The following is part 2 of 3 in a series of articles titled, "The Social Determinants of Heart Health" by Jason Ausili, PharmD, MSLS, Head of Pharmacy Transformation for EnlivenHealth, as well as other contributors to Ask Your Pharmacist.

The journey to a healthier heart starts at the pharmacy. Community pharmacists stand on the front lines of preventative care, acting as vital educators and allies for their patients. As the most accessible healthcare provider, who better to help Americans in the fight against the leading cause of death for over 100 years? Through their expertise in medication management, counseling techniques, and other strategies, pharmacists can significantly improve patient outcomes and build a stronger foundation for healthy hearts.

As part of its mission to optimize cardiovascular care, the website for noted national population health initiative Million Hearts® lists the following key focus areas for healthcare providers:

Improve Appropriate Aspirin or Anticoagulant Use
Improve Blood Pressure Control
Improve Cholesterol Management
Improve Smoking Cessation
Increase Use of Cardiac Rehabilitation

Let’s examine each of these areas a little more closely, focusing on how pharmacists can help.

(NOTE: Although performing medication reviews and educating patients on appropriate use is second nature to the profession, pharmacists practicing in states where scope of practice offers either direct or indirect authority (under collaborative practice) to initiate, modify, or discontinue medications can take the following suggestions to the next level. If you currently lack this authority, visit Ask Your Pharmacist’s “For Advocates” page to learn what you can do to change that.)

Focus Area #1: Anticoagulation

Many cardiovascular conditions, like heart disease and atrial fibrillation, increase the risk of blood clots forming and blocking arteries. This is where anticoagulant medications play a crucial role. These medications work by “thinning” the blood, making it less likely to clot and potentially causing a heart attack or stroke. However, anticoagulants are powerful tools that come with potential risks of bleeding if not used properly. Enter pharmacists.

To ensure anticoagulants are used safely and effectively, pharmacists can:

Review the Patient’s Medical History: To ensure anticoagulants are the right choice for their patients, the pharmacist should assess their individual risk factors and potential interactions with other medications.
Explain Proper Medication Use: Once a medication is prescribed, pharmacists can provide clear instructions on how patients should take their medication, including timing, dosage, and potential side effects.
Monitor Patient Progress: Through regular consultations, pharmacists can monitor their patients for further blood clotting irregularities and adjust their dosage as needed, answering any questions that arise during treatment.

When it comes to anticoagulants and reducing the risk of cardiovascular complications, the key to safe and effective use is collaboration between pharmacists, their patients, and the rest of the care team.

The SDOH Factor: Health literacy is a determining factor in patients with cardiovascular disease. People who understand their disease, as well as the benefits and risks of anticoagulants, experience better outcomes than those with less knowledge about their health problems. Financial expense can also be an issue; while standbys like warfarin can be found for less than $20, many other anticoagulants can cost in the thousands of dollars.

Focus Area #2: Blood Pressure Management

High blood pressure poses a significant threat to cardiovascular health. It puts undue strain on the heart and the blood vessels, silently increasing the risk of heart attack, stroke, and other complications. Fortunately, effective blood pressure management can dramatically mitigate these risks.

In the fight for healthy blood pressure, pharmacists can become their patients’ greatest allies. They can:

Review Medication Regimens: Based on individual need and medical history, a pharmacist can help patients choose the right blood pressure medication, adjust dosages when necessary, and ensure compatibility with other medications they’re taking.
Offer Lifestyle Advice: Pharmacists are a fantastic resource who can provide personalized guidance on healthy lifestyle modifications, including diet, exercise, stress management, and tobacco cessation—all of which can significantly impact blood pressure control.
Monitor for Side Effects: Pharmacists can closely monitor their patients for any potential side effects of blood pressure medications and provide solutions to manage them effectively.

By working hand-in-hand with their pharmacist, patients can effectively manage their blood pressure, reducing their risk of cardiovascular complications and living a healthier life.

The SDOH Factor: As with anticoagulants, medication cost can be a factor in managing blood pressure. While many ACE inhibitors are inexpensive, some can cost $100 or more per month. Also, food choice can play a role in high blood pressure; processed food, canned goods, and other foods with high sodium levels can cause dangerous blood pressure spikes. While food insecurity and access to healthy foods are common SDOH barriers, Healthy People 2030 adds that, “healthy dietary patterns can help lower the risk of chronic disease.”

