1. Healthy Heart Initiative and the Role of the Pharmacist Alexis Beyer, PharmD, NCPS Cherokee Indian Hospital Healthy Heart Pharmacist

2. Objectives Understand the Healthy Heart Initiative grant program and the benefits of risk reduction. Understand the Healthy Heart Initiative grant program and the benefits of risk reduction. Assess the need and value of pharmacist participation in the Healthy Heart Initiative grant program. Assess the need and value of pharmacist participation in the Healthy Heart Initiative grant program. Understand the outcome measures for tracking cardiovascular health. Understand the outcome measures for tracking cardiovascular health. Compare patient outcomes of Eastern Band Cherokee Indian (EBCI) Healthy Heart participants with that of EBCI patients diagnosed with diabetes but NOT enrolled in the Healthy Heart Program. Compare patient outcomes of Eastern Band Cherokee Indian (EBCI) Healthy Heart participants with that of EBCI patients diagnosed with diabetes but NOT enrolled in the Healthy Heart Program.

3. Facts At a Glance 3.3 Million: Number of American Indians & Alaska Natives (AI & AN) according to 2007 U.S. Census 3.3 Million: Number of American Indians & Alaska Natives (AI & AN) according to 2007 U.S. Census 16.3%: Number of AI & AN adults diagnosed with DM compared with 8.7% of non-Hispanic Caucasians 16.3%: Number of AI & AN adults diagnosed with DM compared with 8.7% of non-Hispanic Caucasians 68%: Percent increase in DM from 1994 to 2004 in AI & AN youth aged 15-19 years 68%: Percent increase in DM from 1994 to 2004 in AI & AN youth aged 15-19 years ~ 2 times higher: Likelihood of AI & AN to have diabetes compared with non-Hispanic Caucasians ~ 2 times higher: Likelihood of AI & AN to have diabetes compared with non-Hispanic Caucasians

4. Facts At a Glance (cont.) 58%: Increase in diabetes prevalence among AI & AN aged 20-29 from 1990 to 1998, compared to 9.1% of general U.S. population 58%: Increase in diabetes prevalence among AI & AN aged 20-29 from 1990 to 1998, compared to 9.1% of general U.S. population 3 times higher: Death rate due to diabetes for AI & AN compared with general U.S. population 3 times higher: Death rate due to diabetes for AI & AN compared with general U.S. population 3 – 4 times higher: The risk for developing cardiovascular disease in AI & AN with diabetes compared with AI & AN without diabetes 3 – 4 times higher: The risk for developing cardiovascular disease in AI & AN with diabetes compared with AI & AN without diabetes 66%: Percent of AI & AN with cardiovascular disease that had prior history of diabetes 66%: Percent of AI & AN with cardiovascular disease that had prior history of diabetes Data from DHHS: http://www.ihs.gov/medicalprograms/diabetes/ http://www.ihs.gov/medicalprograms/diabetes/

5. Healthy Heart Initiative Indian Health Service (IHS) Grant Program Indian Health Service (IHS) Grant Program Targets individuals with Diabetes Targets individuals with Diabetes Clinical, team-based, intensive case-management approach using current clinical guidelines Clinical, team-based, intensive case-management approach using current clinical guidelines Goal: Reduce the risk of cardiovascular disease Goal: Reduce the risk of cardiovascular disease Funded by IHS Special Diabetes Program for Indians (SDPI) Funded by IHS Special Diabetes Program for Indians (SDPI) Division of Diabetes Treatment and Prevention Division of Diabetes Treatment and Prevention

6. Participation Criteria Inclusion Criteria Inclusion Criteria Diagnosis of diabetes Diagnosis of diabetes Exclusion Criteria Prediabetes Pregnancy or postpartum < 1yr Dialysis Age < 18 Current substance abuse Unstable chronic conditions Diagnosis of cancer & on chemo or radiation

7. Cherokee HHI Staff Full Time Full Time Certified Nursing Assistant Certified Nursing Assistant Registered Nurse Registered Nurse Exercise Physiologist Exercise Physiologist Part Time Part Time Physician’s Assistant Physician’s Assistant Pharmacist Pharmacist

8. Participation Requirements Baseline visit Labs Monthly case management visits Balancing Your Life and Diabetes: Honoring the Gift of Heart Health Completion of Course: Balancing Your Life and Diabetes: Honoring the Gift of Heart Health Monthly activities Monthly activities Encouraged but not required

9. Incentives for Participation in Cherokee’s HHI program Medication alignment Medication alignment Medication pick-up at clinic visits; no wait time Medication pick-up at clinic visits; no wait time Prizes & healthy meals provided at activities Prizes & healthy meals provided at activities Points for all visits and activity participation; grocery voucher Points for all visits and activity participation; grocery voucher INCREASED CONTROL OF CV RISK!!! INCREASED CONTROL OF CV RISK!!!

