Patient Education and

Counseling
Dr. HAMID SAEED
Assistant Professor
University College of Pharmacy
University of the Punjab
• Education:
– the process of receiving or giving systematic instruction, especially at a school or

university

– OR

– the act or process of imparting or acquiring general knowledge, developing the

powers of reasoning and judgment, and generally of preparing oneself or others

intellectually for mature life

– Patient Education:

– process of assisting the patient to gain knowledge, skill, and a value or attitude related

to a health problem or for health promotion

– OR

– the process by which health professionals and others impart information to patients

and their caregivers that will alter their health behaviors or improve their health status
• Counseling
– professional guidance of the individual by utilizing psychological
methods especially in collecting case history data, using various
techniques of the personal interview, and testing interests and aptitudes

– Patient Counseling

– a professional relationship that empowers diverse individuals, families,

and groups to accomplish mental health, wellness, education, and
therapy goals.
• Patient counseling is defined as providing
medication information orally or in written
form to the patients or their representatives on
directions of use, advice on side effects,
precautions, storage, diet and life style
modifications
Introduction
• Means consultation or advise or
• A service consisting of giving advise on
problems.
• It describes the sympathetic interaction
between Pharmacist and patient when go
beyond the conveyance of straightforward
information about medicines and how and
when to use it.
• A correct diagnosis and therapy will be
ineffective unless the patient knows how to
use & outcomes of therapy.

• Patient counseling is unique responsibility of

Pharmacist through which patient understand
and motivated to adhere to the prescribed
regimen of therapy.
 Communication

• Communication is the transfer of information

meaningful to those involved.
• It is the process in which messages are
generated and sent by one person and received
and translated by another person.
 Challenge

• Intended message is generated by the sender

• Its meaning is translated by the receiver
• Verbal or written,
• Not always translated to mean what was
originally intended.
 Communication Explained

• Each person exists in their own world

• defined by their personal history and concepts
of self and others.
• Messages are interpreted in a way that is
consistent with his or her world and responds
based on these interpretations.
 Interpersonal Communication

• is the transmission and reception of verbal and non-

verbal messages between people.

• Where applicable

• Whether counseling patients, communicating with

physicians, or interfacing with associates, pharmacists
use their interpersonal communication skills daily.
• Patient-Pharmacist (interpersonal)

• Health care providers – Pharmacist (Inter-

professional)
 Benefits
• Essential to improve the use of medications by patients and ensure
optimal therapeutic outcomes.

• Can Improve patient adherence to drug therapy through appropriate

strategies, including patient counseling and education.

• Verbal or written recommendations to physicians to resolve drug

therapy problems can be an effective strategy for drug therapy
changes.
 Primary Functions

• Establishment of an ongoing relationship

between the professional and the patient.
• Exchange of information necessary to assess a
patient’s health condition, implement treatment of
medical problems, and evaluate the effects of
treatment on a patient’s quality of life.
 Main Objectives
• To understand the illness experience of the patient
• To establish that each patient’s experience is unique
• Foster a more egalitarian relationship with patients
• Build a therapeutic alliance with patients to meet
mutually understood goals of therapy
• Develop self-awareness of personal effects on patients
 Communication Regarding Drug Therapy

• Purpose of medication
• How medication works
• Dose and duration of therapy
• Goals of therapy
• How effectiveness will be monitored
• Adverse effects and how to deal with them
• Drug specific issues
 Communication Skills

– Communication skills
• takes time and practice to master,

• aim is to develop strong relationship with the patient

• Depend upon comfort level and confidence

 Followings are the skill required for effective communication
– Active Listening (hearing what is being said)

» A dynamic process, hearing and interpreting the words being

spoken

» Listening is a passive process

» Active listening means – give patient attention and

concentration free of interruption

» Interruption (external and internal)

 Listening Technique

• Stop talking. You can’t listen while you are talking.

• Get rid of distractions.
• Use eye contact to show you are listening.

• React to ideas rather than the person.

• Read nonverbal messages.
• Provide feedback to clarify the message.
– Empathy

» intellectual identification, experience of ones

feelings, thoughts and attitudes

» Example, nodding your head, making a statement

and follow up questions

– Building Rapport

» Make your first impression

» Sets the tone of interview

» Patient feel comfortable thus, communication would be more open

and honest, otherwise withheld

» Start with greetings, how you want your problem to be addressed

– Open and Close ended questions

» Open ended preferred – provide more in-depth information

 » Examples – how was your day or how is it going with the

medication

» Are you feeling well today…?

