program orientation - ppcn...healthmaprxtm cardiovascular (cv) health program process of care...

HealthMapRxTM Program for Cardiovascular Health

PROGRAM ORIENTATION

I. HealthMapRxTM CV Health Program Overview (Slides)

II. Process of Care

Process of Care CV Health Assessment Guidelines CV Health Care Documentation

III. CV Health Patient Self-Management

Credential

HealthMapRxTM Cardiovascular (CV) Health Program Process of Care

ASSESSMENTS GOALS CLINICAL SELF-MANAGEMENT Monthly visits for the first

CREDENTIAL three months

ON

IN

ITIA

L VIS

IT S

ERIE

S

If applicable: Program review Knowledge Assessment Test

∇ Body composition ____________________________ Consent to release medical ∇ Cardiovascular information (in enrollment

packet)

History of CV Health includes assessments:

∇ Body composition ∇ Cardiovascular Health ∇ Glucose ∇ Lifestyle ∇ Medication Therapy

Health ∇ Lifestyle ∇ Medication Therapy

CLINICAL SELF-MANAGEMENT Visits every 30-60 days as needed to achieve goals

ON

GO

ING

VIS

ITS W

HEN

APP

LICABLE

*

∇ Body composition ∇ Cardiovascular Health ∇ Lifestyle ∇ Medication Therapy

Skills ∇ Blood pressure

monitoring ∇ Nutrition ∇ Medication Management ∇ Stress Management ∇ Activity Plan

____________________________

If applicable:

∇ Body composition ∇ Cardiovascular


□ Beginner

CLINICAL SELF-MANAGEMENT Minimum of quarterly visits

ON

EVERY V

ISIT

Visit documentation Communication

∇ Fax SOAP note to physician

∇ Provide Credential Status Card to patient

Performance ∇ Visits with health care

provider timely ∇ Progress on goals ∇ Blood pressure every

three months ∇ Lipid profile annually ∇ Document ongoing

compliance with remaining performance elements through Clinical Assessments

____________________________

If applicable: ∇ Body composition ∇ Cardiovascular


*See HealthMapRx Cardiovascular Health Program Assessment Schedule

□ Proficient □ Advanced

□ Beginner □ Proficient □ Advanced

□ Achieved □ Partially achieved □ Somewhat achieved

□Not Achieved

□ Achieved □ Beginner □ Partially achieved □ Proficient □ Somewhat achieved □ Advanced □Not Achieved

□ Achieved □ Partially achieved □ Somewhat achieved

□Not Achieved

□ Beginner □ Proficient □ Advanced

©2007 APhA Foundation All Rights Reserved. Version 3.0

HealthMapRxTM Cardiovascular (CV) Health Assessment Guidelines

ASSESSMENT DESCRIPTION FREQUENCY Program Review ∇ Participant Agreement

(policies and procedures) ∇ Review health care team

members, roles and communications expectations

∇ Agree on consistent procedures for obtaining objective clinical measures (lab results, BP, etc.)

∇ First visit

Documentation ∇ Consent to release medical information1

∇ First visit

History of CV Health ∇ Complete History of CV Health Form

∇ Review personal health goals established by the patient’s physician and/or other providers

∇ First visit

∇ Every visit

Body Composition ∇ Height ∇ Weight ∇ BMI ∇ Waist circumference

∇ Every visit ∇ Every visit ∇ Auto-Calculates ∇ Min Annually

Cardiovascular Health ∇ LDL ∇ Total Cholesterol ∇ HDL ∇ Triglycerides ∇ Systolic BP ∇ Diastolic BP ∇ Pulse ∇ CV Health Risk

∇ Min. Annually ∇ Min. Annually ∇ Min. Annually ∇ Min. Annually ∇ Every visit ∇ Every visit ∇ Every visit ∇ Min. Annually

Lifestyle ∇ Diet ∇ Exercise ∇ Smoking cessation ∇ Alcohol use ∇ Caffeine use ∇ Other behavior goal(s)

∇ As appropriate

Medication Therapy ∇ Persistence ∇ Compliance self-report % ∇ Compliance refills +/- 6

days ∇ Number of assessed

medications

∇ Initial visit, then as necessary

Visit Documentation ∇ Complete Patient Visit Form ∇ Enter visit data into QARx

database

∇ Every visit

Communication ∇ Provide patient with a copy ∇ Every visit


ASSESSMENT DESCRIPTION FREQUENCY of the CV Health Credential Status Card

∇ Prepare and fax Physician communication (SOAP note) regarding patient appointment1,2

∇ Every visit

Self-Management Credential 3

∇ Conduct baseline Knowledge Assessment

∇ Conduct Skills Assessment ∇ Conduct Performance

Assessment ∇ Initiate patient education

required for knowledge, skills, performance improvement

∇ Prevention measures Dental exam Eye exam Flu shot Pneumonia shot

∇ Recognize Patient Self-

Management Program goal achievement (celebrate success)

∇ First visit series

∇ Second visit series

∇ Third visit series ∇ Every visit (as

applicable)

∇ Every six months ∇ Min. annually ∇ Annually ∇ Appropriate for

age ∇ Every visit

1 Send copy of patient’s consent to release medical information to other providers if requesting protected health information (such as labs) 2 (Optional) Send Introduction Letter to Physician to explain program and patient’s participation 3 See the Specific Patient Self-Management Credential Assessments. The pharmacist may need to assess and re-assess Knowledge, Skills and Performance depending on patient progress.


Copyright © 2006-2007, APhA Foundation. All Rights Reserved. Form Version: 1.0m Updated: 9/18/07

Patient: _________________________________ Age _______ Gender M / F Date of Birth __ __ / __ __ / __ __ __ __ Physician ________________________ MD Phone # _________________ MD Email ________________________ MD Fax # ___________________ Visit Date/Time __ __ / __ __ / __ __ __ __ __ __:__ __ Pharmacist ____________

Visit # ___ Visit Minutes ______ Visit Location ___________________________

Care Documentation HealthMapRxTM CV Health

Date Started Category Description Duration (days) Work Missed (days) __ __ / __ __ / __ __ __ __ __Home __Urgent Care __ER __Hospital __ __ / __ __ / __ __ __ __ __Home __Urgent Care __ER __Hospital __ __ / __ __ / __ __ __ __ __Home __Urgent Care __ER __Hospital __ __ / __ __ / __ __ __ __ __Home __Urgent Care __ER __Hospital

Illnesses Since Last Assessment

Start Date

Drug Brand (Generic)

Dose

Route

Freq.

