Public and Preventative Health

Kiara Torres-Garcia, Pharm D

Nick Buttermore, Pharm D
Objectives

1. Define public and preventative health.

2. Understand the roles played by the United States Preventative Screening Task Force
(USPSTF) and Centers for Medicare and Medicaid Services (CMS) for public and
preventative health.
3. Navigate USPSTF and CMS resources to guide patient decision making.
4. Explain health screening recommendations based on patient-specific factors.
5. Describe the various components of annual wellness visits (AWVs).
6. Understand the implications of Beers List for AWVs and best practice.
What are Preventative and Public Health?

Preventative Health: Public Health:

“Routine health care that includes screenings, “The science of protecting and improving the
check-ups, and patient counseling to prevent health of people and their communities” [CDC
illness, disease, or other health problems. foundation]
Public health promotes and protects the health
of people and the communities where they live,
learn, work, and play. [APHA]
 Public and Preventative Health Big Players

PREVENTATIVE Health
PUBLIC Health Organizations:
Organizations:
• United States Department of • United States Preventative
Health and human Services (HHS) Screening Task Force (USPSTF)
• Centers for Disease Control (CDC) • Centers for Medicare and
• Food and Drug Administration Medicaid Services (CMS)
(FDA)
• Indian Health Services (IHS)
• World Health Organization
(WHO)
What are USPSTF and
CMS?
• USPSTF:
• Focuses on preventative services in primary
care
• Gold standard for screening services

• CMS:
• Regulator of Medicare, Medicaid/CHIP
• Provide regulations for AWV requirements
 How to Navigate / Discussion

CMS Website for AWV: USPSTF Homepage:

• https://www.cms.gov/Outreach-and-Education/Medicare • https://www.uspreventiveservicestaskforce.org/uspstf/
-Learning-Network-MLN/MLNProducts/preventive-servic
es/medicare-wellness-visits.html
Pharmacists and Public / Preventative Health

Direct Patient Care:

• Annual Wellness Visits (AWVs)

• Vaccination services
• Medication Therapy Management Services
• Counseling over drug and disease states
• Emergency response

Non-patient care:

• Research
• Patient advocacy
• Public health agencies
 IPPEs:

Medicare Annual • Review of patient’s medical and social health

history and includes education about other
Wellness Visits preventative services
(AWVs) and Initial • 1 IPPE per lifetime within 12 months after part B
Preventative begins
• Providers only (includes physical examination)
Physical Exam
(IPPEs)
AWVs:

• Review of patient’s personalized prevention plan

of services and includes a health risk assessment
• Providers or other health professionals (that’s
you!!)
Medicare Annual Wellness Visits (AWVs) and
Initial Preventative Physical Exam (IPPEs)
 Update Health Reimbursement Arrangement (HRA)

Medical History
Medicare Mental Assessment
Annual Wellness
Functional Ability
Visit (AWV)
Components PHQ-2/PHQ-9

Immunizations and Screenings

Advanced Care Planning

Assessment of Social Determinants of Health

Update Health
Reimbursement
Arrangement (HRA)
• What is an HRA?
• Employer-funded group health plan
• Still require insurance! (Medicare)
• Patient completes a packet of info before visit:
• Demographic data
• Health status self-assessment
• Psychosocial risks
• Behavioral risks
• Activities of daily living
 Update Health Reimbursement Arrangement (HRA)

Medical History
Medicare Mental Assessment
Annual Wellness
Functional Ability
Visit (AWV)
Components PHQ-2/PHQ-9

Immunizations and Screenings

Advanced Care Planning

Assessment of Social Determinants of Health

 Obtain a Medical History

CURRENT LIST SURGICAL PAST MEDICAL SOCIAL HISTORY MEDICATION

OF PROVIDERS HISTORY HISTORY RECONCILIATION
 Update Health Reimbursement Arrangement (HRA)

Medical History
Medicare Mental Assessment
Annual Wellness
Functional Ability
Visit (AWV)
Components PHQ-2/PHQ-9

Immunizations and Screenings

Advanced Care Planning

Assessment of Social Determinants of Health

Mini-Cog
• Step #1: Three Word Registration

• Step #2: Clock Drawing

Word Recall:​ 1 point for each word
_______ (0-3 pt)​ recalled​

Clock Draw:​ Normal clock = 2 points​

_______(0 or 2 pt)​ Abnormal = 0 points​

Total Score:​ < 3 points validated

_______(0-5 pt)​ for dementia screening​

• Step #3: Three Word Recall

Mini Mental State Examination (MMSE)
• Conducted if patient’s Mini-
Cog score was < 3

Scoring​
24 – 30 ​ No cognitive impairment​
18 – 23 ​ Mild cognitive impairment​
0 – 17 ​ Severe cognitive impairment​
 Update Health Reimbursement Arrangement (HRA)

Medical History
Medicare Mental Assessment
Annual Wellness
Functional Ability
Visit (AWV)
Components PHQ-2/PHQ-9