– Leading question

» Suggest or demand a particular answer

» You do not miss any doses of your medication, do you

» Patient feel obliged to say no I don’t, since he/she should not

miss the dose

– Silence
• More significant than you realize

• Allow silence after the question so that patient can reflect upon your

question

• But it may indicate that patient has not understood your question

– Why Questions
• Avoid these questions that may force him to defend his choices and

actions

• Example, instead of asking why do you miss your doses – ask – what

cause you to miss your doses

 Barriers to Effective Communication

• Physical

• Psychological

• Administrative

• Time conflict.

• Environmental barriers such as a lack of privacy or furniture that creates

physical barriers between patients and doctors/pharmacists and can
prevent effective communication.

• Environmental barriers are examples of physical barriers.

• Semantics relate to meanings of words and symbols used in
interpersonal communication.

• Words only contain meaning in terms of people’s reactions to them.

• Words can also have multiple meanings.

• Therefore, effective patient communication requires the use of

words that are carefully chosen.

• Jargon should be clearly defined or avoided. Semantics is an

example of a psychological barrier.
• Perception is how a message is perceived by a patient.

• The patient may view the doctor as only being interested in

diseases, drugs and money, not people.

• If the patient views the doctor as being incompetent or

uncaring, he/she is less likely to trust the doctor’s advice.

• Perception is an example of a psychological barrier.

• Negative attitude from doctors or pharmacists are usually caused by a
lack of confidence and low self-esteem.

• Many doctors believe that it is not their job to counsel their patients,
but it is.

• Negative attitude is an example of a psychological barrier.

• Personal barriers include low self-confidence, shyness, dysfunctional

internal monologue, lack of objectivity, cultural differences, discomfort
in sensitive situations, and conflicting values to healthcare practice.
• Administrative barriers such as management may view the lack of money
compensated for communication as a reason not to communicate.

• More money is made by prescribing medication, not caring for patients.

• Time limits are very common when it comes to pharmacists and patients.

• Time restraints are often excuses not to counsel, though it often does not
take very long.
Communication – Pharmacist and Patients

• You and patient have unanswered questions

• You and patient have misunderstandings
• Patient experience problems to therapy
• Patient can “monitor” their own responses to treatment
• Patient make their own decisions regarding therapy
• Patients may not reveal information to you unless you
initiate a dialogue
 Patient-Pharmacist
Communication

• Verbal Communication

• Non-verbal

• Verbal Communication

• Helping Model

• Medical Model
• Helping Model
• Patient centered approach
• Provider is more active and patient is passive
• Pharmacist assists the patient with exploring the problem
and possible solutions.
• The helping model facilitates a discussion between the
pharmacist and the patient and allows the pharmacist to
gather more information to improve therapeutic outcomes.
• Medical Model
• Patient answers questions and follow
directions.
o Non-verbal Communication
o sending messages without words

o Appropriate nonverbal cues are also critical for effective communication.

o Behavioral scientists have reported that 55 percent to 95 percent of our

communication is nonverbal. 1

o Facial expressions, body posture, gestures, tone of voice and use of eye

contact are all forms of nonverbal communication.

o influenced by individual and cultural differences

o Questionnaire
• Patient’s Education
Patient Education - Introduction

What is Patient Education?

• Skill Building and

Responsibility – Patients
need to know when, how,
and why they need to
make a lifestyle change

• Group Effort – Each

member of the patient’s
health care team needs to
be involved
Why Patient’s Education

Patient Education Value – The results of clear communication

• Increased Compliance – Effective communication and

patient education increases patient motivation to comply
• Patient Outcomes – Patients more likely to respond
well to their treatment plan – fewer complications
• Informed Consent – Patients feel you’ve provided the
information they need
• Utilization – More effective use of medical services –
fewer unnecessary phone calls and visits.
• Satisfaction and referrals – Patients more likely to
stay with your practice and refer other patients
Patient Education Rationale

Model of Patient Education Outcomes

Knowledge and Health Status

Attitude Changes · Physical health
· Increased understanding · Well-being
· Increased confidence · Symptoms
· Increased satisfaction · Complications
· Improved emotional state
Patient
Education
· Print
· Verbal Behavior Changes Costs
· Multimedia · Health services utilization · Length of stay
· Combination · Compliance · Utilization
· Lifestyle · Provider image
· Self-care · Regulatory
compliance
The Effective Educator

• Effective Patient Educator skills include:

+ Determining patient concerns
+ Avoiding Assumptions
+ Explaining things clearly

• Question the educator must ask:

+ How do I determine patients’ needs and concerns?
+ How do I treat patients equally and as individuals?
+ How do I know when I’ve explained things clearly?
Patient Education - Steps

Four Steps to Educating

• Assess – Define patient and family needs

and concerns; observe readiness to learn.
• Plan – Set objectives with your patient;
select materials.
• Implement – Put the plan in motion; help
patients along the way to reach the
objectives you’ve set together.
• Document – Create a written history and
keep records.

