PHAR 652 Exam #1 (Review)

What does the Omnibus Reconciliation Act of 1990 (Section 4401), abbreviated as OBRA ‘90, establish for Medicaid patients?

• Prospective drug utilization review

• Record-keeping requirements

• Requirement to offer counsel

According to OBRA ‘90, what do we have to discuss with the patient?

• Drug name

• Dosage form, route, dosage, and administration schedule

• Intended use and expected action

• Action in the event of a missed dose

• Common severe side effects, interactions, and therapeutic contraindications (and how to avoid them and action if they occur)

• Potential drug-drug interactions or drug-disease contraindications

• Proper storage

• Techniques for self-monitoring

• Refill information

What are the three prime questions to ask patients during counseling?

What do they each comprise of?

1. What did your doctor tell you this medication was for?

• May prompt additional questions or explanations

2. How did your doctor tell you to take this medication?

• Quantity, dose, and frequency (i.e., how many, how much, and how often)

• If a device, demonstrate proper technique to patient

• Your first dose can be taken… (when)

• Storage/quantity/refills

• Time to see a benefit or when the MD will follow up

3. What did you doctor tell you to expect?

• Most common adverse effects (including how to manage, if a drug should be discontinued or dosage decreased, and if a patient should call their MD)

• Severe (but rare) adverse effects to be aware of (and when to call MD)

• Potential drug interactions

• Goals of therapy and monitoring for efficacy/toxicity

• Take caution to not “information dump”

The Code of VA 54.1-3319 requires pharmacists to offer counseling to anyone presenting a new prescription, using professional judgement to determine the method of communication.

Which methods can counseling be offered through?

• Face-to-face communication

• Sign posted that can be seen by patients

• Notation on the bag

• Notation on the prescription container

• By telephone

Why do we as pharmacists counsel?

• Patient education

• Patient motivation

• Improve adherence

• Reduce medication-related problems

• Legal compliance

• Liability

When are the requirements to counsel not applicable?

• Hospital inpatients

• Nursing home residents

• When the patient refuses the offer to be counseled (patients have a right to informed refusal)

open-ended questions

Definition: questions that can’t be answered in “yes” or no”

• Allows for a wider variety of answers

• Allows us to obtain a lot of necessary information

show and tell

1. Show the medication being dispensed and how it is used if applicable

2. Tell by filling in the blanks from the patient’s responses to your open-ended prime questions

Pharmacists’ Patient Care Process (PPCP)

• Collect the necessary subjective and objective information about the patient to understand the relevent medical/medication history and clinical status of the patient

• Assess the collected information and analyze the clinical effects of the patient’s therapy based on the patient’s health goals to identify and prioritize problems and achieve optimal care

• Develop an individualized, patient-centered care Plan with other health care professionals and the patient/caregiver that is evidence-based and cost-effective

• Implement the care plan with other health care professionals and the patient/caregiver

• Follow-up: Monitor and evaluate the effectiveness of the care plan and modify it with other health care professionals and the patient/caregiver as needed

What recommendations on patient counseling are in our Elder textbook?

• Introduce self to patient

• Identify purpose of consultation/interaction

• Confirms pertinent patient data

• Medication name and dose

• Indication

• How to take

• Storage instructions

• Side effects

• Disease monitoring

• Refill instructions

• Closure

What best practices should be considered for patient counseling?

• Educate, not scare

• Show and tell

• Open-ended questions

• Ask what questions the patient has

• Elicit patient understanding of counseling material using the “teach-back” or “ask-tell-ask” method

• Clarify and explain any unclear or missed points

• Consider those who are hearing/visually impaired, illierate, speak a different language, or are HALT (Hungry, Angry/Anxious, Lonely, Tired)

• Be knowledgeable about adherence, special populations, and health literacy

• Adapt to potential barriers

health equity

the state in which everyone has a fair and just opportunity to attain their highest level of health

intersectionality

the interconnected structures and systems that create inequality among people and populations based on social categories of difference

What are social determinants of health (SDOH)?

the conditions of the places people live, learn, work, play, and worship in that affect a wide range of health risks and outcomes

categories and of social determinants of health

• Economic stability (EIE DMS)

  • Employment

  • Income and wealth gaps

  • Expenses

  • Debt

  • Medical bills

  • Support

• Neighborhood and physical environment (PP HTS)

  • Parks

  • Playgrounds

  • Housing

  • Transportation

  • Safety

• Education (LL EHV)

  • Literacy

  • Language

  • Early childhood education

  • Higher education

  • Vocational training

• Food

  • Hunger

  • Access to healthy options

• Community and social context (SS CDW)

  • Social integration

  • Support systems

  • Community engagement

  • Discrimination

  • Workplace conditions

• Health care system (PP HQ)

  • Provider availability

  • Provider linguistic/cultural competency

  • Health coverage

  • Quality of care

How do social determinants of health affect the health of the people of our community?