Immunizations and Screenings

Advanced Care Planning

Assessment of Social Determinants of Health

Functional Ability – Activities of
Daily Living (ADLs)
Functional
Ability –
Health &
Safety
Screening
Functional Ability – Fall risk assessment
 Update Health Reimbursement Arrangement (HRA)

Medical History
Medicare Mental Assessment
Annual Wellness
Functional Ability
Visit (AWV)
Components PHQ-2/PHQ-9

Immunizations and Screenings

Advanced Care Planning

Assessment of Social Determinants of Health

Patient Health
Questionnaire-9 (PHQ-9)
Total PHQ-9 Depression
Score Severity
1–4 Minimal
Depression
5–9 Mild Depression

10 – 14 Moderate
Depression
15 – 19 Moderately
Severe Depression
20 – 27 Severe Depression
When do we take action?

• Severe Depression (20-27) Yes

• Moderately Severe Depression (15-19) Yes

• Moderate Depression (10-14) Yes

• Mild Depression (5-9) Yes

• Minimal Depression (1-4) Yes

• YOU ALWAYS CAN!!!

 Update Health Reimbursement Arrangement (HRA)

Medical History
Medicare Mental Assessment
Annual Wellness
Functional Ability
Visit (AWV)
Components PHQ-2/PHQ-9

Immunizations and Screenings

Advanced Care Planning

Assessment of Social Determinants of Health

Screenings

USPSTF Recommendations
Cervical Cancer

Case:
• 66 yo female
• History:
o 1 Pap Smear (2022)
• Patient is here for a follow-up AWV. She recently came back from a trip to Ethiopia to visit
family. She mentioned during the visit that she moved to the US in 2021.

• Would you recommend Cervical Cancer Screening for this patient?

 Cervical Cancer
USPSTF Recommendations

Population Method Frequency

Women 21-29 years old Cytology 3 years

Women 30-65 years old Cytology 3 years

Primary hrHPV testing 5 years

Costesting 5 years
Breast Cancer
Visit:
Case: Breast Cancer Risk Assessment Tool:
Online Calculator - NCI
• 42 yo white female
• PMH:
• Mass found in left breast, noncancerous (2008)
• Biopsy (2008)
• Menarche: 13 yo
• Family History
• Mom: Breast Cancer (2006), HTN, HLD
• Aunt: Breast Cancer (2009), Stroke, HLD
• Dad: HTN, Diabetes

• Would you recommend Breast Cancer Screening for this patient?

Breast Cancer
USPSTF
Recommendations

Women 50-74 years old:

Mammogram every 2 years
Colorectal Cancer
USPSTF Recommendations

Population Method Frequency

Adults 45-75 years old High-sensitivity guaiac fecal occult blood test (HSgFOBT) Annually

Fecal immunochemical test (FIT) Annually

Stool DNA-FIT/Cologuard 1-3 years

Computed tomography colonography 5 years

Flexible sigmoidoscopy 5 years

Flexible sigmoidoscopy + FIT 10 years (+ FIT yearly)

Colonoscopy screening 10 years

Prostate Cancer
USPSTF Recommendations

Men 55-69 years old:

• Decision to be screened for prostate cancer should be an individual one

• Screening Test: prostate-specific antigen (PSA)
• High PSA level: Cancer, BPH or Prostatitis
• False positive results

Men 70 years or older:

• Do not screen
Lung Cancer

Case
• 74 yo male
• PMH
o Former Smoker (Quit Date: 2010)
• Patient here for his annual AWV. Patient mentioned during the visit that he started
smoking when he was 15 years old.

• Calculate pack-history.
• Would you recommend a Lung Cancer Screening for this patient?
Lung Cancer
USPSTF Recommendations
• Adults 50-80 years old: 20 pack-year smoking history AND
o Currently smoke or have quit within the past 15 years

• Screening: Low-dose computed tomography (CT) Medicare:

• Frequency: Annually • If you meet all of these conditions:
• 50-77 yo
• No s/sx of lung cancer
• Stop screening if: (asymptomatic)
• Not smoked for 15 years • Current smoker or quit smoking
within the last 15 years
• Limited life expectancy • 20+ pack years
• Limited abilty to have lung surgery • Receive order from HCP
Abdominal Aortic Aneurysm
USPSTF Recommendations

• Men 65-75 years old with smoking history

• Screening: Ultrasonography
• Frequency: Once

• Women with smoking history:

• Insufficient evidence to screen

• Medicare:
• FH of AAA
• Man 65-75 yo and have smoked at least 100
cigarettes in your lifetime
Osteoporosis
USPSTF Recommendations

• Women 65+ years old

• Postmenopausal women < 65 years who
are at increased risk of osteoporosis:
• Fracture Risk Assessment (FRAX) tool
• Parental history of hip fracture
• Smoking/Excess alcohol
consumption
• Low body weight
• Screening test: dual-energy x-ray
absorptiometry (DXA) of the hip and
lumbar spine
 • Once every 24 months if you meet 1 or more of these
Osteoporosis conditions:
o Estrogen-deficient and at risk for osteoporosis
Medicare o X-rays show possible osteoporosis, osteopenia, or
vertebral fractures
Coverage o Taking prednisone or steroid-type drugs or are
planning to begin this treatment
o Diagnosed with primary hyperparathyroidism
o Monitored for treatment efficacy
Labs/Tests

