Patient-Centric Medication Management

Communication Skills for Pharmacists

Importance of Communication

• Interpersonal communication skills are critical for effective practice in clinical roles such as identifying and reviewing patients’ medication, providing medication counselling, offering information, or ADR monitoring.
• Pharmacists need to be aware of the messages they send, how they are perceived, how to interpret messages from others, and how to adapt communication for different audiences and situations.
• Good communication skills are a prerequisite for effective participation in ward rounds and clinical meetings.
• Effective communication underpins the pharmacist-patient relationship, whether in the pharmacy, clinic, or at the bedside.

Communication Theory

• Communication is fundamentally the sending and receiving of messages, primarily using sight, hearing, and occasionally touch in pharmacy practice.
• Empathy is at the heart of effective communication, defined as the ability to see and feel as another person does. Being aware of internal psychological states and modifying non-verbal communication can enhance interactions.

Verbal Communication

• Occurs through spoken or written words; meaning can be subtly modified by non-verbal qualities like tone of voice.
• Language: Use simple language and avoid unnecessary medical terminology with patients (e.g., “heart attack” instead of “myocardial infarction”). Knowledge of local/regional languages is helpful.
• Vocabulary: Develop vocabularies for both professional and everyday terms for successful communication.
• Pronunciation: Differences in pronunciation of medical terms and medicine names can cause confusion and errors; pharmacists have a role in standardising this.
• Abbreviations: Prescribing terms and abbreviations can be misinterpreted, leading to dosing errors. Identifying confusing terms and checking meaning with the author is safest.
• Stages in Verbal Communication (Structured Approach):
  • Introduction: Establish connection, build rapport, trust, engage interest, exchange courtesies, general enquiries. Acknowledge distress to build rapport.
  • Opening: Introduce and briefly explain the topic.
  • Business: Main messages are delivered or information is obtained.
  • Reconnection: Make a personal reconnection before ending, ensure understanding and clarify.
  • Closure: Non-verbal cues (e.g., gathering papers) signal the end. Concluding courtesies for a positive encounter.

Non-Verbal Communication

• Includes body language (movement/position of head, limbs, body) and professional attire. Approximately 50% of a message’s conveyance comes from body language.
• Aspects: Proximity (distance maintained, intimate/personal zones used by healthcare professionals), touch, eye contact, facial expressions, head movements, hand/arm gestures, body postures.
• Interpretation: Interpreting non-verbal signals and adjusting one’s approach (e.g., softening voice, open body posture) can improve interaction.

Written Communication

• Different styles are appropriate for different purposes (e.g., professional journals vs. patient information leaflets).
• Clarity and Precision: Dosage instructions on labels, while second nature to pharmacists, can be unclear for patients (e.g., “Take one tablet daily” lacks specific timing).
• Patient Information Leaflets (PILs): Require a detailed and precise style in easily understood terms.
• Case Note Annotation: Must be concise and legible, conforming to local standards.

Communication in Professional Practice

• Inter-professional Communication: Challenging during service establishment, requires courtesy, willingness to help, reliable information, and teamwork. Focus on patient welfare.
• Overcoming Resistance: Focus on patient needs, add pharmaceutical value, acknowledge others’ abilities, and support their roles. Avoid open or implied criticism.
• Prioritisation: Avoid trivia and focus on significant patient care issues.
• Uncertainty: Do not bluff if unsure; acknowledge, find information, and communicate later.
• Patient Presence: Be cautious discussing drug-related issues in front of patients to avoid challenging the prescriber’s integrity or affecting patient faith.
• Telephone Conversation: Maintain control, focus content, end when purpose achieved. Preparation (main points, structure) is useful.
• Case Note Annotation: Conveys important information, serves as a legal record. Must be clear, precise, dated, and signed. Includes issue, reasoning, recommendation, author’s name, position, and contact. Pharmacists in some countries may carry equal or greater legal blame for not documenting potentially harmful therapy.

Developing Communication Skills

• Best developed by observing others, regular practice with reflection, and discussion with colleagues.
• Role plays are useful for building confidence and practicing specific situations.
• Structured approach with supervision fosters skills and confidence, ensuring service quality.
• Information Delivery: Check client’s knowledge, adapt information, keep messages short (5 minutes or less verbally), use written information for detail, plan message structure, place key messages at beginning/end, use repetition.
• Information Management: Skills to retrieve and store information are crucial in a rapidly changing IT environment.

