health care burden and the medication experience: engaging our medically complex learners and...

Health Care Burden and the Medication Experience:

Engaging our medically complex learners and families

Molly Ekstrand, RPh AE-C CDE

Mom and Medication Management Pharmacist

Certified Asthma and Diabetes Educator

Park Nicollet Clinic, St Louis Park, MN

How many times have you heard…?

“I (we) can control this myself, without medication”

“Do I really need 3 prescriptions for…”

“What do all these chemicals do in my body?”

“I think I felt better before all these drugs”

“My whole life revolves around drugs and doctors”

“We can’t afford her medications.”

“Drugs don’t work in people who don’t take them.”

C. Everett Koop, MD

For 88% of chronic and complex diseases, drugs are a first choice for medical intervention Medco Data Presented 2010

Medication Experiences and MTM

Understand how 'The Medication Experience' can impact decision making about medication use.

Implement strategies to engage and support learners and families to balance medical needs with academic success.

Questions to run on

How often do you engage your patients in a conversation about their medication?

How many times a day are your patients taking their medicines?

How many different ways are your patients administering their medication?

How often do they visit their pharmacy or pharmacies?

These can be signs of healthcare burden!

1980 1990 2000 2010

60

50

40

30

20

10

0

We’re not making progress…

Medication non-adherence rates 1979-2011

33-50% of patients adhere to chronic regimensClaxton, et al. A Systematic Review of the Associations Between Dose Regimens and Medication Compliance. Clinical Therapeutics 2001, 23:1296-1310.

24% of e-prescriptions sent were never filled within 6 months of the written date

Direct association between dosing frequency and medication adherence

Claxton, et al. A Systematic Review of the Associations Between Dose Regimens and Medication Compliance. Clinical Therapeutics 2001,

23:1296-1310.

Did someone say…?

9

Asthma Stepwise Approach

2007 Asthma Guidelines. www.nhlbi.gov

ADHD Guidelines and Algorithm

11

Diabetes Algorithm

The Conundrum

Evidence Based Medicine and Treatment Guidelines

vs.

The Patient’s Medication Experience

The Medication Experience

Patient’s subjective experience of taking a medication in daily life

Gained expertise with a medication in his own body

May include positive or negative bodily effects

Alter the way they take their own medication

Uncovering, understanding and utilizing these experiences in practice represent an effective way to improve the medication outcomes of patients.

Shoemaker SJ, Ramalho de Oliveira D. The meaning of medications for patients: the medication experience. Pharm World Sci 2008;30:86–91.

Medication Experience Themes

Meaningful EncounterSigns of losing controlSigns of getting olderCause questioning

Meeting with StigmaSocial Stigma with drugs/diseases

Shoemaker, S.J.; Ramalho de Oliveira, D.; Alves, M.R.; Ekstrand, M.J.

Patient Educ Couns. 2011 Jun;83(3):443-50. Epub 2011 Mar 23.

More Medication Experience Themes

Bodily Effects Magic Elixir Negative Effects

Unremitting Nature Chronic medication use, day in

and day outExerting Control

Changing meds to fit with lifestyle

Shoemaker, S.J.; Ramalho de Oliveira, D.; Alves, M.R.; Ekstrand, M.J.

Patient Educ Couns. 2011 Jun;83(3):443-50. Epub 2011 Mar 23.

What do I do now?

Strategies were identified to help providers tailor their care to overcome medication experience barriers.

Motivational Interviewing

meets

Medication Counseling

Callie, 13yo

Social History: 2nd oldest, family of 4 kids. Married parents, dad travels a lot.

Current Medical Issues Asthma and allergies since ~4yo, no hospitalizations.

Frequents the health office for coughing and wheezing. Seen in Urgent Care last week, URI.

– Just finishing her antibiotic and prednisone course.

–More comfortable with her albuterol. Also prescribed ICS/LABA combo which she admits ‘I keep forgetting’ Sometimes I feel like my voice gets funny.

Callie, 11yo, continued

Presents in clinic with mom, urgent care follow-up Mom surprised that Callie hasn’t been using her controller

regularly. Callie feels ashamed that she forgets Mom feels ashamed that she hasn’t paid closer attention Callie admits that when she does use it regularly, her voice

changes. ‘I sound funny.’