Focus Area #3: Cholesterol Management

Cholesterol plays a vital role in the human body. However, an imbalance in different types of cholesterol can significantly impact cardiovascular health. LDL cholesterol — often referred to as “bad” cholesterol — can build up in arteries, narrowing them and increasing the risk of heart attack and stroke. Conversely, HDL cholesterol — known as “good” cholesterol — helps remove LDL cholesterol from the bloodstream. Effective cholesterol management focuses on lowering LDL and raising HDL levels.

Pharmacists can partner with their patients to manage their cholesterol levels. Here’s how:

Review Lab Results: By interpreting cholesterol test results, pharmacists can consult with their patients, explaining the different cholesterol types and their impact on the patient’s health.
Choose the Appropriate Medication: Depending on cholesterol levels and risk factors, pharmacists can recommend the most suitable medication and explain how it works to their patients, addressing questions and concerns about potential side effects.
Promote Healthy Lifestyle Changes: Pharmacists can offer personalized advice on diet, exercise, and weight management, all of which play a crucial role in lowering LDL and raising HDL cholesterol levels.

A healthy cholesterol profile can significantly reduce the risk of cardiovascular complications, and pharmacists are perfectly positioned to guide and support patients every step of the way.

The SDOH Factor: Like blood pressure medication and anticoagulants, the cost of cholesterol medication could be a barrier for some people. While generic versions range from $10-$50 per month, brand name statin prices can be as high as $500 for a month’s supply. It also goes without saying that cholesterol is affected by food choice; high-cholesterol foods like fried food, fast food, processed meats, sugary desserts, and other convenience foods have all been shown to be harmful to a person’s health. According to recent research published in the Journal of the American Heart Association, evidence supports that SDOH are linked to cardiovascular disease risk factors, including excess cholesterol.

Focus Area #4: Tobacco Cessation

Tobacco use is one of the leading preventable causes of cardiovascular disease. Smoking damages blood vessels throughout the body, including those supplying the heart and brain. This damage can lead to atherosclerosis, a condition where plaque builds up in the arteries, restricting blood flow and increasing the risk of heart attack and stroke. Quitting smoking is one of the most impactful things a person can do to improve their cardiovascular health.

Pharmacists are on the front lines of tobacco cessation efforts and can significantly support patients who want to quit. Here are 3 ways pharmacists can help:

Recommend Evidence-Based Medications: Depending on the level of dependence and other factors, pharmacists can develop a quit plan and recommend medications proven to increase quit success rates, such as nicotine replacement therapy (NRT) or prescription medications.
Provide Educational Resources: Pharmacists can offer patients educational materials and information about the benefits of quitting smoking, the different cessation methods available, and the potential challenges they might encounter. They can also connect patients with national and local smoking cessation programs, support groups, or online resources.
Offer Support and Counseling: Pharmacists can be a source of ongoing support and encouragement for patients trying to quit. They can provide regular check-ins, address concerns, and help patients navigate potential obstacles.

By offering these services, pharmacists can empower patients to quit tobacco use, significantly improve their cardiovascular health, and enjoy a longer, healthier life.

The SDOH Factor: Individuals living in poverty, facing discrimination, or living in unstable housing situations often experience higher levels of stress and anxiety, triggering tobacco use as a coping mechanism and making it difficult to quit. And while a majority of people are aware that smoking is harmful to their health, they still feel that the relief outweighs the harm. Pharmacists can play a crucial role in addressing these challenges by offering targeted support, connecting patients with resources, and promoting a holistic approach to smoking cessation that considers the social and economic factors impacting their patients' lives.

Focus Area #5: Cardiac Rehabilitation

Cardiac rehabilitation (CR) is a medically supervised program designed to help individuals recover from a cardiac event, such as a heart attack or surgery, and improve their overall cardiovascular health. CR programs typically involve exercise training, education about heart-healthy lifestyles, and counseling to manage stress and anxiety. These components work together to strengthen the heart, improve endurance, and reduce the risk of future cardiovascular complications. Participation in cardiac rehabilitation has been shown to significantly decrease mortality rates and improve quality of life for patients with heart disease.

