Osteoporosis Care Tool Kit

This education program is a product/publication of the National Community Pharmacists Association (NCPA). Copyright © 2006. All rights reserved. Any reproduction, photocopying, storage or transmission by magnetic or electronic means without the

expressed written consent of NIPCO/NCPA and the payment of appropriate fees is strictly prohibited by law.

Patient History/Data Base for Osteoporosis NAME: DATE:

RACE: GENDER: DOB:

MENSTRUAL HISTORY: AGE AT MENARCHE: AGE AT MENOPAUSE: TYPE OF MENOPAUSE: (circle one) NATURAL ARTIFICAL

HISTORY OF AMENORRHEA:

FAMILY HISTORY OF OSTEOPOROSIS:

BODY TYPE (weight/frame size):

CALCIUM INTAKE : AVERAGE DAILY DIETARY INTAKE:

CALCIUM SUPPLEMENT YES NO

PRODUCT:

DOSING REGIMEN:

SELF-REPORT OF ADHERENCE:

VITAMIN D INTAKE: SOURCE QUANTITY/DAY

MULTI-VITAMIN

MILK

VITAMIN FORTIFIED CEREAL

OTHER

DO YOU SMOKE/USE TOBACCO? YES NO IF YES, WHAT TYPE? HOW OFTEN?

DO YOU DRINK ALCOHOL? YES NO IF YES, WHAT TYPE? HOW OFTEN?

HISTORY OF FRACTURES—DATE:

SKELETAL SITE:

DEGREE OF TRAUMA:

FALLS—# OCCURANCES/MONTH:

HISTORY OF PROLONGED SEDENTARY PERIODS:

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MEDICATION USE: DRUG DOSE DURATION

ORAL GLUCOCORTICOIDS

ANTICONVULSANTS

SEDATIVES

ANTINEOPLASTICS

ALUMINUM-CONTAINING ANTACIDS

THYROID HORMONE

MEDICAL CONDITIONS: MULTIPLE MYELOMA YES NO HYPERPARATHYROIDISM YES NO

HYPERTHYROIDISM YES NO

HYPOGONADISM YES NO

TYPE 1 DIABETES YES NO

RHEUMATOID ARTHRITIS YES NO

OBSTRUCTIVE JAUNDICE YES NO

SEVERE MALNUTRITION YES NO

ROUTINE EXERCISE: TYPE OF EXERCISE

TIMES PERFORMED/WEEK

DURATION OF PERFORMANCE

YEAR SUSTAINED PROGRAM STARTED

HISTORY OF BMD TESTING: DATE

SITE TESTED

RESULTS

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Osteoporosis/Fracture Prevention Plan DATE: ____________ Calcium Intake

• Dietary plan:

• Calcium supplementation plan:

• Contraindications: yes no

• Recommended daily intake/allowance:

AGE ELEMENTAL CALCIUM MG/DAY

BIRTH–6 MONTHS 400

6 MONTHS–1 YEAR OLD 600

1–5 YEARS 800

6–10 YEARS 800-1200

≥11YEARS 1,200 – 1,500

CALCIUM SALT % ELEMENTAL CALCIUM

CA CARBONATE 40

CA CITRATE 21

CA GLUCONATE 9

CA GLUBRONATE 6.5

CA LACTATE 13

DIBASIC CA PHOSPHATE 23

TRIBASIC CA PHOSPHATE 39

CALCIUM PRODUCT

CALCIUM SALT

CALCIUM SALT MG/UNIT

ELEMENTAL CALCIUM MG/UNIT

RECOMMENDED UNITS/DAY

ACTUAL

EXAMPLE TUMS ULTRA® CALCIUM CARBONATE

1,000 400 3 TABLETS

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Vitamin D Intake

• Current average daily intake/allowance:

• Recommended daily intake/allowance:

AGE VITAMIN D IU/DAY

BIRTH–50 YEARS OLD 200

51–70 YEARS OLD 400

>70 YEARS OLD 600

• Vitamin D supplementation plan:

Exercise • Patient education

⇒ What is weight-bearing exercise ⇒ Avoid immobility

Proposed Exercise Plan: Type of Exercise

Times Performed/Week

Duration of Performance

• Patients with known cardiovascular disease or men over 40 and women over

50 years of age with multiple cardiovascular risk factors should consult with a physician before beginning a moderate-intensity or greater exercise program.

• Patients with established osteoporosis need a physical examination prior to beginning an exercise program.

