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Hello. Thank you for joining me today as we talk about coordinating multidisciplinary care and adherence and secondary stroke prevention, key roles for pharmacists. My name is Doctor Craig Beavers. I'm a cardiovascular clinical pharmacist at Baptist Health Paducah and a vice president of operations in the cardiovascular service line lead for Baptist Health System. And I'm also an adjunct associate professor for the University of Kentucky College of Pharmacy in Lexington, Kentucky. Today's learning objective is how do you coordinate multidisciplinary pharmacist inclusive care strategies that reduce the risk of recurrent non-cardiiombolic ischemic stroke without compromising safety, ensuring timely initiation, monitoring, and adherence to antithrombotic therapy. So we'll start with a case that we'll kind of walk through and then by the end, you'll kind of be aware of what the best solution would possibly be. So we have a 66-year-old male present who presented 3 days ago with stroke symptoms, which is later confirmed to be a subacute subcuar infarct measuring less than 1. 5 centimeters in diameter. No signs of atrial fibrillation. All other diagnostic tests were negative or within normal limits. Past medical history includes hypertension, hyperlipidemia, non-obstructive coronary artery disease, type 2 diabetes, and a history of smoking, which he quit 5 years ago. He is going to be discharged in high-intensity statin therapy, metformin, aspirin, and a new prescription for clopidogrel. The patient lives with spouse. He is on Medicare insurance in the United States and lives on a fixed income. Which of the following could the pharmacist assist to assure adherence with this patient? A or 1, coordination of transport. B, patient education and follow-up check-in. 3, obtain manufacturer assistance via the copay card. 4, remove aspirin to reduce polypharmacy. So as we transition in, and as I said, you'll be aware of what potentially the correct answer would be as we talk about those conversations. Pharmacists are key players for optimizing the patients with both cardio and or cerebrovascular diseases. Pharmacists possess unique knowledge and skill sets that provide a diverse array of services that can be patient-specific, which include the things you think about traditionally like education, drug interaction screening, drug therapy monitoring, working with pharmacogenetics, drug information, and of course, pharmacodynamic and pharmacokinetic dosing. They can provide facility-specific services where they help develop the protocol, guidelines and policy development and review any other formulary or change requests related to these processes. Research. Key players in quality improvement initiatives that impact patient outcomes and lives, formulary management and financial stewardship, and of course, medication safety. And then globally, pharmacists can play a role with government and societal committees on societal guideline and policy development, legal consultation, and public health initiatives. I think it's important to remember for any healthcare clinician or patient that medications are complex and to not take that complexity for granted. The patient has their own factors that contribute to the response and effort with the, the therapy, including weight and body, renal function, genetics, cost adherence factors, their own, uh, mental feelings and emotions around medications and treatment. Drugs themselves have different inhibition and bioavailability, therapeutic window aspects, metabolism, and clarity and clearance. And then, of course, there's system and provider aspects, who selects the agents, what's gonna be monitored, what other drug interactions could be at play, Are they gonna have procedures, what other complications may occur, and all these things play in a cycle and make this process that could be complex. But pharmacists are key players that can help navigate and bring success for patients with complex comorbid diseases. And pharmacists are across the care continuum in comprehensive medication management and transitions of care. Pharmacists exist in clinics, in the pharmacy, in the hospital, and in home health or skilled nursing facilities at discharge, and all play a key role in providing that handoff and success during transition to make sure the patient is able to navigate their regimen and are key players in ensuring that Everything is optimal and optimized, and we'll see examples of this, specifically the stroke population, as we go through the, the conversation. What are the factors that impede transitions of care or predictors of readmission? There's medication management issues where there's poor reconciliation upon admission or discharge, unclear instructions. The patient can have transportation issues. There's poor communication or poor handoff, insufficient patient education. The follow-up appointment is not in a timely standpoint and also transportation issues or patient awareness about follow-up and signs and symptoms of other management issues like medication and dietary non-nadherence, or even the patients having the ability to recognize signs and symptoms of their disease state or, uh, side effects related to medications. The medication history and reconciliation reconciliation process is super critical on the transitions of care both in and out of the facility, and it should occur at each process at the entry and entry point, whether you're in an inpatient or in a clinic or other setting. And why is this incredible critical? Cause numerous