10. Pharmacist’s Role Baseline patient visit Baseline patient visit Follow-up case management visits Follow-up case management visits Medication fills for Medication fills for Nurse case management visits Nurse case management visits Provider medical visits Provider medical visits Pharmacy case management visits Pharmacy case management visits Dose changes and/or new medications Dose changes and/or new medications Participate in all team activities Participate in all team activities Prepare and teach group classes Prepare and teach group classes

11. Baseline Pharmacist Visit Full MTM review Full MTM review DM SOC DM SOC Immunizations Immunizations Labs/Vitals Labs/Vitals Medications Medications Education Education Recommendations for provider Recommendations for provider Count/align all medications Count/align all medications

12. Pharmacist Involvement in Case Management & Goal Setting Intensive Monthly individual visits Quarterly f/u with provider Goal Setting Goal Setting Specific Specific Attainable Attainable Tobacco Cessation Education Tobacco Cessation Education

13. Patient Classes Patient Classes Balancing Your Life and Diabetes: Honoring the Gift of Heart Health Balancing Your Life and Diabetes: Honoring the Gift of Heart Health Group class Group class Meets weekly for five weeks Meets weekly for five weeks Pharmacist leads class on diabetes medications Pharmacist leads class on diabetes medications

14. Cherokee HHI Activities Family Involvement Walks/Easy hikes Healthy Tips Cookout Exercise classes Ti-chi Yoga Zumba Stress Management Healthy Holiday Parties Gardening Tips

15. Treatment Targets/Outcome Measures Glucose Control Glucose Control A1c < 7% A1c < 7% BP Control BP Control <130/80 <130/80 Lipid Control Lipid Control Primary target: LDL < 100 (< 70 with CVD) Primary target: LDL < 100 (< 70 with CVD) Secondary: TG <150 Secondary: TG <150

16. Cherokee Healthy Heart Participant Results 81 Total Participants Patient measures at day zero Patient measures at day zero A1c at goal: 32 A1c at goal: 32 BP at goal: 36 BP at goal: 36 LDL at goal: 49 LDL at goal: 49 TG at goal: 33 TG at goal: 33 HDL at goal: 23 HDL at goal: 23 Current patient measures A1c at goal: 34 BP at goal: 55 LDL at goal: 57 TG at goal: 41 HDL at goal: 32

17. Cherokee Healthy Heart Participants

18. Cherokee Healthy Heart Participant Results Since Baseline HHI Visit 78 of 81 patients enrolled in Cherokee’s Healthy Heart Initiative Program have improved in at least one area since their baseline visit 81 Patient Participants Reduction in A1c Reduction in A1c 40 (49.38%) 40 (49.38%) Reduction in BP Reduction in BP 37 (45.68%) 37 (45.68%) Reduction in LDL Reduction in LDL 29 (35.80%) 29 (35.80%) Reduction in TG Reduction in TG 36 (44.44%) 36 (44.44%) Increase in HDL Increase in HDL 39 (48.15%) 39 (48.15%)

19. Diagnosed with DM; Why Participate in the HHI Program? Non-HHI pts HHI pts Total # Pts 316081 A1c at goal 886 (28.04%) 34 (41.98%) BP at goal 976 (30.89%) 55 (67.90%) LDL at goal 1523 (48.20%) 57 (70.37%) TG at goal 206 (6.52%) 41 (50.62%) HDL at goal (F) 50420 HDL at goal (M) 47612

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

21. Summary Healthy Heart Initiative grant program Healthy Heart Initiative grant program Reduce CVD through targeted risk reduction Reduce CVD through targeted risk reduction Pharmacists are valuable assets in disease state management Pharmacists are valuable assets in disease state management Intensive case-management improves patient outcomes Intensive case-management improves patient outcomes

22. Interested in HHI Grant Program? Division of Diabetes Treatment and Prevention www.ihs.gov/MedicalPrograms/Diabetes/ www.ihs.gov/MedicalPrograms/Diabetes/ www.ihs.gov/MedicalPrograms/Diabetes/ diabetesprogram@ihs.gov

23. Contributions Special thanks: Special thanks: LT Janet Dudley, PharmD LT Janet Dudley, PharmD Pharmacy Resident for CIHA Non-HHI pt data collection Non-HHI pt data collection Chenoa Gass, RN Chenoa Gass, RN Cherokee Healthy Heart Nurse Case Manager HHI pt data collection HHI pt data collection

24. References Cherokee Indian Hospital Electronic Health Record, 2012. Cherokee Indian Hospital Electronic Health Record, 2012. Colorado School of Public Health (n.d.), Healthy Heart Initiate Program. Retrieved on January 21, 2012 from: http://www.ucdenver.edu/academics/colleges/PublicHealth/research/cente rs/CAIANH/sdpi/Pages/sdpi.aspx Colorado School of Public Health (n.d.), Healthy Heart Initiate Program. Retrieved on January 21, 2012 from: http://www.ucdenver.edu/academics/colleges/PublicHealth/research/cente rs/CAIANH/sdpi/Pages/sdpi.aspx http://www.ucdenver.edu/academics/colleges/PublicHealth/research/cente rs/CAIANH/sdpi/Pages/sdpi.aspx http://www.ucdenver.edu/academics/colleges/PublicHealth/research/cente rs/CAIANH/sdpi/Pages/sdpi.aspx Indian Health Service (n.d.), Diabetes in American Indians and Alaska Natives. Retrieved on May 3, 2012 from: http://www.ihs.gov/medicalprograms/diabetes/ Indian Health Service (n.d.), Diabetes in American Indians 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 Information Clearinghouse. Retrieved on May 3, 2012 from: http://diabetes.niddk.nih.gov/ National Institutes of Health (n.d.). National Diabetes Information Clearinghouse. Retrieved on May 3, 2012 from: http://diabetes.niddk.nih.gov/ http://diabetes.niddk.nih.gov/

25. Questions Alexis Beyer, PharmD, NCPS Cherokee Indian Hospital alexis.beyer@cherokeehospital.org alexisrosebeyer@gmail.com