Evaluate - Evaluation is critical and should be continuous through all four steps! This
will help you stay on track and spot problems quickly.
Patient Education - Introduction

Maximizing Teaching Moments

• Time is limited

• Patient Education must

be as efficient and
effective as possible

• Educators must think

of every moment with
patients as a teachable
moment!
Patient Education – Step 1 - Assessment

Assessment

• Assessment provides you with

essential information about
your patient

• Patient education success

depends on the assessment of
needs, concerns, and
preferences

• Assessment should be ongoing

– make it a part of every
encounter with your patient.
Patient Education – Step 1 - Assessment

Grasping Patient Concerns

• Avoiding Assumptions –
+ Never assume! Incorrect assumptions can be counterproductive.
+ Gather as much information on the patient’s situation as you can
early on.

• Getting to Know Your Patient –

+ Review the patient’s chart first
+ Introduce yourself by name and clearly explain your role
+ Ask basic, introductory questions
– Support – is there family or a friend who can assist with care?
– Limitations – address known physical or mental problems early
– Cultural History – Note language barriers and cultural preferences
Patient Education – Step 1 - Assessment

Recognizing Diversity

• Understanding Cultural Issues

+ Treat all patients without judgment
+ Show respect – remain open to the
unfamiliar
+ Gain patient trust
+ When in doubt – ask questions!

• Challenging your own views

+ Set aside all your conflicts
+ Avoid making assumptions about
your patients
Patient Education – Step 1 - Assessment

Grasping Patient Concerns

• Establishing Rapport –
+ The patient must feel comfortable with you
+ When meeting a patient:
– Try to be empathetic
– Avoid focusing on a chart
– Make Eye Contact
– Communicate nonverbally if there are language barriers
– Ask about a book the patient may be reading

• Learning the Patient’s Perspective –

+ Fears, worries, misconceptions – get everything out in the open early!
+ Ask: “When you think of (this condition), what do you think of?
+ Patient concern should be primary focus in your education plan.
Patient Education – Step 1 - Assessment

Asking the Right Questions

• Answers should uncover core beliefs – Ask specific

questions - ask to discover what motivates your
patient:
+ “What are you afraid that might happen?”
+ “What barriers get in your way?”
+ “When you tried this before, what problems did you have”
Closed Open
• Asking open-ended questions
Are you upset? – Increases
What’s bothering you? the
information you get and decreases
Are you in pain? thedescribe
How would you number of
your pain?
Is this hard for you to deal with?
What are some problems this is causing?
questions you need to ask. How and when do you take your medicine?
Are you taking your medicine every day?
Patient Education – Step 1 - Assessment

Grasping Patient Concerns

• Determining readiness to learn – Your patient will present

challenges if resistant to education
+ Motivation – Patients are motivated when they learn how their lives
could improve. Focus on the benefits of education.
+ Attitude – Denial, Fear, Anger, Anxiety – all could be barriers to
education. Patient must know that he or she will make gains by
learning new skills.
+ Outlook – A patient’s beliefs about their situation could effect
education. Let them know that learning new skills can help them feel
better or slow disease progression.

• Assessing Patient Skills – Request a demonstration of what he

or she has learned in the past
Patient Education – Step 1 - Assessment

Understanding the Support Network

• Redefining the Family

+ Patient support is a cultural issue. “Family” could be anybody the
patient designates.
+ When possible, let your patient designate a person to receive info
from the team.

• Assessing Your Patient’s Support

+ The patient’s support should be trusted and able to carry out tasks.
+ Look for the following when the patient’s support is present:
Does the patient . . . Does the support person . ..
Seem pleased with this person’s input? Appear with the patient frequently?
Look forward to visits with this person? Show concern for the patient?
Interact favorably with this person? Encourage following medical advice?
Patient Education – Step 1 - Assessment

Evaluating Your Assessment

Look back on the info you have gathered and determine if you are ready
to move on to the next phase

Needs and Concerns: Skills:

What are the patient’s needs? What health-promoting skills does the

What are his or her concerns? patient possess?

What does the patient already know? What skills will the patient need to
develop?

Beliefs and Attitudes:

Behavior:
What does your patient believe?
What barriers your patient have that
How are support people coping?
need to be changed?
What barriers do the patient’s support
people have?
Patient Education – Step 2 - Planning

Planning

• Once you know your patients needs, planning

begins.

• You both should set some mutually agreeable

goals.

• Gather the materials you need to meet these

goals

• When building your plan, make building

patient skills and addressing concerns the top

priority!
Patient Education – Step 2 - Planning

Setting Goals

• Thinking Realistically
+ Goals should focus on what is necessary / critical to patient survival first.
+ Pay attention to patient concerns – they could stand in the way of
progress
+ Respect stated limits – if a patient has refused to do something, try to
work around the problem and incorporate something new as best you can.