amounts of evidence have shown that this process reduces adverse stroke events, reduces readmissions, improves inpatient mortality, and also decreases medication costs by reducing overprescribing and avoidance and, and changing of, of, and, uh missing of changing of therapies. The other thing that needs to be happening during the process of transition and into the phase when a patient comes into the clinic is addressing any risk of non adherence. That can be done by screening patients for, uh, interactions or other non-adherence aspects such as using a scoring tool like the medication, uh, Marinsky medication adherence questionnaire. They have a heart failure compliance questionnaire. It's modified. However, you can modify those questions to be any disease state and are very successful, or just simply asking leading questions like how often do you mention medications or not follow your diet or how do you obtain your medications? And you really have to look at the motivations of non-adherence, whether it be communication-related barriers, the patient's own immun motivation, or the socioeconomic, and those factors can overlay on top of each other. In terms of socioeconomic, it's understanding their healthcare coverage. Do they need to work with a social worker to provide access, or how are they going to get or receive their therapy and get to the pharmacy? Uh, do you need to explore drug discount programs in, in states and countries that require or have those, has the ability to help with the cost of therapy? Do they need to be using generic therapies or if they work in an area that has mail-order pharmacies to help with there are transportation issues and providing or access to discount drug programs. And then complexity, trying to change it to one polypill or once a day dosing that decreases the number of pills and the overall cost of therapy. The other thing is working through communication barriers. So if they're a non-English speaker or a non-native language speaker using an interpreter or incorporating healthcare professionals of a similar race structure or culture. If they have depression or psychiatric psychological illness, working with motivational strategies, and even if they don't have those illness, motivational interviewing is a key way to understand and engage the patient in their therapeutic journey and also providing shared decision making, looking for social support and healthcare from provider of friends, and then pillbox or memory aids, and if they have low functional literacy, visual aids that are, make the process accessible and providing teachback. The core components that need to exist in stroke education need to talk about overall medication therapy management, modifiable risk factors, cardiovascular risk factors to be able to modify for primary secondary prevention, stroke education as a whole, medication adherence and the importance of adherence, patient engagement and how to self-manage self-care, uh, all the factors that are tied with stroke management or secondary risk factors, and overall improvement of quality of life. Effective education and discharge counseling for patients of stroke includes addressing barriers, performing medication reviews, engaging caregs and other team members, optimize written materials, employing the teach back method where the patient repeats back the education you provided them, identify and follow up on drug-related problems while you're doing the education or if you've identified thoughts and things as you do the process, really emphasizing self-care, access or assessing the patient resources, using various different teaching methods, visual aids. Reading material, videos, using inpatient and outpatient settings. So not just doing it while they're in the hospital in that teachable moment, of course, when they make that transition to an outpatient setting, and ensuring the plan is communicated to all providers. And that's not just the providers that are the physicians who may be caring for the patients, but the nursing team or the pharmacy team that will be getting that handoff. And then, of course, it's important to understand the motivation. Understanding and educate in layman's terms the disease and risk and translating that to the patient. What is their perceived need, including the patients and, uh, and decisions, including shared decision-making processes and help them reinforce the why. And then not necessarily giving into fear. You don't want to minimize the risk, but help them understand the risk-benefit of treatment or not treatment, and educate about the signs and symptoms of management. So do pharmacists engage in these activities or these types of activities work in secondary stroke management? So this is one study, and there's several different examples, but I've highlighted a few versions that pharmacists educate in stroke interventions amongst patients with stroke. And the design was an open label prospective interventional trial between two university hospitals for 3 months where a clinical pharmacist-led education occurred versus control. And during the process, they determined the effect of the clinical pharmacist intervention on the treatment with adherence and quality of life. And so the pharmacist provided this medication therapy management process. They did medication reconciliation, they did education, and they did some degree of follow-up at 1 month, discharge 1 month and 3 months. And what they looked at is treatment adherence and quality of life, and they use the Marinsky adherence scale and the stroke specific specific quality of life.