Patient Assessment - L1 & L2

What are the causes of suboptimal outcomes?

-Inappropriate Prescribing -Inappropriate delivery -Inappropriate behavior by patient -Patient idiosyncrasy -Inappropriate monitoring

*Discrepancies* What are some barriers that exist between providers and healthcare professionals that contributes to the health literacy problem?

-Medical words/terminology -Shame/embarrassment -Cultural differences -Illness/medications involved -Sensory loss -Rushed teaching -Fear and stress

PQRST*A*

*A*ssociated symptoms

What are some causes of failure to receive medication?

*Barriers to or access to the needed care* -Examples: 1. Physical (distance to pharmacy, patient unable to ambulate easily) 2. Financial (can not afford ± insurance coverage) 3. Not available (market shortages) 4. Patient perceptions of medication(s) 5. Failure of caregivers or care setting

What are some patient interviewing techniques?

*Clarifying the patient's meaning* -"What do you mean by 'breathing trouble'?" *Encouraging patients to continue* -Use verbal (i.e. "I see...", "Mm hmm...") and non-verbal (i.e. nodding) *Echoing to elicit more details* -Stating last word of patient's statement as a prompt *Constructive use of open-ended and close-ended questions (Broad v. Narrow questions)* *Only ask one question at a time to avoid confusion* *Ask for specifics when possible to quantify data* -"How many times a week do you feel dizzy ?" *Offer choices when needed* -"Is the pain sharp/stabbing or dull/aching?" -"Please describe your pain?" may be better (more open)

Qu*E*ST

*E*stablish that the patient is an appropriate self-care candidate.

*P*QRSTA

*P*rovocative or palliative

_____________ represent the very last line of instruction that either enables patients to take their medications properly or causes further confusion.

*Prescription medication labels* -Long after patients have left the hospital, doctor's office, or pharmacy and moments before patients actually self-administer a medication, they still have the prescription label to guide them as to how to take the drug safely and effectively.

P*Q*RSTA

*Q*uality or quantity

*Qu*EST

*Qu*ickly and accurately assess the patient

PQ*R*STA

*R*egion or radiation

PQR*S*TA

*S*everity

QuE*S*T

*S*uggest appropriate self-care strategies.

QuES*T*

*T*alk with the patient.

PQRS*T*A

*T*iming/ Temporal relationship

The average reading level is 7th - 8th grade, but most health information is written at _____ grade reading level.

*≥ 10th*

The most vulnerable populations typically have the most limited health literacy skills. What are these populations?

-Adults who are poor -Hispanics/Latinos -Immigrants -Adults with chronic physical or mental conditions -Elderly (age ≥ 65 yo): --Literacy skills go down as age goes up --Of those age ≥ 70 yo only ~ 1% have Proficient Health Literacy

How does the mismatch that contributes to health literacy impact the concerns of the provider and the healthcare system?

-Missed appointments -Cancelled procedures -Malpractice claims -- not helpful in terms of cost or healthcare satisfaction -Unhappy customers/patients -Callbacks/time to repeat instructions -Medical mistakes/medication errors

The demands and complexity of our health system overwhelm even well educated adults. What are the results of this mismatch?

-negative outcomes for patients -greater cost to the healthcare system -provider frustration

What things should be considered when making a therapy plan that is tailored to the patient's needs?

-physical -mental -cultural needs

Effective teach back comprises a four step process. What are the four steps?

1. *Clinicians should place the burden of communication and understanding back on their own shoulders*. - For example, "I have covered a lot of information about high cholesterol today, and I want to make sure I did a good job of explaining this." 2. *The session should be focused on a specific behavior*. - For example, "Can you tell me when and how you will take this medicine?" 3. *The patient should be corrected as needed*. 4. *Reassessment* serves as a quality control and is the only way to determine whether the patient understands the information; this is the most important and most often overlooked step. If the patient does not understand, the facts should be explained again in a different manner. Clinicians should continue to explain until both they and the patient agree that the information has been understood.

What are 4 ways that you can ensure that you're using plain language in your verbal and written communication with patients?

1. *Content: limited and culturally sensitive* - Convey only the most important points (about 3) to the patient so as to not overwhelm them. Even well educated people won't remember more than 3 points. 2. *Organization/structure: reader-focused* - Not too much content - Short, conversational sentences - Begin each section with the most important point so that readers can easily skim the document. 3. *Writing: clear, using simple terms and proven techniques* 4. *Design: layout and graphics support key messages* - Use headers and bullet points to help the reader find the information they're looking for in an easy and efficient manner. - Put important information in bold

What are some methods for conducting a good face-to-face counseling session that caters to improving health literacy issues?