Short answer:

• Creates health disparities: preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health

• Affects the following health outcomes: mortality, morbidity, life expectancy, health care expenditures, health status, functional limitations

Examples:

• Higher rates of chronic diseases among populations of people of color

• Poorer health outcomes

• Reduced life expectancy

• Lack of stable income or employment → Food insecurity, unstable housing, chronic stress

• Unsafe neighborhoods → Increased health risks, hindered physical activity

• Limited access to affordable, healthy food options → Poor nutrition, higher risk of obesity, diabetes, and heart disease

• Limited access to quality education and stable, well-paying jobs → Decreased health literacy and financial stability, no access to benefits like health insurance

• No strong social connections → Loneliness, poor mental health

individual decisions that affect health

• Diet and nutrition

• Physical activity

• Substance use (e.g., smoking)

• Sleep

• Sexual activity

• Disease screening

environmental (social) factors that affect health

• Education

• Employment

• Income

• Family and social support

• Community safety

What is the role of pharmacists in community engagement?

• Public health and disease prevention

  • Health promotion and communication

  • Disease screening

  • Point-of-care testing

  • Immunization services

  • Substance abuse prevention

• Patient care and education

  • Direct patient care

  • Health education

  • Patient advocacy

  • Medication therapy management (MTM)

• Healthcare access and navigation

  • Closing healthcare gaps

  • Care coordination

  • Dispelling misinformation

• Community leadership

  • Oftentimes the first-line accessible resource for patients

  • Health equity

  • Research and innovation

What has happened in Richmond history (and specifically in the East End) that has led to health disparities? How did they impact current health behavior and attitudes?

• Jim Crow laws (racial segregation and inequity)

• MCV used Black bodies for anatomical study and experimentation

• Black patients had limited access to quality hospital care

• Highway construction and public housing that divided people by race and socioeconomic status, creating disparities between the East End and other parts of RVA

Impact:

• General distrust of medical institutions → Delayed care, low participation in preventive screenings, skepticism toward health messaging

• Persisting health disparities

  • Higher rates of hypertension, obesity, diabetes, and infant mortality

  • Lower life expectancy

What acts have been established in history to try resolving health disparities?

• Title VI of the Civil Rights Act of 1964 (no one can be excluded from participation, be denied benefits, or be subjected to discrimination under any program or activity that receives federal financial assistance)

• Medicare Act of 1965 (if hospitals and nursing homes wanted federal Medicare and Medicaid funding, they had to end discriminatory practices)

VCU Medical Center

• Regional referral center that sees patients all over the east coast, with 72% of the population residing in the primary service area

• Largest safety net health system in Virginia, with 66% patients being either uninsured or enrolled in government-sponsored programs

East End of Richmond, VA and community assets

• Includes neighborhoods like Church Hill, Fulton, and Fairfield that have housing communities

• One of the city’s oldest African American communities and has deep cultural and historical roots—notably associated with Black entrepreneurship, faith communities, and civil rights leadership

• Redlining, urban renewal, and disinvestment (especially in the middle of the 1900s) led to a higher percentage of low-income households, of those living in poverty, of those without insurance, of those with low education attainment, and of those with food insecurity

Community assets:

• Faith-based organizations and churches

• Community-based organizations

• Cultural pride and resilience

• Local food and health initiatives

  • Richmond Health and Wellness Program (RHWP)

    • Healthy meal program

    • Tele-wellness clinics

    • Vaccination clinics

    • Growth in research in terms of  pharmacogenetics/genomics (PGx) implementation, adverse drug events (ADEs) in older adults, and drug discovery

  • Food is Medicine program with VCUHS Inpatient Services

  • VCU Health Hub (addressed food insecurity by building a health education and wellness center next to a grocery store in a food desert)

social and economic determinants of health (in the context of Richmond’s East End)

• Economic stability

  • High poverty and unemployment rates

  • Limited access to well-paying jobs and generational wealth

• Neighborhood and physical environment

  • Limited grocery stores (historical “food deserts”)

  • Unsafe or aging housing conditions

  • Crime and lack of safe recreation spaces

• Education

  • Schools historically under-resourced → Lower graduation rates and literacy gaps

• Access to healthy food and transportation

  • Food deserts

  • Efforts like The Market @ 25th and community gardens help mitigate past inequities

• Community and social context

  • Strong social ties and community pride are protective factors

  • Discrimination and systemic inequities increase stress levels

• Health care system

  • Fewer clinics and primary care providers

  • Transportation barriers to large hospitals like VCU Medical Center

implicit bias

attitude or stereotypes that affect our understanding, actions, and decisions in an unconscious manner

What is the relationship between older adults and adverse drug events (ADEs)?