Purpose

Prescriber

Stop Date

Adherence (Y/N) Persistent Compliant +/-6 days

80%+ of refill

Problem w/meds

?

Current Medications – include Herbals and OTCs

Assessments Provider’s Subjective Observations:

Headache Nasal congestion Dry eyes and/or mouth Loss of appetite Changes in taste Excessive thirst Cough Dehydration Blurred vision

Rash Flushing Sweating Dizziness Weakness Rapid heart beat or palpitations Constipation Swelling of legs, fluid retention Vision changes

Insomnia or agitation Sedation or lethargy Lack of alertness Hypotension Nausea or gastrointestinal effects Ataxia or gait changes Sexual dysfunction Weight gain Other:____________________________

Review of Systems None of the symptoms below


Provider’s Objective Observations:

Body Composition Assessment Recorded Value Date Patient Self-Management Goal Target Date Height in inches <Current | New> Weight in pounds <Current | New> BMI (Calculated) <Current | New>

Waist Circumference in inches [annually] <Current | New>

Cardiovascular Health Assessment Recorded Value Date Patient Self-Management Goal Target Date LDL Cholesterol (mg/dL) [annually] <Current | New> Total Cholesterol (mg/dL) [annually] <Current | New> HDL Cholesterol (mg/dL) [annually] <Current | New> Triglycerides (mg/dL) [annually] <Current | New> Systolic BP (mean) <Current | New> Diastolic BP (mean) <Current | New> Pulse (mean) <Current | New>

Cardiovascular Risk (as a %) <Current | New>

Lifestyle Assessment Recorded Value Date Patient Self-Management Goal Target Date Achievement ratings:

NA-Not achieved ND-No data

PA -Partially achieved ACH-Achieved

Nutrition overall _NA _ND _PA _ACH Dietary Caloric _NA _ND _PA _ACH <Current | New> Dietary Fat _NA _ND _PA _ACH <Current | New> Dietary Sat. Fat _NA _ND _PA _ACH <Current | New> Dietary Sugar <Current | New> _NA _ND _PA _ACH

Dietary Sodium _NA _ND _PA _ACH <Current | New> Exercise Intensity: Ο Low Ο Moderate Ο Vigorous <Current | New> Exercise Type: Ο Regular Ο Aerobic Ο Strength <Current | New> Weekly Exercise Frequency <Current | New> Daily Exercise Minutes <Current | New> Smoked in last 12 months? Ο Yes Ο No <Current | New> Current Packs per day <Current | New> Alcohol in last 12 months? Ο Yes Ο No <Current | New> Drinks per week <Current | New> Caffeine in last 12 months? Ο Yes Ο No <Current | New> Caffeine mg/day <Current | New> Behavior goal (other): _NA _ND _PA _ACH

CV Health Care Documentation – Page 2


CV Health Care Documentation – Page 3

Self-Management Assessment Recorded Value Date Patient Self-Management Goal Target Date Patient Self-Management Credential: Knowledge __Beg __Prof __Adv <Current | New> Skills __Beg __Prof __Adv <Current | New> Performance __Beg __Prof __Adv <Current | New> Prevention Measures: Dental Exam Current [every 6 months] Ο Yes Ο No <Current | New> Eye Exam Current [annually] Ο Yes Ο No <Current | New> Foot Exam Current [annually] <Current | New> Ο Yes Ο No

Flu Shot Current [annually, as appropriate] Ο Yes Ο No <Current | New> Pneumonia Shot Current [age appropriate] Ο Yes Ο No <Current | New>

Provider’s Assessment:

Plan for Patient’s Care

Provider’s Plan:

Date Planned/Sent

Type Provider Sent To Referral ? Reason (intervention, labs, etc.) __ __ / __ __ / __ __ __ __

Follow-up Communications

__Electronic __Verbal __Written (fax/mail/patient) __Other __Yes __No __ __ / __ __ / __ __ __ __ __Yes __No __Electronic __Verbal __Written (fax/mail/patient) __Other

__Yes __No __ __ / __ __ / __ __ __ __ __Electronic __Verbal __Written (fax/mail/patient) __Other

__Yes __No __ __ / __ __ / __ __ __ __ __Electronic __Verbal __Written (fax/mail/patient) __Other


Patient: _________________________________ Date of Birth __ __ / __ __ / __ __ __ __ Pharmacist ________________________ Phone # ____________________ Physician _________________________ Phone # ____________________ Other Provider _____________________ Phone # ____________________

Patient Map for Better Health My Next Scheduled Visit: Date: ___ ___ / ___ ___ / ___ ___ ___ ___ Time: ___ ___ : ___ ___ My health concern… What I need to do… What I did and when I did it… For example: Concerns that I have about my health or prescription, over-the-counter, or herbal medications

Examples: Health goals I have set, lab tests I need to get, appointments I need to keep, or questions I need to ask my physician, pharmacist or other health care providers

Examples include: I started taking my “medication name” once each day on “date” –OR– I had my cholesterol checked on “date” –OR– I started walking 20 minutes a day three days a week on “date”

Body Composition

Cardiovascular Health

Glucose Control

Lifestyle

Medication Therapy

Action Plan (between now and my next scheduled visit)

Self-Management Other:

CARDIOVASCULAR HEALTH KNOWLEDGE ASSESSMENT

APhA Foundation

Copyright © 2006. APhA Foundation. All rights reserved. This assessment is the exclusive property of the APhA Foundation. Unauthorized disclosure or use is strictly prohibited. Version 1.0a

CARDIOVASCULAR HEALTH KNOWLEDGE ASSESSMENT

APhA Foundation

36 Questions

Directions:

The assessment contains a total of 36 questions. The purpose of this assessment is to determine how much you currently know about your cardiovascular (CV) health and the best ways to manage it. The results of the assessment will be helpful to developing a plan to meet your individual needs for managing your hypertension and/or hyperlipidemia and general heart health. You and the pharmacist will work together to help you learn all of the material covered in the assessment.

Your feedback about this assessment is very important because the assessment is a part of an important pilot project you are participating in. After you are finished, you will be asked to fill out a survey about the assessment to provide feedback on how to improve this assessment for use in helping others to manage their diabetes.