• Helping a Patient Make Life Changes

+ If your patient needs to make lifestyle changes, make sure he or she:
– Understands the need for changing behavior
– Has the confidence to complete the required tasks
– Successfully begins to change behavior.
Patient Education – Step 2 - Planning

Building Bridges

• Effective Plan –
+ Essential Skills – what a
patient needs to know
+ Benefits and Barriers – what
a patient’s concerns are Bridge
Patient Needs Patient Concerns
+ For a plan to be effective,
you must find ways to build
bridges between patient
needs and patient concerns.
+ The bridges you build will
be framed by what you
learned during assessment
Patient Education – Step 2 – Planning

Building Bridges

Below are some simple examples of ways in which someone might decide to bridge the gap
between needs and concerns.

Patient Needs Patient Concerns Bridge

Patient should exercise “Exercising hurts” “By exercising, you’ll improve
muscle strength, which
lessens pain. Let’s find an
exercise that works for you.”

Chemotherapy is required “My hair will fall out” “Chemo kills quick-growing
cells, like hair and cancer. In
the meantime, let’s see what
kind of hat, turban, or wig we
can find.”
Heart patient should lower “I won’t get to eat all of my “Low-cholesterol foods can be
cholesterol. favorite foods” tasty. Here are some great
recipes. And you can also treat
yourself once in a while.”
Patient Education – Step 2 - Planning

Setting Goals

• Finding Resources

+ Printed Materials, Video or Audio CDs/DVDs, Electronic content

+ Look for inconsistencies between your goals and those of the materials.

+ Make sure the resources are up-to-date

+ Patient Education publishers provide information on patient education techniques and

practices.

+ Premade plans may be available from pharmaceutical companies or other organizations. Be

careful they are not biased!!

+ Clinical pathways that your facility already uses can work as effective plans.

+ Disease-specific or voluntary organizations may provide materials.

+ Experienced colleagues can be useful resources in helping you come up with a plan.
Patient Education – Step 2 – Planning

Evaluating Your Plan

Make sure the plan contains the information that your patient both needs and wants to know
– discuss with your patient and support people

Needs and Concerns: Skills:

How well does your plan cover what your How will the plan develop the life-
patient needs to know? enhancing or essential skills your patient
What part of the plan address patient concerns? needs?

Beliefs and Attitudes: Behavior:

Where in the plan are your patients beliefs and How will the plan influence or even
attitudes addressed? change your patient’s behavior?
How does your plan address any barriers that the
patient may have?
Patient Education – Step 3 - Implementing

Implementing

• Implementing your plan begins with

reassessment
+ Surprises can arise that will cause you to adjust

the plan.

• Assess continually

+ Reassess the patient during each contact

+ The success of your plan depends on the quality

of your assessment and the patient’s ability to

meet goals.
Patient Education – Step 3 – Implementing

Getting your Message Across

• Providing a Good Learning Environment

+ Tone of voice, eye contact, and touch vary for all cultural
backgrounds
– Use the knowledge you gained during assessment
+ Environment
– Good lighting
– Comfortable temperature
– Low noise
– Room to spread out
+ Privacy
– If possible, seek out a place you can work privately with the patient
and his or her support person
Patient Education – Step 3 – Implementing

Getting your Message Across

Your priorities and your patient’s should be clearly stated, mutually understood, and mutually
agreed upon.

• Setting Implementation
Priorities
+ Let your patients know:
– What they should do and why
– When they should expect results
– Possible danger signs to watch
for
– What they should do if problems
arise
– Whom they should contact for
referrals
Patient Education – Step 3 – Implementing

Working Toward Goals

Thinking in terms of improvements, recovery schedule, and follow up care

• Alerting Patients to What’s Ahead

+ Develop time frames for you patients
+ Provide a number to call in case conditions change – make them feel self-directed
and in control.
+ Let patients know what to accept – avoiding surprises and promoting patient
acceptance
+ Emphasize on quality-of-life changes over cures

• Thinking Small
+ Small steps are better than none – take small steps toward achieving a goal
+ Avoid overloading the patient with information
+ Accept whatever number of steps the patient is willing to accept, and always offer
the opportunity to learn more at a later time.
Patient Education – Step 3 – Implementing

Getting Your Message Across

• Keep content simple

+ Speak with all patients using simple language
+ Focus on one goal or behavior change per visit
+ Highlight key concepts and provide printed materials
+ Stay interactive – let the patient show you what he/she learned

• Use visuals
+ Drawings, visuals, illustrations can reinforce key concepts
+ Some people learn visually
+ Illustrations boost comprehension
Patient Education – Step 3 – Implementing