Special Considerations for Indian Pharmacists

• Face considerable challenges due to lack of familiarity with modern therapy, contaminated/counterfeit medicines, unpredictable supply, and an educationally/culturally diverse population.
• Challenges include finding appropriate symbols/diagrams for illiterate/innumerate patients and communicating when a common language is not shared.

Patient Counselling

Need for Patient Counselling

• Safe and effective use of drugs depends on well-informed patients.
• Prescribers often have limited time to explain medication use due to heavy patient loads.
• Lack of information can lead to therapeutic failure, adverse effects, increased expenditure, hospitalisation, and antibiotic resistance.

What is Patient Counselling?

• Process of providing information, advice, and assistance to help patients use medications appropriately.
• Given verbally by the pharmacist directly to the patient or representative, supplemented with written material.
• Assesses patient’s understanding of illness and treatment, provides individualised advice. Requires familiarity with pathophysiology and therapeutics, and good communication skills.

Outcomes of Effective Patient Counselling

• Better patient understanding of illness and medication role.
• Improved medication adherence.
• More effective drug treatment.
• Reduced incidence of medication errors, adverse effects, and unnecessary healthcare costs.
• Improved quality of life and coping strategies for adverse effects.
• Improved professional rapport between patient and pharmacist.

Communication Skills for Effective Counselling

• Utilises both verbal and non-verbal communication skills.
• Verbal: Language (simple, avoid medical terms, use local language if possible), paralinguistic features (tone, volume, pitch, rate of speech - accounts for 40% of message reception).
• Non-verbal: Body language (movement, position of head/limbs/body) and professional dress (accounts for ~50% of message conveyance). Proximity (intimate or personal zones generally used).
• Qualities of a Good Counsellor:
  • Good listener (attentive, observes verbal/non-verbal behaviour).
  • Flexible (tailors advice to individual needs).
  • Empathetic (understands patient’s suffering).
  • Non-judgemental (does not judge based on illness/group).
  • Tolerant (acknowledges patient’s agitation/hostility).
  • Communicates confidently (improves patient acceptance).

Steps of Patient Counselling

1. Preparing for the Session: Know about the patient and treatment (case notes, prescription, previous dispensing records, drug information references if unfamiliar). Consider patient’s mental/physical state; modify or postpone if necessary.
2. Opening the Session: Introduce self, greet by name, clearly identify purpose of session (e.g., “tell you about your medication”). Gather information using open-ended questions (e.g., “What did your doctor tell you about your illness?”) and reflective questioning. Avoid direct/embarrassing questions, excessive curiosity, moral judgments, interruptions, or arguing.
3. Counselling Content: The core of the session. Commonly covered topics include:
   • Name and strength of medication.
   • Reason prescribed or how it works.
   • How to take (amount, frequency).
   • Expected duration of treatment.
   • Expected benefits and possible adverse effects.
   • Possible medication or dietary interactions.
   • Advice on correct storage.
   • Minimum duration for therapeutic benefit.
   • What to do if a dose is missed.
   • Special monitoring requirements (e.g., blood tests).
   • Arrangements for further supplies.
   • Lifestyle changes (diet, exercise) may also be discussed.
   • Prioritise points based on time. Use simple, understandable language, avoiding medical jargon. Gather family information if they are collecting medication.
4. Closing the Session: Check patient’s understanding using feedback questions (e.g., “Can you remember what this medication is for?”). Address any new questions or doubts. Summarise main points. Provide contact information if appropriate.

Counselling Aids

• Medication Cards: Written summary of medications, easy to understand, useful for patients on many long-term medications. Can be handwritten or computer-generated. Should be updated with regimen changes.
• Patient Information Leaflets (PILs) (also CPI/CMI): Written information in simple language about illness, treatment, medications, and lifestyle changes. Reinforce verbal advice, improve understanding. Useful for literate patients. Pharmacists can develop PILs in local languages, which should be peer-reviewed and approved by medical staff.
• Readability of PILs: Flesch Reading Ease (FRE) formula can be used; a score less than 60 is difficult, ideal is 70-80. Readability improves with simple words and short sentences.
• Pictograms: Useful for illiterate and innumerate patients.

Patient Groups Requiring Counselling

• Patients receiving specific medications (e.g., antibiotics, narrow therapeutic window drugs like warfarin).
• Patients on complex medication regimens (e.g., anti-tubercular drugs).
• Patients receiving medications via specialised delivery systems (e.g., inhalers).
• Patients with a history of poor medication adherence.
• Elderly patients taking multiple medications.
• Patients being discharged from hospital.
• Patients referred by physicians.