Each question is followed by four possible answers. Select the best answer for each question and fill in the corresponding lettered space on the answer sheet. Mark only one answer for each question.

Let the assessment administrator know when you are finished, and he/she will collect your booklet and answer sheet. He/she will then score your assessment and the pharmacist will go over the results with you to develop a plan that meets your needs for learning more about managing your heart health.

Your score is based on the number of questions you answer correctly. There is no penalty for guessing, so try to answer every question, even if you must guess.

REMEMBER TO MARK ALL OF YOUR ANSWERS ON THE SEPARATE ANSWER SHEET, and be sure that each mark is heavy and dark and completely fills the answer space. If you change an answer, be sure to completely erase the previous mark.

1. High blood pressure can affect your body by

A. making the heart work harder to pump blood B. decreasing blood flow to the kidneys C. damage small blood vessels in the eye D. all of the above

2. Hypertension refers to

A. high blood pressure B. low blood pressure C. high cholesterol D. low cholesterol

3. Left untreated, high blood pressure can cause

A. stroke B. heart attack or heart failure C. blindness D. all of the above

4. What is the most desirable blood pressure?

A. less than 140/90 B. less than 120/80 C. less than 200/110 D. less than 160/80

5. One of the leading complications of high cholesterol is

A. cancer B. heart disease C. bone damage D. muscle spasms

6. Symptoms of high cholesterol include

A. headache B. lightheadedness C. weakness D. none of the above, there are no symptoms when you have high cholesterol

Page 1 Go on to the next page

7. Pills taken for high blood pressure are designed to

A. help your blood pressure to stay in the desired range B. increase the workload on the heart C. cure high blood pressure D. cure diabetes

8. You should stop taking oral medication when you

A. feel bad B. experience a long-term illness C. change your diet D. have been told to do so by your doctor

9. You are taking pills for your high blood pressure and you have developed a rash. What

should you do?

A. Take fewer pills each day B. Take more pills each day C. Stop taking the pills D. Tell your doctor or healthcare team

10. Which of the following is an appropriate way to store your medications at home?

A. Place them on a shelf in the bathroom. B. Keep them in your car. C. Place them in a plastic bag in the refrigerator. D. Place them in an appropriate container approved by your healthcare provider.

11. If your physician prescribes you a new blood pressure medication, you should ask your

physician or pharmacist

A. How does the medication work? B. What are the common side effects of this medication? C. What time of day should I take this medication? D. All of the above.


12. When you travel, your medications and supplies should be

A. packed in your luggage B. carried with you C. left at home D. sent ahead to your destination

13. The desired reading for LDL cholesterol is

A. Less than 100 B. Less than 200 C. More than 100 D. More than 200

14. If the bottom number of your blood pressure is over 100, you should

A. increase oral medication B. stop eating salt C. begin exercising more frequently D. call your doctor or other healthcare professional

15. When using a home blood pressure monitor to take your blood pressure reading

A. Do not use caffeine 30 minutes before B. Rest for 3-5 minutes before C. Use a correctly sized blood pressure cuff D. All of the above

16. Blood pressure monitoring indicates

A. the level of glucose in the blood B. the level of cholesterol in the blood C. the force of blood on the walls of your arteries D. whether complications of high blood pressure are present

17. When should self-monitoring of blood pressure be performed?

A. Only before breakfast B. Only before lunch C. Only before dinner D. When directed by your healthcare professional


18. You check your blood pressure in the morning before you take your blood pressure medicine and notice that it is much lower than usual. The best thing to do is to

A. sit down for a few minutes and check it again B. ignore it C. don’t take your morning medication D. drive to the emergency department

19. When should patients with high blood pressure be assessed by their eye doctor?

A. Never B. Every year C. Every 2 years D. Only after complications develop

20. A primary goal of monitoring blood pressure is to

A. reduce cholesterol levels B. determine how much salt to eat C. determine if you are taking the right amount of medicine at the right times D. determine the amount of stress in your life and how to reduce it

21. In overweight patients with high blood pressure, losing weight may accomplish all of the

following EXCEPT

A. lower blood pressure B. decrease the risk of diabetes C. decrease the risk of heart disease D. increase the number of medications needed to manage high blood pressure

22. Which food contains the lowest amount of sodium?

A. Canned chicken noodle soup B. Dill pickles C. Low fat cottage cheese D. French fries


23. When a food contains less than 5 milligrams (mg) of sodium, it is called

A. Salt free B. Low sodium C. Unsalted D. Tasteless

24. Eating foods that are low in fat may decrease the risk of

A. nerve disease B. kidney disease C. heart disease D. eye disease

25. Which of the following foods contains monounsaturated, or “good,” fat?

A. Bacon B. Sour cream C. Butter D. Olive oil

26. If you are trying to lower your cholesterol, which foods should be eaten in limited

quantities?

A. Fruits and vegetables B. Red meats C. Cereals and grains D. Skim milk

27. Which of the following are ways to reduce sodium in your diet?

A. Use fresh poultry, fish and meats rather than canned or processed meats B. Use herbs, spices and salt-free seasoning blends when cooking C. Cook rice, cereals and pasta without adding salt D. All of the above

28. Regular exercise may do all of the following EXCEPT

A. improve “good” cholesterol levels B. reduce heart rate C. help with weight management D. increase “bad” cholesterol levels


29. Which of the following are good ways to increase your level of physical activity?

A. Use stairs instead of an elevator B. Get off at the bus stop one or two stops early C. Park your car at the far end of the lot at work or at the shopping mall D. All of the above

30. Which of the following is NOT a moderate level physical activity?

A. brisk walking B. bicycling C. reading D. gardening

31. For a person with high blood pressure, if you quit smoking for one year, you will

decrease your risk of heart disease by more than

A. 50% B. 5% C. 10% D. 0%

32. Which of the following is NOT a positive way to manage stress?

A. Exercise B. Meditation C. Deep breathing D. Smoking

33. Once your blood pressure is controlled, you should see your primary care physician and

have your blood pressure measured at least every

A. 3-6 months B. 12 months C. 24 months D. 5 years

34. Which of the following life style modifications have been shown to reduce blood pressure?

A. Weight reduction B. Dietary sodium reduction C. Increased physical activity D. All of the above


35. Your cholesterol levels should be checked

A. at least once a year B. once a week C. every 3 years D. every 5 years

36. Ways to help control high blood pressure include all of the following EXCEPT

A. reduce stress B. increase exercise C. change physicians D. lose weight

THIS IS THE END OF THE ASSESSMENT. LET THE ASSESSMENT ADMINISTRATOR KNOW YOU ARE FINISHED AND RETURN ALL OF YOUR

ASSESSMENT MATERIALS.

