Role of Public Health:

• Help to increase awareness of chronic disease and management
• Be a convener to help bring partners together (healthcare teams / Pharmacy / Quality Improvement orgs, health information technology, payers)
• Share Information (national and state initiatives / programs)
• Promote the implementation of healthcare policies to support quality, value, and improved population health outcomes, and to reduce health disparities
• Promote health prevention and chronic disease self-management by supporting a multi-disciplinary team approach
• Can provide technical assistance to programs in reviewing quarterly data by utilizing staff evaluators and epidemiologists to assist with data interpretation
• Provide scientific expertise on evidence-based interventions
• Provides clout and importance to interventions

Role of the Pharmacist:

• Fills prescriptions per providers orders, after checking for any contraindications
• Educate patients on how and when to take medicine, advising on potential side effects
• Advises about general health topics
• Teaches other healthcare practitioners about proper medication therapies for patients
• Completes insurance forms
• Oversees the work of pharmacy technicians and pharmacists in training (interns)

Source - www.bls.gov/ooh/Healthcare/Pharmacists.htm#tab-2

How to Partner with the Pharmacist:

• Learn what pharmacists can and cannot do in your state by checking with the Board of Pharmacy
• Meet with local pharmacists to discuss their role in hypertension control and management such as; performing in-pharmacy blood pressure (BP) checks, advising on home BP self-monitoring, educating patients on hypertension medications, and tracking refill patterns
• Meet with local pharmacists to discuss their role in diabetes control and management such as; in-pharmacy blood glucose checks, advising on home blood glucose monitoring, educating patients on diabetes medications, and tracking refill patterns
• Discuss possible models for hypertension and/or diabetes management with engaged pharmacists providing resources and/or examples (i.e. team-based care models)

Case Manager/Nurse:
Case Managers are frequently Registered Nurses (RNs) who:

• Develop, implement, and evaluate individualized care plans for patients
• Advocate for the safety of patients
• Act as a liaison between healthcare providers, families of patients and the patients themselves
• Educate their patients and their families on how to follow their care plans

How to Partner with the Case Manager/Nurse:

• Share tools and resources on how to identify and track patients with a diagnosis of diabetes and/or hypertension
• Educate Case Managers on available community resources to assist the patient in chronic disease management
• Share information regarding state and national programs
• Convene like healthcare providers to share resources and effective patient management techniques

Role of the Community Health Worker (CHW):

• Typically, lay person from the community
• Provides general health education
• Serve as role models and community advocates
• Increase access to healthcare resources
• Collect data for research/quality improvement purposes

For more information, see Community Health Worker in the
Health Care Models button on the home page

How to Partner with the Community Health Worker (CHW):

• Advocate and promote the implementation of CHW role descriptions and policies within healthcare systems/provider practices
• Share information regarding available community resources to assist patients with chronic disease
• Promote health prevention and chronic disease self-management by supporting a multi-disciplinary team approach

Insurer/Employer:

Entities other than the patient that finance or reimburse the cost of health services. In most cases, this term refers to insurance carriers, other third-party payers, or health plan sponsors (employers or unions).

How to Partner with the Insurer/Employer:

• Assist and advocate for Insurers to rework new models of care to pay for diabetes and high blood pressure medications and supplies to include home monitoring
• Assist Insurers who collect and share data for quality improvement
• Partner to improve public awareness through education

A generalist physician and/or non-physician practitioners (nurse practitioners and physician assistants)

Role of the Primary Care Provider:

• Serves as the entry point for the patient's health care needs
• Takes continuing responsibility for providing the patient's care
• Serves as an advocate for the patient, coordinating the entire health care system to benefit the patient

How to Partner with the Primary Care Provider:

• Identify which providers in your state are reporting to a national quality program such as NCQA (see Basic Component Button on home page)
• Share available community resources to assist their patients (i.e. blood pressure screenings/smoking cessation/ etc...)
• Discuss current patient tracking for patients with hypertension and/or diabetes
• Share resources with PCP and office to assist with blood pressure and diabetes management (i.e. algorithms)
• Convene healthcare team to explore how all can work to their highest level

Source - http://www.aafp.org/about/policies/all/primary-care.html

Role of the Behavioral Health Specialist:

• Assist primary health care providers in recognizing and treating mental disorders and psychosocial problems
• Assist in preventing relapse or morbidity in conditions that tend to recur over time
• Evaluate patient care plans with primary care team
• Teach patients, families and staff about care, prevention and treatment enhancement techniques

How to Partner with the Behavioral Health Specialist:

• Convene healthcare teams including PCP/staff and Behavioral Health Specialist to promote improved communication resulting in team-based, patient-centered care
• Advocate for improved awareness and coverage of mental health /behavioral disorders
• Share resources for patient tracking (i.e. hypertension and/or diabetes)
• Share information regarding community resources for patients with mental health/behavioral disorders