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

3. 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.

4. 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.

6. N Engl J Med 2018; 378:

7. 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

8. 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

9. 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

10. 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.

11. 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.

12. 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

13. Barbershop Project: Results Intervention Group (N=132)
Outcome
Intervention Group (N=132)
Control
Group (N=171)
Systolic Blood Pressure- mmHg
Baseline
6 months
/- 10.3
/- 11.0
/- 12.0
/- 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)

14. 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.

15. 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

16. Moving forward with Community Pharmacies

17. 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

18. 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

19. 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

20. 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

21. Next Steps for Implementation in Your Community?