1. *Don't change your conversational tone when speaking to patients with low literacy.* - Speaking slowly and remembering not to use medical jargon is important, but many providers tend to change their conversational tone. Doctors have a tendency to speak in a louder voice, as if addressing a child; this can be perceived as insulting to some patients and should be avoided, because *low health literacy can be associated with a palpable stigma*. This change in tone can have detrimental effects; *it can offend patients or, more often, may cause them to feign a false understanding, thus contributing to further misunderstanding*. 2. *Don't forget to ask the patient if they have any questions*. - Pharmacists should specifically ask patients for any questions they might have about their prescriptions. *"What questions do you have?"* is more effective phrasing than "Do you have any questions?" 3. *Pharmacists should keep their message simple* - Focus on what is pertinent for the patient to know in order to take the drug correctly. 4. *Use patient education tools, such as pill cards* - *Actively educating* patients with a pill card makes it easier for the pharmacist conducting the counseling.

What are 2 pharmacy/pharmacist specific interventions to help improve medication safety and adherence among patients with low health literacy?

1. *Face-to-face Counseling* 2. *Standardized Labeling*

What are some causes of medication use without indication?

1. *Limited duration therapies are continued for an inappropriate amount of time*. -Example: Topical products that are intended for short term use, are applied for longer than they should be due to lack of communication between health care providers and the patient. 2. *Medications not reconciled and adjusted appropriately with transitions of care* -Example: Proton pump inhibitors (PPIs) started in the ICU to prevent stress ulcers are taken even after the patient is released from the hospital. Patients may even be on these medications for years after they were in the ICU because nobody ever told them to stop taking them.

What are 2 evidence-based solutions to address health literacy?

1. *Plain Language* -Use of common, non-technical language for both written and verbal communication 2. *Use of "Teach Back"* -Asks patient to repeat back or show back key points in order to assure patient understanding of communication These are recommended by the AMA for use with everyone.

What are some causes of untreated indications?

1. *Provider(s) may not know indication exists* -could be due to lack of communication -patient could be having symptoms, but the problem hasn't been diagnosed yet. 2. *Missed opportunity for preventative therapies* -Vaccinations (need changes over time) -ACE Inhibitors for renal protection --in patients with diabetes and kidney disease, giving them an ACE inhibitor can help decrease damage to the kidneys

What are some causes for overdosage (Supra-therapeutic)?

1. *The dose is not adjusted for impaired renal or hepatic functioning* -These drugs may accumulate to toxic even at normal doses 2. *The dose is too high given a patient's weight, age, sex, and/or other health conditions* 3. *Inappropriate titration* (too quickly/too much)

What are some causes for improper drug selection?

1. *The drug may be contraindicated* in specific patient groups or those with specific conditions -Should avoid NSAIDs in patients with heart failure (HF) -Beer's List (medications to avoid in elderly) 2. *The drug may be in the inappropriate dosage form/route for patient* -this could happen when a patient (such as a peds patient) needs a chewable or liquid form of a drug, but the pill form was ordered.

What three things are covered under the health literacy umbrella?

1. Build relationships 2. Ensure Understanding 3. Partner

What are the 7 AMA recommended teaching strategies?

1. Create a "shame-free" setting 2. Slow down 3. Limit points (about 3) 4. Use living room words 5. Invite other listeners 6. Use pictures, models, diagrams, etc. 7. Teach Back - Ask patient to repeat back or show back key points

Give 3 examples of adverse drug reactions?

1. Drug allergies to new medications 2. when a patient experiences side effects from the medication (may be minor or severe) 3. When a patient experience an idiosyncratic response to therapy

What are some strategies to prevent DRPs?

1. Good communication/relationship -Important for getting complete information 2. Thorough review and interviewing that covers things such as: -Current and past disease states -Symptoms and treatments -Medications (Rx, OTC's, in office, etc) 3. Asking the patient what they are taking a medication for (open ended prime question) -Know to look up potential off label uses of medication 4. Know what needs to be monitored for levels/effects -Targeted peak (just after dose) and trough (just before next dose) concentrations for select IV antibiotics (i.e. Vancomycin, Tobramycin) 5. Double checking patient age and weight 6. Checking patient renal and hepatic functioning -Can calculate renal function based on lab values -Must continually review for chronic therapies 7. Screen medications for interactions -Can use Lexicomp, Micromedex, or others (consider checking 2 sources) 8. Determine when/how patient is taking all medications with regard to meals/food 9. Assess for any barriers to access/compliance 10. Ensure appropriate monitoring for safety and efficacy of all therapies

What are some causes for sub-therapeutic dosages?

