Effective Patient Counseling tips

Forums PEBC OSCE Effective Patient Counseling tips

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    Effective patient counseling is not simply the provision of information. Information is prerequisite to compliance, but the timing and organization of the message and involvement of the patient are also critical in determining what the patient understands and remembers. The counseling encounter should be thought of as an opportunity for information exchange. You are the expert on drug therapy, but patients are experts on their daily routines, how they understand their illness and its treatment, whether they anticipate any problems taking the medicine as prescribed, and so forth. Each of these points needs to be assessed if counseling is to be effective. The counseling checklist provided here was developed to increase the probability that the patient will comply with the treatment regimen. It is assumed that before the pharmacist counsels the patient, he or she will first assess the appropriateness of the drug therapy.

    Patient Counseling Checklist

    – Introduce yourself: It is important for patients to know they are speaking with the pharmacist. They may be reluctant to ask questions or express concerns if they believe they are speaking to a technician or clerk. Pharmacists should greet the patient. Extend your hand, and state your name: “Hello, I’m James Smith, your pharmacist.” This begins the relationship.

    – Identify to whom you are speaking: If you are talking to the patient directly, information is less likely to be confused or distorted than if you are talking to the patient’s agent, who must pass the information on to the patient. In third party communication, written information becomes even more important than when directly communicating with the patient. Pharmacists may need to call patients if they believe that the information truly needs to be communicated directly to them.

    – Ask if the patient has time to discuss the medicine: If patients do not have time to listen, the information will be ineffective. The information should be written and/or the patient should be contacted at a more convenient time. For a new patient, a database should be established so that appropriate decisions may be made in the future.

    – Explain the purpose/importance of the counseling session: People listen and learn more effectively when they are given reasons for what is being asked of them. For example, patients are less likely to take tetracycline with food or dairy products if they are told that decreased absorption and effectiveness of the drug may result. For new patients, it will be necessary to explain why the information being gathered is needed.

    – Ask the patient what the physician told him/her about the drug and what condition it is treating: Find out what the patient knows or understands about his or her disease. There is no reason for the pharmacist to present information that the patient already has mastered. Generally speaking, in any effective counseling session, the patient should speak more than the healthcare provider. The purpose of the session is to ensure that patients leave the pharmacy with knowledge about the proper use of the medication. It really doesn’t matter whether the patient gets this information from the pharmacist or physician. Accurate information that the patient supplies should be supported and praised. Inaccurate information should be corrected, and information that is omitted should be added. Use any available patient profile information.

    – Prior to providing information, ask the patient if he/she has any concerns: Often, patients will not vocalize concerns about the drug(s) they are about to take or the condition the doctor is treating unless they are asked. It is important to address these concerns immediately, with as much understanding as possible. Until the concern is addressed, the patient will not register or internalize any other information that is provided. The pharmacist should make every effort to understand the concerns of the patient and treat the concerns with the attention they deserve.

    – Listen carefully and respond with appropriate empathy: These skills are absolutely essential to an effective counseling session. The relationship between the patient and practitioner is a key variable in predicting compliance with treatment regimens. Patients need to view healthcare providers as competent, trustworthy professionals who care about what happens to them. Listening and empathic responding are effective tools for communicating caring. (See the Building Effective Relationships column in the October 1998 issue of U.S. Pharmacist.)

    – Tell the patient the name, indication, and route of administration of the medication: This and the steps that follow will generally be performed after determining the appropriateness of the medication and filling the prescription. Telling patients the name of the medication helps them get used to identifying it. This is especially important in case of an emergency (e.g., a child ingesting it, overdose). Stating the indication reinforces the diagnosis and creates confidence in the appropriateness of the therapy. While the route of administration often seems obvious, pharmacists often encounter cases of patients taking a medication by the wrong route. It should not be assumed that printing this information on the label will cover these points. Many patients cannot read, and those who can read often don’t.

