 V. Pharmacist Step #5: 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.

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 VI. Pharmacist Step #6: Pharmacist Education Checklist:

Education Points **Please make sure you have discussed the following items with the patient by initialing in the next column**	Pharmacist’s Initials
I have reviewed all of the patient’s medications with the patient.
I have discussed all potential drug interactions with the patient.
I have provided disease state education on blood pressure to the patient.
I have discussed in detail the medications for blood pressure with the patient.
I have discussed the importance of medication adherence with the patient.
I have discussed over-the-counter medication use as it relates to blood pressure with the patient.
I have discussed how to read and understand prescription labels/packaging with the patient.
I have showed the patient how to use a pillbox for medication maintenance.
I have discussed when to call in for refills with the patient.
I have discussed blood pressure goals with the patient.

Section VII. Pharmacist Step #7: Interventions/Recommendations made (check appropriate box per intervention and list each intervention):

• Education on hypertension awareness

• Diet: _______________________________________________________________________________

• Exercise: _______________________________________________________________________________

• Medication duplication: _______________________________________________________________________________

• Condition not treated: _______________________________________________________________________________

• Drug-disease interaction: _______________________________________________________________________________

• Drug-food interaction: _______________________________________________________________________________

• Drug-drug interaction: _______________________________________________________________________________

• Inappropriate Dose: _______________________________________________________________________________

• Therapeutic suggestion/alternatives: _______________________________________________________________________________

• Noncompliant: _______________________________________________________________________________

• Adverse drug event: _______________________________________________________________________________

• Other: _______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Section VIII. Pharmacist Step #8: Follow up plan:

18. Remind the patient about the upcoming education session. Ask the patient when is a good time for your follow-up

telephone call after your education class next month?

Day: __________________ Date: ________________ Time: __________________

19. Patient will need more education in the following areas (by phone):

 Medication management

 Blood pressure self monitoring

 Other: ___________________________________________________________

20. Does patient’s PCP need to be notified?

• Yes

• No

Why? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________