Smoking

• Cigarette smoker: yes no • Cessation plan:

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6

Fall Prevention Counseling Guide

• Routine eye examination • Wear glasses? yes no

⇒ Do not attempt walking without glasses • Appropriate footwear

⇒ Comfortable, low heels ⇒ Sturdy

• Ensure main routes around home are free of obstacles ⇒ Remove electric and telephone cords ⇒ Remove or firmly anchor rugs

• Good lighting throughout • Handrails in bathroom, halls and stairs • Reduce slipperiness of bathtub and shower floors • Recent falls? yes no

Explain:

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Osteoporosis Patient Monitoring

PATIENT NAME: DATE: SUBJECTIVE

CALCIUM INTAKE ADHERENCE TO DIETARY INTAKE PLAN:

ADHERENCE TO CALCIUM SUPPLEMENT REGIMEN:

SELF REPORT OF MISSED DOSES/WEEK:

REPORTED SIDE EFFECTS OR PROBLEMS:

EXERCISE EXPERIENCE TYPE OF EXERCISE

TIMES PERFORMED /WEEK

DURATION OF EACH PERFORMANCE

YEAR SUSTAINED PROGRAM STARTED

MEDICATION EXPERIENCE—DRUG REGIMEN

ADMINISTRATION TECHNIQUE:

ADHERENCE—SELF REPORT OF MISSED DOSES/WEEK:

EXPERIENCES—ADRS:

OTHER PROBLEMS:

FALL HISTORY DATE:

CAUSE OF FALL:

CONSEQUENCES:

CORRECTIVE ACTION:

DATE:

CAUSE OF FALL:

CONSEQUENCES:

CORRECTIVE ACTION:

DATE:

CAUSE OF FALL:

CONSEQUENCES:

CORRECTIVE ACTION:

QUALITY OF LIFE # DAYS OF WORK LOST IN PAST MONTH:

IMPACT ON DAILY LIFE ACTIVITIES:

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OBJECTIVE HEIGHT

BMD TESTING DATE: TYPE OF MACHINE: T SCORE:

ASSESSMENT

PLAN

FOLLOW-UP PHARMACIST DATE: TIME:

PHYSICIAN DATE: TIME:

PHARMACIST: ___________________________ SIGNATURE: _________________________

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Competitive Analysis Worksheet Competitor: Products offered: Services offered:

Geographic area served: Marketing efforts:

Detailing Ads newspaper

Ads – TV/ radio

Educational programs

Patient support groups

Other Strengths:

Weakness:

Comments:

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Bone Density Screening Supply and Equipment Checklist:

Ultrasonometer and all related supplies Operation manual Extension cords Outlet strips Water bottle Alcohol spray Cloth towels Paper towels Gloves Hand sanitizer

General Supplies: Nametag Lab coat Garbage can Garbage can liners Consent Forms Result Forms Educational Materials Product Samples Educational brochures Cash box/cash Receipts Clipboards Pens Poster Putty Duct tape Scissors Stapler Masking/scotch tape Optional: small clock Optional: tissues Optional: Breath mints

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Bone Density Consent Form

Name ____________________________________ Male Female Date ________________________ (please print) Address ___________________________________City __________________________________________ State ________ ZIP ____________ Telephone _________________ Date of Birth___________ Age_______ Physician ___________________________Address _____________________________________________ Have you been diagnosed with osteoporosis? Yes No Have you ever had a hip/spine or full body bone density test? Yes No If you answered “yes” to the questions above, a bone density screening may not be right for you. Please ask the technician for more information.

Do you have risk factors? Indicate (√) if you are or you have any of the following: A personal history of fracture as an adult. A history of fracture in first-degree relative (e.g., mother, father, sister, brother only). Caucasian Race. Female gender. Poor health/ frailty. Current cigarette smoking. Low body weight (Less than 127 lb.). Low calcium intake (lifelong). Excessive alcohol intake or alcoholism. Impaired eyesight despite adequate correction. Recurrent falls. Sedentary lifestyle or inadequate physical activity. Chronic diseases such as rheumatoid arthritis, multiple sclerosis, COPD, hyperparathyroidism, etc.

Please specify: ___________________________________________________________ Drug therapy affecting bone health such as anticonvulsants, cytotoxic drugs, excessive thyroxine,

glucocorticosteroids (i.e. prednisone, cortisone), heparin, lithium, etc. Please specify: ________________________________________________________________________

For Women Only:

Do you have an estrogen deficiency in that you have experienced one of the following? o Early menopause before age 45 and are not on estrogen replacement; o Removal of both ovaries and are not on estrogen replacement; o Prolonged absence of menstrual cycle (greater than 1 year) before menopause; o Menopause and are not on estrogen replacement.