Our Goals: Better asthma control! Ideally use controller regularly

Family Goals: Better asthma control! Fit meds in with life, minimize side effects.

Strategy: Acknowledge Patient Choice

Patients have the ultimate choice in their health and utilization of medication.

Ask what their wishes are for their health. Ask them to explain their thoughts, respect

them. Avoid the ‘Righting Reflex’

http://shareddecisions.mayoclinic.org

Strategy: Provide Tailored Education

Understand patient’s experiences and thoughts on health and medications

Train on inhalers to minimize side effectsRealities:

–Preventive medicine is non-gratifying

–Drugs have side effects

–Drugs are expensive

Jacob, 8 yo

Social History: Oldest of 2 kids, married parents, engaged family, one parent works in healthcare

Current Medical Issues: ADHD diagnosed beginning of first grade (1.5 years ago)

– Adderall XR AM and Guanfacine twice daily. Fairly stable– Sees Specialist, Psychologist

Concussion/TBI after tree fall over spring break– 2 Night PICU at Childrens, – MANY follow up MD appointments, and tests. – Physical/Occupational therapy– Many activity and academic restrictions

Increasingly complex regimensTreatments | Monitoring Decreasing healthcare support

Shift towards self-management

Poor care coordination

Evidence-based guidelines are disease-specific

Increasing treatment burden

Failure to cope

Poor fidelity to the treatment program

Promotion of treatments

…And you’re reading for at least 30 minutes too, right?

Minimally disruptive healthcare

May CR, Montori VM, Mair FS. BMJ 2009; 339:b2803

Health care delivery designed to reduce the burden of treatment on

patients while pursuing patient goals

http://minimallydisruptivemedicine.org

Strategy: Empower and Prioritize

Motivational Interviewing Strategies Ask open ended, non-confrontational questions

–Tell me more about that.

–How does that make you feel?

–Let’s pick two things today… Allow the patient to

–Identify their health goals

–Identify solutions to problems

http://shareddecisions.mayoclinic.org

Annette, 17yo

Social history: Older brother left for college last fall, Parents divorced 3 years ago. ‘Things have been different around my house’ …’I don’t want to be different than my friends.’

Current Medical Conditions: Type1 Diabetes since 9yo. Had one severe

hypoglycemic episode at school, fearful of hypoglycemia

– Endocrinologist every 3 months

Depression/Anxiety: Sertraline, controlled now, had severe anxiety attacks when parents split

– Counselor about once a month

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What are Annette’s Med Experiences?

1. Exerting control

2. Unremitting Nature

3. Magic elixir

4. All of the above

Answer: All of the above! Not taking her insulin at school, Magic elixir with the Sertraline, Unremitting nature with her complex regimen.

Strategy: Negotiation

Help patient utilize objective data to realize value of or need for drug therapy

Home glucose monitoring Home blood pressure monitoring

Allow patient to set goal and timeframe. Hold them accountable.

Strategy: Building Trust

Build a relationship with your patient 3 visits? The magic number?

Show them you’re on their side Want to work with them Explain your role: ‘Helping YOU get the

most from your medications’ Reducing your health risks, Keeping your body safe.

Sam, 11yo

Social History: Parents divorced, Middle child, Half time with each parent. Differing parenting styles.

Current Medical Issues: ADD diagnosed in second grade, poor test scores and

teacher input, seemed to correlate with home struggles. – Concerta daily, better adherence at mom’s house

– Dad feels he should be able to focus better, ‘He eats a ton of junk at Mom’s house, not mine.’

Sam gets frustrated and tearful at school, feels in the middle

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Strategy: Building Trust

Build a relationship with your patient/family

Understand family’s experiences and thoughts on health and medications

Show them you’re on their side Want to work with them Explain your role: ‘Helping Sam thrive

academically’ Reducing potential risks of side effects.

Sam knew it helped, kept some in the nurse office.

Strategy: Backing Off

Set lifestyle goals with patient

to achieve health goals, set

follow-up and hold them accountable.

Focus on another health goal or drug therapy issue. Hopefully they will see progress and willingness to move forward.

QUESTIONS? PLEASE CONTACT ME

MOLLY.EKSTRAND@PARKNICOLLET.COM952-993-2087

Engage your patients in

conversations about their

medications.