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Jill Sederstrom is a Contributing Editor
Effective patient counseling improves patient adherence. Here’s some things you can do to enhance your skills.
About 3.8 billion prescriptions are written each year; however, an estimated one in five are never filled, according to a 2017 Morbidity and Mortality Weekly Report from the CDC. In addition, approximately 50% of prescriptions are taken incorrectly based on timing, dosage, or frequency of duration recommendations.
This nonadherence has costly implications. Each year, costs associated with nonadherence are estimated to be between $100 and $300 billion in the United States, according to the CDC.
Research shows that pharmacist counseling can improve patient adherence, but despite these studies, overall adherence rates have continued to remain low over several decades.
"We haven't changed the way we talk to patients," says Bruce Berger, PhD, president of Berger Consulting, a company that provides education and training on motivational interviewing techniques. "We're stuck in an old paternalistic model of care, where we tell people what to do and assume if we educate them that's enough."
To enhance patient counseling skills, experts believe pharmacists need to move beyond reciting medical knowledge to a more collaborative and conversational approach-even when the time for each patient interaction is short.
Here are some specific strategies pharmacists can use to perfect their counseling skills.
Patient counseling can be hindered by several factors, but the biggest obstacle for most pharmacists is time.
Jen Alexander, PharmD, pharmacy manager at NuCara Pharmacy in Pleasant Hill, IO, also noted that time is the biggest obstacle to effective counseling. In her current role at a regional chain she's given sufficient time to interact with each patient, but says she's had jobs in the past where that wasn't the case.
"The other thing is patients who aren't receptive, and that's discouraging," she says, adding that even in these cases she tries to highlight the most important information for a patient for a given medication. In the hospital setting, patients may not be receptive to counseling efforts because they may be overwhelmed by a new diagnosis or simply aren't in a frame of mind where they can process the information, says Jacqueline L. Olin, PharmD, BCPS, FASHP, a professor of pharmacy at Wingate University School of Pharmacy, Charlotte, NC.
Other potential obstacles include a patient's health literacy, cultural, or language barriers, a perceived lack of privacy in a community pharmacy setting, or an incomplete picture of a patient's health state or habits.
Brittany L. Melton, PhD, PharmD, assistant professor of pharmacy practice at the University of Kansas School of Pharmacy, and colleague Zoe Lai, recently assessed pharmacy services and opportunities to improve patient satisfaction. They looked at 50 different pharmacy and pharmacy service studies done between 2006 and 2016.
"Patient satisfaction was higher (and) they were more loyal to the pharmacy when they had a good relationship with the pharmacist,” says Melton. “It's those interpersonal skills, being able to relate with the patient and provide them information on their level that seemed to have a pretty significant impact."
Alexander says pharmacists in her state, Iowa, are required to provide counseling for each new prescription. This helps pharmacists establish that interpersonal relationship with pharmacy customers. It’s an approach that pharmacists in other states, where this is not a requirement, might want to consider.
"It's easy to hide behind the counter and check the prescriptions and make sure it's all right, but they need to see your face, they need to know who you are, and need to know you are doing what is best for them even if they are in a hurry," Alexander says.
Most pharmacists don't have a lot of time to establish this interpersonal relationship; however, Berger believes pharmacists can use the time they do have more wisely by restructuring the communication they have with patients.
"We've got to mine down to what's causing this patient who has diabetes to not take their medication when their blood sugar is substantially elevated," he says. "Is it because of side effects? Is it because they feel OK and don't realize how serious this is? It is because of the cost of the medication?"
Berger offers an eight-hour e-learning course through Purdue University and the NCPA bookstore on improving communication with patients using motivational interviewing. Berger says pharmacists should consider "sense making" when interacting with patients, or the idea that patients’ behaviors and decisions about their care are primarily driven by how they make sense of their illness, their medications, or their perceptions of their healthcare professionals.
When people are ambivalent or resistant to change, he says, it is frequently caused by incomplete or incorrect knowledge. For example, a patient who has high blood pressure, may not understand why the medication is needed because he or she feels fine.
"A sense leads to a conclusion, which leads to a decision about a behavior. The sense is I feel fine, the conclusion is I am fine," Berger says, adding that patients may then choose not to take the medication.
To combat this incorrect knowledge, Berger recommends asking open-ended questions in a nonthreatening manner that reflect back the patient's feelings, attitudes, or baseline knowledge about a given medication. This approach better positions a pharmacist to intervene and tailor his or her response to specifically address patient concerns in a conversational manner and invite the patient to reconsider their decision.
"We've got this idea in healthcare that we are driving the bus and the patient is the passenger. The reality is the patient is driving the bus and we're trying to influence the routes," Berger says.
Another strategy is to use what Norm Tomaka, BS Pharm, MS, FAPhA, a clinical consultant pharmacist and media advisor for the APhA, refers to as teach back, or a strategy that asks patients to reflect back what they've learned. For example, a pharmacist may teach a patient how to properly use an inhaler and then have the patient demonstrate what they've learned.
"The teach back method will unravel all these mysteries about a patient's health literacy without having to directly say ‘Do you understand what I am saying?’" he says.
At her pharmacy, Alexander uses a summary wrap-up at the end of her counseling sessions that reiterates the most important aspects that the patient needs to remember. She also tries to sit down with a patient or have regular eye contact to make sure the patient is engaged in the conversation.
The goal with all three approaches is the same: to ensure patients are receptive and walk away from the interaction with the information they need.
"If a patient comprehends their therapy and they buy into their therapy, they are much more likely to comply," Tomaka says.
Pharmacists are often charged with educating a patient about his or her prescription, but the entire pharmacy can play a role in promoting those exchanges.
"We have clerks and we have pharmacy technicians and they all know how important it is that patient cannot leave until the pharmacist talks with them," Alexander says, adding that this has just become a regular part of the pharmacy's workflow.
Pharmacists can also hone their own communication skills by watching the language other pharmacists use during their patient counseling sessions and incorporating effective phrasing into their own scripts.
Effective patient counseling isn't just about providing education, it's equally important to make sure that message has been received.
"As much as the pharmacist has to have the knowledge of what they are talking about, they have to have the ability to evaluate that it's really being heard," says Olin. Pharmacists can help foster patient retention of information by asking open-ended questions or even providing resources, such as written instructions, calendars that outline complex dosing regimens, or links to videos that help reinforce a critical skill.
These supplemental tools can assist patients who may have additional questions once they leave the pharmacy or hospital doors, but experts say these tools don't take the place of a pharmacist.
An essential part of any patient counseling exchange should be letting the patient know how to get in touch with the pharmacist again if they have any questions or concerns.
"If there is a relationship between a pharmacist and a patient, a patient will feel comfortable in contacting that pharmacist for more information, but you have to build that trust,” Tomaka says.