AUTHORIZATION & RELEASE: I understand this is a screening and is not meant to substitute for health care offered by my physician or other health care provider. I, intending to be legally bound, hereby release all health care personnel, ______________Pharmacy®, and all sponsoring agencies from all responsibility in connection with the screening. I understand that the screening results will be provided to me and that I am responsible for any follow-up with my physician. I understand that these results may be sent to my physician named above and maintained by ________________Pharmacy® as part of a confidential record and may be included in a summarized format or statistical analysis for group data. I have read and understand this Authorization and Release.

SIGNATURE OF PATIENT or CAREGIVER DATE ACKNOWLEGEMENT OF NOTICE OF PRIVACY PRACTICES: I have received a copy of the _______________Pharmacy® Notice of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by __________Pharmacy® and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

SIGNATURE OF PATIENT or CAREGIVER DATE

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CPT Codes for BMD Tests CPT Test

76076 PDXA (peripheral DXA)

76078 RA (radiographic absorptiometry)

76977 QUS (quantitative ultrasound)

78350 SPA (single photon absorptiometry)

G0130 SXA (single energy x-ray absorptiometry)

G0132 pQCT (peripheral quantitative computed tomography)

CPT Codes for Medication Therapy Management and Monitoring Medication Therapy Management Service Codes (MTMS) Medication Therapy Management Service(s) (MTMS) describe face-to-face patient assessment and intervention as appropriate, by a pharmacist. MTMS is provided to optimize the response to medications or to manage treatment-related medication interactions or complications.

MTMS includes the following documented elements: review of the pertinent patient history, medication profile (prescription and non-prescription), and recommendations for improving health outcomes and treatment compliance. These codes are not to be used to describe the provision of product-specific information at the point of dispensing or any other routine dispensing-related activities. 0115T Medication therapy management service(s) provided by a pharmacist, individual, face-to-face

with patient, initial 15 minutes, with assessment, and intervention if provided; initial encounter 0116T subsequent encounter + 0117T each additional 15 minutes (List separately in addition to code for the primary service)

(Use 0017T in conjunction with 00115T, 00116T)

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Selected ICD-9 Codes for Osteoporosis Condition Code

Osteoporosis, generalized 733.00 Osteoporosis, circumsciptia 731.0 Osteoporosis, disuse 733.03 Osteoporosis, drug induced 733.09 Osteoporosis, idiopathic 733.02 Osteoporosis, postmenopausal 733.01 Osteoporosis, posttraumatic 733.7 Osteoporosis, senile 733.01 Screening for unspecified endocrine, nutritional, and immunity disorders

V77.9

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STATEMENT OF MEDICAL NECESSITY

PATIENT NAME: _____________________ DATE: ______

ADDRESS: ______

CITY: __ STATE: ___ ZIP:____________

HOME PHONE: _________ DATE OF BIRTH: _______________________

DIAGNOSIS (ICD-9): 733. __ __ OTHER ________________ (PLEASE BE AS SPECIFIC AS POSSIBLE)

PATIENT PROBLEM(S): ______

REQUESTED OSTEOPOROSIS CARE SERVICES:

Comprehensive osteoporosis self-management education

Medication administration instruction

Specify: All meds

Specific meds

Medication adherence assessment, education, and monitoring

Osteoporosis screening (BMD test)

GOALS OF SERVICE REQUESTED:

Number of Authorized Visits:

I consider these requested services to be a necessary part of the patient’s care for the following reason: New diagnosis Change in symptoms or condition which necessitates change in self-management or Re-education or refresher training

__________________________________ ________________ Physician’s Signature Date

PHYSICIAN NAME (PRINT): ____________

PRACTICE ADDRESS: _____ TELEPHONE: ___ PIN/NPI: _____ ____________

3. PATIENT’S BIRTH DATE

6. PATIENT RELATIONSHIP TO INSURED

8. PATIENT STATUS

10. IS PATIENT’S CONDITION RELATED TO:

a. EMPLOYMENT? (CURRENT OR PREVIOUS)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

10d. RESERVED FOR LOCAL USE

1a. INSURED’S I.D. NUMBER (FOR PROGRAM IN ITEM 1)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (INCLUDE AREA CODE)

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH

b. EMPLOYER’S NAME OR SCHOOL NAME

c. INSURANCE PLAN NAME OR PROGRAM NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described below.

SEX

F

HEALTH INSURANCE CLAIM FORMOTHER1. MEDICARE MEDICAID CHAMPUS CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.