Getting Your Message Across

• Mixing Education Media

+ You will never have all the time you
would like so supply your patients with
educational material
+ Give your patients printed material, or
even video or audio material - go over
what they should focus on.
+ Different patients respond to different
material – the more options, the better
+ Document what you’ve coached on –
so your team knows what’s been
covered
+ Ask your patient to demonstrate what
he or she has learned.
Patient Education – Step 3 – Implementing

Reinforce the message: Choosing the right patient education materials

• Choose material with special emphasis on:

+ Clear focus and goals
+ Headings that present key concepts for busy,
scanning, or low-literacy readers
+ Step-by-step instructions
+ Practical tips to improve daily living
+ A clear language level that matches the bulk of
your patients
+ Translations if your patient population warrants it
Patient Education – Step 3 – Implementing

Reinforcing the message: How to use patient education materials

• Highlight Key Concepts

+ Open and flip through the booklet or brochure with the patient
+ Write in any notes of your own
• Check a Patient’s Understanding
+ Ask your patient to repeat complex explanations back to you
• Involve a Patient’s Family
+ Suggest bringing in a support person to show the materials to
also and to hear your instructions
• Build on Success
+ Build on skills the patient is confident in and motivated by
Patient Education – Step 3 – Implementing

Overcoming Challenges

• Reassessing Patient Concerns

+ Patients can become resistant
+ Physical and emotional stress of illness can present challenges
+ Ask open ended questions to understand new concerns
– What’s standing in your way? What concerns you about doing things?
• Helping a patient over a barrier
+ Reassess, looking for core concerns
+ Address concerns such as pain, fear, misunderstanding
+ Consult with other members of the health care team
+ Arrange for follow-up care
+ Get help from the patient’s support person when appropriate.
• Reading Patient Signals
+ Continually assess and include into your plan
+ Emphasize the benefits of education instead of nagging the patient
 Patient Education – Step 3 – Implementing
Overcoming Challenges
Breaking Through Barriers – Here are some examples of barriers you may encounter, along
with some ways to work through them
Barrier Behavior
Denial, anger, anxiety, or depression Patient is distracted, disinterested,
hostile, or doesn’t believe there’s a
problem.
Physical Pain Patient is unable to concentrate
Acute Illness All patient’s energy is focused on
coping with the illness. Patient finds
it difficult to learn
Learning disability Patient finds it difficult to
comprehend educational materials
presented
Implementation
Tell your patient that these feelings
are normal, that anyone would be
concerned. Use the opportunity to
reassess for new concerns.
Focus on managing your patient's
pain before
implementing the plan.
Address patient’s fear, pain or
anxiety first, and then focus on
developing new skills.
Try to give a wide variety of
materials. Including demonstrations.
Patient Education – Step 3 – Implementing

Evaluating Your Implementation

Needs and Concerns: Skills:

How will your patient successfully integrate the What new skills has your patient learned to
essential new skills needed into daily life? improve the quality of his or her life?
How have the patient’s concerns been Where will he or she seek assistance when
addressed? ready to learn more?

Beliefs and Attitudes: Behavior:

Which new skills have positively affected your What elements of your patient’s behavior
patient’s perceptions about his or her condition? promote healthy habits?
Which behaviors could be improved later?
Patient Education – Step 4 – Documenting

Documenting

• Patient records - inform colleagues

what you’ve done.
• Properly documented patient education
can help you meet Meaningful Use
Requirements for reimbursement
• Patient education documentation is an
important part of education and review
standards
• A record of patient education provides
future health care providers a starting
point should your patient need
assistance in the future
Patient Education – Step 4 – Documenting

Keeping Detailed Records

Meaningful Use – documenting patient education within your EMR/EHR provides evidence that
you have met the Meaningful Use criteria for patient education.
EHR (electronic health record) EMR (electronic medical records)

 A digital record of health

 A digital version of a chart
information

 Streamlined sharing of updated,  Not designed to be shared outside

real-time information the individual practice

 Allows a patient’s medical  Patient record does not easily travel

information to move with them outside the practice

 Access to tools that providers can  Mainly used by providers for

use for decision making diagnosis and treatment
Patient Education – Step 4 – Documenting
Keeping Detailed Records

Joint Commission (www.jointcommission.org) – documenting patient education and the

individual learning preferences of each patient also provides evidence for the Joint Commission
whose minimum compliance goals for patient communication and education are summarized
below
PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment, and
services.

PC.02.03.01 The hospital provides patient education and training based on each patient’s needs and
abilities.

RI.01.01.03 The hospital respects the patient’s right to receive information in a manner he or she
understands

RI.01.02.01 The hospital respects the patient’s right to participate in decisions about his or her care,
treatment, and services.

