Exam 2 Master Set - Clinical Communications

What are some example questions to use to collect Chief Complaint?

- What brings you into clinic today?

- Tell me how well your new medications have been working for you?

- What would you like me to help you with when it comes to your medications?

What are some example questions to use to collect History of Present Illness?

- How long has this been happening?

- When did it start?

- Has anything made it better / worse?

What are some example questions to use to collect Past Medical History?

- Tell me about any serious illnesses or medical problems you have had in the past.

- Are there any medical conditions that run in your family?

What are some example questions to use to collect Medication History?

- What other medications have you taken in the past for these same symptoms / problems?

- Did they help?

- How would you feel about taking that medication again?

What are some example questions to use to collect Medication Experience and Personal Goals?

- What is your attitude toward taking medications?

- What concerns do you have about taking medications?

- How do you remember to take your medication?

- How often would you say you forget to take a dose of medication?

- Where do you keep your medication?

- How much assistance with taking your medications do you receive from other family members?

What are some example questions to use to collect Vital Signs / Laboratory Test Results (as available)?

- If your doctor orders blood tests, where do you have those done?

- What lab work have you had done recently?

- Do you monitor your blood pressure / blood sugar / etc. at home?

- What are your recent results?

What are some example questions to use to collect Allergic Reactions and Drug Intolerances?

- Tell me about your medication allergies.

- What happens when you take that medication?

What are some example questions to use to collect Social History (Tobacco, Illicit Drugs, Alcohol)?

- How often do you have alcohol?

- Are you now, or have you ever, been a smoker?

- Do you use illicit drugs?

What are some example questions to use to collect Lifestyles (Diet and Exercise)?

- Tell me about what you typically eat.

- What did you have for breakfast today?

- Do you eat 2 or 3 times a day?

- Are you active at work? Lifting or moving things?

- Do you make an effort to get active outside of work?

- What type of activity?

- How many minutes? How many days per week?

What are some example questions to use to collect Vitamins / Herbals (OTC, CBD, Medical Marijuana)?

- Do you use any over-the-counter or herbal medications or vitamins?

- Do you use any CBD products or medical marijuana?

What are some example questions to use to collect Frequency of Missed Doses?

- How often would you say you miss a dose of this medication?

What are some example questions to use to collect or name an adverse effect specific to a medication and if the patient has experience this side effect?

- Sometimes people experience ________ when they take this medication.

- Does this ever happen for you?

What are some example questions to use to collect the names of surrogate outcomes or disease-oriented outcomes?

- When was the last time you checked your BP at home?

- When was the last time you had the rash?

- When was the last time you had to go to the hospital for _____?

What are some example questions to use to collect or ask the patient how their medication is working towards / helping them reach that goal?

- Have you noticed any difference in how frequently you _____?

- Do you know what your blood pressure should be?

- Has _______ gone away or improved?

How would you go about identifying a drug therapy problem correctly?

- There is an interaction between.....

- I believe medication XYZ may be causing this problem ABC.

- The dose of medication LMNOP is not high enough / too high.

How would you go about offering potential solutions for resolving a drug therapy problem?

- Start new medication

- Stop medication

- Change dose of medication

- Change lifestyle factors

- Get additional monitoring

- Etc.

How would you go about offering to take responsibility for resolving the drug therapy problem?

- I'd like to call / fax / walk over and talk to / send a message to your provider to see what they would like to do about this

- Do not change anything until you have heard back from me or your provider

What is a Drug Therapy Problem (DTP)?

Any undesirable event experiences by a patient that involves, or is suspected to involve, drug therapy that interferes with achieving the desired goals of therapy and requires professional judgement to resolve

What are some other names for Drug Therapy Problems (DTPs)?

Medication Related Problems

Drug Related Problems

Medication Therapy Problems

What is a Drug Therapy Assessment (DTA)?

Process of assessing drug-related needs and identifying and resolving drug therapy problems

What information is collected and analyzed to help us develop a Prioritized Drug Therapy Problem list?

Current Symptoms

Current Medications

Social History

Labs

Vital Signs

What four things are used to develop a Drug Therapy Problem List for each Condition?

What issues can arise with each thing?

INDICATION - unnecessary drug therapy, needs additional therapy

EFFECTIVENESS - ineffective drug, dosage too low, needs additional monitoring

SAFETY - adverse drug reaction, dose too high, needs additional monitoring

COMPLIANCE - adherence, cost

What are some common causes for Unnecessary Drug Therapy?

Duplicate Therapy

No medical indication at this time

Non-drug therapy is more appropriate

Addiction / Recreational drug use

Treating an avoidable adverse reaction

What are some common causes for Needing Additional Drug Therapy?

Preventative therapy

Untreated conditions

Synergistic therapy

What are some common causes for Ineffective / Inappropriate Drugs?

More effective drug is available

Condition refractory to drug

Dosage form is inappropriate

Drug is not indicate for the condition

What are some common causes for Dosage being Too Low?

Frequency is inappropriate

Incorrect administration

Drug interaction

Incorrect storage

Duration is inappropriate (too short)

What are some common causes for Needing Additional Monitoring?

Need further labs

Need to check blood sugar levels

Need to get BP readings

What are some common causes for Adverse Drug Reactions?

Undesirable effects

Unsafe drug for the patient

Drug interactions

Incorrect administration

Allergic reactions

Dosage increases / decreases that occur too fast

What are some common causes for Dosage being Too High?

Excessive dose

Frequency is inappropriate

Incorrect administration

Drug interactions

Duration is inappropriate

What are some common causes for Adherence Issues?