1. Inappropriate dose selection for patient age/weight 2. Poor follow-up on dose monitoring/titration

What are the seven counseling points you want to hit?

1. Introduction and Counseling Questions 2. Medication name, strength, form, and dosing 3. Review indication and mechanism of action 4. Special instructions (take with food, storage, etc.) 5. Monitoring for safety and efficacy 6. Potential side-effects and what to do 7. Assess for questions and apply teach back method

What are the 9 areas to be included in the patient history?

1. Patient Demographics 2. Chief Complaint 3. History of Present Illness (HPI) 4. Past Medical History 5. Family History 6. Social History 7. Medication History and Allergies 8. Immunization History 9. Review of Systems

What are the 8 categories of DRPs identified by Hepler and Strand?

1. Untreated indication 2. Medication use without indication 3. Sub-therapeutic dosage 4. Overdosage (Supra-therapeutic) 5. Improper drug selection 6. Failure to receive medication 7. Adverse drug reaction 8. Drug interaction

Evidence for plain language and clear communication has been shown to make a difference in which 4 areas?

1. Well crafted plain language materials 2. Teach back 3. Programs with personal support or tailoring 4. Certain web and media approaches

What are explanatory models?

A method used when describing a rationale for how or why events happen. Can be utilized during patient interviews to gather an understanding of the patient's beliefs on how or why an illness developed and how and why an illness should be treated. Explanatory models have been designed to include behaviors and information-gathering techniques that *allow for open communication between the healthcare provider and patient*. Use of explanatory models during the patient interview helps to *elicit the patient's experience and beliefs regarding the illness and treatment of the illness*. These models can help the healthcare professional have more of a *patient-centered interview* and obtain more information about the *patient's perspective, including experiences, beliefs, values, and feelings, regarding their illness*.

Give an example of a qualitative measure that would be included in the HPI/HPC.

Cough is productive with bloody sputum

SCHOL*A*R-MAC

Aggravating factors

SCHOLAR-M*A*C

Allergies

AMA

American Medical Association

Describe a Patient-centered interview.

An interview style in which the *clinician creates an environment where the patient's concerns are addressed as a high priority*. The patient is highly *involved and engaged* in the interview. This type of interviewing method *allows the patient to communicate their needs, which are then incorporated into the care plan* for the patient. Using a patient-centered interviewing process *will introduce information that the clinician would not have learned about using a clinician-centered interviewing approach*. Utilizing a patient-centered interviewing approach also allows for the *introduction of cultural elements* into the patient-pharmacist discussion. Because *culture can influence healthcare-seeking practices and belief systems regarding how disease states are manifested and treated*, obtaining the patient's input in regard to their medical concerns could help when creating a patient care plan.

Describe a Clinician-centered interview.

An interview style in which the *clinician guides the interview in his or her preferred direction*. *The clinician's issues of concern may be given priority over the patient's concerns*. Patient interaction may be limited. Often healthcare providers, including pharmacists, start a patient interview with a specific goal in mind, which is to *gather the information they need to confirm what they think is wrong* with the patient so that they can recommend treatment. This type of interview primarily consists of the clinician asking a series of questions and listening to the patient's response. This method of interviewing is mostly *under the control of the clinician*. The clinician typically asks questions to obtain details to help determine the patient's problem based on his or her personal knowledge base In this method of interviewing, *the patient's thoughts, perceptions, and concerns about the condition are not considered*. The patient may not feel as if the clinician is interested in what they have to say or how they feel. Many clinicians may unintentionally use a clinician-centered approach with a patient.

S*C*HOLAR-MAC

Characteristics

SCHOLAR-MA*C*

Comorbidities

Follow-up is important for identifying _____.

DRPs. -there is no way to know how a patient reacts to a medication unless you follow up with them after they start taking it.

What is Direct therapeutic monitoring?

Direct monitoring indicates measuring the concentration of a drug (or its metabolite) in the blood or other sample. This is used when the concentration in the sample will correlate with the therapeutic and/or toxic effects of the medications.

True or False: Patients with low health literacy often comprehend more when written explanations are provided.

False Patients with low health literacy often comprehend more when directions are *explained verbally*.

Define Health Literacy

Health Literacy is a person's ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment. This includes being able to: -read -write -communicate -compute (numeracy) -understand -and apply health-related tasks Health literacy also includes his or her cultural experiences, understanding of health concepts and pathophysiology, and *basic communication skills*.