Barriers to Patient Counselling

• Patient-based: Unawareness that pharmacists provide counselling, gender/language differences.
• Provider-based: Lack of knowledge/confidence, heavy patient load for prescription filling.
• System-based: Not legally mandatory, no official reimbursement for counselling, lack of privacy.

Strategies to Overcome Barriers

• Provider-based: Update knowledge/counselling skills, develop confidence by focusing on specific drug types initially.
• General: Ask patients “Have you used this medication before?”, encourage questions, media campaigns.

Medication Adherence

Determinants of Medication Non-Adherence

• A complex interaction of factors.
• Predisposing factors: Demographic factors, patient’s knowledge, attitudes, beliefs, and perceptions about illness, severity, cause, prevention, and treatment.
• Medication-related factors:
  • Long duration of treatment.
  • Adverse effects.
  • Complexity of regimen (e.g., number of medicines, frequency of dosing).
• Negative Impact in India: Illiteracy, poor understanding of disease/treatment, poor socioeconomic status, poor pharmacist involvement in education, high patient load for doctors, lack of medical insurance for non-communicable diseases, lack of carers for elderly.

Consequences of Non-Adherence

• Treatment failure.
• Increased chance of hospitalisation.
• Increased medical and non-medical expenditure.
• Decreased quality of life.

Methods to Detect Medication Non-Adherence

• Patient Interview: Simple, easy, provides additional information on attitudes, but may be inaccurate if patient is not forthcoming, and difficult for long periods due to recall bias.
• Diary Keeping: Patient records symptoms and medication use. Advantages: easy and practical. Disadvantages: time-consuming, requires literacy, no objective measure of actual drug intake.
• Weighing of Inhaler Canisters: Accurate, direct, objective measurement of medication use, but cannot determine correct timing or technique.

Intervention Strategies to Improve Adherence

• General: Most studied interventions are patient-oriented and educational (oral, written instructions, educational leaflets). No single method has proven consistently superior.
• Provider-targetted: Education of healthcare workers (physicians, community pharmacists, nurses).
• Patient-targetted:
  • Educational strategies: Oral or written instructions, audiovisual materials, individual/family/group education.
  • Behavioural strategies: Medication diaries, dosettes, verbal agreement, tailoring regimen to patient convenience, reminders (mail or telephone). Packaging with dose reminders can improve adherence.
  • Affective strategies: In-depth counselling, home visits, generating family support.
• Pharmaceutical formulations: Sustained-release, long-acting, transdermal, depot preparations can decrease dosing frequency and improve convenience.
• Patient Involvement: Patients should be involved as equal partners in health decisions; doctors should act as expert advisors.
• Key Principles from Research:
  • Comprehensive programmes improve adherence more.
  • Multiple interventions (educational, behavioural, affective components) have an additive effect.
  • Written instructions alone are less effective than other educational interventions.
  • Group education improves direct measures of adherence and utilisation.
  • Physician’s communication skills are a very important factor.
  • Tailoring or cueing: Matching regimen with daily routine (e.g., mealtimes).
  • Simplification: Reducing number of medicines and dosing frequency (e.g., combination products).
  • Focus on key points: Restrict information to four key points.
  • Check for recall: Essential to confirm understanding.
  • Address side effects: Inform patients what to do if side effects occur (e.g., stop, contact doctor, persevere).

Role of the Pharmacist in Improving Medication Adherence

• Unique Position: Pharmacists can physically show medication and relate information directly to the drug.
• Education: Provide verbal education and written individualised information.
• Collaboration: Advice to prescribers on simplifying drug regimens.
• Adherence Aids: Provide medication cards or aids like dosettes.
• Assessment: Identify predisposing, enabling, and reinforcing factors contributing to non-adherence. Assess patient’s knowledge of drug therapy and usual habits, specific problems (e.g., swallowing tablets, opening child-proof containers), and ability to comprehend/recall information.
• Communication Strategies:
  • Be friendly and approachable, improve communication skills.
  • Consider spiritual and psychological needs.
  • Encourage patients to discuss concerns.
  • Elicit patient’s perception of illness/feelings/expectations.
  • Use active listening and empathy.
  • Give clear explanations, check understanding.
  • Negotiate treatment plan, check attention to adherence.
  • Simplify therapeutic regimen, be aware of patient’s wishes, involve patient in decisions.
  • Improve home support, monitor beneficial/side effects, provide long-term support/continuity of care.
  • Speak the same language, shorten pharmacy waiting time.

Patient Medication History Interview (MHI)

Need for MHI

• Medical professionals require complete and reliable medication history to review current and identify suitable additional treatments.
• Research shows pharmacists provide the most accurate medication history compared to other health professionals.
• It is the foundation of the medicine reconciliation process.

