Introduction to Pharmacy

Practice and Simulation

PHAR456
Beirut Instructors: Dr. Marwan Akel; Dr. Jihan Safwan; Dr.
Ahmad Dimassi; Dr. Maya Khoury; Dr. Siham Kanaan
Bekaa Instructor: Dr. Rasha Jbara
Lebanese International University
School of Pharmacy
Spring 2020-2021
1
 3. Dealing with
Patients/Medication
Adherence/Visits
3.A Dealing With Patients and Health Care Professionals
3.B Dealing With Patient Adherence Issues
3.C Organizing Patient Visits
 Learning Outcomes
• By the end of the lecture, the student will be able to:
• Describe new attitudes, roles, and skills needed to develop effective patient
relationship
• Describe key factors that impact effective primary patient education
• Describe effective techniques to communicate about patients with other healthcare
professionals
• Identify other terms used to define medication adherence
• Describe common misconceptions and requirements for medication adherence
• List common adherence risk factors
• Discuss methods used to assess medication adherence
• Describe techniques used to improve medication adherence
• Describe purpose and structure of a patient visit/pre-visit for a chronic disease
3.A Dealing With Patients and
Health Care Professionals
 New Era in Pharmacy Profession
• Pharmacy profession is becoming more actively involved in direct
patient care
• Pharmacists are considered an essential part of the healthcare team
• New roles for pharmacists as care providers and educators for
patients primarily about their chronic diseases
• All of theses factors require pharmacists to develop and acquire new
communication skills to effectively communicate with other
healthcare professionals and patients in order to optimize patient
care and health
 Developing Effective Patient Relationship
• Patients’ attitude towards healthcare provider as “all knowing”
authority figure has changed
• Patients have wide access to information related to health issues
through internet
• Patients want to be active participants in their care and be viewed as
a “person” not a “disease” (as they are the ones managing their
chronic disease most of the time)
• Patient-Provider relationship has changed to partnership where
providers act as facilitators and advocates for patients’ self care
 Developing Effective Patient Relationship

In these new partnership roles, pharmacists need to evolve their skills

These skills include:

• Communication skills (ex: open ended questions...)
• Patient assessment skills (ex: history taking)
• Limited physical examination skills
• Patient education skills (ex: teach back method)
• Improved Cultural Sensitivity
• Adherence support skills (ex: human behavior knowledge, interventions to improve
adherence, effective communication)
 Primary Patient Education
• Primary patient education: patients understanding pertinent facts
about their disease, diet, exercise, home testing, etc.
• It is the foundation of a patient’s ability to adhere to prescribed
therapy for their chronic disease
• Pharmacists traditionally are providers of secondary education (i.e.:
verifying that patients understand how to take their medication
properly)
• In their new patient centered role, pharmacists will be primary
educators and thus should familiarize themselves with key factors
that impact patient understanding of key elements of knowledge
 Primary Patient Education
• Standard comprehensive lecture formats have low utility (ready
availability of material on the Internet)
• Preferred learning style: needs-based, individualized, highly interactive
techniques, with or without initial needs assessment
• Goal of primary education: Verify patient understanding of important
information and skills (NOT providing info)
• Verification = teach-back method= verbalizing or demonstrating
understanding
• Teach-back method is effective as patient remembers more information
for longer periods of time
 Primary Patient Education
• Self-Efficacy: patients will only attempt an activity or learn material
that they think they can accomplish
• If overwhelmed with multiple activities to initiate or large volumes of
material to learn, they give up and do not try
• Small focused steps, done sequentially that build upon previous
sessions, are much better than large one-time comprehensive
approaches
• Small focused steps lead to better accumulation of knowledge and
better adherence
 Primary Patient Education
• Confounding patient variables can also affect educational efforts or
necessitate changes in educational technique
• Teach-Back method/open-ended questions/interactive teaching helps
the pharmacist quickly identify these potential problems
• These variables include:
Health Literacy (use easy lay language)
Age/Geriatric (impaired vision/hearing, lack of dexterity needed to administer
medications)
Culture/Language/Health beliefs
Disease itself (improve patient’s symptoms to improve receptivity of info)
 Primary Patient Education
• Individualize education approaches: giving same material to everyone
is a suboptimal approach
• Patients have a wide range of knowledge levels (due to internet)
• Pharmacist is required to assess each individual’s knowledge,
preferred learning styles, attitude towards their disease, and
availability
 Effective Communication With Health Care
Professionals
• Each profession has its own language and communication protocols
• This affects the accuracy of critical communication about patients
with other health care providers
• Dialogues between different professionals can be confusing and
fraught with misunderstanding
• Solution is for everyone to use a common language when discussing
patients
• Most widely used communication protocol in health care is that used
by physicians to communicate to each other about patients
 Effective Communication With Health Care
Professionals
• This protocol generally has 4 major steps:
• A brief description of the patient (name, age, gender, and relevant prior
medical history is presented)
• The reason for the call and the current situation are discussed using a chief
complaint medical history protocol such as “LOQQSAM” (Objective data such
as physical examination and laboratory results can be added if available)
• Pause to allow the physician to assimilate and analyze the information
presented
• If the physician doesn’t arrive quickly at the correct assessment, the
presenter can put forward his/her assessment or recommendation using “I”
messages
 LOQQSAM

