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Drug Information and Commuication Strategies in Pharmacy Table 6. Nonverbal Communications Concept Proxemics Definition Use of physical distance between people Chronemics Use of time Oculesics Use of eye contact Haptics Use of touch Kinesis Use of body movements Objectics Use of objects Vocalics Use...

Drug Information and Commuication Strategies in Pharmacy Table 6. Nonverbal Communications Concept Proxemics Definition Use of physical distance between people Chronemics Use of time Oculesics Use of eye contact Haptics Use of touch Kinesis Use of body movements Objectics Use of objects Vocalics Use of vocal tone and pitch Questions to Consider with Patients, Caregivers, or Providers - What types of activities are most appropriate? - What are the cultural differences in physical location? - How close to sit/stand next to the patient/provider? - How long did the patient/provider have to wait? - Was the patient on time? - How long is the clinic visit? - What are the cultural differences on time? - Is the amount of eye contact appropriate? - W hat are the cultural differences on looking directly in the eyes or looking away? - Is looking at the computer/device appropriate during an encounter? - W hat is this saying about the person’s attitude, honesty, intelligence, and feelings? - Does this touch come across as superficial or demeaning? - Is this communicating empathy, warmth, or acceptance? - What are the patient/provider boundaries with physical touch? - Is this something the provider is comfortable doing? - Are the gestures consistent with words/emotions? - What will pointing or other gestures convey? - Where are the gestures aimed? (direction of pointing) - W hat does thumbs-up/thumbs-down mean and is this accepted in all cultures? What are other gestures that are not acceptable in certain cultures? - Which direction is the provider’s back pointed toward regarding the patient? - W hat does the provider’s clothing show about them? (e.g., wrinkled vs. dirty, jewelry, formal vs. informal, use of laboratory jacket) - W hat patient educational materials are used or available for patients? - How is the waiting area arranged and organized? - What reading materials are offered? - A re there any distracting uses of objects (e.g., clicking of pen, tapping of foot, beeping from telephone) - Does communication focus on quality over quantity (e.g., clarity, inflections, emphasis) - W hat volume is appropriate, and does this change between cultures? 3. Engage in active listening. a. React to ideas and not the person (e.g., not judging a patient for not taking their medications, but seeking out their reasoning behind the nonadherence). b. Read the patient’s body language. c. Listen to the patient’s tone of voice as well as the patient’s words. d. Ask for clarification as needed, and seek understanding of the patient’s motives. e. Write down notes of the patient’s thoughts and values at the same time as writing down follow-up questions to ask after the patient finishes talking. f. Permit silence in the interaction by allowing the patient to pause and think or allow for silence between questions and thoughts. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-539 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 539 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy 4.  Show empathy. a. Showing empathy helps patients know they have an advocate as they ask three important questions subliminally within their mind: “What’s going on?” “What’s going to happen next?” “How am I being treated?” Table 7 provides several types of showing empathy. Table 7. Showing Empathy Action Used Reflecting Purpose To show understanding of a person’s feelings Encouraging To convey interest and to encourage the person to continue talking and sharing Summarizing To review progress and to pull together important ideas and facts Clarifying To help clarify what is said, to get more information, and to help the speaker see other points of view Restating To show listening and understanding of what is being said and to help the speaker clarify what they are saying To acknowledge the - “You have done a really good job of keeping track of your blood worthiness of the other pressure readings this past month” person - “You have had a lot of really good ideas on how you might be successful in quitting smoking” Validating Examples - “You seem very upset” - “You’ve had a really tough time getting answers to your questions” - “You wish you knew more about this vaccine” - “Please tell me more about that” - “These are difficult topics to talk about. Your openness and honesty in discussing this with me is really brave.” - “To make sure I heard you right, it sounds like you are saying…” - “Before we move on, let me try to sum up what you are telling me” - “These are some of the big ideas you’ve brought up” - “You have had a really hard time making healthy choices with your foods. What has worked for you so far?” - “Where did you experience those muscle pains?” - “How often has this happened?” - “It sounds like you would like to try all your oral medications options before switching to insulin. Is that right?” - “Your lack of trust with the government has you secondguessing whether you want to get a vaccine” b. Empathy generally avoids “clichés” (e.g., “If I read between the lines…”), immediately trying to fix or minimize the problem (“the righting reflex”), being empathetic without responding empathetically, or confusing empathy with becoming too personally involved. 5. Choose key questions at key times. a. Framing the question: Allows the person to know why the question is being asked and be prepared for what is to come. “To get the most out of your HIV medications, I may need to ask a few questions and they may be difficult to answer.” b. Use of prompts: Allows all involved to know what to expect and know where to focus attention (e.g., pointing finger at an object) and helps finish thoughts or ideas. “You mentioned you were going to send a drug information question. When would you like this to be answered?” c. Probing questions: Ask for more focused or clarifying information. “In what ways?” “Tell me more about…” “How did that make you feel when…” d. Open-ended questions: Create deep responses with more detail, especially early in conversations; however, these can take more time to employ. “How do you take this medication?” “What are you hoping to answer with this conversation?” e. Closed-ended questions: May allow for further clarification when specific details are needed in a time-efficient manner but may reduce patient openness and are more passive. “How many tablets do you take?” “Do you still take this medication?” ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-540 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 540 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy f.  