Older adults often encounter ADEs, leading to higher hospitalization rates

What condition is a leading cause of ADE-related hospitalizations in older adults?

hypoglycemia

What best practices for interpreting?

• Document patient’s preferred language in electronic health record (EHR)

• Cultural mediator (complete pre- and post-session meetings between clinician and interpreter)

• Seat interpreter ideally slightly behind the patient

• Talk directly to the patient (so first and second person, never third person)

• Use short sentences or phrases

• Transparency (speak exactly what was spoken)

• Avoid jargon, difficult medical terminology, or idioms

• Avoid summarizing the discussion or treatment recommendation

What is the difference between a translator and an interpreter?

What are the types of interpreting methods?

• Translators: work with written text (e.g., write a patient consent form in another language for the patient)

• Interpreters: provide direct oral communication during vists (face-to-face or virtual)

  • Consecutive: Prescriber → Interpreter → Patient (can be slower but more clarifying)

  • Simultaneous: As the prescriber is talking, the interpreter translates it at the same time to the patient (can be faster but more confusing/distracting)

What rights are patients entitled to regarding access to interpreting services?

• Title VI of Civil Rights Act of 1964: prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal assistance

  • Mandates interpreter services (albeit unfunded) for patients with limited English proficiency, with the exception of Medicare Part B

• Executive Order 13,1666 of 2000: required institutions to evaluate systems they have for patients with limited English proficiency

  • Revoked in 2025

• Section 504 of the Rehabilitation Act: forbids organizations and employers from denying individuals with disabilities an equal opportunity to receive program benefits and services

• Title III of the Americans with Disabilities Act: prevents discrimination of people with disability in places of public accommodation, including doctor’s offices

• House Bill 2147: ordered a work group to be convened to study the provision of translated directions for the use on prescription labels

• Virginia House Bill 516: determines a pharmacy must notify a person who is disabled has options to be able to access their prescription label at no extra cost

benefits of trained interpreters

• Shorter hospital stays

• Fewer readmissions

• Patient satisfaction

• Cultural liaison

• Meets legal requirements

importance of language services

• Medication errors (commonly caused by communication issues, particularly with patients that have limited English proficiency, or LEP)

• Safety events

• Liability

What are the guidelines established by the Virginia Board of Pharmacy for the visually impaired?

Pharmacists must notify visually impared patients of the following accommodations (free of cost):

• Audible

• Braille

• Large print

What are the issues with using ad hoc nonprofessional medical interpreters?

• Not trained

• Risk of breaching confidentiality

• Conversational versus medical fluency of language

• Minors should never be used to interpret except in emergencies

barriers to interpreting access

• Time

• Cost

• Availability

• Clinician knowledge

What is the process of how insulin is produced and works in the body of someone who does not have diabetes?

1. Eat food

2. Carbohydrate-containing foods are broken down by digestive system into glucose, an important source of fuel for many organs

3. Blood glucose levels rise

4. Glucose can only be used if it enters cells, so the pancreas produces a chemical messenger called insulin, releasing it into the bloodstream for that job

5. Blood glucose levels decrease

How many people in the U.S. have diabetes?

How many people in the U.S. have prediabetes?

Why is knowing these numbers important for a participant to know?

38.4 million Americans have diabetes

96 million Americans have prediabetes

Importance: Demonstrates the widespread public health burden of these conditions and highlights that prediabetes is a serious, widespread precursor to type 2 diabetes that can be prevented or delayed through lifestyle changes, the very goal of the DPP program

• As many as 1 in 3 American adults could have diabetes by 2050

• Without intervention, 15-30% of individuals with prediabetes will go on to develop diabetes at a rate of 15-30% each year within five years

• Must identify and treat early

What is the most common cause of death for people with diabetes?

Also, list other health complications.

Most common cause of death: heart disease

Other health complications:

• Kidney disease

• Nerve and blood vessel damage

• Vision problems

What is the primary risk factor for developing type 2 diabetes?

Also, list other risk factors.

