Poor medication adherence leads to $100 billion in healthcare expenditures annually.
When a nonadherent patient was admitted to the emergency department several times a month for several months, Kim Tran, PharmD, a pharmacist at the Community-University Health Care Center at University of Minnesota in Minneapolis, started meeting with him once a week. “During the first meeting, I introduced myself and my role on the care team and established goals with the patient,” she says. “Then we moved on to troubleshoot why he wasn’t meeting his health goals.”
The patient shared that he was a chronic alcohol user who also had a seizure disorder. When he drank, he would pass out and not take his antiseizure medications, which then led to having seizures that sent him to the emergency department, Tran recalls.
“We explored several ways that he could remain on his antiseizure medications even if he was not ready to stop drinking,” Tran says. “He first kept his medications in bottles by his bedside to try and remember, but found it difficult to recollect if he took the dose that day or not. Then, we tried placing weekly medications in a medication box, with each day written on it so the patient could tell if he took medication that day. By doing this and continuing weekly check-ins, the patient was in the driver’s seat of managing his own health. He was allowed to set his own goals and empower himself. This eventually led to decreased emergency department use because his seizures disappeared when he took his medications daily.”
A study in the journal Social Health estimated that poor medication adherence in the United States leads to $100 billion in healthcare expenditures annually. Because of the variety of services pharmacists provide, they have unique opportunities to work closely with patients to help them understand barriers to medication adherence and develop individualized plans that address those barriers, says Batoul Senhaji-Tomza, PharmD, MPH, assistant dean of curriculum and associate professor at Touro College of Pharmacy in New York. Here are nine methods to help nonadherent patients.
1. Assess why the patient is nonadherent.
“Before you can begin to help someone, you need to get to the root cause of why they stopped taking or are not taking their medications properly,” says Fernando Gonzalez, RPh, MS, assistant professor of pharmaceutical sciences at Long Island University Arnold and Marie Schwartz College of Pharmacy in Brooklyn.
According to a survey conducted by Express Scripts in collaboration with Russell Research, more than two-thirds of medication nonadherence is behavior-driven; it’s either caused by forgetfulness or procrastination. “Respondents stated that they didn’t want human intervention to correct these harmful behaviors and rated family members as the least effective source of medication reminders,” says Kyle Amelung, PharmD, BCPS, senior manager of clinical solutions at Express Scripts. “However, technology-based medication reminders are well-received, especially among adults under age 55.”
Other common reasons why a patient may be nonadherent are busy schedules, substance abuse, depression, misconceptions about potential adverse effects or therapy outcomes, high cost, having a complex medication regimen, and low literacy, says Senhaji-Tomza.
When conducting medication adherence assessments, pharmacists can address barriers by guiding patients by asking open-ended questions. For example, pharmacists can adopt a variation of the Morisky Medication Adherence Scale (MMAS). “The MMAS scale uses an eight-point scale of open-ended questions geared toward measuring specific medication-taking behaviors and attitudes,” Senhaji-Tomza says.
2. Review a patient’s medication plan with them.
When meeting with a patient, Tran says pharmacists should discuss each medication individually and highlight the reason for taking the medication, how it will help achieve health goals, possible side effects, and how the patient can obtain it and take it safely. The pharmacist should assess all of a patient’s current medications and how they interact, taking into consideration the patient’s individual lifestyle and health conditions. By doing a review, pharmacists may be able to find out if a patient isn’t adherent and why.
3. Provide enhanced patient counseling.
Counseling considers a patient’s lifestyle and diet based on region and culture. “These factors can have varying effects on the way a medication may behave in someone’s body,” Tran says.
Sarah A. Boswell, PharmD, a clinical pharmacist at Cherokee Health Systems in Knoxville, TN, is a proponent of using the teach-back method during counseling to determine if a patient comprehends the information she provides by having the patient summarize it. “If a patient understands their drug therapy and buys into it, they are much more likely to adhere,” she says.
4. Establish trust.
A pharmacist can establish trust by answering the patient’s questions, being an attentive listener, and showing empathy to their concerns and feelings. “The patient will see you as a resource to help them improve their health and be more motivated to be accountable,” Boswell says.
Following up with patients helps ensure they’re meeting goals and that side effects and concerns are quickly addressed. “Through frequent followups, trust is formed and relationships are built,” Tran says. “Once patients trust a pharmacist and they start meeting their health goals, they are more likely to continue with the current therapy.”
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5. Communicate effectively.
Effective communication is born out of effective listening. “It can be tempting to only provide information; however, starting with open-ended questions enables a pharmacist to learn more about a patient’s specific difficulties and tailor any counseling to that specific situation,” says Clark Kebodeaux, PharmD, BCACP, clinical assistant professor at the University of Kentucky College of Pharmacy in Lexington, Kentucky.
Tran emphasizes that pharmacists use accessible and respectful language to help patients understand health issues and how medications and lifestyles contribute to and treat each disease state. “When needed, we use interpreters who are more familiar with a patient’s individual culture and are able to help pharmacists understand more about a patient’s lifestyle, such as meal choices,” she says.
6. Help patients set goals.
Tran says she sets all goals together, such as laboratory goals (such as A1c or blood pressure) and the patient’s personal goals (such as running a mile or playing with grandchildren). As laboratory goals start to improve, patients may feel physically better. “With each encounter, we revisit goals and assess whether or not the patient has achieved them. If not, the care team assesses how to adjust the goal and make it more achievable,” she says.
7. Take advantage of technology.
Many consumers are tech savvy and embrace opportunities to use technology. Express Scripts, for example, has capitalized on mobile health applications that allow patients to review medication lists, set reminders, and receive clinical messaging and coaching sessions from certified healthcare professionals. “Patients can even add over-the-counter medications and herbal or dietary supplements to their profile, allowing medication interactions to be flagged based on their complete medication list,” Amelung says. “These tools are also leveraged during physician and pharmacy visits, which leads to better health discussions and decisions at the point of care.”
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To promote clinical engagement and greater adherence, Express Scripts offers a game-like approach to medication management. “Through a mobile application, patients can accumulate points and earn rewards by logging health data and achieving medication goals,” Amelung says.
“Our data show that improved clinical engagement equates to better care experiences, better health outcomes, and lower costs year-over-year.”
8. Help patients save money.
One way to help patients save money is for pharmacists to help Medicare Part D patients choose the best plan for them during the open enrollment period, Gonzalez says.
“A pharmacist can input the patient’s prescription needs as well as other important healthcare information, such as deductibles, copayments, and mail order options to help them choose the plan that would save them the most money,” he says.
9. Employ existing programs.
Several nationally sponsored programs are available to support pharmacists in reinforcing medication adherence, Senhaji-Tomza says. For example, Simplify My Meds is a free service available through the NCPA. “The program helps pharmacists consolidate and coordinate all of a patient’s prescription pickups on the same day every month,” she says. “Participation saves patients multiple trips to the pharmacy while streamlining pharmacy operations, therefore freeing time for pharmacists to engage in more meaningful patient interactions.”