    – Inform the patient of the dosage regimen: Patients should be told the dosage regimen in order to either reinforce what the doctor instructed or inform them for the first time. While a particular dosage regimen may seem straightforward or obvious, it may be interpreted incorrectly. For example, not everyone eats three meals a day. Patients with diabetes may eat six or seven mini-meals each day. Therefore, directions that state, “Take one tablet after meals and at bedtime,” may prompt some patients to take their medications more than the intended four times per day.

    – Ask the patient if he/she will have a problem taking the medication as prescribed: This is an important question that is seldom asked by any healthcare provider. Yet, research shows that the complexity of the dosage regimen can greatly affect compliance. In fact, once-a-day dosing generally achieves rates of compliance of greater than 80%, while four-times-a-day dosing reduces compliance to below 40%. This has significant implications for the pharmacist. The total cost of care needs to be considered, not just the cost of the drug. Noncompliance as a consequence of complex dosage regimens may result in hospitalization of the patient. Pharmacists should attempt to resolve problems related to the dosage regimen, either through tailoring the regimen or working with the physician to change the medication to a less complicated dosing schedule.

    – Tailor the medication regimen to the patient’s daily routine: Making a connection between taking a dose of medication and a regular daily task will enhance compliance. This could include identifying when the patient wakes up and goes to bed or which meals the patient eats. Pharmacists should not assume that patients follow a common routine (e.g., eating three meals a day). They should ask patients about their routines before suggesting a plan.

    – Tell the patient how long it will take for the drug to show an effect: If patients are not told when to expect onset of action, they may believe the medication is not working. Patients may cease taking a medication, or they may take too much because they believe one dose did not work.

    – Tell the patient how long he/she might be taking the medication: Patients need to have a reasonable expectation of how long they will need to take the medication. This helps them get into a “mind set” of compliance. It also helps to eliminate unrealistic expectations. Moreover, it gives patients a chance to express concerns about the length of treatment.

    – Tell the patient when he/she is due back for a refill (and the number of refills needed): Patients need to plan in order to be compliant, and this information assists them in doing so. The information may be given in the form of a verbal contract. The pharmacist could say, “Mrs. Jones, the doctor has given you a 30-day supply. Therefore, I’ll see you on June 30th for your refill. See you then?” By doing this, the pharmacist lets the patient know when to come back in. Stating the date may also remind the patient if there is a scheduling conflict.

    – Emphasize the benefits of the medication: Pharmacists should make every effort to support the chosen therapy and tell patients about the benefits of the treatment before they discuss potential side effects. This not only helps to put side effects in perspective, but it also promotes patient confidence in the therapy. Lack of confidence in the chosen therapy results in a higher incidence of noncompliance.

    – Discuss major side effects of the drug: The more specific pharmacists’ advice can be, the better. Will the side effects go away, and if so, within what period of time? Are there steps the patient can take to prevent, alleviate or manage the side effects? What should they do if side effects don’t go away or become intolerable? Effective counseling helps patients understand the extent of the risk they are taking by using a medication. It is possible that some patients will not want to know about any side effects, and some will want to know all possible side effects. Pharmacists must develop a flexible approach to the dissemination of information. Leaflets are an excellent way to provide patients with additional information.

    – Point out that additional, rare side effects are listed in the information sheet: An information sheet summarizing facts about the medication should be given to the patient at the end of the counseling session. Emphasize the rarity of some of the side effects listed, and encourage the patient to call if he/she has any concerns about these.

    – Use written information to support counseling when appropriate: For literate patients, written information has been shown to reinforce verbal instruction. It gives the patient tangible information to refer to in case he/she forgets what the pharmacist has said. In addition, it can be used to promote more effective counseling. Written information may be given to patients to look over while their prescription is being filled. This can prepare patients to ask better questions and the pharmacist will do less talking.

    – Discuss precautions (e.g., activities to avoid) and beneficial activities (e.g., exercise, decreased salt intake, diet, self-monitoring): It should not be assumed that the physician has discussed these things with the patient. Ask patients what they have been told, and discuss if necessary.