"Dealing With Patients and Health Care Professionals." Patient

Assessment in Pharmacy Eds. Richard N. Herrier, et al. McGraw-
Hill, 2015
Sample Dialogue Using Medical Model

"Dealing With Patients and Health Care Professionals." Patient

Assessment in Pharmacy Eds. Richard N. Herrier, et al. McGraw-
Hill, 2015
 Effective Communication With Health Care
Professionals
• One similar process used for nurse-physician communication in many
hospitals is the SBAR technique:
• Situation: describes pertinent patient demographic data and the
reason for the call
• Background: presents detailed medical information about the patient
that is relevant to the situation
• Assessment: Caller (nurse) assessment is presented
• Recommendation: nurse provide a recommendation, or tell the
physician what action the caller (nurse) is requesting
SBAR Technique

"Dealing With Patients and Health Care Professionals." Patient

Assessment in Pharmacy Eds. Richard N. Herrier, et al. McGraw-
Hill, 2015
3.B Dealing With Patient
Adherence Issues
 Medication Adherence
• Medication non-adherence is a major public health problem
• Patients with poor adherence can cost the health care system much more
than patients with high adherence
• Adherence to diet, exercise, and other therapeutic modalities is even less
than for medications
• “Adherence” is the term used in the US (compliance no longer used)
• “Concordance” is the term used in UK to reflect partnership between
patient and provider
• “Persistence” refers to how many pills are picked up from the pharmacy
and is more of an economically focused term
Types of Non-Adherence

"Dealing With Patient Adherence Issues." Patient Assessment

in Pharmacy Eds. Richard N. Herrier, et al. McGraw-Hill, 2015
 Providers’ Adherence Misconceptions
Misconceptions
• They only manage during follow-up visits, the rest of the time patients
Providers manage patients’ chronic disease manage their disease

Self motivation and cheerleading style OR • Behavioral science has shown it has low utility and can even worsen
threatening, chastising approach can improve adherence
adherence

• Although they take more medications and have more barriers to adherence,
Elderly patients have lower medication
studies has shown they have better adherence than younger populations
adherence rates than younger populations

• Studies repeatedly show that traditional educational programs have little or

Educating patients is enough to ensure optimal
no effect on medication adherence in asymptomatic chronic diseases
adherence

Providers are aware of how much medication • No, as evidence changes with time and less than the thought optimal
adherence is required to cure acute illness or gain adherence might be as effective as the optimal one
benefit from chronic disease therapy
 Requirements for Medication Adherence
• Three requirements for patients to adhere to medication regimens:
1. Sufficient understanding of the chronic disease and the medications being
used to treat it
2. Motivation to take the medication
3. Implementation of necessary behavior changes