RC.02.01.01 The medical record contains information that reflects the patient's care, treatment, and
services. (EP 1 notes specifically: “The patient’s communication needs, including preferred language for
discussing health care”)
Patient Education – Step 4 – Documenting

Additional Joint Commission Requirements

Core Measures National Patient Safety Goals

 Smoking Cessation  Comprehensive drug information
 Heart Failure  Anticoagulant information
 Heart Attack  Infection Control
 Pneumonia • Hand washing
 Pregnancy • Healthcare Associated infections
 Stroke o MRSA, VRE, C-DIFF, PNEUMONIA

 Pediatric Asthma • Central Line

 Mental Health • Pre-Op / Post-Op care
 Influenza  Fall Prevention
 Risk Factors  Focus on behavior change
 Suicide prevention
http://www.jointcommission.org/
performance_measurement.aspx
 Warning sign content for patients and families
http://www.jointcommission.org/standards_information/
npsgs.aspx
Patient Education – Step 4 – Documenting

Keeping Detailed Records

• Knowing the Education Process

+ TJC surveyors want to see whether you understand the patient
education process.
+ TJC wants to see documentation, and what kind of education
materials you use
• Making Use of Forms
+ The documents you keep can be used for training, to help outpatient
specialists, or for future patient assistance if needed
• Getting Patient Feedback
+ Feedback from the patient and family provides valuable perspective
on the effectiveness of patient education
+ Consider surveys, documents for patients to sign, questionnaires
 First Patient Visit

• Topics for Discussion

• What is TB
• How TB spreads and how to prevent it
– Importance of examining contacts
• Symptoms of TB
• TB can be cured– even among HIV+ patients
• Treatment of TB
– duration; where to receive; importance of adherence
and completion
 First Patient Visit

• Directly Observed Therapy

• What to expect; what to do next
– the need to minimize travel (i.e. to cattle posts)
until after completion of treatment
• Emphasize importance of knowing HIV status
• Reinforcement of HIV prevention messages
 Additional Topics to Discuss
Throughout Treatment

• Description of treatment drugs (show pills)

– amount and frequency of drugs
– possible side-effects of drugs

Image source: Gary Hampton, World Lung Foundation • Treatment during continuation phase
• Importance of adherence
• Importance of good nutrition and abstaining
from smoking and alcohol
• Frequency and importance of sputum
collection

Image source: Pierre Virot, World Lung Foundation

• Assignment
• Education Points regarding disease and
therapy in Un-controlled Diabetic Patients on
Insulin (NPH (N) + Lispro)
• Due Date:
 WHY Counsel?
• To promote adherence to medications
and avoid treatment failure and future
hospital admissions
• Helps patients cope with their disease
and any medication side effects that
might occur
• Important to avoid potential drug
interactions with OTC, herbal, and
prescription medications
75
 Patient Counseling Methods
• The structure of the counseling session is
divided into
• four groups
• Introduction of the session.
• Content of the session.
• Process followed.
• Conclusion of the session.
 Introduction
• Review the patient record prior to counselling.
• Conduct an appropriate patient counselling introduction by self and
patient.
• Explain the purpose of counselling session.
• Obtain pertinent initial drug related information. E.g.: drug allergies,
and other medications.
• Warn the patient about taking other medications including OTC
drugs, herbals, or botanical drugs and alcohol which could inhibit or
interact into the prescribed medication.
• Determines whether the patient has any other medical conditions that
could influence the effects of their drug or enhance the likelihood of
an ADR.
• Asses the patient understandings of reason for therapy.
• Assess any actual or problems of importance to the patient.
 Counseling Content Item
• Discuss the name and indication of the medication.
• Explain the dosage regimen including duration of therapy when
appropriate.
• Assist the patient in developing a plan to incorporate the
medication regimen into his/her daily routine.
• Explain how long it will take for the drug to show its effect.
• Discuss storage and refilling information.
• Emphasize the benefits of completing the medication as
prescribed.
• Discuss the potential side effect.
• Discuss how to prevent or manage the side effects of the drug.
• Discuss the precautions.
• Discuss the significant drug
• Drug-drug, food, and drug-disease interaction.
• Explain precisely what to do if the patient
misses the dose.
• Explore the potential problems of the patient.
 Counseling Process Items
• Provide an accurate information.
• Use language that the patient is likely to understand.
• Use the appropriate counselling aids to support
Counselling.
• Present the fact and order in a logical order.
• Maintain control & direction of the counseling session.
• Probes for additional information.
• Use open ended question.
• Display effective non-verbal behaviors.
 Counseling Conclusion
• Verify the patient understanding via feedback.
• Summaries by acknowledging or emphasizing
key points of information.
• Provide an opportunity for final concerns or
questions.
• Help the patient to plan, follow up and next
consecutive steps.
 HOW to Counsel
• Be aware of barriers to counseling
– Disease state: dementia, stroke
– Language: verify primary language
– Hearing/vision problems
– Environmental: noise, lack of privacy
– Educational level (reading ability)
– Patient motivation: disinterest in learning
– Lack of pharmacist training/time