SIGNED DATE

ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)

MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:

17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)

17a. I.D. NUMBER OF REFERRING PHYSICIAN

FromMM DD YY

ToMM DD YY

1

2

3

4

5

625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

(For govt. claims, see back)

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERERENDERED (If other than home or office)

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY

CODE ORIGINAL REF. NO.

$ CHARGES EMG COBRESERVED FOR

LOCAL USE

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE& PHONE #

PIN# GRP#

PICA PICA

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

5. PATIENT’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH

c. EMPLOYER’S NAME OR SCHOOL NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)

YES NO��

( )

If yes, return to and complete item 9 a-d.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB? $ CHARGES

22. MEDICAID RESUBMISSION

23. PRIOR AUTHORIZATION NUMBER

MM DD YY

CA

RR

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PA

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AN

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PH

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ICIA

N O

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YES NO

YES NO

1. 3.

2. 4.

DATE(S) OF SERVICE Typeof

Service

Placeof

Service

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

DIAGNOSISCODE

PLEASEDO NOTSTAPLEIN THISAREA

FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG

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� Single Married Other

� � �

� �

� �

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� �Employed Full-Time Part-Time Student Student

Self Spouse Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (VA File #) (SSN or ID) (SSN) (ID)

( )

�

� � � � � �

�M

SEX

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DAYSOR

UNITS

EPSDTFamilyPlan

F G H I J K24. A B C D E

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PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM CMS-1500 (12/90), FORM RRB-1500,APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS)

SAMPLE

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Osteoporosis Management and Screening Service Business Plan Services Planned Goals of Service(s) Target Start Date: To be Done Implementation

Timeline Anticipated Cost

Assigned To/

Comments

Regulatory Considerations Machine registration and fees Y N

Site Development and Preparation Location for screenings and other services Y N

Remodeling Y N

Furniture Y N

Equipment Y N

Supplies Y N

In Store Logistics Patient care documentation system Y N

Pharmacist staffing Y N

Staff incentives Y N

Training of employees Y N

Advertising and Promotion In-store Y N

Patient – In store identification Y N

Patient – Direct mail Y N

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Advertising and Promotion Physician – Direct mail

Targets:

Y N

Physician – Detailing

Targets:

Y N

Other referral sources Y N

Website Y N

Other: Y N

Reimbursement Determine screening fees Y N

Determine method for collecting payment from patient Y N

Method for filing and tracking claims (billing software or service) Y N

Financials Return on investment analysis Y N Tracking revenue and service delivered Y N Evaluation of Service(s) Revenue targets Y N

Patient goals Y N

Other: Y N

Ongoing Operations Policy and procedure manual Y N

BMD machine calibration Y N

Advertising and promotion Y N

Scheduling screening events Y N

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Return on Investment Analysis Direct Expenses Year One Year Two

Remodeling

Furniture Equipment Supplies

Patient care documentation system

Pharmacist staffing

Staff incentives

Training of employees

Advertising and promotion

Indirect Expenses Year One Year Two

Overhead attributable to program [%sq ft of space x % of time used = % of total store overhead or percentage of total sales attributable to program = % of total

store overhead]

Total Expenses

Direct Revenue Year One Year Two Prescription Revenue Year 1: ____ new osteoporosis prescriptions x 12 fills x $ __ gross profit/fill Year 2: ____ new osteoporosis prescriptions x 12 fills x $ __ gross profit/fill

Professional/Screening Fees Year 1 ____ patient screenings at $___ ____ patient management visits at $___ Year 2 ____ patient screenings at $___ ____ patient management visits at $____

Total Direct Revenue

Indirect Revenue Year One Year Two

_____ % of screening customers will buy calcium supplements Year 1 __ customers buying calcium x $__ gross profit x 12 purchases/yr Year 2 __customers buying calcium x $__ gross profit x 12 purchases/yr

Total Indirect Revenue

Total Revenue

Profit

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Sample Patient Dialog on BMD Test Results Sally Smith, a 48 year-old female, participated in a BMD screening and wanted to know the results once it was complete. The following could be discussed with her: Sally, your T-score results from your ultrasound screening are a -1.68. This puts you at medium risk for osteoporosis. You also have 4 risk factors (female, Caucasian, low calcium intake and post menopausal) which, together with your T-score, may further increase your risk for osteoporosis-related fractures. I would recommend you take this information to your next appointment and discuss your results with your physician. Your physician might decide you need to also have a hip and spine test, which is considered to be the gold standard to determine your true risk level for fracture. In the meantime, it is important to be sure you are getting 1,000 – 1,500 mg of calcium plus 200 I.U. vitamin D per day in your diet or through vitamin supplementation as well as performing weight bearing exercises, such as walking, to reduce future bone loss.

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