 | |  | |  | |  | |  |
Pharmacy Clinic
Cases
Patient Counseling
Introduction
Counseling: mutual exchange of ideas & opinions (Webster’s New World Dictionary)
Drug counseling can be defined as an individualized process to help patient better
manage the health problem.
(Bartlett, E. et. al. At last, a definition. Patient education & counseling. 7: 323-324,
1985)
Counseling is a skill of integrating drug information, patient information, patient
assessment, & communication.
Effective medication counseling requires the pharmacist to perform the functions of a
drug expert, information provider, patient helper, patient interviewer, and problem
solver.
To establish an effective patient counseling process, the following must be available:
• Qualified pharmacist who knows all the ways of patient counseling
• Place
• Time
Patient counseling Techniques
The IHS Model
1. The PRIME QUESTIONS
1. What did your doctor tell you the medication is for?
2. How did your doctor tell you to take the medication?
3. What did your doctor tell you to expect?
2. SHOW & TELL
1. What do you take the medication for?
2. How do you take it?
3. What kind of problems are you having?
3. FINAL VERIFICATION
Just to make sure that I did not forget to tell you anything important, will you go
over how are you going to use the medication?
(U.S. Public Health Service: Indian Health Service 1991)
PAR Techniques
P-PREPARE
How to anticipate potential barriers to counseling?
1. using the prescriptions
- the patient’s name
- the medication
- new or repeat prescription
2. using the patient profile
3. using personal knowledge of the patient
4. mental preparation (Just before counseling, review the environment – the
pharmacy & yourself)
A-ASSESSMENT
Assessing means LOOKING & LISTENING for clues to barriers.
- look for nonverbal clues
- listen for verbal clues
start assessing from the moment you identify your patient, continue as you
introduce yourself, and keep looking & listening for barriers to counseling.
R – RESPONDING
Say..Do…Don’t
For Each Patient/Prescription The Pharmacist Shall:
II. Collect, synthesize, and interpret the relevant information - in order to
provide pharmaceutical care a pharmacist must have relevant, comprehensive and
timely information in order to make appropriate decisions about the suitability of the
prescribed therapy (or lack of therapy). Therefore, a database on each patient must
be established.
III. List and rank the patient's drug-related PROBLEMS (if any exist) - a list is
made of all actual and potential drug-related problems. These problems must be
listed as specifically as possible so that the solution is as clear as possible. For
example, a problem should be listed as "patient has been prescribed a subtherapeutic
dose of the appropriate drug", not "the dose of the drug is wrong." These problems
are then ranked by the pharmacist in regard to severity, risk to the patient, etc. This
forms the basis for what the pharmacist will take responsibility for in the
pharmaceutical care process.
IV. Establish a desired pharmacotherapeutic outcome for each drug-related
problem - this should be as specific as possible and should identify clearly what is
desired by the pharmacist and patient. For example, a desired pharmacotherapeutic
outcome is to eliminate or make manageable the side effects of a particular drug,
once it has been established that this is the appropriate drug to treat a particular
condition.
V. Determine feasible pharmacotherapeutic alternatives that could achieve the
desired outcome in this patient - a specific listing of all possible pharmacotherapeutic
alternatives are generated which will resolve the identifiable drug-related problems.
VI. Choose the "best" pharmacotherapeutic solution and individualize the
therapeutic regimen - this step results from discussing with the patient the
alternatives generated in step V.
VII. Design a therapeutic drug-monitoring plan to determine whether the desired
therapeutic outcome has been achieved - in order to provide pharmaceutical care the
pharmacist must be able to determine whether the desired therapeutic outcome has
been achieved. The pharmacist must determine what additional information or tests
must be collected to monitor the patient's progress. This would include assays,
blood pressure readings, etc.
VIII. Implement the individualized regimen and monitoring plan - here the
pharmacist communicates to the patient and providers of care to the patient (family,
HCP's), the plan to monitor how the patient is doing. Again, a mutual commitment to
the plan from the patient and these others is essential if the plan is to be successful.
IX. Follow-up to measure success - part of the idea of taking responsibility for
the drug therapy of the patient is to follow-up to determine whether the process has
been successful. Is the patient have success with the drug therapy or have new
drug-related problems emerged. While patients do have certain responsibilities for
their own care, the pharmacist's responsibilities do not end once the patient has left
the pharmacist's practice setting.
Patient Counseling Checklist
1. Introduces self
2. Identifies patient or the patient's agent.
3. Asks if patient has time to discuss medicine.
4. Explains the purpose/importance of the counseling session.
5. Asks the patient what the physician told him/her about the drug and what it
is treating. What does the patient know or understand about the disease. Use any
available patient profile information.
6. Asks about and addresses any concerns of the patient prior to information
provision.
7. Responds with appropriate empathy, listening, attention to concerns. Uses
these skills throughout the counseling session.
