Moving forward with Community Pharmacies and Additional Community Settings Jan D. Hirsch, BSPharm, PhD, FNAP Chair Clinical Pharmacy UC San Diego School of Pharmacy

Can barbers cut BP too? Ron Victor, M.D. Burns & Allen Chair in Cardiology Research Professor of Medicine, UCLA Director, Hypertension Center Associate Director, Cedars-Sinai Heart Institute It’s a real honor to join team Cedars and I want to thank everyone for making me feel so welcome. I’m going to tell you about the barbershop HTN study I started in Dallas and, with your help, will re-invent in LA. But first some back ground about HTN in AA.

Background: Non-Hispanic Black Men Highest HTN-death rate in the U.S. Less physician interaction and lower HTN treatment & control rates than black women Are barbershops the right place to improve HTN control? It’s a real honor to join team Cedars and I want to thank everyone for making me feel so welcome. I’m going to tell you about the barbershop HTN study I started in Dallas and, with your help, will re-invent in LA. But first some back ground about HTN in AA.

N Engl J Med 2018; 378:1291-1301

Enhanced Intervention 40 Barbershops randomized (500 patrons) Baseline 20 barbershops 15 patrons/shop Enhanced Intervention Barber-pharmacist BP mgt. Active Comparator Barber health educator 6 Month Follow up Extension Study 12 Month Follow up Male BARBER-1 was a cluster randomized trial conducted on 1300 HTV male patrons of 17 AA-owned barbers in Dallas county Texas

Role Model Poster Characterization: 45 year old man recently diagnosed hypertension, diabetes and high cholesterol Membership: recent hypertension Risk Behavior: no regular doctor Goal: get a regular doctor Influencing factor: social support Barrier to change: too busy working and taking care of children to take care of himself Positive Outcome: be there for his children Stage of Change: Contemplation to Action

Enhanced Intervention Barber‘s Blood Pressure Work Station Wireless transmission Also Both groups will get results of their BP readings by independent survey staff at baseline and at 6- and 12- month follow-up. Cohort member card with barcode Pharmacist visits

Pharmacists Role in Barbershop HTN Program At least monthly appointments in barbershops Check BP Modify drug therapy under full scope collaborative practice agreement Monitor electrolytes –iStat device Send progress notes to PCP South Central LA pharmacy delivered medications to barbershops It’s a real honor to join team Cedars and I want to thank everyone for making me feel so welcome. I’m going to tell you about the barbershop HTN study I started in Dallas and, with your help, will re-invent in LA. But first some back ground about HTN in AA.

Intervention Group HTN Medication Management Approach Step 1: CCB + ARB or ACEi amlodipine + telmisartan Step 2: + thiazide-type diuretic indapamide Step 3: + aldosterone antagonist eplerenone It’s a real honor to join team Cedars and I want to thank everyone for making me feel so welcome. I’m going to tell you about the barbershop HTN study I started in Dallas and, with your help, will re-invent in LA. But first some back ground about HTN in AA.

Baseline Characteristics Intervention Group (N=132) (95% cohort retention) Male Characteristics Intervention Group (N=132) Control Group (N=171) # of Barbershops 28 24 Years in Business 17.3 +/- 14.2 18.1 +/- 8.3 # of Participants 132 171 Age- yrs 54.4 +/- 1-.2 54.6 +/- 9.5 Married 47% 50% Household income < $25,000 41% 30% Any health insurance 85% 88% Regular medical provider 77% 79% Barbershop Patronage Duration- yrs Frequency of visits (every # of weeks) 10.2 +/- 9.6 2.0 +/- 0.9 11.5 +/- 9.0 2.1 +/- 1.1

Barbershop Project: Results Intervention Group (N=132) Outcome Intervention Group (N=132) Control Group (N=171) Systolic Blood Pressure- mmHg Baseline 6 months 152.8 +/- 10.3 125.8 +/- 11.0 154.6 +/- 12.0 145.4 +/- 15.2 Hypertension Control at 6 mos.- no. (%) BP < 140/90 mmHg BP < 135/85 mmHg BP < 130/80 mmHg 118 (89.4) 109 (82.6) 84 (63.6) 55 (32.2) 32 (18.7) 20 (11.7) Mean no. of blood pressure medications per participant 2.6 +/- 0.9 1.4 +/- 1.4 Drug Class- no. (%) ACEi or ARB Calcium channel blocker Diuretic Aldosterone antagonist Beta-blocker 130 (98.5) 125 (94.7) 61 (46.2) 14 (10.6) 71 (41.5) 56 (32.7) 49 (28.7) 2 (1.2) 33 (19.3)

What Made Intervention Work: Multifaceted Pharmacists: PharmD with training by MD specialists Convenient Access More intensive medication therapy than PCPs 2 more medications per patron More potent choices in each drug class (e.g., telmisartan, indapamide) Lower BP target (<130/80 mmHg vs. 140/90) Consistent patronage Endorsement by barbers It’s a real honor to join team Cedars and I want to thank everyone for making me feel so welcome. I’m going to tell you about the barbershop HTN study I started in Dallas and, with your help, will re-invent in LA. But first some back ground about HTN in AA.

Next Steps: Sustainment and Spread Collaboration with LAC DPH, Cedars-Sinai, USC School of Pharmacy on CDC grant SB 1264: Medi-Cal payment for hypertension medication management provided by qualified pharmacists Expand availability of Comprehensive Medication Management, including hypertension, in community pharmacies through the California Right Meds Collaborative Educate all stakeholders about the value of pharmacists providing CMM

Moving forward with Community Pharmacies

Moving forward with Community Pharmacy Collaborative practice protocol between primary care physicians (PCPs) and community pharmacies Literature reveals? Experience and Challenges Key elements for an implementation plan to improve hypertension management

Collaborative Practice Protocol with Community Pharmacies: Literature Limited number of studies Limited description of implementation Key elements Patient population Scope of agreement/protocol Pharmacist credentials Integration between organizations IT Processes Communication

Collaborative Practice Protocol between separate entities: Experience Scope of Agreement Hypertension meds only? Multiple physicians? Sites? Which patients? How identify? Pharmacist credentials Access Electronic Medical Record Credentialing and Privileging Pharmacists and Staff Remote Access Documentation & Communication Templates Communication Pharmacist, Physician, Staff, Patient Organizations

Hypertension Collaborative Practice Protocol What do you think? Best models for Collaborative Practice Protocols Key players, components & processes Barriers to Creating Implementing Assessing Outcomes Facilitators Hypertension Collaborative Practice Protocol Community PCPs and Community Pharmacists

Next Steps for Implementation in Your Community?