82
 Minimize Barriers:
• Proper environment
– Private, quiet
• Free of distractions, e.g., patient should have pain
controlled, ask patient to lower volume on the TV etc.
– Introduce yourself
• Greet the patient
• Explain your purpose
• Ask the patient’s permission to counsel

83
 Minimize Barriers:
• Know your audience
– Educational level: tailor talk for understanding
– Use appropriate language
– Religious or ethnic beliefs
• e.g. need to avoid blood products or specific foods

84
 Minimize Barriers:
• Be specific
– Name of medication (brand/generic), dose, dosage
form, schedule
– List precautions: e.g., use sunscreen, avoid milk
– How to administer (Sub-Q, PO, IM etc.)
– Special directions and precautions
– Necessary lab tests

85
 Minimize Barriers:
• Be selective
– Cover major / common side effects
– Cover major / common drug interactions
– Cover patient specific indication
– Emphasize benefits of medication
– What to do if dose(s) missed
– Duration of therapy
– Provide written information
– Summarize key points

86
 Minimize Barriers:
• Be sensitive/empathetic
– Listen to the patient
– Speak distinctly and clearly
– Return later if patient indisposed, not alert,
distracted, has visitors etc.

87
 Minimize Barriers:
• Elicit feedback to assess understanding
– Improves coping if side effects occur
– Increases adherence to improve health
– Verifies patient’s comprehension
• Ask open ended questions
• Ask if any final questions

88
 Assess Patient’s Understanding
• “Just to make sure I did not leave anything
out, could you tell me…
– What is the medication used for?”
– When are you going to take the medication?”
– What side effects might you experience?”
– What will you do if that occurs?”
– What will you do if you miss a dose?”

89
 Example: Warfarin Counseling
• DO • DON’T
– Address patients formally – Address patients by their
– Ask what the patient knows about first names
warfarin or Coumadin®
– Assume the patient
knows all or nothing
about the drug

90
 Example: Warfarin Counseling
• DON’T
DO
– Explain that warfarin is an used
anticoagulant
to slow the blood clotting
– process
Explain to prevent
that unwanted
warfarin works by blood clots the vitamin K
inhibiting
– Ask patients
dependent clotting
to callfactors
their doctor
and that
if they
it is notice
an emergency
bleeding that
they don’tifnormally
situation they see any
haveblood

91
 Example: Warfarin Counseling
• DON’T
DO
– Identify
List every
thereason
specific
anyone
reason
might
the patient
be on warfarin
is taking it and how
long they might be expected to take it

92
 Example: Warfarin Counseling
• DON’T
DO
– Explain
Give thethe
patient
signsthe
andimpression
symptomsthatof bleeding
they are going
such astobloody
bleed
nose,
to death
blood in the urine, a stool that changes color or
darkens, bruises that never go away or increase in size

93
 Example: Warfarin Counseling
• DO
DON’T
–
– Ask the patient
Assume to tell
the patient all their
realizes thedoctor/
need todentist
notifyetc. all the
all health
medications
care providersthey are takingallincluding
concerning nonprescription
the medications they are ones
on;
(e.g., pain medications, vitamins, herbal products)
OTCs are often not considered medications

94
 Example: Warfarin Counseling
• DO
DON’T
–
– Ask the patient
Indicate that thetoonly
avoid taking
good painOTC pain medications
medications are those such
foundasonaspirin,
unless they have discussed it first with their physician
prescription
– Recommend Tylenol® as the OTC pain reliever of choice with their
physician’s knowledge as well

95
 Example: Warfarin Counseling
• DON’T
DO
– Tell the patient to
what
double
to doup
if on
he their
or shenext
forgets
doseaifdose
they miss
– one
Ask the patient to inform their physician or anticoagulation
clinic if a dose is missed

96
 Example: Warfarin Counseling
• DO
DON’T
– Stress the need
Minimize for follow-up
the importance appointments
of follow-up by anand
blood draws
anticoagulation clinic or a physician
– Indicate that it is normal for doses to change from
time to time

97
 Example: Warfarin Counseling
• DON’T
DO
– Ask
Limitthe
orpatient
forbid the
to eat
patient
a constant
to eat and
salads
moderate
or vegetables,
diet where
they eatavegetables
though renal diet used
and salads
by an ESRD
in a consistent
patient may
manner
include
and
neitherrestrictions
some over do nor stop eating what they normally eat

98
 Example: Warfarin Counseling
•• DO
DON’T
– Summarize key points covered
–
– Assume the patient has no final questions
Ask if the patient has any other questions
–
– Assume the the
Ascertain that patient has
patient understood
understands all you have discussed
the information
–
– Thank
Forgetthetopatient
leave and leaveinwritten
a note information
the chart
– Ask them to view the in-house educational TV program if available
– Document as required