Goal of MHI

• To obtain a complete and accurate summary of the medications a patient has been using, along with other information that can contribute to pharmaceutical care.

Timing and Context

• Should be obtained at the beginning of hospital admission to influence drug therapy selection.
• The nature of the interview depends on the patient’s condition; pharmacists must tailor questions.

Aspects of Medication Use Assessed

• Detailed Information:
  • Currently or recently prescribed medicines.
  • Medicines purchased without prescription (OTC).
  • Vaccinations (if relevant).
  • Alternative or traditional remedies (e.g., Ayurveda, Siddha, Unani).
  • Description of reactions and allergies to medicines (history of previous allergies/ADRs).
  • Medicines found to be ineffective.
  • Adherence to past treatment courses and use of adherence aids.
  • Indication/Purpose of each medication.
  • Dosing regimen (dose, route, frequency, duration).
  • Perceived efficacy and side-effects.
  • Medication administration techniques and use of medication aids.
  • Specific problems relating to medication use.
  • Possibility of pregnancy in women of childbearing age.
  • Social drug use (alcohol, tobacco, pan masala, etc.).
  • Evidence of drug abuse.
  • General attitudes towards illness and medication use.

Pharmacist’s Contribution during MHI

• Establish rapport with the patient.
• Explain their role in patient management.
• Conduct preliminary medication counselling.
• Plan ongoing patient management/pharmaceutical care.

Steps Involved in Taking a Medication History (Appendix II,)

1. Self-preparation:
   • Collect relevant data from available sources.
   • Thoroughly understand the patient’s co-morbidities.
   • Prepare a provisional list of medications.
   • List questions to focus on patient-specific needs and save time.
2. Privacy and confidentiality:
   • Consider factors related to privacy, especially in hospital settings (bedside).
   • Involve patient’s carer/family with permission if the patient cannot communicate.
   • Maintain confidentiality of collected data.
3. Purpose of interview:
   • Introduce self and explain the purpose and potential benefits of the interview.
   • Respect the patient’s right to decline.
4. Conduct of interview:
   • Use communication skills (listening, body language, voice intonation, history-taking).
   • Adopt a suitable seated position for comfort.
   • Use the patient’s first language if possible.
   • If the patient cannot communicate, involve family/carer with permission.
   • Use open-ended questions (e.g., “Please tell me how you take your medications”) to encourage knowledge and beliefs.
   • Ask questions non-judgementally.
   • Use close-ended questions to confirm details.
   • Avoid exhaustive or unimportant questions.
5. Conclusion:
   • Check if all important information has been obtained.
   • Ask if the patient has any questions.
   • Encourage the patient to provide more information later.
6. Documentation and follow-up:
   • Document all information for ongoing pharmaceutical care.
   • Compare documented medications with information from other HCPs for discrepancies (medication reconciliation).
   • Bring discrepancies to the attention of medical staff.

Medication Review

Role and Definition

• Involves the review of a patient’s medication regimen to ensure therapy is appropriate, safe, efficacious, and cost-effective.
• Daily review is desirable to keep up with changes in drug therapy, ideally following the patient from admission to discharge.
• Pharmacists engage in clinical activities like identifying factors affecting medication management, assessing drug therapy, monitoring outcomes, intervening to resolve drug-related problems, and educating patients/carers.

Goal of Medication Review

• To optimise drug therapy and patient health outcome by identifying and solving drug-related problems (DRPs) and ensuring all therapeutic objectives are met.

Significance of Medication Review

• Enables pharmacists to:
  • Assess whether desired therapeutic outcomes are achieved.
  • Monitor for drug-related problems/toxicity.
  • Ensure rational and quality use of medicines.
  • Assess patient compliance (medication adherence).
  • Assess the completeness of medication charts.

Components of Medication Review

• Medication Order Review (MOR)/Treatment Chart Review (TCR).
• Clinical Review/Daily Progress Review.
• Detection and management of Adverse Drug Reactions (ADRs).
• Residential Medication Management Reviews (RMMRs) and Home Medicines Review (HMR) for community settings.

Medication Order Review (MOR)

• A fundamental responsibility of clinical pharmacy practice and the basis for other activities.
• Identify any condition or DRP requiring a change in drug therapy.
• Review for appropriateness by considering all relevant information (presenting complaints, clinical assessment, allergy status, lab investigations, treatment plans, daily progress).
• Data sources: Treatment chart, case notes, laboratory results, patient medication history interview (MHI).
• Steps involved in MOR:
  1. Collection and interpretation of patient-specific information (including MHI).
  2. Assessment of therapeutic goals.
  3. Identification of drug-related problems.
  4. Individualising medication regimens.
  5. Monitoring of treatment outcomes.
  6. Medication chart endorsement.
  7. Documentation.