8. Tells the patient the name and indication of the medication.
9. Tells the patient the dosage regimen.
10. Asks patient if he/she will have a problem taking the medication as
prescribed.
11. Tailors the medication regimen to the patient's daily routine.
12. Explains how long it will take for the drug to show an effect.
13. Tells the patient how long he/she might be on the medication.
14. Tells the patient when he/she is due back for a refill.
15. Emphasizes the benefits of the medication and supports the drug before
talking about side effects.
16. Discusses major side effects of the drug and whether they will go away in
time. Discusses how to manage the side effect or what to do if the side effect does
not go away and it becomes intolerable.
17. Points out that additional rare (emphasizes this to patient) side effects are
listed in the information sheet (to be given to the patient at the end of the
counseling session). Encourages patient to call if he/she has any concerns about
these.
18. Uses written information to support counseling.
19. Discusses precautions (activities to avoid, etc.).
20. Discusses beneficial activities (e.g. exercise, decreased salt intake, diet)
21. Discusses drug-drug, drug-food, drug-disease interactions.
22. Discusses storage recommendations, ancillary instructions (shake well,
refrigerate, etc.)
23. Explains to the patient in precise terms what to do if he/she misses a
dose.
24. Checks for understanding by asking the patient to repeat back key
information (drug name, side effects, missed doses, etc.).
25. Rechecks for any additional concerns or questions.
26. Tells patient to always check medicine before leaving pharmacy.
27. Uses appropriate language throughout counseling session
28. Maintains control of the counseling session.
29. Provides accurate information.
30. Organizes the information in an appropriate manner.
How to help the patient treat the disease?
1. The basic counseling skills
- listening & Questioning skills (what, how, when)
- leading skills
- reflecting skills
- summarizing skills
- confronting skills
- interpreting skills
- informing skills
- referring/consulting skills
3. slow/use interactive techniques
- provide information in small manageable increment
- fill in the gap
- actively involve the patient in the counseling process by creating an interactive
dialogue
- verifying patient understanding
4. Set the stage for future encounters
- explaining to patient how to monitor for disease control (specific tests, &
examination)
- avoid ‘ parental-type’ sanctions
5. Monitoring & follow-up counseling (at return visits)
- disease control & complication, sign & symptom presentation, disease
progression or drug-induced
- compliance problems
a. Recognize potential compliance problems
b. Identify probable causes of non-compliance
- knowledge deficit: misunderstanding or lack of information
- practical impediments: forgetfulness, difficulty in taking medicines
- attitudinal barriers: faith in medications
c. Manage the non-compliance
Introduction
Counseling: mutual exchange of ideas & opinions (Webster’s New World Dictionary)
Drug counseling can be defined as an individualized process to help patient better
manage the health problem.
(Bartlett, E. et. al. At last, a definition. Patient education & counseling. 7: 323-324,
1985)
Counseling is a skill of integrating drug information, patient information, patient
assessment, & communication.
Effective medication counseling requires the pharmacist to perform the functions of a
drug expert, information provider, patient helper, patient interviewer, and problem
solver.
To establish an effective patient counseling process, the following must be available:
• Qualified pharmacist who knows all the ways of patient counseling
• Place
• Time
Patient counseling Techniques
The IHS Model
1. The PRIME QUESTIONS
1. What did your doctor tell you the medication is for?
2. How did your doctor tell you to take the medication?
3. What did your doctor tell you to expect?
2. SHOW & TELL
1. What do you take the medication for?
2. How do you take it?
3. What kind of problems are you having?
3. FINAL VERIFICATION
Just to make sure that I did not forget to tell you anything important, will you go
over how are you going to use the medication?
(U.S. Public Health Service: Indian Health Service 1991)
PAR Techniques
P-PREPARE
How to anticipate potential barriers to counseling?
1. using the prescriptions
- the patient’s name
- the medication
- new or repeat prescription
2. using the patient profile
3. using personal knowledge of the patient
4. mental preparation (Just before counseling, review the environment – the
pharmacy & yourself)
A-ASSESSMENT
Assessing means LOOKING & LISTENING for clues to barriers.
- look for nonverbal clues
- listen for verbal clues
start assessing from the moment you identify your patient, continue as you
introduce yourself, and keep looking & listening for barriers to counseling.
R – RESPONDING
Say..Do…Don’t
For Each Patient/Prescription The Pharmacist Shall:
II. Collect, synthesize, and interpret the relevant information - in order to
provide pharmaceutical care a pharmacist must have relevant, comprehensive and
timely information in order to make appropriate decisions about the suitability of the
prescribed therapy (or lack of therapy). Therefore, a database on each patient must
be established.
III. List and rank the patient's drug-related PROBLEMS (if any exist) - a list is
made of all actual and potential drug-related problems. These problems must be
listed as specifically as possible so that the solution is as clear as possible. For
example, a problem should be listed as "patient has been prescribed a subtherapeutic
dose of the appropriate drug", not "the dose of the drug is wrong." These problems
are then ranked by the pharmacist in regard to severity, risk to the patient, etc. This
forms the basis for what the pharmacist will take responsibility for in the
pharmaceutical care process.