Use mnemonics like SCHOLAR-MAC (symptoms, characteristics, history, onset, location, aggravating factors, remitting factors, medications, allergies, conditions) to assess a patient’s problem and symptoms systematically and comprehensively. In most cases, it may not be appropriate to ask a question for each factor, but this standardized approach can help a practitioner to avoid omitting important information. Table 8. Using the SCHOLAR-MAC Acronym to Collect Patient Information A patient asks, “Can you help me figure out why I have all this swelling?” SCHOLAR-MAC Example Questions Symptoms “What is your main concern?” Characteristics “Describe the swelling. How much worse is it now than normally?” History “Have you had swelling in the past?” Onset “When did you notice this starting?” Location “Where is the swelling located?” Aggravating factors “W hat makes the swelling worse? Do you notice a difference in the morning vs. when you have been on your feet all day?” Remitting factors “What has made the swelling better?” Medications “What medications have you tried to help with the swelling?” Allergies “What allergies do you have to medications?” Conditions “What other medical conditions do you have?” g. Avoid leading questions. These types of questions can force a patient or provider to answer in the manner expected of them instead of what is true and accurate to them. “You take your Genvoya with food, right?” “You don’t miss any doses, do you?” h. Avoid compound questions. In most cases, a patient or provider will only remember the last question asked of them and can forget the first part of the question. Instead, break down these complex questions into individual and concise questions. “How are you doing with your snacking, and what can you be doing better to get more fruits and vegetables into your diet?” i. Avoid circling back to already answered questions or duplicate questions because this repetition can show a lack of listening or engagement in the conversation. j.  Use the BATHE (background, affect, troubling, handle, empathy) procedure when dealing with a patient’s problems when there is an emotional component or when the problem significantly alters quality of life. Table 9. BATHE Procedure BATHE Example Questions Background “What is going on in your life?” assesses the circumstances surrounding the encounter, but if the patient has already discussed this, move on to “Affect” Affect “How do you feel about that?” helps the patient elicit their emotional response. This can help the patient identify their own feelings in a situation Trouble “What troubles you the most about this?” focuses on the symbolic meaning behind the patient’s situation Handling “How are you handling that?” helps determine the patient’s ability to respond to the situation Empathy “That must be very difficult for you” reflects understanding and validates the patient’s response is reasonable, given the circumstances For more information, visit https://www.ncbi.nlm.nih.gov/pmc/articles/PMC181054/pdf/i1523-5998-001-02-0035.pdf. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-541 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 541 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy B. Tailoring for Individual Patients and Health Care Professionals 1. Communicate drug information with patients or caregivers. a. Motivational interviewing (MI) is effective to initiate, guide, and maintain goal-oriented thoughts and behaviors. i. The purpose of MI is to create a conversation about change to strengthen personal motivation for and commitment to a specific goal or targeted change. ii. The “Spirit of MI” strengthens rapport and positive outcomes for patients by encouraging collaboration, the 4 “A’s of acceptance” (autonomy, absolute worth, affirmation, accurate empathy), evocation, and compassion. Effectively using the components of MI should center around these principles to empower patients and reinforce that they are an important part of their own care. iii. The “Four Fundamental Processes of MI” help create a framework for effectively implementing MI for patients. Table 10 discusses some practical ways to use these processes when engaging with patients and practitioners. Table 10. The Four Fundamental Processes of Motivational Interviewing Process Engaging Focusing Evoking Planning Purpose Process of establishing a mutually trusting and respectful helping relationship Components/Examples - Reflective listening: “You are worried what this new diagnosis will mean for your family”: “You’ve grown up avoiding medications and now the doctors you respect are advising you to take medications” “If you knew your medications were working, you wouldn’t miss as many doses throughout the week” Process of strategically - Summary statements: “Here’s what I’ve heard. Let me know if I’ve centering both the missed anything…” “Let me see if I understand…” provider and the patient - Agenda mapping: “Which aspect of diabetes do you want to focus on goals today?” “We’ve talked about some of the things you can do during the day to cut back on smoking. Let’s talk about medications that can improve your chances of quitting” Process of drawing out the - Elaboration: “Tell me more.” “In what ways” patient’s thoughts while -Q  uery extremes: “What is the worst thing that could happen if you empowering the patient make this change?” “What is the best thing…?” to take ownership of their - L  ooking forward: “If you were 100% successful in making this goals (the “bridge” to change, what would life look like in 10 years?” planning) -L  ooking backward: “What was life like before you had a drinking problem?” -E  ncourage “change talk”: “Why would you want to make this change?” Process that allows the - Elicit-provide-elicit: “What do you know about…? (elicit)” “Do you patient to create their own mind if I share some information about…? (provide)” “What thoughts plan by promoting selfdo you have about this now? (elicit)” efficacy and autonomy - Timing key questions: “Given what you’ve told me, what do you think you will do next?” “What’s your next step in order to …?” - Asking permission: “Taking this medication correctly can be complicated. Do you mind if I give you a few pointers and tips to get the most out of taking it?” ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-542 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 542 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy b. Other key components of MI i.  Encourage change talk. This is any form of communication that moves the patient toward an attitude of change, though it may not always be appropriate if the patient is unwilling to consider the change. “If you knew avoiding fast food would decrease your risk of disease, you would consider changing up your lunch habits.” “What is the best reason for you to make this change right now?” ii.  Avoid and soften sustain talk. The patient may get trapped in communication while nothing is accomplished and circle back to their original thought process, though this can help build rapport for patients with resistant behavior. “You can’t see yourself giving up smoking.” “Why haven’t you quit smoking yet?” iii.  