99
 Warfarin Counseling
Summary
• Reason for being on anticoagulation
• Side Effects ( major and minor with expected
frequency)
• Signs of major bleeding
• Anticipated duration of therapy
• Adding or discontinuing medications
• Dietary considerations
• Arrangements for future blood draws

100
 Communicating Points in Patient Counseling

• Disease Counseling
– Nature of the disease

– Severity of the disease

– Require lifestyle modifications

– Importance of drug therapy in the disease

– Importance of compliance in drug therapy

– Effects on quality of life if not controlled

• Lifestyle Counseling
– Diet

– Smoking

– Exercise

• Physical Activity Counseling

– Is exercise necessary if not why

– If necessary then why

– Relevance of physical activity with the disease

• Medication Counseling
– Importance of drug in controlling disease

– Importance of drug therapy – dose, frequency and timings

– Counseling points varies for each drug used

– Drug interaction with other drugs

– Drug interactions with food

– Line of action in case of serious ADRs and interactions

– Drug effects in concomitant disease

• Counseling regarding complications
– Acute complication that can arise

– Complications due to non-compliance

– Complications due to overdose

– Complications due to concomitant drugs or disease

• Specific population counseling
– Effect of drug/disease in elderly

– Effect of drug/disease in pediatrics

– Pregnancy

– Multiple disorders
• Counseling regarding self
monitoring/assessment
– Self-assessment parameters

– Self monitoring of drug therapy

Importance of counseling the Patient

Patient related benefits are:

• Improved therapeutic outcome
• Improved adherence to therapy
• Decreased medication errors and misuse
• Enhanced patient self management
• Potential for decreased healthcare cost
• Prevention of adverse effects
Pharmacist benefits are:
• Enhanced professional status
• Establishment of essential components of
patient care
• Enhanced job satisfaction through improving
patient outcome
• Revenue Generation through payment for
counseling
• Fulfillment of legal responsibility.
 Important Considerations
• During the provision of consultation Pharmacist
also consider and report ADRs.
• He continues primary healthcare role of giving
advise to the patient in response of symptoms.
• He also maintain prescription based medication
record (PMR), it will be beneficial for chronic
and elderly patients for the confirmation of
doses, ADRs and drug interactions.
 Factors to be considered in tailoring
counseling
Characteristics of the patient
• Age, cultural background, disabilities, type of
employment and lifestyle, gender and
socioeconomic situation.
Characteristics of Drug
• Prescription or non-prescription drug, drug
with high risk of interaction or adverse effects
are recognized.
Characteristics of condition
• Patient emotion (HTN), patient embarrassment
(cancer, AIDS, psychotic illness), lifestyle
modification (Smoking, obesity or diabetes).
 Characteristics of situation
Certain situations can create challenges and call for
different emphasis in counseling these include:
• When patient become angry, fearful or emotionally
upset.
• When patient’s aims are in conflict with Pharmacist’s.
• Medication incidents such as wrong medication or
dose.
• Non therapeutic related concerns such as child abuse
to threatened suicide.
Characteristics of the Pharmacist
Various Pharmacist factors involved in patient
counseling are:
• Level of knowledge about the patient.
• Pharmacist’s ability to communicate and time
he has.
• Attitude of Pharmacist.
 Counseling the elderly Patients
• Elderly patients comprise a growing segment
of Pharmacist’s clients.

• The number of illness and medication used

tend to increase with age, therefore each
patient should be considered on individual
basis.
 Issues in counseling elderly Patients
• High drug use both prescription and non-prescription.
• High incidence of illness particularly chronic illness.
• Increased risk of drug related problems and
inappropriate drug use, adverse drug reactions, etc.
• Increased limitations and disabilities such as hearing
loss, vision impairment, physical and mental
disorders.
• Decline in cognitive functions, sleep problems.
• Difficulties adhering to medication regimen
misunderstanding, forgetfulness, disabilities,
cost, etc.
• Attitudinal barriers to communication, slow,
hard hearing.
• Literacy and cultural issues.
• Access and affordability to health care
services.
Tailoring counseling for elderly patients
• Recognize feelings and attitude towards aging.
• Conduct regular medication reviews and be alert for drug
related problems. Psychotic drugs should be aggressively
monitored.
• Educate elderly patients about self monitoring.
• Allow time to make patient comfortable.
• Allow for disabilities identify.
• Provide follow-up particularly for patient that live alone.
• Provide privacy as they become embarrassed while
sharing personal information.
• Emphasize adherence address the causes of
non-adherence.
• Select appropriate counseling method and aids
large print labels, compliance packaging, other
written materials.
• Involve care givers and community support.
Family member who can give time,
community pharmacist can make home visits.