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Feb 20, 2024

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1 Individual Care Plans and Resources Windy L. Tanner South University NSG 4055 Illness and Disease Management Across Lifespan CP02 Professor Kara Bral MSN, RN April 18, 2022

2 Individual Care Plans and Resources Coronary artery disease (CAD) affects many Americans of various age groups. Preventive screenings and awareness campaigns are ways to identify people at risk for heart disease or early in the disease process. Hypertension, diabetes, hypercholesteremia, obesity, and a sedentary lifestyle increase the chances of developing heart disease. In many instances, the disease is advanced before a diagnosis, leaving the individual with a chronic illness that lifestyle modifications must be made to manage the medical condition appropriately. Education concerning resources is part of the healthcare providers' duties. The proper identification of means needed, such as medications, education, nutrition, and medical care, is necessary for care management (January et al., 2019). Cardiac rehabilitation, smoking cessation programs, and adherence to medicines can help participant J. L. on her journey to managing heart disease. Addressing the needs of the individual by developing a patient-centered plan of care is vital in improving the quality of life for people with chronic conditions. Cardiac Rehabilitation Cardiac Rehabilitation (C. R.) is a way to improve an individual's overall health with heart disease. In the rural community I live in, we have a hospital-based C. R. center that can enroll patients diagnosed with heart disease. Participants are included in group exercise and individual fitness, with education on behavior modification education concerning diet, smoking, healthy choices, training, and medication adherence. The goal is to improve overall cardiac function and the quality of life for the individual. To qualify for the program, an individual needs an order by a medical provider and a diagnosis of heart disease. Qualifying medical indications approved by Medicare are coronary artery bypass grafting, myocardial infarction, percutaneous coronary angioplasty, chronic stable angina, heart valve repair or replacement, heart failure,

3 peripheral artery disease, and heart or lung transplant (Simon et al., 2018). Treatment of intermittent claudication with supervised exercise therapy increases walking distance by 180% and is a class 1 recommendation by the AHA and the ACC (Simon et al., 2018). Various insurance providers, including Medicare, Medicaid, and private carriers, cover the program's cost with a small copay of around $20.00 to $40.00 per session. The American Heart Association (AHA) and the American College of Cardiology (ACC) recommend 36 sessions of the C. R. program. Some facilities offer grants and scholarship programs for participants to help offset the cost and encourage attendance when the cost is a factor (Rubin, 2019). Applications are income- based and can be obtained through the hospital foundation program. It includes questions concerning the income and expenses incurred by the household, people in the home, and insurance. The scholarship committee processes the application and is mainly driven by the ability to afford the copay. If the individual has a high risk for worsening health, specific provisions can be made for a special waiver granted by the facility. Medicaid and Medicare provide transportation for individuals who already qualify for these benefits. It must be arranged in advance through an 800 number. Enrolling and participating in a cardiac center-based or home-based rehab program reduces mortality and increases cardiovascular and health quality outcomes. Smoking Cessation Program In atherosclerotic cardiovascular disease (ASCVD), mortality is significantly higher than other medical conditions. Exposure to secondhand smoke and active smoking accounts for 30% of coronary heart disease mortality. Females have a 25% higher risk of developing CAD than males with the same exposure. Smoking also directly affects serum lipids, decreasing the high- density lipoprotein (HDL). Reducing the amount of tobacco or stopping altogether improves

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4 overall health by lowering your risk for hypertension, stroke, cancer, and diabetes (Gallucci et al., 2020). Quitting smoking is one of the best things you can do for your health. Many resources are available to help support the journey to stop smoking. The website Smokefree.gov is a free service that assists individuals in planning to become smoke-free. It is a self-help program that allows individualized planning and has a variety of smoke-free texting programs. It provides nicotine replacement therapy (NRT). The program has a guide for tips and inspiration with apps to download to help you become smoke-free. Smokefree.gov offers education, NRT, self-help tools and information, advice, weight management strategies, and healthy alternatives to managing stress (US Department of Health and Human Services, National Institutes of Health, n.d.). The smoking cessation program is a public service that is free to all consumers that can be utilized by anyone with a computer, smartphone, or tablet (Khanijahani, 2020). Improving cardiovascular health is possible by implementing a stop smoking plan, as suggested by the smoke-free website. Medication Adherence The cost of medications is a significant burden on individuals, especially CAD patients. Pharmacy-based medication adherence interventional programs aim to increase the percentage of individuals at risk for heart disease who take their medications as prescribed. Blood pressure medication noncompliance increases an individual's chance of death from 50% to 80% in cardiovascular disease. Cardiovascular-related hospitalization rates increase by 26% for people with hypercholesteremia who do not adhere to the prescribed lipid-lowering medication therapy (Jacob et al., 2022). Tailored pharmacy-based adherence interventional resource is a recommendation by the Community Preventive Service Task Force (CPSTF) to improve medication adherence by interviewing the patient, implementing health strategies for medication