Dancing with discord. Sustain talk is about resistance in making a targeted behavior change, whereas discord is about conflict within a personal relationship. It is important to repair the relationship by maintaining the Spirit of MI using reflections to diffuse a situation (e.g., “You are angry with our pharmacy team”), shifting focus (e.g., “You’ve got strong opinions about that topic. Maybe we should talk about something else?”), and/or emphasizing personal choice (e.g., “We can’t make you take your medications. We just want to give you the information so that you can make the best choice for yourself”). iv.  Avoid the righting reflex. The patient may not feel validated or cared about if the provider is trying to fix their problem or their way of thinking. Instead, focus on autonomy and allowing the patient to make the decision. “I’m sorry you are going through a very hard time. I’d really like to hear more about what you are going through.” 2. Communicate drug information with health care professionals using the PPCP. a.  Collect information to better assess the drug information opportunity (e.g., demographics, situation, background, history of present illness, “SCHOLAR-MAC” information). i. Define the problem or issue. “What is the patient’s chief concern, or the problem being addressed?” ii. Clarify the problem or request additional information such as blood tests or information from the patient history. iii. Determine the health care professional’s timeline for when they need an answer shared back with them, and if applicable, ask for a preferred mode of delivery. b.  Assess the situation to plan for a successful resolution. i. If necessary, consider why this situation occurred in anticipation of asking clarifying questions or requesting additional information. “Is this likely an oversight or an intended choice by the prescriber?” ii. Assess and analyze the therapeutic alternatives in pursuit of the best recommendation for resolving the situation. “What is the strength of the evidence to support each recommendation?” “How might the recommendation change depending on the additional patient information requested?” iii. Decide on the best audience and recipient to better frame the recommendation. “What will they know or want to know?” (a) Discipline: Physicians, nurse practitioners, and physician assistants generally have a different level of knowledge of therapeutics and evidence-based medicine. (b) Generalist vs. specialist: “Is this therapeutic recommendation within or outside their area of specialty?” (c) Academic vs. nonacademic: “Is this information directly applying to a patient, or is it academic in nature?” ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-543 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 543 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy (d) Personality of the provider: “Is this provider open to recommendations from an outside source?” “Will they process this recommendation and consider the implications, or directly apply the recommendation?” (e) Differences in communication styles: “Does this provider prefer more detail, or do they prefer simple communication?” “Will they be more likely to read a fax or listen to a voicemail?” c.  Plan and implement communication of drug information to the health care professional. i. Choose an appropriate vehicle to communicate with the provider depending on the urgency and nature of the drug information. (a) Fax: May send to provider’s office if issue is not time-sensitive and if relationship with provider is not well established (b) Email: May be viable when the provider/pharmacist relationship is established but the issue is not time-sensitive (c) Telephone/video call: Can be used if the patient care issue requires immediate attention or further clarification is necessary. This may include talking to the provider’s health care team (e.g., nurse, medical assistant, receptionist) for gathering further information. (d) Low-priority message: Can be used if the pharmacist/provider shares electronic health records with non-urgent patient care situations (e) Page/high-priority message: Can be used during time-intensive and urgent situations and if an issue needs to be resolved immediately to prevent harm to patient ii. Deliver the message to the provider while being clear, complete, concise, timely, professional, and organized. (a) Identification of self and greeting should catch attention with level of urgency: “Good morning, Dr. Smith; it has come to my attention…” “Hello Nurse Karen, we have been treating a mutual patient and…” (b) Give a solution with appropriate verbiage according to the strength of the recommendation. “I strongly recommend we…” “If deemed appropriate by both you and the patient, we might consider…” iii. Provide a rationale and offer evidence to support the recommendation (see Tables 3 and 4). d.  Follow up with the health care professional or patient to make sure the problem or drug information situation is resolved. Be prepared to modify your recommendation in response to new information or a challenge from the provider. 3. Tailor verbal and written communication styles to patients and health care professionals. a. Effective communication with providers generally follows the “SBAR” format: i.  Situation – Briefly describe the situation or the patient problem. ii.  Background – Add necessary information to understand the problem. iii.  Assessment – Provide an assessment of the problem, such as cause and severity. iv.  Recommendation – Make recommendations to address or resolve the problem. v. Table 11 highlights the application of SBAR in a situation for which a pharmacist must communicate a recommendation to a provider regarding a bleeding event with aspirin. This format can be tailored in several ways depending on the nature of the interaction and can be presented in both verbal and written communications. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-544 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 544 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy Table 11. Example Use of SBAR for Patient-Specific Recommendation Patient Case Example: Bleeding risk with aspirin SBAR Example Communications Situation “Good morning Dr. Jacobs. I am communicating today regarding a mutual patient, Jane Doe, and a concern for increased bleeding with her current aspirin medication” Background “Jane is a 76-year-old who currently takes aspirin 81 mg daily for primary prevention of a heart attack or stroke. She also currently takes warfarin (pharmacy-to-dose) for atrial fibrillation together with other medications for hypertension and hypothyroidism. She has no history of coronary artery disease or other self-stated disease states” Assessment “Given the patient’s age and concurrent warfarin therapy, adding aspirin would greatly increase the risk of serious bleeding. Moreover, patients similar to Jane in the ASPREE trial had an increased risk of bleeding and