health care burden and the medication experience: engaging our medically complex learners and...
TRANSCRIPT
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
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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…?
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Asthma Stepwise Approach
2007 Asthma Guidelines. www.nhlbi.gov
ADHD Guidelines and Algorithm
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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
Engage your patients in
conversations about their
medications.