Page 7

ID Code: __ __ __ - __ __ __ - __ __ __

Date Completed: __ __ / __ __ / __ __ __ __ MM DD YYYY

CV Health Knowledge Assessment Scoring Sheet

I. MEDICAL Correct? IV. MEALS Correct?

1. D 21. D

2. A 22. C

3. D 23. B

4. B 24. C

5. B 25. D

6. D 26. B

Section I score ____ of 6 27. D

Section IV score ____ of 7

II. MEDICATION Correct?

7. A V. MOTION Correct?

8. D 28. D

9. D 29. D

10. D 30. C

11. D Section V score ____ of 3

12. B

13. A VI. MANAGEMENT Correct?

Section II score ____ of 7 31. A

32. D

III. MONITORING Correct? 33. A

14. D 34. D

15. D 35. A

16. C 36. C

17. D Section VI score ____ of 6

18. A

19. B TOTAL SCORE ____ of 36

20. C BEGINNER < 25

Section III score ____ of 7 PROFICIENT 25-31

ADVANCED 32-36

Blood Pressure Monitoring Page 1 Copyright © 2006. APhA Foundation. All rights reserved. Unauthorized use, disclosure or reproduction is strictly prohibited. Version 1.0

APhA Foundatio ills Assessment Blood Pressure Monitoring (if required*) n Patient Self-Management: CV Health Sk

ote: the following can either be observed directly or determined by the answers to the questions below.

Proficiency Checklist N

Checklist Notes Yes No Level*

1. and understands reason(s) B Monitors when directedfor home monitoring*

2. Prepares monitor by adjusting settings B

3. Uses appropriate size cuff* B

4. uring P Blood pressure is taken at consistent times dthe day, such as in the morning or evening

5. t arm only for digital monitors) and on

P The same arm is used whenever the blood pressure is taken (lefa bare arm

6. ter P Blood pressure is not taken immediately afwaking in the morning or after exercising

7. Waits for 30 minutes after food, caffeine, tobacco P or alcohol, before taking blood pressure

8. Doesn’t talk while taking blood pressure P

9. A repeat reading is taken 2-3 minutes after the first P reading

10. Knows situations that require increased monitoring A (i.e., when medication is changed)

11. Has monitor calibrated by the physician once each y

A ear * Indicates the proficiency level (i.e., Beginner, Proficient, Advanced) to which each item applies

Number of Beginner items marked “Yes” _____ Number of Proficient items marked “Yes” _____

Questions for the Participant Satisfactory r

Answe ?

Question Yes No Level*

12. What is your ideal blood pressure? B

13. At what point should you call your doctor? B

14. When do you monitor your blood pressure (e.g., at least 2-3 times per week)? B

15. you think affects your blood pressure (e.g., diet, medication, exercise, A What dostress)?

16. When would you question the accuracy of the reading and what would you do? A * Indicates the proficiency level (i.e., Beginner, Proficient, Advanced) to which each item applies

Number of Beginner items marked “Yes” _____ Number of Advanced items marked “Yes” _____


his participant is: T

Beginner ________

Knows what the monitor does and why it is important

Is learning how to use the monitor

Must answer YES to a combined total of: 6 Beginner checklist items and questions

Proficient ________ Demonstrates proper blood pressure monitoring technique

Is capable of obtaining monitor readings

Can interpret the readings

Uses monitor with confidence to obtain readings

Can interpret the readings and explain fluctuations

M 6 Beginner checklist items aust answer YES to a combined total of: nd questions; AND 6 Proficient checklist items

Advanced ________ Understands complexities of monitor

Knows when to question readings

Can explain how he/she manages any observed fluctuations in glucose values

Must answer YES to a combined total of: 6 Beginner checklist items and questions; AND 6 Proficient checklist items; AND 4 Advanced questions

Comments:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


APhA Foundation Patie alth Skills Assessment Blood Pressure Monitoring nt Self-Management: CV He

Preferred Responses

1. Monitors when directed.

• es

hanging

result in better blood pressure control and greater success meeting blood pressure targets.

2. Prepares monitor by adjusting settings

• how or verbalize how to adjust time/date and other features on monitor with confidence.

3. Uses appropriate size cuff.

• urement will not be accurate. The inflatable part of the cuff must fit around the upper arm.

4. Blood pressure is taken at consistent times during the day, such as morning or evening

• blood pressure, it is best to take the blood pressure at the same time during the day.

5. used whenever blood pressure is taken (left arm only for digital monitors) and on a bare arm.

• re can vary between the left arm and the right arm, so it is important to be consistent..

6. immediately after waking in the morning or after exercise, such as walking or climbing stairs.

• Either take your blood pressure before you exercise or 60 minutes afterward.

7. Waits for 30 minutes after food, caffeine, tobacco or alcohol before taking blood pressure.

• All of these can change your blood pressure.

8. Doesn’t talk while taking blood pressure.

Patient is able to verbalize their individualized monitoring plan, frequency of monitoring and reason for monitoring, such as: (1) Monitor the treatment. Self-monitoring providinformation to know whether your medications or other treatments (diet, exercise) are working. Keeping track of changes can help you and your health care team can make decisions about your ongoing treatment strategy, such as adjusting dosages or cmedications. (2) Encourage better control. Taking your own blood pressure measurements has been shown to

Patient can s

If a cuff is too large or too small, the blood pressure meas

Blood pressure can vary throughout the day. When looking for trends in your

The same are is

Blood pressu

Blood pressure is not taken


• Talking can increase your blood pressure or interfere with the reading.

9. A repeat reading is taken 2-3 minutes after the first reading.

• A repeat reading ensures accuracy of the monitor.

10. Kn g.

ring or if there has been a persistent change in the blood pressure readings noted.

11. Ha

• A monitor should be calibrated with the physician’s monitor so that there can be a good the office and at home. This will also make sure your

monitor is working correctly.