Primary risk factor: Being overweight or obese (accounts for 80-90% of people with type 2 diabetes)

Others:

• Age (> 45)

• Race and ethnic origin

• Family history

• Certain medications

• Sedentary lifestyle and lack of exercise

• Gestational diabetes and large babies

• Low HDL (< 35 mg/dL)

• High triglycerides (> 250 mg/dL)

• High blood pressure (> 140/90 mmHg) or undergoing treatment for high blood pressure

What are common symptoms of diabetes?

• Polydipsia

• Polyuria

• Weakness

• Drowsiness

• Blurred vision

• Increased hunger

• Slow wound healing

prediabetes

Definition: condition in which person’s blood glucose (sugar) levels are higher than normal but not high enough for a diagnosis of type 2 diabetes

• Can lead to heart disease, stroke, and type 2 diabetes

• Can oftentimes be reversed

type 1 diabetes

• Develops when body’s immune system destroys its beta cells of the pancreas, thus not being able to produce insulin

• Patients must administer insulin through daily injections or insulin pump

• Accounts for 5-10% of diagnosed cases of diabetes

• Develops primarily in children and young adults

type 2 diabetes

• Body does not use insulin properly

• Most common form (90-95% of all diagnosed cases)

• Can develop at any age

• Highly associated with obesity

• Can be prevented or delayed at in-risk populations through lifestyle modifications, like weight loss and regular physical activity

• Preventing this type is the focus of the National Diabetes Prevention Program (DPP)

gestational diabetes

high blood sugar that develops during pregnancy and usually disappears after birth, though it increases the risk of developing type 2 diabetes later in life

How did the DPP trial (1996-2001) work?

• 3,234 participants who all had prediabetes and were overweight

• Split into three groups:

  • Metformin

  • Lifestyle intervention

  • Placebo

• Followed participants for three years

Which intervention of the DPP trial (1996-2001) proved to be the most effective?

Lifestyle intervention

What is the relative impact of the DPP intervention in the 1996-2001 trial on subgroups (i.e., age, race, gender)?

Age:

• Lifestyle intervention was found to be more effective in older participants (> 60)

• Metformin intervention was found to be more effective in younger participants

Race:

• Both interventions were effective across all racial and ethnic groups studied

• Possible disparities in reach

Gender:

• Both interventions were effective for men and women

• Metformin proved most effective in women with gestational diabetes

How is the DPP structured?

Two phases over the course of one year: 

• Phase 1 (Months 1-6):

  • 16 required group sessions to be delivered over 26 weeks in a strict chronological order with the same group, location, and time

  • Meet weekly for group cohesion and support

  • Develop lifelong skills for healthy living through step-by-step changes, for controlling the external environment, and for managing psychological and emotional factors

• Phase 2 (Months 7-12)

  • Minimum of 6 sessions must be offered (flexibility in the order)

  • Meet monthly or bimonthly

  • Provide additional support and learning opportunities to help transition them from having frequent support from a lifestyle coach and group to maintaining their lifestyle changes independently

Why does the DPP last for a year?

• Proven effective through research

• Long-term success

• Peer support

Who is eligible for the DPP?

• All participants must be:

  • At least 18 years old

  • Have a BMI > 25 (> 23 if Asian American)

  • Be AT RISK for type 2 diabetes

    • A minimum of 35% of participants must have prediabetes diagnosed through a blood test within 1 year of enrollment OR a history of gestational diabetes

    • Other 65% is eligible if they screen positive for prediabetes based on the National DPP Risk Test

By the end of the first 6 months of the DPP, participants should achieve one of the following goals:

• Lose at least 5% of their starting weight

• Lose at least 4% of their starting weight and log an average of 150 minutes of activity each week

• Lower HbA1C by 0.2%

By the end of the second 6 months, participants should achieve at least one of the following goals:

• Keep off the weight they lost

• Keep working toward their weight or HbA1C goals, if they haven’t reached them

• Lose more weight if they want, but no more than 1-2 pounds a week

• Keep getting at least 150 minutes of activity each week

What are the 8 Diabetes Training and Technical Assistance Center (DTTAC) guiding principles?

1. Goals are clearly defined and realistic

• 4-7% weight loss

• 150 minutes of moderate physical activity per week

• Weekly habit formation action plans

2. Program is not restrictive or prescriptive

3. Lifestyle coach is supportive, accepting, and empathetic

4. Lifestyle coach serves as a group facilitator rather than expert teacher

5. Group members offer each other ideas, support, and problem solving

6. Participants’ realities and needs are taken into account

7. Lifestyle coach adheres to National DPP curriculum

8. Lifestyle coach supports participants in behavior change

What are the unofficial participant goals of the DPP?