SC*H*OLAR-MAC

History

HPC

History of Present Condition

HPI

History of Present Illness

What is Indirect therapeutic monitoring?

Indirect monitoring involves checking for an effect or something other that the drug level itself that indicates how/if it is working.

What is the importance of patients understanding their medication instructions?

Instructions regarding how patients should take their medications are vitally important. Patients' recall and understanding of these messages are predictive of medication adherence, which leads to increased medication safety and efficacy.

What are some things to keep in mind when performing Caregiver Interviewing?

Know who you are speaking to and their relationship to the patient -Ensure you are speaking to the correct person If the patient is present, effort should be made to include him/her in the interview, etc. -*Speak directly towards the patient when possible* Be sensitive to the situation of the caregiver

SCHO*L*AR-MAC

Location

Which provider/system mismatch risk is not helpful in terms of cost or healthcare satisfaction?

Malpractice claims

SCHOLAR-*M*AC

Medications

*Discrepancies* What are some things that the majority of patients struggle with understanding?

Most struggle with understanding how to: -Take medicines -Prep for lab/diagnostic tests -Choose a provider -Use an insurance plan -Read food labels -Use medical devices -Manage chronic health conditions

Give an example of a quantitative measure that would be included in the HPI/HPC.

Number of loose stools in past 24hr

Why is the following information important to obtain during a the patient history portion of the patient interview? *Chief Complaint*

Often the chief complaint *will indicate the main focus or purpose of the visit*. It may not necessarily be a "complaint"; it may be an explanation of the reason for the referral or visit with the patient.

SCH*O*LAR-MAC

Onset

One of the pharmacy/pharmacist specific interventions to help improve medication safety and adherence among patients with low health literacy, is to implement standardized labeling. What are the advantages that standardized labeling would provide?

Patients receive medication information from a multitude of *fragmented and constantly changing sources*. A successful system should make these sources *complement, not oppose, each other*, with the goal of *reinforcing reliable and easy-to-understand content* about the safe and effective use of medications. Prescription medication labels represent *the very last line of instruction* that either enables patients to take their medications properly or causes further confusion. It is the responsibility of both pharmacies and pharmacists to be involved in advocating for a better system of *medication labeling that is patient-centered* and that offers information that is understandable, accessible, and easily implemented. The *U.S. Pharmacopeia (USP)* regularly promotes *standards for improved medication labels*, reflecting formats that utilize lessons of health literacy and *offering content that is patient-centered*. As these changes are more widely adopted, all pharmacies and pharmacists should work to implement prescription labels that correspond with the USP patient-centered medication guidelines.

Patients with limited literacy skills have: 1. Decreased ability to read and use ________ instructions, _______ slips, and consent forms. 2. Decreased knowledge of and poorer ______ with medication and self-care regimens for chronic conditions. 3. Decreased glycemic control and ↑ rates of _______ among patients with diabetes 4. Decreased knowledge and likelihood of getting __________ such as mammograms, pap smears, or immunizations. 5. Increased _________, costs, and mortality

Patients with limited literacy skills have: 1. Decreased ability to read and use *medication* instructions, *appointment* slips, and consent forms. 2. Decreased knowledge of and poorer *compliance* with medication and self-care regimens for chronic conditions. 3. Decreased glycemic control and ↑ rates of *retinopathy* among patients with diabetes 4. Decreased knowledge and likelihood of getting *preventative care* such as mammograms, pap smears, or immunizations. 5. Increased *hospitalizations*, costs, and mortality

Why is the following information important to obtain during a the patient history portion of the patient interview? *Immunization History*

Pharmacists are immunizers in many locations, so knowledge of immunization history can inform the pharmacist of the *need to provide vaccines*.

Aligning health communications with core national efforts can:

Reduce health disparities/provide culturally sensitive care Prevent and manage chronic conditions Prepare for and manage disasters Improve the safety and quality of care Prevent hospital readmissions Save time and money Enhance consumer/provider and community relationships

How are you going to collect patient information?

Relationship development and maintenance Focused v. comprehensive interview Patient centered v. clinician centered interview Use of explanatory models (get more patient perspective) Acknowledgement of cultural differences Make a plan

SCHOLA*R*-MAC

Remitting factors

Why is the following information important to obtain during a the patient history portion of the patient interview? *Review of Systems*

Reviewing specific body systems, through either interview or physical assessment, can help provide more information about a medical condition and *can help evaluate, rule out, or identify drug-related problems*.

What is the purpose for the patient interview? List the possibilities.