12. Wh

• Your physician will determine your blood pressure goal. The patient should be able to state rally, the desirable blood pressure is less than

120/80.

13. At

•ddition, if

your home reading shows that your blood pressure is higher than normal and you , chest pain, numbness or tingling in the face

or limbs, contact your medical office immediately or seek emergency treatment.

14. How

• ey disease or

cardiovascular disease, you may need a goal lower than that of someone without these , your physician may want

more frequent reading initially until the blood pressure control is optimized.

15. What

• There are many things that can affect your blood pressure reading, including time of day, to provide a

complete listing to be considered proficient, but should have a general understanding.

16. Whe

ows situations that require increased monitorin

• A change in medication may require increased monito

s monitor calibrated by the physician once each year.

comparison between readings at

at is your ideal blood pressure?

what the goal of their treatment is. Gene

what point should you call your doctor?

Contact your doctor if you have any unusual or persistent increases in your blood pressure. Also ask what reading should prompt an immediate call to the medical office. In a

experience symptoms such as severe headache

often do you monitor your blood pressure?

You, your doctor and other providers will decide about what your home blood pressuregoal is and how often you should monitor. If you have diabetes, chronic kidn

conditions. If your physician is adjusting your medications

do you think affects your blood pressure reading?

exercise, recent caffeine or alcohol ingestion, etc. The patient doesn’t have

n would you question the accuracy of the reading and what would you do?


• The patient should be familiar with basic trouble-shooting, such as zeroing-out the digital monitor, taking a repeat reading, noting any changes in the time of day the blood pressure was checked, etc.

Nutrition Plan Page 1 Copyright © 2006. APhA Foundation. All rights reserved. Unauthorized use, disclosure or reproduction is strictly prohibited.

APha Foundation Patient Self V Health Skills Assessment Nutrition Plan -Management: C


Proficiency Checklist N


1. ., obesity) have B What effect does body weight (e.gon blood pressure management?

2. Why is meal planning important? B

3. What effect do fats have on cholesterol levels? B

4. t does salt/sodium have on blood B What effecpressure?

5. What effect does alcohol intake have on health? P

6. nds of fat are there and how do their effects A What kidiffer?

7 A . What is a DASH diet? * Indicates the proficiency level (i.e., Beginner, Proficient ed) to which each item applies

, Advanc

Number of Proficient items marked “Yes” _____ Number of Advanced items marked “Yes” _____


Number of Beginner items marked “Yes” _____

Answe ?


Questions 8-12 refer to a food label

8. How many servings are in the package? P

9. How many calories per serving? P

10. How many calories are in the entire package? P

11. How much fat is there per serving? P

12. How much sodium is there per serving? P

13. What food types have the most saturated (bad) fats? P

14. What food types have the most unsaturated (good) fats? A

15. ’s house and A What should you do if you are traveling or having dinner at a friendknow that the salt/sodium intake for that meal is likely to be high?

16. s to your making good food A What situations in your life are likely to be barrierchoices and how do you handle these situations?

* Indicates the proficiency level (i.e., Beginner, Proficient, Advanced) to which each item applies

Number of Beginner items marked “Yes” _____ Number of Advanced items marked “Yes” _____



Beginner ________

n cardiovascular health management and that Understands that what he or she eats has an effect omeal planning is an important part of m nagement a

Must answer YES to a combined total of: 4 Beginner checklist items

Proficient ________ Understands the effects of calories/obesity, fats and sodium on health

Knows how to read a food label and how to plan a meal to make healthy choices

Must answer YES to a combined total of: 4 Beginner checklist items; AND 7 Proficient checklist items and questions

Advanced ________ Can modify daily meal plans with respect to various situations (e.g., travel, activity, holidays)

Identifies barriers to healthy food choices

Must answer YES to a combined total of: 4 Beginner checklist items; AND 7 Proficient checklist items and questions; AND 5 Advanced checklist items and questions

Comments:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


APha Foundation Patient Self CV Health Skills Assessment Nutrition Plan

-Management:

Preferred Responses

1. What effect does body weight (e.g., obesity) have on blood pressure management?

•

work harder and people who are overweight tend to have or develop high blood pressure.

. Why is meal planning important?

•

to be prepared and help to control the amount of calories and fat eaten through out the day.

. What effect do fats have on cholesterol levels?

• ats will cause the cholesterol levels to rise, especially if a large amount of them are eaten.

. What effect does salt/sodium have on blood pressure?

• e the blood pressure. It is recommended to try to limit the sodium to 2.4 grams per day.

. What effect does alcohol have on health?

•

s, have only a moderate amount — one drink a day for women; two drinks a day for men.

. What kinds of fat are there and how do their effects differ?

•

e

s

ave as well, but not as severe as

saturated fat. It is found in vegetable oil and margarine.

When someone is overweight or obese, blood pressure management becomes difficult. High blood pressure makes your heart

2

Meal planning is important to help the patient manage their weight, sodium intake and cholesterol. Meal planning allows the patient

3

Saturated f

4

Sodium may increas

5

Drinking too much alcohol can raise blood pressure. It also can harm the liver, brain, and heart. Alcoholic drinks also contain many calories, which matter if you are trying to lose weight. If you drink alcoholic beverage

6

There are three different kinds of fat (saturated fat, monounsaturated fat, and polyunsaturated fat). Saturated fat is the worst type of fat. This is the fat that will causyour LDL to increase. It is found in bacon, sausage, cheese, egg yolk, lard, etc.). It is important to limit the intake of this fat (less than 17 gm per day). Monounsaturated fat ithe best type of fat to eat. It should have little or no effect on your LDL. It is found in olive oil, canola oil, peanut butter. Polyunsaturated fat is ok fat. It is recommended to honly in moderation. It may cause a slight increase in LDL


7.

• fats and cholesterol. It also focuses on

menu planning with sodium lower than the average that people in the United States eat. The dium diets.

8. the package?

9. rving?

10. the entire package?

11.

12. rving?

13.

• Foods that have the most carbohydrates include: bread (esp. white bread), pasta, potatoes,

14.

• Foods that contain the fewest carbohydrates include: meat/protein, vegetables, high fiber

5. What should you do if you are traveling or having dinner at a friend’s house and know that the

•

meal are not as hungry and you will hopefully eat less. You may want to ask your

host to prepare foods for you without added salt, and you could bring along your salt substitute.

