HOW TO TALK SO YOUR PATIENTS WILL LISTEN

HOW TO TALK SO YOUR PATIENTS WILL LISTEN

Lunch & LearnApril 16, 2013

Simplify My Meds

• Adherence can be improved when patients coordinate refills (“refill synchronization”) at a single pharmacy

• Facilitates improved adherence• Improves pharmacy operations

Medication Synchronization Revenue Calculatorwww.ncpanet.org/revenuecalculator

NCPA Program Support

• Program Materials– Pharmacy Operations Manual– Customizable Program Forms– Physician Outreach Tools

• Marketing Materials– FREE Starter Kit

• Training and Support– Tutorials – Lunch & Learns

Learn More

• For More Information– www.ncpanet.org/adherence – [email protected]

• Online Tutorial– www.ncpanet.org/SMMtutorial/smmtutorial.html

HOW TO TALK SO YOUR PATIENTS WILL LISTEN

Jerry Meece, RPH, FACA, CDEPlaza Pharmacy and Wellness Center

[email protected]

What Has Been Your Experience With Trying to Facilitate Behavior 

Change in Your Patients?

Chronic Care Coaching

• Asthma

• Diabetes

• CV disease

• Obesity

• COPD

Adherence to What?

Physical Activity

Nutrition

Medication

Monitoring

• What % of diabetes patients are in control on lipids, blood glucose, blood pressure?  

• of patients ceased SMBG testing in 2010

• of all prescriptions called in or written were never picked up

• Patients taking 5 or more RXs were taking them wrongof the time

How Well Are We Doing?

14%

23%

25%

50%

Chronic Disease Adherence Rates in US

51%Adherence to Treatment for Hypertension in US

“In developed countries, adherence to medications among patients suffering chronic diseases averages only 50 percent.”

– World Health Organization 2003Adherence to Long‐Term Therapies: Evidence for Action

Sources: Adherence to Long-Term Therapies: Evidence for action. World Health Organization 2003. Available at: http://www.who.int/chronic_conditions/adherencereport/en/.

.

Why Is This Issue Important To Pharmacists and Health Care? 

Time in Medical Care

2,400 minutes

0.02% of time awake

Time Outside of Medical Care

10,512,000 minutes

99.98% of time awake

Why Focus on Chronic Care Behavior?

Source: Adherence to Long-Term Therapies: Evidence for action. World Health Organization 2003.

U.S. Annual Costs of Poor Adherence

• $75 billion – $100 billion

• 125,000 deaths

• 10% – 25% of hospital and nursing home admissions

Why Aren’t We Doing Better?

What’s the Difference?

• Compliance: The extent to which a patient follows medical instructions. (How well you do and follow what I say)

• Adherence: The extent to which a person’s behavior  corresponds with agreed recommendations from a health care provider. (How well you apply a plan that we agreed upon)  

• Persistence: Adherence to the plan over time

Reasons for Poor Adherence

• Poor Patient Provider Communication– 21% completely disagree on decisions made and course of action

• No plan for implementing recommendations

• Poor understanding of the plan

• Enthusiasm (or lack of) of execution by the HCP

Parkin and Skinner, 2003

Sources: Adherence to Long‐Term Therapies: Evidence for action. World Health Organization 2003. Available at: http://www.who.int/chronic conditions/adherence report

For a Patient to be Adherent

• Must fully understand and comprehend the plan

• Be in full agreement with the course of action

• Be committed to the execution and what is increasingly a multi‐step solution

• Have follow‐up provided as changes occur

• Diabetes • Obesity• Hypertension• Hyperlipidemia• Medications• Inactive lifestyle• Financial Issues• Beliefs about ability to change 

• Keeping records• Keeping appointments• Changes at home• Diet• Exercise• Glucose monitoring• Environment• Culture• Confidence/Ability

Paralysis By Ambivalence

Typical Health Care Encounter

“The pill for your lipids is to be taken at bedtime”

“Walk 30-45 minutes 5 days a week”

“Watch your salt intake”

“Check your blood sugar 4 times a daybefore a meal and 2 hours after but rotate times”

“You need to lose 25 pounds”“Take your diabetes meds am and pm after meals, except the capsule, take it at bedtime”

“If this doesn’t improve we’ll have to start insulin”

“Don’t eat anything white”

“We’ve got to get that A1C down”

Typical Health Care Encounter

Clinic visit NextClinic visit

Recommendations(Orders)

Adherence to recommendations

J Meece 2007©

Will the side effects bother me?

How much do I need?

How much is too much?

What’s an A1C?

What can I really eat?

But…

Happens!

Do diabetes patients tell their doctors when they cut‐back on medication use due to cost?

Why Patients Don’t Talk with Clinicians About Their Medication Cost Problems

• I didn’t trust my providers enough (8%)• Not enough time during the visit (24%)• I didn’t think it was important enough (33%)• I felt embarrassed (36%)• I didn’t think they could help (56%)• And…the number one reason:

Piette JD, et al. American Journal of Public Health. Volume 94:10. October 2004

Number 1 Reason?

“No one ever asked me.” (61%)

Piette JD, et al. American Journal of Public Health. Volume 94:10. October 2004

Solutions Aren’t Easy: What We Know

• No single strategy works for everyone

• Interventions must be tailored to the individual

Family Medicine Net Guide. Patient Adherence Explained. Available at: http://www.fmnetguide.com/vo2iss1/feature.html.