• The impact on adherence to medications for each of these three

requirements differs between acute and chronic medications
• For both acute and chronic, teach-back techniques are used to verify
understanding (by either demonstration or verbalization )
Requirements for Medication Adherence

"Dealing With Patient Adherence Issues." Patient Assessment

in Pharmacy Eds. Richard N. Herrier, et al. McGraw-Hill, 2015
 Acute Medications
• Patient understanding plays a major role
• It is easy to be motivated to take medications that will end the
symptoms
• The behavioral changes (taking medication) are short lived, lasting for
only a few days
• Education and verification of patient understanding have a significant
impact on subsequent medication adherence in patients with acute
symptomatic diseases
 Chronic Medications
• Motivation and behavioral changes are the major forces in determining
subsequent medication adherence
• Understanding about disease and medications is still the foundation for ultimate
patient adherence, but has far less impact
• No obvious symptoms: more difficult for patients to motivate themselves to take
medication to prevent some vague future complications
• Patients must feel and accept that something is wrong with them, feel motivated
to prevent future problems by using medication, and believe that the pros of
taking medicine will in the long run outweigh the cons
• The behavioral aspects are overwhelming: patients are required to make lifelong
changes in diet and exercise and take medications for the rest of their lives
 Acute vs. Chronic

Acute
• Patient understanding plays a
major role
• Education has a significant
impact
• Easy to motivate (symptoms)
• Behavioral changes short lived
Chronic
• Motivation and behavioral
changes are the major forces
• Education has far less impact
• Hard to motivate (no symptoms)
• Behavioral changes life long
 Risk Factors for Suboptimal Adherence
• Theoretical Factors:
1- Locus of control:
• Patients with an external locus of control feel that events are either in the hands of God
or are determined by fate and that they as an individual have little control over what
happens
• Patients with an internal locus of control feel that they have great influence over what
happens to them
• Patients with an internal locus of control have significantly higher medication adherence
rates than patients with an external locus of control
2- Transtheoretical model
• Five stages of readiness for change (FYI)
 Risk Factors for Suboptimal Adherence
• Actual factors:
• These are real world issues that in most cases are fairly obvious to most
health care providers
• Examples:
• Disease state: in asymptomatic diseases (hypertension and hyperlipidemia) adherence
rate is much less than symptomatic ones such rheumatoid arthritis
• Physical Handicaps: might interfere with proper administration of eye drops, inhalers,
nasal sprays, and opening child-resistant prescription bottles
• Previous compliance history: who previously had poor adherence usually will have a
similar pattern of non-adherence
Risk Factors for Suboptimal Adherence

"Dealing With Patient Adherence Issues." Patient Assessment in Pharmacy Eds. Richard N. Herrier, et al. McGraw-Hill, 2015
 Assessing Medication Adherence Problems
• Medication adherence can be assessed by both subjective and objective
means
• Subjective Method:
• Interviewing the patient about adherence problems during their routine primary care
visit
• Limitation: patients might fail to truthfully answer about adherence because they are
trying to avoid the embarrassment of the provider chastising them about adherence
issues
• Solution: avoid the threatening approach and instead “set the stage” at the initial visit
• How to set the stage?
 Confirm it is the patient’s disease and their accurate input is important
 State that you realize that there will be some difficulties in working medication taking into their daily
routine and you are going to work with the patient to get the best possible results
 Assessing Medication Adherence Problems
• Subjective Method:
• Setting the Stage at the Initial Visit

