Transcript Title slide for basic presentation

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!
We’re not making progress…
6060
5050
4040
3030
2020
1010
0
0
1981
1980
1982
1990
1983
1984
2000
2010
Medication non-adherence rates 1979-2011
33-50% of patients adhere to chronic regimens
Claxton, 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 Encounter
Signs
of losing control
Signs of getting older
Cause questioning
Meeting with Stigma
Social
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 out
 Exerting 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 effects
Realities:
– 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
…And you’re reading for at least 30 minutes too, right?
Increasingly complex regimens
Treatments | Monitoring
Decreasing healthcare support
Shift towards self-management
Evidence-based guidelines
are disease-specific
Promotion of treatments
Poor care coordination
Increasing treatment
burden
Failure to cope
Poor fidelity to the treatment program
Minimally disruptive healthcare
Health care delivery designed to
reduce the burden of treatment on
patients while pursuing patient goals
http://minimallydisruptivemedicine.org
May CR, Montori VM, Mair FS. BMJ 2009; 339:b2803
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.
Engage your
patients in
conversations
about their
medications.
QUESTIONS?
PLEASE CONTACT ME
[email protected]
952-993-2087