IV. Establish a desired pharmacotherapeutic outcome for each drug-related
problem - this should be as specific as possible and should identify clearly what is
desired by the pharmacist and patient. For example, a desired pharmacotherapeutic
outcome is to eliminate or make manageable the side effects of a particular drug,
once it has been established that this is the appropriate drug to treat a particular
condition.
V. Determine feasible pharmacotherapeutic alternatives that could achieve the
desired outcome in this patient - a specific listing of all possible pharmacotherapeutic
alternatives are generated which will resolve the identifiable drug-related problems.
VI. Choose the "best" pharmacotherapeutic solution and individualize the
therapeutic regimen - this step results from discussing with the patient the
alternatives generated in step V.
VII. Design a therapeutic drug-monitoring plan to determine whether the desired
therapeutic outcome has been achieved - in order to provide pharmaceutical care the
pharmacist must be able to determine whether the desired therapeutic outcome has
been achieved. The pharmacist must determine what additional information or tests
must be collected to monitor the patient's progress. This would include assays,
blood pressure readings, etc.
VIII. Implement the individualized regimen and monitoring plan - here the
pharmacist communicates to the patient and providers of care to the patient (family,
HCP's), the plan to monitor how the patient is doing. Again, a mutual commitment to
the plan from the patient and these others is essential if the plan is to be successful.
IX. Follow-up to measure success - part of the idea of taking responsibility for
the drug therapy of the patient is to follow-up to determine whether the process has
been successful. Is the patient have success with the drug therapy or have new
drug-related problems emerged. While patients do have certain responsibilities for
their own care, the pharmacist's responsibilities do not end once the patient has left
the pharmacist's practice setting.
Patient Counseling Checklist
1. Introduces self
2. Identifies patient or the patient's agent.
3. Asks if patient has time to discuss medicine.
4. Explains the purpose/importance of the counseling session.
5. Asks the patient what the physician told him/her about the drug and what it
is treating. What does the patient know or understand about the disease. Use any
available patient profile information.
6. Asks about and addresses any concerns of the patient prior to information
provision.
7. Responds with appropriate empathy, listening, attention to concerns. Uses
these skills throughout the counseling session.
8. Tells the patient the name and indication of the medication.
9. Tells the patient the dosage regimen.
10. Asks patient if he/she will have a problem taking the medication as
prescribed.
11. Tailors the medication regimen to the patient's daily routine.
12. Explains how long it will take for the drug to show an effect.
13. Tells the patient how long he/she might be on the medication.
14. Tells the patient when he/she is due back for a refill.
15. Emphasizes the benefits of the medication and supports the drug before
talking about side effects.
16. Discusses major side effects of the drug and whether they will go away in
time. Discusses how to manage the side effect or what to do if the side effect does
not go away and it becomes intolerable.
17. Points out that additional rare (emphasizes this to patient) side effects are
listed in the information sheet (to be given to the patient at the end of the
counseling session). Encourages patient to call if he/she has any concerns about
these.
18. Uses written information to support counseling.
19. Discusses precautions (activities to avoid, etc.).
20. Discusses beneficial activities (e.g. exercise, decreased salt intake, diet)
21. Discusses drug-drug, drug-food, drug-disease interactions.
22. Discusses storage recommendations, ancillary instructions (shake well,
refrigerate, etc.)
23. Explains to the patient in precise terms what to do if he/she misses a
dose.
24. Checks for understanding by asking the patient to repeat back key
information (drug name, side effects, missed doses, etc.).
25. Rechecks for any additional concerns or questions.
26. Tells patient to always check medicine before leaving pharmacy.
27. Uses appropriate language throughout counseling session
28. Maintains control of the counseling session.
29. Provides accurate information.
30. Organizes the information in an appropriate manner.
How to help the patient treat the disease?
1. The basic counseling skills
- listening & Questioning skills (what, how, when)
- leading skills
- reflecting skills
- summarizing skills
- confronting skills
- interpreting skills
- informing skills
- referring/consulting skills
3. slow/use interactive techniques
- provide information in small manageable increment
- fill in the gap
- actively involve the patient in the counseling process by creating an interactive
dialogue
- verifying patient understanding
4. Set the stage for future encounters
- explaining to patient how to monitor for disease control (specific tests, &
examination)
- avoid ‘ parental-type’ sanctions
5. Monitoring & follow-up counseling (at return visits)
- disease control & complication, sign & symptom presentation, disease
progression or drug-induced
- compliance problems
a. Recognize potential compliance problems
b. Identify probable causes of non-compliance
- knowledge deficit: misunderstanding or lack of information
- practical impediments: forgetfulness, difficulty in taking medicines
- attitudinal barriers: faith in medications
c. Manage the non-compliance