5 adherence, and providing alternatives to high-cost medications. This provides a team-based approach to support adherence programs. Individually tailored programs can dispense a 90-day supply, generic, and fixed-dosed combination to help reduce the medication costs and copays. E- prescribing for medications and bi-directional communication between the medical provider and pharmacists improve medication adherence rates. The medical provider can identify when health visits are scheduled and the prescription drug fill rate and explore the options if nonadherence is observed (Center for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention, Million Hearts [CDC], 2020). Atrial fibrillation (AF) and CAD places the patient at higher risk for mortality and morbidity; therefore, medication adherence is vital. The team approach between healthcare prescriber and pharmacist plays a critical role in monitoring, educating, and implementing strategies to improve patients' rate of taking these medications as prescribed (Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention, Million Hearts [CDC], 2022). Several local pharmacies and most pharmacy chains in our area offer individual tailored adherence tools to assist patients in medication adherence. The requirement is for the patient or the health care provider to request a consultation with the pharmacist. There is no application process for the program. Insurance coverage varies for this service and the pharmacy's ability to provide daily assistance, depending on staffing and workload. The casual relationship between the pharmacist and patient has a massive impact on patient knowledge, health behaviors, and disease management (Mc Namara et al., 2019). Plan of Care The care plan consists of an individualized, patient-centered approach to meeting goals set by the patient and caregiver. Objectives must be realistic, with timelines set to accomplish the task. The patient drives the entire plan, and the quality of life desired by the patient is the focus

6 of any well-devised holistic care plan. The participant identified that she doesn't always comply with her prescription medications due to finances. She also stressed the importance of being able to perform daily tasks and continue being as productive as possible. She discussed how her ability to walk long distances had been affected by CAD and PAD. She is a smoker and has no desire to quit at this time. After analyzing this information and involvement with the patient and caregiver, constructing a care plan will be the best option for developing and implementing patient-centered goals. Center-based C. R. offers the best solution for improving her activity level. Education on the program is essential to include the benefits of participating, the length of the program, and costs. A review of copays and transportation concerns is beneficial in the development phase to identify any barriers to meeting the objective. Home C. R. may need to be the option if these significant barriers cannot be overcome. Having the center-based C. R. meet with the participant during the planning phase to answer any questions and discuss fees and other options is another way to implement an exercise program into the care successfully. The participant expresses a need to understand medications and has limited resources to afford medications. A pharmacy consult will be conducted early to discuss her medication list, costs, and ways to obtain samples when funds are limited. Her primary pharmacy will be contacted to see if they offer an individualized, tailored adherence program or discounts with 90-day prescriptions. A referral for the adherence program will be made to her pharmacy if it is provided. If not, pharmacies that offer this service will be provided to the patient. Education on reasons to participate will be included in the discussion of medication adherence to incorporate the benefits of this resource (Mc Namara et al., 2019). J. L. does not desire to stop smoking. The website Smokefree.Gov will be included in her education to explore and discuss with her family and healthcare provider. The

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7 increased risk of stroke associated with smoking must be addressed to provide all the facts related to her chronic medical condition (Kazemzadeh et al., 2016). Behavior modification strategies start with establishing links between behaviors and CAD, developing plans to lower the risk of disease advancement. Participation in C. R. or exercise programs, medication adherence, and smoking cessation are behavior modifications to include in the patient-centered care plan. Vulnerable Populations Health equity is defined as the attainment of the highest level of health for all people by Healthy People 2030. A health disparity is a particular type of health difference closely linked with social, economic, or environmental disadvantage. Understanding the concepts assists individuals, healthcare providers, and communities align their resources and efforts to collaborate on change to benefit the majority (Healthy People 2030, n.d.). Disadvantages in rural areas to participating in center-based C. R. are travel distance to the center, flexibility of C. R. hours, cost, and patient options for participation. Limited resources decrease the options vulnerable populations have by being able to choose different C. R. providers. Having only one provider also limits available space for new enrollments, and scheduling conflicts are more likely to occur due to the limited space and coordination with other personal responsibilities. Disadvantages to C. R. participation include gender and racial bias, and socioeconomic or psychological factors. Advanced age and the physical health of an individual can also be a disadvantage to participating in cardiac rehabilitation. The physical condition plays a significant role in being able to attend C.R. due to fatigue and difficulty in traveling to C. R. (Chindhy et al., 2020).