mortality without much added benefit after adding aspirin 81 mg daily for primary prevention” Recommendation “I recommend discontinuing aspirin 81 mg daily as soon as possible and continuing with therapeutic dosing of warfarin alone” SBAR = situation, background, assessment, recommendation. Information from: Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS® Program. Available at http://teamstepps.ahrq.gov/; Institute for Healthcare Improvement (IHI). SBAR Tool: Situation-Background-Assessment-Recommendation. Available at www.ihi.org/resources/ Pages/Tools/SBARToolkit.asp. b. Telephonic communication i. Ask for or look up the patient’s or provider’s preferred telephone number, and contact him or her at that number. ii. Before discussing specific patient information, do the following: (a) Confirm the identity of the recipient or caller, and if necessary, ask for date of birth or other verifying demographic information. (b) Verify the patient has time to talk (“Would you have a few minutes to talk about…”). Including a simple question like this at the beginning of any interaction can help build trust and rapport with patients because it shows that their time is valuable and respected. iii. Protect patient privacy while using discretion with details. Limit details left in messages. “This is _____, the pharmacist at XYZ pharmacy, with a message for (patient name). Please call me back at (number)” (e.g., do not discuss confidential information). iv. If possible, note whether the listed telephone number is a home phone, personal cell phone, or work phone. v. Use the teach-back method to verify the correct understanding of messages (“To make sure I communicated this correctly, can you please repeat back what I told you to do?”). vi. For efficiency and consistency, consider developing documentation templates for common encounters in the electronic medical record (e.g., requests for refills, anticoagulation test results, intravenous antibiotic results). vii. Document the content and results of the communication in the patient’s medical record. c. Email etiquette: See Box 1 for methods to refine email etiquette when communicating with patients, providers, or other health care professionals. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-545 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 545 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy Box 1. Things to Avoid in a Formal Email to a Patient or Health Care Professional Forwarding chain mail Replying to all senders when reply is “I agree” and there are several recipients Expressing strong emotion Using email to circumvent having a conversation on a difficult subject matter Requesting a read receipt on every email Using all-capital letters Nonstandard fonts (anything except Calibri, Times New Roman, Arial) Spelling errors Sarcasm and jokes Forwarding messages that the sender would want to be kept private Claiming others’ ideas as one’s own Being extremely lengthy and redundant Forgetting to answer the original sender’s questions if a reply Emoticons Drifting off-topic Email Etiquette. ASHP.org. https://www.ashp.org/pharmacy-technician/about-pharmacy-technicians/advanced-pharmacy-technician-roles-toolkits/ medication-history-technician-toolkit/email-etiquette?loginreturnUrl=SSOCheckOnly; 10 Rules of Pharmacy Email Etiquette. Pharmacy Times. March 2021. Available at https://www.pharmacytimes.com/view/10-rules-of-pharmacy-email-etiquette; Silberman L. 25 Tips for Perfecting Your Email Etiquette. Inc.com. June 2010. Available at www.inc.com/guides/2010/06/email-etiquette.html. d. Telehealth use i.  Telehealth is the use of electronic information and telecommunication technologies to support or promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Example technologies include video conferencing, telephonic communication, store and forward imaging, and remote patient monitoring. ii.  Telepharmacy is defined in the Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy (Model Act) as “the provision of pharmacist care by registered pharmacies and pharmacists located within U.S. jurisdictions through the use of telecommunications or other technologies to patients or their agents at distances that are located within U.S. jurisdictions” (https://nabp.pharmacy/resources/model-pharmacy-act/). iii. W hen using telehealth or telepharmacy, it is important to know whether these services can be billed through a patient’s insurance and financial justification can be provided for services rendered. Some third-party organizations, such as OutcomesMTM and other telehealth servicers, work to bridge the gap between payers and patients and can provide better access to care for patients. During the COVID-19 pandemic, many states, payers, and organizations have expanded payment for telehealth services in an attempt to improve accessibility of health care professionals, including pharmacists. iv. For helpful tips on communicating with patients, caregivers, and other health care providers, see https://www.pharmacist.com/Practice/Practice-Resources/Telehealth for more information. C. Assessing Health Literacy 1. Health literacy: Degree to which individuals have the ability to obtain, process, and understand the basic health information and services needed to make appropriate health decisions a. Four literacy domains identified: reading, writing, speaking, and basic numeracy. These are generally what is considered when thinking of “general literacy,” but others exist such as scientific domain (e.g., basic purpose and function of various organs), cultural domain (e.g., beliefs, customs, and social identify), and civic domain (e.g., applying health information to make decisions regarding general public policy). ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-546 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 546 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy b.  According to a report of adults by the Program for the International Assessment of Adult Competencies completed in 2017, only 14% scored at the highest levels of literacy, and only 10% scored at the highest levels of numeracy in the United States. c. The National Assessment of Adult Literacy categorizes health literacy into four performance levels: i.  Below basic (level 1): Around 14% of the population or about 40 million Americans. These adults may be able to interpret short, simple text to perform routine tasks. However, those at level 1 have trouble matching information or identifying numbers to use in mathematical problems. ii.  Basic (level 2): An additional 22% (about 50 million American adults) can solve routine mathematical problems or make simple inferences. However, people with level 1 or level 2 skills would find it difficult to interpret a dose chart on an over-the-counter cold medication to calculate the correct dose for a child. Yet, some individuals at level 2 may be able to look at a very basic and simplified correction factor scale and add units of insulin to their normal bolus dose, although a more complex scale may be difficult for them to interpret. iii.  