Com∙mu∙ni∙ca∙tion /kəˌmyo͞oniˈkāSHən/Noun:

The exchanging of information or news

Patients have most of their answers within them

It is our job to help them find them

Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping patients change behavior. The Guiford Press, New York, NY. 2008 pp. 3-10

Teen Daughters Lift 3,000-Pound Tractor Off Dad

Jesse Skoubo/Albany Democrat-Herald via AP Photo April 10th, 2013

Core Components of Motivational Interviewing (MI)

• Collaborative goal setting

• Open ended questions

• Reflective listening

• Empathy

Rosengren DB. Building Motivational Interviewing Skills: a practitioner workbook.The Guilford Press. New York, NY. 2009

Examples ‐‐ Discussion• Simple request ‐ “Tell me….” 

• “What” and “How” questions are effective

• “Why” questions aren’t effective; provoke defenses

• If a person can answer in one word (yes, no, a number) the question was not open‐ended.

Open Ended Questions or Inquiry

Rosengren DB. Building Motivational Interviewing Skills: a practitioner workbook.The Guilford Press. New York, NY. 2009 p59

Two Biggest Clinician Fears:

• I’ll miss something if they don’t go for the facts right away 

• The patient will ramble on forever  

Reflective Listening

• Be present• Show you are trying to understand• Listen, listen, listen!• To be a mirror reflecting the speaker:

– repeat the words you have heard– short summaries– reflect meaning

• Non‐verbal: – Attentive, open, non‐judgmental

Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping patients change behavior. The Guiford Press, New York, NY. 2008 pp. 3-10

Examples of “stems”:• So, you are saying …. • It sounds like …..• You are wondering if....• I hear you saying….• You are…

Reflective Listening

Rosengren DB. Building Motivational Interviewing Skills: a practitioner workbook.The Guilford Press. New York, NY. 2009 p35

Empathy

• Goals– Seek to understand  emotions, thoughts and values

– Patient experiences being seen, heard and understood

• Tasks– Attend to and reflect expressed thoughts, emotions, values

– Express a degree of understanding

Examples of Empathy

• “You seem pretty frustrated.”• “So, it’s really hard to …• “Most people I know would be distressed about …

• “I think I understand how you feel. Many of my colleagues also …

Remember this? Intervening In Between

Clinic visit NextClinic visit

RecommendationsAdherence to recommendations

Reinforcement of recommendations

MonitoringCoachingTeaching

J Meece 2007©

Create a Collaborative Plan

Create a Plan

Carry out the Plan

Adapt the PlanOr move to another goal

Review the Results

• Specific• Measurable• Attainable• Realistic• Timely

Setting Goals

TDI Education News Vol 2:1 January 2010

“The most important thing in communication is to hear what isn't being said. ”

‐‐‐‐Peter Drucker

How Do YOU Learn The Best?

The Star Spangled Banner

Star Spangled Banner -- Chords

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Tablature Jimmi Hendrix - Woodstock 1968 - Star Spangled Banner

Communication Strategies

• Explain things clearly in plain (non‐medical) language– “Blood pressure pill” instead of “antihypertensive”– “Take one pill right before breakfast and one pill right before dinner”

• Connect activities to things already in their daily routine

• Focus on key messages and repeat• Use a “teach back” technique to check understanding

– “To be sure I was clear can you show me how you would give your insulin”

• Use patient‐friendly educational materialshttp://www.sowegaahec.org/uploads/130_Handout.pdf?PHPSESSID=dbe331d55a0022384c15ac40f7de3dcf

Herndon E and Joyce L. Getting the Most from Language Interpreters Family Practice Management 2004 (June) p37

Problem Solving – A Five Step Process

• Step 1: Explore the Problem or Issue– What is the hardest thing about caring for your diabetes?  Tell me more about that.

• Step 2: Clarify Feelings and Meaning– So how does that make you feel? OR– How do you feel about that?

Funnell MM, Anderson RM. Empowerment and Self-Management of Diabetes. Clinical Diabetes. 2004; 22(3); 123-127

Problem Solving – A Five Step Process

• Step 3: Develop a plan – Ask the patient– What would you like to do about this?– Where would you like to be with this problem 3 months from now?

– What are your options?   What might get in the way?

– Who could help you?  – What would happen if you do nothing?– Use the conviction and confidence ruler

Funnell MM, Anderson RM. Empowerment and Self-Management of Diabetes. Clinical Diabetes. 2004; 22(3); 123-127

Problem Solving – A Five Step Process

• Step 4: Commit to Action– What are some of the steps you could take?– When are you going to do it?– How will you know if you are successful?– What is the one thing you will do when you leave here today?

• Step 5:  Evaluate the patient’s progress and continuously modify the planFunnell MM, Anderson RM. Empowerment and Self-Management of Diabetes. Clinical Diabetes. 2004; 22(3); 123-127

Remember: The goal is to develop a collaborative plan

Create a Plan

Carry out the Plan

Adapt the PlanOr move to another goal

Review the results

Take Home Messages

• Everyone wants to life a long happy life• Our patients are more confused than unmotivated

• Management of a chronic care disease is tough

• Our patients face many obstacles to self‐care and those obstacles change

• Good conversations lead to good outcomes

And If You Have Time To Ask Only One Question:

• “What do you find most challenging about managing your (insert chronic condition)?”

And listen

Thanks for listening…. Jerry

[email protected]