Collection and Interpretation of Patient-Specific Information

• Information types: Patient demographics (age, sex, body weight), social history, presenting complaints, past medical history, allergy/sensitivity status, current/recent medications, relevant lab tests, other investigations.
• Sources: Patient, case notes, medication chart, nursing notes, observational charts, laboratory results, discussions with medical/nursing staff.
• Pharmacists obtain medication history through MHI, which is often more complete and accurate than what medical staff obtain.
• Medication Reconciliation: Comparing data collected during MHI with medication charts to identify discrepancies and DRPs.

Assessment of Therapeutic Goals

• Essential to understand individual patient’s therapeutic goals (e.g., cure, symptom elimination, prevention, slowing progression, improved quality of life) to determine appropriateness of drug therapy.

Identification of Drug-Related Problems (DRPs)

• Definition: Any event or circumstance involving drug treatment that interferes or potentially interferes with an optimum outcome of medical care.
• Eight Categories (Hepler and Strand):
  1. Untreated indication.
  2. Improper drug selection.
  3. Subtherapeutic dose.
  4. Overdosage.
  5. Adverse drug reactions.
  6. Failure to receive drugs.
  7. Drug interactions.
  8. Drug use without indication.
• DRPs should be prioritised by severity and discussed with the physician, with suitable corrective strategies recommended.

Individualising Medication Regimens

• Consider the patient’s overall medication regimen, especially for chronic diseases.
• Aim to simplify the regimen to maximise long-term adherence.
• May involve: switching to slow-release, different route/time of administration, cheaper but effective medication, or combination formulations (after individual drug doses are stabilised).

Monitoring of Treatment Outcome

• An ongoing process involving review of clinical status, laboratory data, and other markers of drug therapy response.
• Pharmacist reviews information from temperature charts, lab data (WBC, ESR, CRP), case note entries, patient interviews, and evaluations by other healthcare professionals.
• Monitoring parameters:
  • Clinical: Signs, symptoms, and clinical charts (diabetic, fluid balance, observation, pain management, bowel, alcohol withdrawal).
  • Laboratory: Biochemistry (electrolytes, renal/liver function), Hematological (WBC, RBC indices, platelets, DC, ESR, Hb%), Microbiology (culture results, antibiotic sensitivities), Other (Echocardiogram, ECG, CT scan, MRI).
• Interpretation requires considering disease features, investigations, drug effects (onset/duration), medication history, and desired outcomes. If objectives are not met, re-evaluate and discuss interventions with clinicians.

Medication Chart Endorsement

• A primary responsibility to ensure medication orders are unambiguous, legible, and complete, preventing errors at prescribing/administration levels.
• Specific annotations:
  • Allergy column completion (e.g., ‘NIL KNOWN ALLERGY’).
  • Clear medication name (full generic name, avoid abbreviations).
  • Clear dose and dosing frequency (avoid ‘u’ for units, ‘µg’ for ‘mcg’, use leading zero for fractional doses).
  • Specified route of administration.
  • Clear date and time of drug administration.
  • Minimum dose interval for ‘as required’ (PRN) medications, and maximum total daily dose (e.g., paracetamol 4g/day).
  • Additional drug administration instructions (e.g., ‘take with food’).
  • Avoid overwriting.
  • Clear and unambiguous cancellation of medication orders (signed by prescriber).
  • Prescription signed by a doctor (legal requirement).
  • Nurse’s signature for each dose administered (for compliance assessment).
  • Adherence to legal and local requirements.
• Pharmacists should explain endorsement purpose to prescribers. Endorsements should be initialled and dated, and charts reviewed daily. Never guess prescriber’s intention from illegible prescriptions.

Documentation

• Pharmaceutical care provided should be an integral part of the patient’s medical record.
• Documentation can be in the medication chart or case notes (with clear title, pharmacist’s signature).
• Computerisation of relevant information can be useful in hospitals with networking systems.

Adverse Drug Reaction (ADR) Detection and Prevention

• Routine medication review is a method for identifying ADRs.
• Documentation: Essential to avoid re-exposure. Complete documentation in the patient medical record, including alert cards/sheets.
• Communication: Notify medical staff and the original prescriber of suspected ADRs.
• Complete in-house documentation for future reference.