Intermediate (level 3): About 53% of the population can summarize text; find and apply facts from denser text; and identify and apply information to solve arithmetic calculations. People in level 3 may be able to determine a healthy weight from a BMI chart or interpret instructions from prescription and over-the-counter drug labels. iv.  Proficient (level 4): Only 12% of the population can analyze and integrate several pieces of information or solve more abstract or multistep mathematical problems. Furthermore, the population in level 4 could likely calculate the correct dose required of a liquid solution from a recommendation made in milligrams per kilogram. 2. Risk factors for low or inadequate health literacy a. Include (but are not limited to) those older than 65, those with less than a high school education, those with low income, those for whom English is a second language, and immigrants and refugees. However, the largest group numerically consists of White individuals. b. The presence of risk factors alone does not reliably identify low or inadequate health literacy. It is vital to assess each individual patient using validated and systematic approaches. 3. Health literacy can be assessed in several different ways to tailor appropriate patient-specific educational sessions. Table 12 details assessment tools that have been developed for research or clinical settings. Some of the tools listed are more academic and research-focused and may be long and unpractical to administer to patients in practical, whereas others serve a more clinical role by being readily available and rather quick to administer. Table 12. Summary of Common Health Literacy Assessment Screening Tools Tool REALM Description List of 66 common words related to anatomy or illnesses where adults read and pronounce words; takes 3 min to administer and score Clinical Pearls - Commonly used in research studies - Does not directly measure comprehension of health information but has been highly correlated with reading comprehension (e.g., readinggrade level) - Primarily assesses reading skills but not numeracy or mathematical ability - R EALM-SF is a shorter version (7-item word recognition) to provide clinicians with a valid, quick assessment and has excellent agreement with REALM ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-547 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 547 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy Table 12. Summary of Common Health Literacy Assessment Screening Tools (cont’d) Tool SAHLSA-50 TOFHLA NVS SILS SAHL-S&E Description Involves reading 50 words where a choice between two distractors is used to indicate understanding; takes 3–6 min to administer Clinical Pearls - Is commonly used in research studies - Is based on the REALM, but of importance, results are not similar to REALM results - Is intended for adults who speak Spanish but is not a Spanish translation of REALM - Users who may want to compare the health literacy of English and Spanish speakers are recommended to use SAHL-S&E Consists of 50 reading - Commonly used in research studies and 17 numeracy items - Results are categorized into inadequate, marginal, or adequate levels involving common of health literacy medical situations; - Spanish versions are available for both the full and the shorter takes up to 22 min to versions of the TOFHLA administer - Scores between men and women varied on the shorter versions - s-TOFHLA is a shorter version that uses only 36 of the reading questions and 4 numeric calculations, takes 7 min to complete Contains six questions - Is commonly used in clinical assessments to assess interpretation - Assesses both literacy and numeracy (includes arithmetic calculations) of a standard nutritional - Is available and validated in both English and Spanish, with both label; takes 3 min to versions correlating with the TOFHLA administer Is only one question: - Commonly used in clinical assessments “How often do you - Response scale is from 1 (never) to 5 (all of the time); response of ˃ 2 need to have someone (sometimes, often, always) has a 54% sensitivity and 83% specificity help you when you read for identifying inadequate health literacy instructions, pamphlets, - Was developed for the Veterans Affairs clinics, but has been tested or other written in the primary care population and is easy to integrate into clinical material from your practice doctor of pharmacy?”; - More reliably identifies those at risk of low/inadequate health literacy takes seconds to 1 min compared with confirming those with adequate health literacy; to administer stronger correlation with s-TOFHLA and REALM in detecting inadequate compared with marginal health literacy - Does not assess numeracy Consists of 18 terms to - Commonly used in clinical assessments test comprehension and - New instrument consisting of similar tests in English and Spanish pronunciation of health- with good reliability and validity related terms; takes 2–3 - For each “term,” a key word with a related meaning and distractor is min to administer used to test the subject’s comprehension as well as their pronunciation of health-related terminology NVS = newest vital sign; REALM = Rapid Estimate of Adult Literacy in Medicine; SAHL-S&E = Short Assessment of Health LiteracySpanish and English; SILS = Single Item Literacy Screener; TOFHLA = Test of Functional Health Literacy in Adults. Agency for Healthcare Research and Quality (AHRQ). Health Literacy Measurement Tools (Revised). Content last reviewed November 2019. Available at https://www.ahrq.gov/health-literacy/research/tools/index.html; North Carolina Program on Health Literacy. Literacy Assessment Instruments. Content last reviewed July 2022. Available at www.nchealthliteracy.org/instruments.html. Additional health literacy tools available at http://healthliteracy.bu.edu/. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-548 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 548 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy 4. Applying health literacy to drug information and providing accurate information while creating print and audiovisual patient educational materials are important for tailored messaging to patients. Specific action items and descriptions for various forms of communication are available using the patient education materials assessment tool (PEMAT) at https://www.ahrq.gov/health-literacy/patient-education/ pemat.html. a. An assessment tool can be used for both printable materials (PEMAT-P) and audiovisual materials (PEMAT-A/V). In these assessments, materials are presented as 24 items for printable materials and 17 items for audiovisual materials, for which the the assessor can mark “Disagree” or “Agree” or, in some cases, “Not Applicable”. These “items” are categorized in domains of “understandability” (with subtopics of content, word choice and style, use of numbers, organization, layout and design, and