    – Discuss drug-drug, drug-food, drug-disease interactions: Patients generally are not aware that other medications, foods, or diseases may interfere with the drug they are taking or affect the condition for which they are being treated. For example, a patient with high blood pressure should be told to ask the pharmacist before taking any medicines for coughs or colds. The patient should also be told why these precautions are necessary.

    – Discuss storage recommendations, ancillary instructions (e.g., shake well, refrigerate): Many patients still store their medications in medicine cabinets in the bathroom—probably the worst place in the house to keep medicine because of heat and humidity. Give general storage recommendations for all medicines, and specific storage recommendations (e.g., refrigeration) and ancillary instructions to the patient.

    – Explain to the patient in precise terms what to do if he/she misses a dose: Actual times of day and specific examples should be used to make this clear. The patient should then be asked, for example, “What will you do if it is 3:00 in the afternoon and you realize you have missed your noon dose?” The only way you can assess whether patients understand is by asking them to repeat back the information. If you ask them if they understand, patients may say yes even if they do not.

    – Check for further understanding by asking the patient to repeat back additional key information: To fully assess whether the patient understands the dosage regimen, you could say, “Mrs. Jones, sometimes information can be a little confusing. Just to be sure I was clear, could you tell me how you are going to take your medication?” The same would be done with side effects, storage conditions, etc. To better control the time this takes, more specific questioning might be useful: “Mrs. Jones, what time will you take your first dose?” Correct answers should be praised and incorrect information should be corrected. Praising has been shown to reinforce compliance.

    – Check for any additional concerns or questions: The counseling session may have raised additional questions or concerns. The pharmacist should ask if this is so and listen respectfully and carefully to what the patient has to say.

    – Advise patients to always check their medicine before they leave the pharmacy: This helps to familiarize patients with their medicine and makes them a partner in ensuring an error has not been made. The pharmacist should say, “Please always check your medicine before you leave the pharmacy. If you have any questions or problems about the way it looks, please notify me. I don’t intend to make any mistakes, but it’s good to be cautious. You are the final check.” By doing this you are emphasizing that this is a partnership in which the patient also has responsibilities.

    – Use appropriate language throughout the counseling session: On occasion, pharmacists use language that is unnecessarily confusing (e.g., hypertension rather than high blood pressure; GI instead of gastrointestinal or stomach). Many patients will not say they are confused because they do not want to appear stupid. If you detect any confusion, it may be helpful to ask, “Have I said something that has confused or concerned you?” Language that is simple and understandable promotes compliance.

    – Maintain control of the counseling session: A great deal of information needs to be covered in order to counsel the patient effectively. Concerns take time to address. Therefore, keep superfluous conversation to a minimum. “Small talk” is helpful to start the counseling session, but it needs to be brief and simply serve to break the ice.

    – Organize the information in an appropriate manner: Generally speaking, the most important information should be provided at the beginning of the counseling session and repeated at the end. In addition, support of the drug should precede side effects. This checklist has been formulated to reflect the recommended organization of the counseling session.

    – Follow up to determine how the patient is doing: Follow-up care is a good way to
    1) differentiate your services;
    2) let patients know you are concerned about them; and
    3) increase your refill prescription business. Very few healthcare providers offer follow-up care. Yet abundant evidence indicates that patients tend not to get their refills on time and some never return at all. Advise patients that not refilling chronic medications on time places them at risk for further problems, and offer reminders about refills. Follow-up care should be done voluntarily and should be as flexible as possible. Keep in mind that some patients may not want it. Patients should be enrolled in a follow-up care program and given options as to how they receive it. For example, some may prefer a telephone call, while others may prefer a postcard, a letter, or a fax. The more flexible you can be in providing this service, the more likely it will work.

    Final Thoughts
    The checklist is provided as a general guide to effective counseling. Many of you are very busy in your practices and may not have the time to thoroughly cover every item. Time, severity of the illness, and type of medication will be major factors in determining how much or how little of the checklist you use.

    It is important to be as thorough as possible to make sure that your patients leave the pharmacy knowing how to take their medications.

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