"Dealing With Patient Adherence Issues." Patient Assessment

in Pharmacy Eds. Richard N. Herrier, et al. McGraw-Hill, 2015
 Assessing Medication Adherence Problems
• Objective Methods
1. Refill record: to measure persistence, an approximation of actual adherences
rates
• Limitations:
• Providers might not have access to patient refill records
• Patients may occasionally use another pharmacy to get their medications
• It might be time consuming and impractical
2. Pill count: count the number of pills remaining (in prescription bottles or pill
organizers) to measure adherence
• Limitations:
• Can be time consuming and impractical
• If patients discover that they are being chastised because of pill counts, they will learn to make sure
that the number of pills left agrees with what the provider expects (ex: throw them before the next
visit)
 Assessing Medication Adherence Problems
• Objective Methods
3. Control of the chronic disease: the degree of control of the disease can indicate
the level of medication adherence
• Limitations:
• White coat compliance: good control of the disease is not necessarily indicative of good adherence
(ex: taking hypertension medication one week before provider’s visit to avoid chastising)
• Poor disease control may not be due to poor adherence (medication regimes may be inadequate
for control)
4. Serum medication levels: for those drugs with readily available therapeutic
serum level values targets
• Limitations:
• Low serum drug levels can also be indicative of genetic polymorphisms, individual variations in
absorption and excretion or nonbioequivalent products
 Assessing Medication Adherence Problems
• Supportive Adherence
• If the objective measures of adherence are inconsistent with the subjective
measures: use supportive adherence probe
• Example: “I noticed there were some missing refills of beclomethasone
inhaler and I’m concerned that there might be a problem.”
• This use of an “I” message makes your concern (as a provider) the main issue
and not their behavior and encourages them to talk about issues (cost, side
effects, etc) that caused them not to refill the medication
 Assessing Medication Adherence

Take home message for assessing

medication adherence:
• No absolutely foolproof method
• Most accurate approach is to set the stage and
use patient interview, plus one or more
objective measures of adherence
 Techniques to Help Patients Improve
Medication Adherence
I. Behavioral Interventions:
• Develop a Routine: help patients develop a routine
• Simplify the Treatment Regimen: reduce the number of medications and the frequency of dosing
• Minimize the Cost: use generic medications when possible
• Tailor the Regimen: adapt the regimen to individual patient routines, schedules, and clinical
findings
• Confirm Appropriate Administration Technique: for patients using medication administration
devices that require a specific technique for efficacy (i.e., inhalers, eye drops) and who are
experiencing suboptimal disease control
• Reward Patient Success: verbal or concrete rewards
• Increase Attention: increase the frequency of contact with the patient (periodic telephone calls,
periodic follow-up visits, seeing the pharmacist between physician visits)
• Enlist Support of Others: especially in implementing dietary or exercise changes (spouse,
caregiver…)
 Techniques to Help Patients Improve
Medication Adherence
I. Behavioral Interventions:
• Use adherence aids:
• For patients who have trouble developing a routine
• Effective as part of a comprehensive adherence support program (not alone)
• Never suggest adherence aids; It means “You are not competent to take care of yourself”, elderly
don’t want to hear this message
• IF suggested, offer a pill organizer as part of a group of choices
• Many patients themselves select devices and use them effectively (Patients are much more likely
to do something if it is their idea as opposed to the provider’s)
• Motivational Interviewing:
• Use of motivational interviewing by itself has not been shown to have significant positive effects
• As with adherence aids, very few patients are candidates for formal motivational interviewing,
since once the reason for nonadherence is discovered, other useful techniques can be used
 Techniques to Help Patients Improve
Medication Adherence
II. Principles of Adherence Support: (a guide for providers)
1. Whose Disease Is It Anyway?:
• Always remember that the patient manages their own disease!
• View yourself as a helpful coach
• Give them several options to choose from
2. All Motivation Is Self-Motivation:
• Provider’s job is to create an environment where patients can comfortably motivate
themselves to adhere to medications
• Avoid the threatening/chastisement or cheerleading approaches
3. Making Long-Term Changes in Behavior Is Not Easy:
• Be patient and supportive as adherence is a long term behavior change that take time
and energy from patients to integrate
 Techniques to Help Patients Improve
Medication Adherence
II. Principles of Adherence Support: (a guide for providers)
4. One Step at a Time:
• Remember “self-efficacy” principle and initiate changes slowly (don’t have them try to make all changes
at once diet, exercise, drugs…)
5. Do Not Chase Numbers:
• Recent medical guidelines provide greater flexibility in establishing target lab values for each patient
• If patient decides that they are unwilling to make more changes (when near acceptable values), accept
it. It is their disease and their life
6. Help the Patient Establish a Routine:
• Help patients integrate medication behavior into existing activities
7. Regularly Assess Adherence Levels:
• At initial visit, “set the stage” during the interview
• At every visit inquire about problems with adherence to dietary, exercise, and medication
• Use two objective measurements to assess adherence
3.C Organizing Patient Visits
 Organizing Patient Visits
• 4 functions (purpose) of patient visits:
1. First:
• Collect data to assess disease control, patient adherence to all aspects of the therapeutic regimen (drugs, diet,
exercise)
• Assess the presence of unwanted complications due to the disease and the medication used to manage that
disease
2. Second:
• Develop and maintain rapport with the patient, which facilitates joint efforts to manage their disease (dealing with
patients’ concerns, perspectives, and emotions regarding their chronic diseases)
3. Third:
• Assist the patients in implementing jointly developed plans to optimize disease control and minimize
complications (patient education, assistance to optimize medication adherence, modification of therapeutic
regimen, referral to specialists, etc.)
4. Fourth:
• Ensure that patients receive appropriate levels of preventive care (tertiary, secondary, and primary preventive
services)
Functions of a Patient Visit for Chronic Disease