USPSTF Recommendations
HIV
USPSTF
Recommendations
• 15-65 years old and in Pregnancy
(including in labor or at delivery)

• Screening: antigen/antibody
immunoassay

• Frequency: Not determined

• Medicare: Annually or Up to 3
times if Pregnant
• USPSTF: Repeat if high risk
 • Adults 18-79 years old
• Screening: Anti-HCV antibody testing followed by
confirmatory polymerase chain reaction testing for +
antibody results
• Frequency:
Hepatitis C • One-time screening for most adults
USPSTF • Periodically, if at risk for HCV infection

Recommendations • Medicare (Once or Yearly*)

• Born between 1945-1965
• High risk (Current* or former use of illicit injection
drugs)
• Blood transfusion before 1992
Chronic Disease Management
Considerations/Recommendations
• A1c: • Foot Exam
• Adults 35-70 years who are overweight or • Yearly for patients with diagnosed Diabetes
obese and asymptomatic
• Eye Exam
• Screening: HbA1C, fasting glucose, glucose
tolerance test • At least yearly
• Every 3 years if normal blood glucose levels • Dental
• uACR: • Every 6 months
• Yearly for patient with diagnosed Diabetes • BMP
• Screening: Urine • Annually
• Blood Pressure
• At every visit
Immunizations

What’s New?
What Immunizations are
recommended for the
Elderly (+65 yo)?
Recommendation Overview:
Adults 19 years or Older
• RSV • Varicella
• COVID-19 • Zoster
• Pneumococcal • Hepatitis A
• Influenza • Hepatitis B
• Tetanus, dipthteria, and pertussis • Meningococcal (MenACWY)
(Tdap) • Human Papilloma Virus (HPV)
• Measles, mumps, and rubella (MMR)
 • Updated (2023–2024 Formula) COVID-19 vaccine
o Moderna
COVID-19 o Novavax
o Pfizer-BioNTech
• Additional dose recommended: 65+ (after 4 months)
RSV
• 1 dose RSV vaccine
• Arexvy®
• Abrysvo™

• Age: 60+

• Special Populations:
• Pregnant at 32-36 weeks
gestation from September
through January.
• Pfizer Abrysvo is the only RSV
vaccine recommended during
pregnancy
 Update Health Reimbursement Arrangement (HRA)

Medical History
Medicare Mental Assessment
Annual Wellness
Functional Ability
Visit (AWV)
Components PHQ-2/PHQ-9

Immunizations and Screenings

Advanced Care Planning

Assessment of Social Determinants of Health

Advanced Care Planning

• Living Will
• Durable Power of Attorney for Health Care
• Medical Decision Making:
• DNR - Do Not Resuscitate
• DNI - Do Not Intubate
• DNH - Do Not Hospitalize
• POLST - Point of Life Sustaining Treatment
• MOLST - Medical Orders for Life Sustaining Treatment
• Completed outside of visit
 Update Health Reimbursement Arrangement (HRA)

Medical History
Medicare Mental Assessment
Annual Wellness
Functional Ability
Visit (AWV)
Components PHQ-2/PHQ-9

Immunizations and Screenings

Advanced Care Planning

Assessment of Social Determinants of Health

Social Determinants of Health

• Regulated by Office of Disease Prevention and Health Promotion

(OASH)
• Economic Stability

• Education Access and Quality

• Health Care Access and Quality

• Neighborhood and Built Environment

• Social and Community Context

References
1.CMS: MLN6775421 – Medicare Wellness Visits (cms.gov)
2.USPSTF Website: Home page | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
3.TUG_test-print.pdf (cdc.gov)
4.Adult Vaccination | CDC
5.Clinical Guidance for COVID-19 Vaccination | CDC
6.Coronavirus: Vaccine Information and Planning
7.Healthcare Providers: RSV Vaccination for Pregnant People | CDC
8.Healthcare Providers: RSV Vaccination for Adults 60 Years of Age and Over | CDC
9.Recommendation: Cervical Cancer: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
10.Recommendation: Breast Cancer: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
11.Recommendation: Colorectal Cancer: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
12.Recommendation: Prostate Cancer: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
13.Recommendation: Lung Cancer: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
14.Lung Cancer Screening Coverage (medicare.gov)
15.Recommendation: Abdominal Aortic Aneurysm: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
16.Abdominal aortic aneurysm screening coverage (medicare.gov)
17.Recommendation: Human Immunodeficiency Virus (HIV) Infection: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
18.Recommendation: Osteoporosis to Prevent Fractures: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
19.HIV Screening Coverage (medicare.gov)
20.Bone Density Test Coverage (medicare.gov)
21.Recommendation: Hepatitis C Virus Infection in Adolescents and Adults: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
22.Hepatitis C Screening Coverage (medicare.gov)