use of visual aids) and “actionability”. Results are calculated and percentage of understandability and actionability can be compared between resources. b. Within each of the domains and topic, items are critically assessed and feedback for applying correct forms of communication are given. For example, materials with “use of numbers” would have numbers that are clear and easy to understand. A label reading “Take 1 tablet in the morning and 1 tablet at night” is easier to understand than “Take twice daily”. In regards to actionability, materials should clearly identify an action a user can take. Material stating “patients who do not use a reminder tool typically forget to take their medications” is not as actionable as the text, “Use a pillbox or alarm on your phone to help you remember to take your medications”. Patient Case Questions 6 and 7 pertain to the following case. The pharmacist is meeting with L.S., a 61-year-old Hispanic woman who is working with the clinical pharmacy team to manage her warfarin dosing. The pharmacist believes that the patient has issues with adherence. This has led to supratherapeutic INRs and even a hospitalization because of excess bleeding. L.S. tells the pharmacist, “I just don’t trust these pills. Sometimes, I don’t feel right, and I won’t take them, but I don’t want to have a clot, so I’ll take a few more the next time.” 6. Which best depicts the response to L.S. that would use the process of “reflective listening”? A. Describe how you feel when you don’t feel very good. B. You are having some issues with warfarin, yet you know it is important. C. It sounds like you are missing some doses, right? D. What can you do to help you not forget to take a dose? 7. L.S. shows the pharmacist a booklet on proper warfarin administration she was given upon hospital discharge but says she is having difficulty understanding the nonpharmacologic concepts described in the book. On further assessment, it is determined this patient grew up in the United States, dropped out of high school, and is not currently living in low-income housing, nor is she worried about housing stability. Which is most likely a risk factor for low health literacy in L.S.? A. Educational level. B. Race/ethnicity. C. Income level. D. Age. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-549 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 549 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy D. Cultural Sensitivity 1. Definitions (dbhds.virginia.gov/) a.  Cultural Knowledge – Knowing about some cultural characteristics, history, values, beliefs, and behaviors of another ethnic or cultural group b.  Cultural Awareness – Recognizing and understanding the cultural implications of behavior. Consider the impact of behaviors on others. c.  Cultural Sensitivity – Integrating cultural knowledge and awareness into individual and institutional behavior. Respond to attitudes, feelings, and circumstances. d.  Cultural Competence – Applying culturally appropriate health care interventions and practices regularly. Accommodate cultural differences in health care. 2. Building cultural awareness. Health beliefs and behaviors affect participation in care and adherence to medications and other treatments. a. Build cultural awareness with patients by asking them questions and identifying their underlying values. It can be important to find and use appropriate resources to perform these tasks with diverse patient populations. EthnoMed was originally developed as a tool for clinicians and health care providers to increase awareness while working with immigrant populations. The website provides information about “immigration, cultural norms and values, experience with Western medicine, culture-specific information and tools pertinent to the clinical encounter, and translated/culturally tailored information for patients” (https://ethnomed.org/). b. The Health Belief Model uses four constructs (perceived susceptibility, severity, benefits, and barriers) to predict whether a patient will participate in disease prevention or treatment. By identifying an individual’s disease-specific beliefs, providers can help identify barriers to adherence and create individualized educational messages. Table 13. Using the Health Belief Model to Identify Issues and Tailor Educational Messages Construct Perceived susceptibility Description Individuals’ beliefs about their likelihood of contracting the disease or condition Perceived severity Concern regarding the seriousness of the condition Perceived benefits Belief that making a suggested change can have an important impact Patient Case Example 73-year-old woman continues to ask her provider for antibiotics to treat common colds and headaches. She states, “Anytime I get sick, a short course of antibiotics does the trick. There really isn’t any downside!” 43-year-old woman states, “I have had high blood pressure most of my adult life and I am still here. I feel just fine” 57-year-old man does not want to explore the benefits of a colonoscopy because “everyone I know who’s had colon cancer has died. I’d just rather not know if I had colon cancer and die happy” Tailored Educational Message Explaining how the continued use of antibiotics can cause significant adverse effects (e.g., kidney disease, Clostridioides difficile infections) and can lead to resistant bacteria, which may affect her loved ones if they become infected Explaining how the effects of high blood pressure can accumulate and present as additional complications (e.g., stroke, heart disease, kidney disease) later in life, but can be prevented by controlling blood pressure to goal according to evidence Explaining how getting a colonoscopy can help detect colon cancer in the earliest stages to allow more effective treatment and prevent the progression to advanced stages might help motivate this patient to seek out imaging ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-550 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 550 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy Table 13. Using the Health Belief Model to Identify Issues and Tailor Educational Messages (cont’d) Construct Perceived barriers Description Beliefs about the negative aspects of change Cues to action Factors that trigger action Self-efficacy Confidence that one can perform the behavior to reach the desired outcome Patient Case Example 20-year-old man is recently diagnosed with celiac disease, but states, “I can’t afford all these gluten-free foods. This is going to be impossible for me” Tailored Educational Message Explaining the benefits of eating gluten-free foods and discussing how many foods are naturally “glutenfree” (e.g., fruits, vegetables, and other whole grains); then, identifying local resources to use to obtain foods more economically 82-year-old woman is unwilling Explaining how the patient’s to take prescription medications supplements (especially St. John’s for depression but instead takes wort) are not completely free of several