"Organizing Patient Visits." Patient Assessment in Pharmacy Eds. Richard N. Herrier, et al. McGraw-Hill, 2015
 Preventive Services
• Tertiary: aim is to prevent complications from the patient’s chronic
diseases (ex: routine diabetic foot examinations for diabetic patients)
• Secondary: screening for the development of comorbid diseases (ex:
hypertension and hyperlipidemia in patients with diabetes)
• Primary: immunizations, weight control, tobacco cessation…
• Depending on the practice site and extent of clinical privileges in
preventive health, pharmacists’ responsibilities range from
recommendations to the primary care provider, to ordering the
tests/procedures and making appointments for those tests and
procedures
 Typical Structure of a Chronic Disease Visit
• There are two basic types of visits:
1. Initial visit (the first time you meet the patient):
• Takes more time (collection and verification of data are more comprehensive, plus time
is needed to develop rapport with patients)
2. Follow up visits:
• Duration of visits usually decreases over time and with improved control of the chronic
disease (longer and more frequent follow-up visits might be needed in patients with
therapy and adherence issues)
• Time required to complete a visit include: time for any physical examination, time to
document the visit in the patient record, and time to conduct any point-of-service testing
 Components of Pre-Visit Planning
• A key to have a time-efficient visit
• Usually done 24-48 hrs before
• Visit agenda to remind the provider
of all the items that need to be
covered during the visit
• Orders completed might include
lab tests, specialist appointment,
testing procedures….

"Organizing Patient Visits." Patient Assessment in Pharmacy Eds. Richard N. Herrier, et al. McGraw-Hill, 2015
 Visit Introduction
• During the introduction (at the start of visits), the provider should ask
patients about their agenda so they can set priorities for the visit
before proceeding
• Ex: “In addition to your regular visit for diabetes, what other issues do we
need to deal with today?”
• This will prevent having new issues that are unrelated to the purpose
of the visit popping up at the end of the visit
• If needed, the provider can go through his/her agenda more quickly,
or postpone items and make time for the patient’s new issues
 Organizing the Flow of the Patient Visit
• Three sets of information required to evaluate every chronic disease:
1. Control of the disease
2. Compliance with the therapeutic regimen
3. Complications due to the disease and the drug therapy used to manage it
• These “Three Cs” will provide a simple organized structure to conduct
a comprehensive visit effectively
• Some organized health care delivery systems use flow sheets or
disease specific checklists to guide the visit and partially document
patient responses and findings
Thank you…