What is a DASH diet?

The DASH eating plan was based on a study of people who had high blood pressure. It follows heart healthy guidelines to limit saturated

menus have 1500 mg and 2300 mg so

How many servings are in

• Refer to a food label

How many calories per se


How many calories are in


How much fat per serving?


How much sodium per se


What food types have the most saturated (bad) fats?

rice, beans, peas, corn, fruit, dairy/milk products.

What food types have the most unsaturated (good) fats?

foods as well.

1salt/sodium intake for that meal is likely to be high?

If you are going to have a high sodium intake for one meal, you could decrease the amount of sodium with the other meals throughout the day, you could increase your exercise for that day, or you could try to snack on healthier low sodium foods prior to going to theso that you


6. What situations in your life are likely to be barriers to your making good food choices and how

• Situations that may be barriers include: job, eating out a lot, not responsible for buying the

•

w-fat dressings); suggest to the person buying food for the household, to buy lower fat and calorie food; choose sugar free desserts, or decrease the portion size of the dessert.

1

do you handle these situations?

food, sweet tooth, etc.

Ways to handle these situations: try to bring your lunch with you to your job; when eating out, choose healthier, low fat foods (broiled or poached meats, salads with lo

CV Health: Oral Medication Page 1 Copyright © 2006. APhA Foundation. All rights reserved. Unauthorized use, disclosure or reproduction is strictly prohibited.

Medication Administration and Situational Dose Adjustment: Oral Medication APha Foundation Patient Self-Management: CV Health Skills Assessment


Answe ?


1. What is the name of your medication? B

2. What type of medication is it and what does it do? P

3. Where should you store your medication? P

4. When should you take your medication? B

5. What should you do if you miss a dose? A

6. you do if you are having a possible side effect from the A What should medication?

7. uld you use to make sure you do not forget to take your A What plan shomedication?


Number of Beginner items marked “Yes” _____ Number of Proficient items marked “Yes” _____ N s marked “Yes” _____

his participant is: umber of Advanced itemT

Beginner ________ tion will be a significant aspect of self-management and will need to Understand that taking medica

be integrated into his/her life

Knows what medication he or she is taking, typical dosage and when to take it

Must answer YES to both (2) Beginner questions

Proficient ________ to describe the mechanism by which his/her blood pressure and cholesterol medication Is able

works

Knows how food impacts the medication’s effect

M both (2) Beginner questions; Aust answer YES to a combined total of: ND both (2) Proficient questions


Advanced ________ Is aware that different situations can impact medication effects

sage adjustments may be needed Manages dosage adjustment situations and anticipates when dodue to changes in diet, exercise or other daily living activities

Must answer YES to a combined total of: both (2) Beginner questions; AND both (2) Proficient questions; AND all 3 Advanced questions

Comments:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


Medication Administration and Situational Dose Adjustment: Oral Medication APha Foundation Patient Self-Management: CV Health Skills Assessment

Preferred Responses

. What is the name of your medication?

• of medications, or

give a description of each medication (i.e. its shape, color, and function)

2. What type of medication is it and what does it do?

• Zestril is

ry for the patient to state, “Zestril is an ACE-Inhibitor that lowers my blood pressure”.

3. Where should you store your medication?

•

in extreme heat or cold. It should not be stored in a humid location such as a bathroom.

4. When should you take your medication?

•

aken in the morning. Others, such as statins, are recommended to be taken at bedtime.

5. What should you do if you miss a dose?

•

y should not double-

up on medications due to a risk of adverse events, i.e. hypotension.

. What should you do if you have a new symptom or possible side effect from your medication?

• pped work with you to decide whether you

should continue or change the medication.

. What plan should you use to make sure you do not forget to take your medication?

• endar, or placing

bottles in a specific place such as by the alarm clock or coffee maker.

1

Patient should be able to either state his or her medications, provide a list

Patient should be able to describe what each pill is indicated for. Example: “My for my heart to help lower my blood pressure and my Lipitor helps me lower my cholesterol.” It is not necessa

Medication should be stored at room temperature unless otherwise indicated and in the containers provided by your pharmacist. It should not be kept

Medication should be taken as directed. Certain medications, such as ACE-Inhibitors, should be t

This depends upon the medication. If the patient has only missed the dose by a few hours, then the medication can be taken as soon as it is remembered. If more time has passed, thepatient should resume with the next scheduled dose. Patients generall

6

Talk to your pharmacist or physician for guidance. Some medications should not be stowithout a taper period. Your physician needs to

7

This will be patient-specific. The important thing is that the patient has some sort of systemto remember the medications. These systems could include a pillbox, cal

Stress Management Page 1 Copyright © 2006. APhA Foundation. All rights reserved. Unauthorized use, disclosure or reproduction is strictly prohibited.

APha Foundation Patient Self-Management: Cardiovascular Health Skills Assessment Stress Management

Questions for the Participant Satisfactory Answer?


1. How does stress affect blood pressure? B

2. Why is it important to manage stress? B

3. Identify 2 or 3 stressors in your life? P

4. Are the stressors in your life physical or mental? P

5. Are the stressors in your life ongoing or temporary? P

6. How can you test whether or how much stress is affecting your blood pressure? A

7. How do you deal with the stressors in your life (e.g., ignore them, drink, act hostile, exercise)? P

8. What can you do to relax (e.g., breathing exercises, banishing bad thoughts, replacing bad thoughts with good ones)? Do you do this? How often?

P

9. What other and more long-term ways can you reduce your mental stress (e.g., make changes, change lifestyle, use support groups, therapy)? Do you do this?

A

10. How can you anticipate stressors in advance? Do you do this? A

11. Name 1 or 2 cardiovascular health support systems or methods that you use (e.g., ADA, family, friends, personal breathing techniques, therapist). P


Number of Beginner items marked “Yes” _____ Number of Proficient items marked “Yes” _____ Number of Advanced items marked “Yes” _____


This participant is:

Beginner ________ Is aware that stress management and coping will be important to successful self-management

Is aware that stress has an effect on blood pressure

Must answer YES to both (2) Beginner questions

Proficient ________ Can identify stressors

Can identify coping techniques

Must answer YES to a combined total of: both (2) Beginner questions; AND 6 Proficient questions

Advanced ________ Uses or seeks coping techniques to deal with life situations that cause stress

Can anticipate and deal with stressors in advance (e.g., lifestyle changes)

Must answer YES to a combined total of: both (2) Beginner questions; AND 6 Proficient questions; AND 3 Advanced questions

Comments:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


APha Foundation Patient Self-Management: CV Health Skills Assessment

Stress Management

Preferred Responses

1. How does stress affect blood pressure?

• Stress can lead to increased blood pressure (due to excess increases during stressful periods). When stress is sustained over periods of time, it can lead to high blood pressure.