Self-Care Consult Patient Education/Counseling Medication Therapy Management Disease State Management Follow-up Immunization screening Smoking Cessation Medication reconciliation -find out what patient is doing at home vs what they did at hospital

*S*CHOLAR-MAC

Symptoms

The ______ and _______ of our health system overwhelm even well educated adults.

The *demands* and *complexity* of our health system overwhelm even well educated adults.

There is a large discrepancy between healthcare providers and the information that they need to convey to their patients and what information the patients are actually able to understand. What factors contribute to this dangerous mismatch?

The demands and complexity of our health system overwhelm even well educated adults.

What type of information is the following referring to? It is important to note that a considerable amount of this information may be found in the patient's chart, and therefore can be gathered during the preparation phase of the patient interview. Information found in the chart can and should be confirmed with the patient during the interview.

The patient history

Describe the importance of face-to-face counseling by a pharmacist and how it impacts health literacy.

The pharmacist is often the patient's *last opportunity for verbal and printed instructions* on how to take medications properly. This role is particularly important, because *patients with low health literacy often comprehend more when directions are explained verbally*.

What is a Review of Systems (ROS) assessment?

The review of systems (ROS) is the portion of the patient history that involves not only a *series of open- and closed- ended questions*, but also a *physical assessment* in which various measurements are taken to assess the patient's health status. In this portion of the patient history, *each body system is reviewed for the presence of signs or symptoms related to the chief complaint* or the primary condition for which the patient is being seen. *A pharmacist typically reviews only those body systems pertinent to the purpose of the visit*.

Describe the makings of a successful patient-centered pharmacy.

The successful patient-centered pharmacy should: -*Address awareness* of limited health literacy -*Detect barriers* that prevent patients from assessing, comprehending and using health information correctly -Identify opportunities for *improvement*

Why is the following information important to obtain during a the patient history portion of the patient interview? *Medication History and Allergies*

This information can help with *medication selection* and to *identify drug-related problems*.

Why is the following information important to obtain during a the patient history portion of the patient interview? *Social History*

This information can help with creating a drug therapy plan that will work with the patient's lifestyle. Also, this can provide insight into current lifestyle and thus *provide areas to address in terms of lifestyle modifications*.

Why is the following information important to obtain during a the patient history portion of the patient interview? *Patient Demographics*

This information not only helps to *identify the correct patient*, but also *provides initial information* regarding the patient's current health status *based on vital signs*. *This information may give you the first insight into drug-related problems*.

Why is the following information important to obtain during a the patient history portion of the patient interview? *Family History*

This information provides clues about *patient risk factors* for disease, thus prompting any needed *screenings*.

Why is the following information important to obtain during a the patient history portion of the patient interview? *Past Medical History*

This listing of past medical illnesses may help explain the *rationale for the use of certain medications* or provide insight regarding the *need for specialized dosing*.

Why is the following information important to obtain during a the patient history portion of the patient interview? *History of Present Illness*

This provides more detailed information about the patient's current issue or *progress since the last visit*.

True or False: The patient history is the key information-gathering method used in both comprehensive and focused interviews.

True

True or False: When obtaining a complete patient history, the Chief Complaint (CC) should be recorded using the patient's own words.

True i.e. use "coughing up blood" not "hemoptysis"

_________ means using Plain Language and Teach Back with ALL patients.

Universal Precautions

Define "Universal Precautions"

Universal precautions *assume that every patient may have low health literacy*, and this creates an environment where care is *optimized for patients of all health literacy levels*. The prevalence of low health literacy is concerning enough to warrant the use of "universal precautions" to minimize the risk that a patient may not understand the health information provided.

What are the 3 prime questions?

What is this med used for? How were you told to take it? What were you told to expect?

A pharmacist may use the patient history to help assess for the presence of _______ and to assess drug therapy.

drug-related problems

Commonly adults do not understand, and ________ do not know it

healthcare professionals

A patient's recall and level of understanding of ____________ is predictive of medication adherence.

medication instructions

What are the important pieces of information to collect from the pharmacy when verifying a patient's home medication regimen?

name, strength, dosing, prescriber, refill history, most recent fill

The _______ is an account of the patient's experience with illnesses, disease states, medication use, or medical procedures.

patient history

The _________ is the key information-gathering method used in both comprehensive and focused interviews.

patient history During a comprehensive patient interview the patient history may cover a period of years. On the other hand, the patient history conducted during a focused patient interview may span a shorter period of time, such as the time since the last visit or the time since the onset of symptoms or disease.

What is the purpose of the patient history?

to provide an organized method for gathering the patient's information during the patient interview and relaying that information to other healthcare providers in oral or written form.