• Small steps/actions that participants may pursue to improve their health and contribute to weight loss and physical activity progress

• Weekly action plans to work on new routines that can become habits over time

• Discussing, problem solving, and supporting and celebrating their progress

talk test

Definition: gauges the intensity of your exercise by using your ability to speak

Levels:

• Low intensity: You can easily talk and sing without feeling out of breath

• Moderate intensity: You can talk comfortably in full sentences, but you cannot sing. You will likely be breathing harder, and your heart rate will be elevated, but you should not be completely out of breath

• Vigorous intensity: You are unable to say more than a few words without pausing for a breath. This indicates a higher, more strenuous level of exercise

MyPlate

Definition: visual guide developed by the USDA that helps individuals build a healthy meal, using a 9-inch plate as a reference for portion sizes

Consists of:

• ½ of the plate with non-starchy vegetables

• ¼ of the plate of protein foods

• ¼ of the plate with carbohydrate foods

• Glass of water or another zero-calorie drink

Note: Using your hand is a practical way to estimate portions. For example, a 3-ounce portion of lean meat is about the size of your palm.

Why is food and activity tracking important?

• #1 predictor of success in the program

• One of the important ways the program and lifestyle coaches support participants in their self-monitoring ability and behavior changes

• Increases awareness, promotes accountability, identifies patterns, refines portion control, and monitors physical activity

What characteristics of food are best for someone trying to lose weight?

• Increased nutrient density, including fiber, vitamins, and minerals

• Be mindful and notice the content of processed food (sugar, fat, salt)

What are ten group facilitation techniques we learned?

1. Ping pong

2. Popcorn

3. Cross questioning

4. Carousel

5. Think-pair-share or subgroups

6. Brainstorming

7. Summarizing

8. Silence

9. Reflective listening

10. Open-ended questions

What are the three Rs of group facilitation?

• Resist the fix

• Resist the temptation to answer all of the questions

• Rely on the wisdom of the group

health literacy and how it is different from literacy

the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others

Difference: Strong literacy skills can still face health literacy challenges

• Not familar with medical terms or how body works

• Interpret numbers or risks to make a health care decision

• Diagnosed with serious illness and scared/confused

• Complex conditions that require complicated self-care

What requires health literacy?

• Pill bottles

• Informed consent

• Appointment slips

• Health education materials

• Insurance applications

• Discharge instructions

People with low health literacy are LESS likely to…

• Understand written and oral information given by health care professionals and insurers

• Act upon the necessary procedures and directions such as medication and appointment schedules (e.g., Pap smear, blood pressure check)

• Be able to navigate the health system and obtain needed services

People with low health literacy are MORE likely to…

• Receive health care services through publicly financed programs

• Incur higher health care costs

• Tend to smoke and drink more

• Get hurt on the job more

• Tend to make less-informed decisions regarding treatment options

What is the impact of low health literacy?

• Lack skills needed to successfully negotiate health care system

• Make more medication and treatment errors

• Less able to comply with treatments

• Higher risk for hospitalization

What are the health-related consequences of inadequate health literacy?

• Poorer health outcomes

  • Increased chronic disease

  • Higher mortality

• Increased healthcare utilization and costs

  • More hospitalizations

  • Greater emergency care use

• Medication and treatment errors

• Impact on decision-making and behavior

  • Poor knowledge of chronic illness management

  • Reduced patient participation

  • Increased health anxiety and depression

• Exacerbated health disparities

characteristics of people at higher risk of low health literacy

• Elderly

• Female gender

• Lower socioeconomic status (*affects people of all social classes though)

• Limited education (not completed high school, *but affects people of all education levels)

• Minority ethnic groups (Hispanic, African American)

• Immigrants

• Homeless

• Incarcerated

• Chronic disease

What strategies are there for people with low health literacy to overcome barriers?

• Sit rather than stand

• Introduce yourself and call your patients by name

• Use orienting statements to demonstrate purpose (e.g., “First, I will ask you some questions. Then I will take your blood pressure”)

• Listen and smile rather than speak

• Use verbal and behavioral cues to identify people at risk for low health literacy (and improve it)

• Be aware and assertive

• Create a shame-free environment and express empathy

• Use simple and clear language

• Focus on what the patient truly needs to know

• Personalize the message

• Ask open-ended questions

• Invite questions using body language

• Teach-back method

• Give health education materials for how patients should administer their medication, monitor, and act upon certain situations

• On prescriptions…

  • Use specific times

  • Use numbers instead of words whenever possible

  • Include indication whenever possible