2. Why is it important to manage stress?

• Relates to number 1. Managing stress will help to better manage your cardiovascular health. When stressed, blood pressure can go up and this makes the heart work harder, which can lead to stroke, heart attack, kidney disease or other chronic problems. Managing stress will also contribute to a happier, healthier life.

3. Identify 2 or 3 stressors in your life?

• Yes = Patient must simply identify 2 or 3 stressors (i.e. work, life, diabetes or other

chronic illness, family, etc… will vary from patient to patient)

4. Are the stressors in your life physical or mental?

• Yes = Patient must identify if stress seems to be mental (examples: fear, depression, coping) or more disease (examples: chronic care related to heart disease) or body related / physical (reduction in abilities, or overall care ). Will help to identify type of stress which can then lead to reducing it.

5. Are the stressors in your life ongoing or temporary?

• Yes = Self-explanatory…Is it a recurring or continuous stressor or one that is short-lived.

6. How can you test whether or how much stress is affecting your blood pressure?

• Yes = Options include testing blood pressure during stressful and non-stressful times,

keeping a stress diary, or combining the two and keeping a stress record and blood pressure record (if monitoring) together.


7. How do you deal with the stressors in your life (e.g., ignore them, drink, act hostile, exercise)?

• Yes = Appropriate ways to deal with stress are acceptable. Answers will vary widely.

Some examples include: talking with others, knowing your limits, expressing feelings / crying (when appropriate), laughing each day, exercise, planning ahead, setting realizable goals, taking breaks, prayer / meditation / religious oriented relaxation or devotion, support group, pets. Inappropriate ways, such as drinking, would equal a no response.

8. What can you do to relax (e.g., breathing exercises, banishing bad thoughts, replacing bad thoughts with good ones)? Do you do this? How often?

• Yes = Identification of a relaxation technique will suffice. Answers will again be various.

Examples are in number 7. More importantly, identification alone does not satisfy the question. An answer must include a time frame that the patient actually conducts one or more of these self management techniques.

9. What other and more long-term ways can you reduce your mental stress (e.g., make changes, change lifestyle, use support groups, therapy)? Do you do this?

• Yes = Self explanatory. Somewhat subjective, and will vary from patient to patient.

Provider must differentiate between immediate relaxation techniques (example: hot bath) versus long-term stress reduction (example: therapist).

10. How can you anticipate stressors in advance? Do you do this?

• Yes = Patient must identify whether or not they can predict (i.e. plan for) stressors. Most important is whether or not they do this. If so, then they satisfy the question.

11. Name 1 or 2 cardiovascular health support systems or methods that you use (e.g., AHA, family, friends, personal breathing techniques, or therapist).

• Yes = Repetitive question, but focuses specifically on cardiovascular health. Focus here is

to identify what patient is stressed with respect to their blood pressure management and how they specifically handle that individual stress.

CV Health Activity Plan. Copyright © 2006. APhA Foundation. All rights reserved. Unauthorized use, disclosure or reproduction is strictly prohibited.

APhA Foundation Patient CV Health Skills Assessment ACTIVITY PLAN Self-Management:

Proficiency Checklist


N


1. B Understands why it is important to walks for 20 minutes three times a week

2. Wears shoes that fit well (i.e., provide ample space) B

3. What effect does regular physical activity have on B you cardiovascular health.

4. )

P What is considered a moderate level activity (ie. brisk walking, bicycling, raking leaves, gardening

5. moderate level activity for thirty P Participates in aminutes daily.

6. Monitors pulse rate in relation to aerobic exercise P * Indicates the proficiency level (i.e., Beginner, Proficient, Advanced) to which each item applies Number of Beginner items marked “Yes” ________ Number of Proficient items marked “Yes” ________


Answe ?


7. What is the optimal level of physical activity to improve your cardiovascular health? B 8. Under what conditions should you consult your health care provider? P 9. Are there types of physical activities that can also reduce your stress level? P 11. What effect does exercise have on your diet? A 12. What products or types of activities should you avoid doing? A * Indicates the proficiency level (i.e., Beginner, Proficient, Advanced) to which each item applies Number of Beginner items marked “Yes” ________ Number of Proficient items marked “Yes” ________ Number of Advanced items marked “Yes” ________



Beginner ________ Understands the basics of proper exercise

Is learning how to incorporate activity into their daily routine

Must answer YES to a combined total of: 4 Beginner checklist items and questions

Proficient ________ Can describe and demonstrate proper activities and measuring levels of activity

Understands why exercise is important

Must answer YES to a combined total of: 4 Beginner checklist items and questions; AND 5 Proficient checklist items and questions

Advanced ________ Describes activities that are most effec e in improving cardiovascular health tiv

Must answer YES to a combined total of: all 4 Beginner checklist items and questions; AND 5 Proficient checklist items and questions; AND both (2) Advanced questions

Comments:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


APhA Foundation Patient Self-Management: Cardiovascular Health Skills Assessment

Activity

Preferred Responses

1. Und s a week.

• eing physically active is one of the most important steps you can take to prevent or control highblood pressure. It also helps reduce your risk of heart disease.