8 Advantages for the aging population concerning C. R. is that the arrangement of transportation through Medicare and Medicaid services is available to offset the burden related to transportation issues. Medication adherence programs with pharmacists are covered under most Medicare and Medicaid plans for the population with this type of insurance coverage. People with chronic medical conditions already have an established relationship with a pharmacist. The established relationship would decrease the burden of participating in medication adherence interviews with the pharmacist and has a vast advantage in discovering why patients do not take medications as prescribed (Fanaroff et al., 2020). Vulnerable populations require special attention to identify and decrease barriers to meeting objectives and goals. Conclusion Chronic illness pose may pose threats to managing healthcare objectives and goals. Identifying resources in the community with education on benefits, costs, eligibility criteria, specific services offered, and how to apply for programs is part of providing patients with healthy options to improve health outcomes. The advantages and disadvantages of participating in available resources must be evaluated and addressed before implementing the care plan. Everyone has unique needs and desires for quality health outcomes. Patient-centered objectives and goals can be managed with a holistic approach, and involvement must include the patient and caregiver.

9 References Center for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention, Million Hearts. (2020). Medication adherence (May 8, 2020). https://doi.org/https://millionhearts.hhs.gov/tools-protocols/tools/medication- adherence.html Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention, Million Hearts. (2022). Appropriate aspirin or anticoagulant use (January 27, 2022). https://millionhearts.hhs.gov/about-million-hearts/optimizing-care/aspirin-anticoagulant- use.html Chindhy, S., Taub, P. R., Lavie, C. J., & Shen, J. (2020). Current challenges in cardiac rehabilitation: Strategies to overcome social factors and attendance barriers. Expert Review of Cardiovascular Therapy , 18 (11), 777–789. https://doi.org/10.1080/14779072.2020.1816464 Fanaroff, A. C., Peterson, E. D., Kaltenbach, L. A., Anstrom, K. J., Fonarow, G. C., Henry, T. D., Cannon, C. P., Choudhry, N. K., Cohen, D. J., Atreja, N., Bhalla, N., Eudicone, J. M., & Wang, T. Y. (2020). Copayment reduction voucher utilization and associations with medication persistence and clinical outcomes. Circulation: Cardiovascular Quality and Outcomes , 13 (5). https://doi.org/10.1161/circoutcomes.119.006182 Gallucci, G., Tartarone, A., Lerose, R., Lalinga, A., & Capobianco, A. (2020). Cardiovascular risk of smoking and benefits of smoking cessation. Journal of Thoracic Disease , 12 (7), 3866–3876. https://doi.org/10.21037/jtd.2020.02.47 Healthy People 2030. (n.d.). Health equity in healthy people 2030 . Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the

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10 Secretary, U.S. Department of Health and Human Services. https://doi.org/https://health.gov/healthypeople/priority-areas/health-equity-healthy- people-2030 Jacob, V., Reynolds, J. A., Chattopadhyay, S. K., Hopkins, D. P., Therrien, N. L., Jones, C. D., Durthaler, J. M., Rask, K. J., Cuellar, A. E., Clymer, J. M., & Kottke, T. E. (2022). Pharmacist interventions for medication adherence: Community guide economic reviews for cardiovascular disease. American Journal of Preventive Medicine , 62 (3), e202–e222. https://doi.org/10.1016/j.amepre.2021.08.021 January, C. T., Wann, L., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., & Yancy, C. W. (2019). 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons. Circulation , 140 (2). https://doi.org/10.1161/cir.0000000000000665 Kazemzadeh, Z., Manzari, Z., & Pouresmail, Z. (2016). Nursing interventions for smoking cessation in hospitalized patients: A systematic review. International Nursing Review , 64 (2), 263–275. https://doi.org/10.1111/inr.12320 Khanijahani, A. (2020). Governance and public health: Implications for targeting smoking in the United States. International Journal of Health Governance , 25 (2), 151–159. https://doi.org/10.1108/ijhg-06-2019-0041

11 Mc Namara, K., Alzubaidi, H., & Jackson, J. (2019). Cardiovascular disease as a leading cause of death: How are pharmacists getting involved? Integrated Pharmacy Research and Practice , Volume 8 , 1–11. https://doi.org/10.2147/iprp.s133088 Rubin, R. (2019). Although cardiac rehab saves lives, few eligible patients take part. JAMA , 322 (5), 386. https://doi.org/10.1001/jama.2019.8604 Simon, M., Korn, K., Cho, L., Blackburn, G. G., & Raymond, C. (2018). Cardiac rehabilitation: A class 1 recommendation. Cleveland Clinic Journal of Medicine , 85 (7), 551–558. https://doi.org/10.3949/ccjm.85a.17037 US Department of Health and Human Services, National Institutes of Health. (n.d.). Explore the smoke free family . https://doi.org/https://smokefree.gov/tools-tips/get-extra-help

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