supplements, including St. adverse effects and are most likely John’s wort. She states, “My doctor causing her current adverse effects. thinks my constipation and dry Also, discussing potential drug-drug mouth are from my supplements, interactions with her supplements and but at least my depression is reviewing her current medication list getting better!” to identify any potential issues 65-year-old states, “At this point, Explaining the improved rates of I just can’t see myself giving up complete smoking cessation with smoking. It was impossible for me the addition of pharmacology to build up the willpower on my (varenicline, bupropion, or nicotine own” replacement) and with the support of several health care professionals 3. Developing cultural sensitivity a. Identify implicit biases to navigate personal thoughts and feelings within the Health Care Model. i. Unconscious (or implicit) bias occurs when this automatic processing is influenced by stereotypes; therefore, these stereotypes affect actions and judgments ii. Take personal inventories of implicit biases for increased self-awareness (https://implicit. harvard.edu/). 4. Fostering cultural competency: The “ETHNIC” model is a framework for culturally competent clinical practice. By considering each of the factors within this model, practitioners can improve their overall cultural sensitivity in patient-care situations to place the patient at the center of care. a. Explanation. It is important to remember illness and disease are two distinct entities, so asking patients or providers to explain their understanding of the issue in their own words can be helpful to better understand the situation. (“Why do you think you are having this symptom?”) b. Treatment. Discovering what treatments have already been pursued can be helpful in knowing what alternatives the patient or provider believes to be effective, safe, or acceptable. (“What have you tried to help with this problem?” – medications, home remedies, traditional therapies, etc.) c. Healers. It is important to realize that patients from various cultures may seek out help and advice from other voices and not exclusively look to “Western” medicine. (“Have you sought help from anyone for this problem?” – friends, physicians, folk healers, etc.) d. Negotiate. Discussing mutually acceptable options that incorporate the patient’s beliefs continue to put patients at the center of their own care. (“We’ve talked about a number of options. Which of these options do you feel most comfortable pursuing?”). e. Intervention. After building rapport and trust, a patient or provider can decide on a specific intervention which may include incorporating alternative treatments, spirituality, and healers as well as other cultural practices. (“In addition to starting this new medication, what are your thoughts on seeking counsel or mentorship from those within your faith community?”) ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-551 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 551 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy f. Collaboration. Including important people in the decision-making process such as family members, other health care team members, healers, and community resources may be considered acceptable and even an important part of different cultures. (“Who else would you feel comfortable sharing your plan for solving this problem with?”). E. Assessing Effectiveness of Patient Education and Adherence to Plan 1. Assessing patient adherence a.  Compliance: Degree to which a patient’s behavior is consistent with the prescriber’s recommendation b.  Adherence: Degree to which a patient’s behavior meets the agreed plan for the prescriber. This is the generally accepted term in the literature in the United States. i.  Persistence: Whether the patient continues a medication beyond the first refill. In general, taking 80% or more of the prescribed doses is considered “acceptable” adherence; however, this may vary depending on the prescription medication (e.g., insulin). ii. Primary nonadherence: Patient never fills or fills but does not initiate the medication or behavior change iii. Secondary nonadherence: Patient begins but subsequently discontinues a medication or behavior change iv. Improper use: Patient continues to take the medication but in a manner inconsistent with the prescriber instructions (e.g., different dose, frequency, or duration) c. Measuring adherence i. Adherence can be indirectly calculated using proportion of days covered or the medication possession ratio from prescription refill history at the pharmacy or while using information from the insurance claims history (http://ep.yimg.com/ty/cdn/epill/pdcmpr.pdf). ii. Direct measurements such as pill counts, finishing pill packets, and other methods can be performed but have several limitations. These can be time- and labor-intensive and cannot determine the reason for nonadherence. For example, a patient may have a higher pill count than expected but may have forgotten to take the medication or may be taking the incorrect dosing, or a patient may be taking a tablet once daily when they are supposed to be taking the tablet twice daily). d. Predicting future nonadherence i. The “Adherence Estimator” is a prospective assessment of the likelihood that a patient will adhere to a newly prescribed medication (e.g., the likelihood a patient with a new prescription for a statin medication will continue to take the medication after the first fill) (Curr Med Res Opin 2009;25:215-38). (a) Purpose: The estimator is simple and easy to administer and score; however, it assesses the risk of nonadherence to a single drug regimen, not the entirety of a patient’s medications (e.g., potential nonadherence is assessed for metformin given to a patient, but current use of other medications the patient may be taking is not assessed). (b) Questions: Patients are asked a series of three questions to measure their perception of the new medication, but questions do not assess the medication’s toxicity, efficacy, or cost. (Three questions are included: “I am convinced of the importance of my prescription medicine.” “I worry that my prescription medicine will do more harm than good to me.” “I feel financially burdened by my out-of-pocket expenses for my prescription medicine.”) (c) Scoring: Each question is scored on a 6-point scale from agree completely to disagree completely, and depending on responses, points are totaled to fall within low, medium, and high risks of nonadherence (https://www.ehidc.org/sites/default/files/resources/files/ Adherence%20Estimator%20Kit_%20Interactive%20PDF.pdf). ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-552 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 552 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy ii. The Morisky questionnaire is another prospective assessment tool used to measure adherence (J Clin Hypertens 2008;10:348-54). (a) Purpose: Useful in identifying and screening for knowledge gaps and motivational issues affecting adherence. Focuses on the entirety of disease-specific drug regimens (e.g., diabetes, hypertension) and predicts the likelihood of adhering to multiple medications. (b) Questions: Available in four- and eight-question formats with questions asking about missed doses, stopping medications, or cutting back on a medication because of adverse effects or disease control (e.g., “Do you sometimes forget to take your diabetes pills?” “Over the past 2 weeks, were there any days when you did not take your diabetes medicine?”) (c) Available in English, French, Chinese, and other languages. These forms are available for a fee, depending on the level of questionnaire desired (e.g., the four- or eight-question scale) (www.moriskyscale.com/). 2. Delivering patient counseling for drug information a. “Universal precautions” approach widely recommended i. Regardless of health literacy, patients may have difficulty with medication concepts because of topic-specific misconceptions or gaps in knowledge or skills. Only 12% of the U.S. adult population has the health literacy skills needed to meet the demands of navigating the health care system. ii. Specific tools aimed at improving verbal and written communication, self-management, empowerment, and supportive systems can be accessed through the Health Literacy Universal Precautions Toolkit at https://www.ahrq.gov/health-literacy/improve/precautions/index.html. b.  “Elicit-provide-elicit” method (https://motivationalinterviewing.org/category/resource-tag/elicitprovide-elicit) i. Elicit what the patient knows or would like to know or whether it is OK if you offer them information. (a) Ask open-ended questions to obtain baseline information important to the patient: “What do you know about the shingles vaccine?” (b) Use the Indian Health Service three prime questions to assess the patient’s baseline knowledge regarding a specific medication. (1) “What did your prescriber tell you the medication was for?” (2) “How did your prescriber tell you to take the medication?” (3) “What did your prescriber tell you to expect?” ii. Provide information in a neutral, nonjudgmental fashion. (a) Ask for permission for providing input. “Do you mind if I share a little information on the vaccine?” “Would it be OK if I give you some stats about the vaccine’s success rates?” (b) Ensure information given remains as objective as possible and is focused on the patient’s core concerns. iii. Elicit the patient’s interpretation of the new information: “What do you think after hearing those points?” “Where does this leave you with getting the shot?” iv. General tips for effective use of the elicit-provide-elicit model (a) Use neutral language as much as possible. “What we know is…” “Some people have found…” “Others have benefited from…” (b) Use conditional words (e.g., “might,” “perhaps,” “consider”) instead of concrete words (e.g., “should,” “must”). (c) Avoid sentences starting with “I” or “You” and focus on the team effort. “We can circle back to this if possible, the next time we see each other.” ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-553 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 553 3/16/23 11:02 AM Drug Information and Commuication Strategies in Pharmacy c. Focus the conversation on key points and what the patient wants to gain from the interaction. A practice called “agenda mapping” can be done in creative ways such as using a visual cue (e.g., easel paper pad, brainstorming web) or other documentation to keep track of a specific topic of interest between visits. For example, a patient with diabetes may be given the choice between “medications”, “movement”, “meal planning”, “monitoring”, or “mental” and the use of labels with these terms can help a patient stay on track to the area of focus at any specific time. “What do you want to focus on the most during this conversation?” d. “Teach-back” and “show-me” methods i. These methods are valuable for everyone to use with each patient. They can help improve patient understanding and adherence, decrease callbacks and canceled appointments, and improve patient satisfaction and outcomes (www.ahrq.gov/sites/default/files/wysiwyg/professionals/qualitypatient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2_tool5.pdf). (a) Keep in mind this is not a test of the patient’s knowledge, but instead a test of how well the concept was explained. (b) Plan the approach. “We covered a lot of information today. I want to make sure I explained myself clearly, so I’d like for you to tell me how you are going to make the change to your insulin dosing.” (c) “Chunk and check.” Use the teach-back method throughout the interaction with the patient, without waiting until the end to repeat all the information. (d) Clarify and check again. If a mistake is uncovered using this method, ask the patient to use repeat-back until they can correctly describe it in their own words. “I want to make sure you are able to get this, so can you repeat that again?” (e) Start slowly and use consistently. Use this method with patients who are familiar at first, and then work this concept into all patient interactions. (f) Practice. Mastery of this concept takes time and individual customization. This can be implemented efficiently if given the time for practice. (g) Use the “show-me” method when dispensing/prescribing new medicines or changing a dose. “Giving a child the correct dose of liquid medication can be challenging. Can you please show me how you plan to give your child their antibiotics?” e. Use handouts (if applicable) together with teach-back. Collect and disseminate published resources for given disease states. “We have a variety of resources to help you count your carbohydrates while giving the correct insulin doses. Would it be helpful if gave you some of these booklets?” f. Use clear communication (“plain language”) when using handouts and other forms of written communication to provide effective education to the audience for first-time understanding (https:// www.cdc.gov/healthliteracy/pdf/checklist-H.pdf). i. Organize to serve the audience. (a) Know the audience and purpose before beginning. (b) Put the most important message first. (c) Present other information in order of importance to the audience. (d) Break text into logical chunks and use headings. ii. Choose words carefully. (a) Write in the active voice: “Take 2 tablets for the next 2 weeks.” (b) Choose words and numbers the audience knows: “Check your blood sugar using the meter and call the pharmacy team if the number is less than 70.” (c) Keep sentences and paragraphs short. (d) Include “you” and other pronouns. iii. Make information easy to find. (a) Use headings and text boxes. (b) Delete unnecessary words, sentences, and paragraphs. (c) Create lists and tables (e.g., create a list of medications that might interact with warfarin). ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-554 02-12_Drug Info n Comm Strat in Pharm_2023_R2.indd 554 3/16/23 11:02 AM