2. We ple space in the toes, support).

• Increasing your activity can also cause problems. You should have the proper equipment,

3. Wha

• Regular physical activity works the heart and blood vessels to keep them in shape. Activity can

4. What is considered l activity (ie. brisk walking, bicyc s, gardening)?

erstands why it is important to walks for 20 minutes three timeB

ars shoes that fit well (i.e., provide am

including shoes, such as for walking.

t effect does regular physical activity have on you cardiovascular health?

also help to keep your weight in the normal range or help you to reduce weight.

a moderate leve ling, raking leave

Common Chores Sporting Activities

Washing and waxing a car for 45-60 minutes

Washing windows or floors fo

Playing volleyball for 45-60 minutes

Playing touch football for 45 minutes

Walking 2 miles in 30 minutes (1 mil

r 45-60 minutes

Gardening for 30-45 minutes

Wheeling self in wheelchair for 30-40 minutes

Pushing a stroller 1½ miles in

e in 15 minutes)

Shooting baskets (basketball) for 30 minutes

Dancing fast (social) for 30 minut

30 minutes

Raking leaves for 30 minutes

Shoveling snow for 15 minutes es

Performing water aerobics for 30 minutes

Swimming laps for 20 minutes

Playing basketball for 15-20 m

St air walking for 15 minutes

inutes

Jumping rope for 15 minutes From the NHLBI

http://www.nhlbi.nih.gov/hbp/prevent/p_active/m_l_phys.htm2006 Running 1½ miles in 15 minutes (1

mile in 10 minutes) 5. Participates in a moderate level activity for thirty minutes daily.

moderate level activity for thirty minutes each day. • The patient describes how they participate in a


7. Wha

• e and

time. It doesn't take a lot of effort to become physically active. All you need is 30 minutes of moderate-level physical activity on most days of the week. Engage a moderate-

ach week or engage in a more

8. Und

• al activity. You should check first with your doctor if you have heart trouble or have had a heart attack, if you're

have a family history of

. Are there types of physical activities that can also reduce your stress level?

ctivities, such as yoga also reduce

10. Wh

• Activity burns calories, so the more activity in your day, the more you will be able to eat and will lose weight more easily.

2. What products or types of activities should you avoid doing? • You should avoid activities that are painful or if you begin to have chest or leg pains. If you have

chest or leg pains, see your physician.

6. Monitors pulse rate in relation to aerobic exercise • Patient demonstrates how to take a pulse.

t is the optimal level of physical activity to improve your cardiovascular health? This should be determined in relation to your current activity level and if vigorous activity is thgoal, in conjunction with your physician. It is different for everyone. You need to start slowbuild up a little at a

level activity for a longer period each day or for more days evigorous activity.

er what conditions should you consult your health care provider? Most people don't need to see a doctor before the start a moderate-level physic

over age 50 and are not used to moderate-level physical activity, if you heart disease at an early age, or if you have any other serious health problem.

9• Yes, most exercise will reduce your stress level. Low-impact a

stress.

at effect does exercise have on your diet/weight management?

maintain your wait, or if you are trying to lose weight, youIncreased activity also helps to increase your “good” (HDL) cholesterol.

1

PSM ID Code: __ __ __ - __ __ __ - __ __ __

Cardiovascular Health Skills Scales Scoring Summary Sheet

Skill Date assessed

Beginner items

passed

Proficient items

passed

Advanced items

passed Rating (circle proficiency level

achieved)*

Blood Pressure Monitoring

Beginner ( 1, 2, 3, 12, 13, 14 ) Proficient ( 4, 5, 6, 7, 8, 9 ) Advanced ( 10, 11, 15, 16 )

Nutrition Plan

Beginner ( 1, 2, 3, 4) Proficient ( 5, 8, 9, 10, 11, 12, 13 ) Advanced ( 6, 7, 14, 15, 15, 16 )

Medication Administration and

Situational Dose Adjustment-Oral

Medications

Beginner ( 1, 4 ) Proficient ( 3 ) Advanced ( 6, 7 )

Stress Management Beginner ( 1, 2 )

Proficient ( 3, 4, 5, 7, 8 ) Advanced (6, 9, 10 )

Activity Beginner ( 1, 2, 3, 7 )

Proficient ( 4, 5, 6, 8, 9, 10 ) Advanced ( 10, 11 )

* The numbers and letters in parentheses indicate the number of skills scale items corresponding to each proficiency level (i.e., Beginner, Proficient, or Advanced) that must be answered/demonstrated successfully to be achieve each proficiency rating for that skill scale.

To achieve a rating of “Proficient” in the Overall Skills Assessment, the patient must achieve a rating of either “Proficient” or “Advanced” in all skill areas. To achieve a rating of “Advanced” in the Overall Skills Assessment, the patient must achieve a rating of “Advanced” in all skill areas.

Date “Proficient” rating achieved

Date “Advanced” rating achieved

Copyright © 2006. APhA Foundation. All rights reserved. Unauthorized use, disclosure or reproduction prohibited. Version 1.0

ID Code: __ __ __ - __ __ __ - __ __ __

Date Completed: __ __ / __ __ / __ __ __ __ MM DD YYYY

Cardiovascular Health Performance Assessment Scoring Sheet

Checklist Yes No N/A Notes Level+

1. Maintains healthcare visit schedule (quarterly minimum)*

P

2. Develops and meets at least two behavior goals every 6 months (Examples include smoking cessation, exercise, meal plan changes, self-monitoring of blood pressure, medication adherence, stress management)*

P

3. Has a blood pressure measured AT LEAST every 3 months*

P

4. Has a lipid profile every 12 months P

5. Demonstrates consistent nutritional program commitment by meeting individual goal AT LEAST 80% of the time**

A

6. Demonstrates regular exercise program participation by meeting individual goal AT LEAST 80% of the time**

A

7. Refills medications within 6 days of scheduled refill each month**

A

8. Patient self-reports taking medication as prescribed for AT LEAST 80% of scheduled doses**

A

9. Has dilated eye exam AT LEAST annually** A

+ Indicates the proficiency level (i.e., Beginner, Proficient, or Advanced) to which each item applies

Copyright © 2006. APhA Foundation. All rights reserved. Unauthorized use, disclosure or reproduction is strictly prohibited. Version 1.0a


Checklist Yes No N/A Notes Level

10. Monitors blood pressure regularly, AT LEAST 80% of the individually defined frequency

A

11. Takes aspirin (if applicable)

12. Takes an ace-inhibitor/A2RB-Angiotensin receptor blocker (if applicable)

13. Has a dental visit AT LEAST every 6 months

14. Has serum creatinine measured at least once a year.

15. Has influenza vaccination annually

16. Has pneumococcal vaccination appropriate for age

17. Does not use tobacco products

18. Avoids or drinks alcohol in moderation

* Must be accomplished to obtain a proficient rating ** Must be accomplished to obtain an advanced rating.

This participant is: __________ BEGINNER (missing any of first four items)

__________ PROFICIENT (achieving a minimum of the first four items)

__________ ADVANCED (achieving a minimum of the first ten items)

Comments: _____________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

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