Pharmacists can play a vital role in supporting patients enrolled in cardiac rehabilitation programs. Here are 5 ways pharmacists can contribute:

Review Medication Regimen: Pharmacists can collaborate with the patient's healthcare team to review their medications and ensure they are optimized for their specific needs following a cardiac event. This may involve adjusting dosages or monitoring for potential drug interactions.
Promote Medication Adherence: Pharmacists can work with patients to understand their medication regimens and address any adherence challenges they might face. They can offer strategies for overcoming barriers and ensuring patients take their medications consistently as prescribed.
Monitor Progress and Address Side Effects: Pharmacists can monitor patients' progress throughout their CR journey, tracking medication effectiveness and addressing any side effects they may experience. They can also offer guidance on how to manage these side effects while continuing treatment.

By providing these services, pharmacists can become valuable partners in cardiac rehabilitation, helping patients maximize the benefits of the program and ultimately improve their long-term cardiovascular health.

The SDOH Factor: Individuals with inadequate health insurance coverage might face financial burdens associated with CR programs, including co-pays, transportation costs, or missed work hours, which could prevent them from enrolling in a cardiac rehabilitation program or force them to stop participating. Plus, patients with low health literacy may not fully grasp the long-term benefits of CR or the potential consequences of non-adherence. Through comprehensive support and collaboration with CR teams, pharmacists can empower patients to overcome SDOH limitations and achieve successful cardiac rehabilitation, ultimately improving their cardiovascular health and quality of life.

How to Operationalize Reimbursement for the 5 Key Focus Areas

Pharmacists can play a vital role in the battle against cardiovascular disease, improving patient outcomes through services like medication management, counseling, and education. To ensure the sustainability and accessibility of these services, securing proper reimbursement is key.

Here’s how pharmacists can provide and get reimbursed for services related to each of the 5 key areas:

(NOTE: pharmacists should be aware of state scope of practice, collaborative practice, and provider status rules and regulation before considering the implementation of the services mentioned. Also, before attempting to bill for these services, pharmacists should complete enrollment, credentialing, and contracting requirements with Medicaid and/or commercial payers. Once enrolled with the payer(s), it is important to follow contract policy and procedure guidance on what CPT codes (e.g., Evaluation & Management, Tobacco Cessation, Medication Therapy Management, etc.) pharmacists are eligible to bill for regarding the services mentioned.)

Anticoagulation:

Implement medication monitoring programs to track INR (International Normalized Ratio) levels and adjust dosages as needed.
Offer education sessions on medication adherence, potential side effects, and healthy lifestyle modifications to optimize anticoagulation therapy.

Blood Pressure Management:

Provide blood pressure monitoring services and medication adjustments within the scope of pharmacy practice.
Offer education on proper blood pressure monitoring techniques, lifestyle changes for blood pressure control, and medication adherence.

Cholesterol Management:

Implement medication monitoring programs to track cholesterol levels and adjust therapy as needed.
Conduct medication reviews and consultations to optimize cholesterol treatment plans.
Offer education on dietary changes, weight management, and exercise to support cholesterol control.

Tobacco Cessation:

Provide tobacco cessation counseling sessions, including behavior modification strategies and support for overcoming withdrawal symptoms.
Collaborate with physicians to prescribe smoking cessation medications (nicotine replacement therapy, prescription medications) when appropriate. Pharmacists can bill for dispensing these medications.

Cardiac Rehabilitation:

Partner with physicians and CR programs to develop medication management plans for patients enrolled in cardiac rehabilitation.

Offer medication education sessions specifically tailored to patients with cardiovascular disease, focusing on adherence, potential side effects, and interactions with other medications.
Consider offering medication synchronization programs to ensure patients have a consistent supply of all their medications, potentially improving adherence and reducing hospital readmissions.

Overall, pharmacists need to be proactive in documenting the value they bring to managing cardiovascular health. By implementing these strategies and collaborating with physicians and other healthcare providers, pharmacists can ensure they are appropriately reimbursed for the services they provide, making these key interventions more accessible and sustainable for patients.

Taking Control of Cardiovascular Health

The human heart is a tireless engine that powers our every move. Like any engine, however, it requires care and maintenance to function optimally. And with the help of trusted healthcare providers — like community pharmacists — taking control of our collective cardiovascular health is within reach. By focusing on areas like anticoagulation, blood pressure management, cholesterol control, tobacco cessation, and cardiac rehabilitation, pharmacists can guide their patients on personalized journeys towards healthier hearts.

5 Keys to Improving Cardiovascular Health: The Social Determinants of Heart Health, Part 2