Does not understand instructions

Patient prefers not to take

Patient forgets to take

Drug product is not available

Cannot swallow / administer the drug

What are some common causes for Cost Issues?

Cannot afford drug

More cost-effective medication is available

What are the two components of a good statement identifying Drug Therapy Problems?

1. Condition

2. Medication

What does prioritization of Drug Therapy Problems depend on?

1. Extent of the Potential Harm

2. Patient's Perception of the Potential Harm

3. Rate at which this Harm is Likely to Occur

How does prioritization of Drug Therapy Problems look in practice?

Chart Review

Patient Interview

Patient Counseling

When does Chart Review occur?

Before you see the patient

How do we identify DTPs with Indication during Chart Reviews?

What questions should be asked?

Match up conditions with medication being used to treat each condition

Is each drug individually appropriate / effective for the problem?

Are these drugs in combination appropriate for the problem?

How do we identify DTPs with Effectiveness during Chart Reviews?

What questions should be asked?

Review the problems that have matching medications

Are all surrogate markers at goal?

Is the dosage form appropriate to treat the condition?

Is the dose high enough?

Is the dosing frequency too far apart?

Is the medication being administered at the optimal time?

Is the duration of therapy too short?

How do we identify DTPs with Safety during Chart Reviews?

What questions should be asked?

Are the doses appropriate based on Renal or Hepatic function and patient age?

Is the dosing frequency too close together?

Is the duration of therapy too long?

Are there any serious drug interactions among all the drugs?

How do we identify DTPs with Adherence during Chart Reviews?

What questions should be asked?

Check refill histories; are the medications being filled at appropriate intervals?

Is the patient able to afford the medication?

What are the four main purposes of a Patient Interview?

1. Assess drug-related needs

2. Identify drug therapy problems

3. Develop a therapeutic relationship

4. Ensure everyone has the most accurate and up-to-date medication list

What is the Prime Question #1?

What information can we give in response to the patient's answer to this question?

What did the doctor tell you this medication was used for?

Can give NAME and INDICATION in response

What is the Prime Question #2?

What information can we give in response to the patient's answer to this question?

How did the doctor tell you to take this medication?

Can give DOSAGE REGIMEN, MISSED DOSE INSTRUCTIONS, and STORAGE / ANCILLARY INSTRUCTIONS

What is the Prime Question #3?

What information can we give in response to the patient's answer to this question?

What did your doctor tell you to expect with this medication?

Can give EFFICACY (benefits, when it will start working, self-monitoring) and SAFETY (common side effects, adverse drug reactions, and how to manage both)

What was the traditional belief regarding interviewing patients?

What did this often lead to?

Unless patients admitted they had a problem, they would never improve

Often lead to blaming the patient and denial on the patient's part

What are the requirements of Motivational Interviewing?

What is the main outcome we hope for patient's to see by the end of interviewing?

Requirements include:

- Developing discrepancies between patient's thoughts and goals

- Understanding patients' reasoning

- Listening with an open mind

Main outcome we hope to see is the patient acknowledging change as an option

What are the three key elements of Motivational Interviewing?

What does each element serve in place of?

1. COLLABORATION - in place of Confrontation

2. EVOCATION - in place of Imposing

3. AUTONOMY - in place of Authority

What are some examples of where and when a pharmacist might use Motivational Interviewing?

Obesity

Diabetes

Hypertension

Medication Adherence

Psychiatric Illness

Behavior Disorders

Substance Abuse

Nicotine Dependence

What are ten specific communication strategies we can use for Motivational Interviewing?

1. Open-Ended Questions

2. Reflections

3. Expressing Empathy

4. Developing Discrepancies

5. Summarizing

6. Affirmations

7. Rolling with Resistance

8. Supporting Self-Efficacy

9. Eliciting and Reinforcing Change Talk

10. Setting SMART Goals

Why is using Open-Ended Questions effective for Motivational Interviewing?

What does it require?

Invites others to "tell their story" in their own words without leading them in a specific direction; encourages patient to do most of the talking

Requires curiosity, humility, and for you to LISTEN to the person's response

Why is using Reflections effective for Motivational Interviewing?

What three components make up Reflections?

Closes the loop in communication to ensure proper understanding

Components include:

- Repeating / Rephrasing

- Paraphrasing

- Reflection of Feeling

What is meant by Paraphrasing when we look at using Reflections during Motivational Interviewing?

Reflection of Feeling?

PARAPHRASING - restating in which the speaker's meaning is inferred

REFLECTION OF FEELING - emphasizing emotional aspects of communication through feeling statements

What are four examples of using Reflections for Motivational Interviewing?

1. It sounds like you. . .

2. You are wondering if. . .

3. So you feel. . .

4. Please tell me more about. . .

What are Discrepancies in terms of Motivational Interviewing?

How can we use these to acknowledge Ambivalence in our attitudes?

Simultaneous and contradictory attitudes or feelings toward an object, person, or action

Helps us distinguish between what we SHOULD do vs. what we are ACTUALLY doing

When is Summarizing particularly helpful in Motivational Interviewing?

Particularly helpful at TRANSITION POINTS, such as:

- After the person has spoken about a particular topic

- When they have recounted a personal experience

- When the encounter is nearing an end

What does Summarizing help to ensure during Motivational Interviewing?

Speaker says what they meant

Listener heard them correctly

Listener interpreted their meaning correctly

What are four examples of ways to Summarize during Motivational Interviewing?

1. Let me see if I understand so far. . .

2. Let me make sure I understand what we just talked about. . .

3. So, you've been saying. . . Is that correct?

4. What you said is important. Here are some takeaways I received from that conversation. . .

What do Affirmations help recognize in Motivational Interviewing?

What does they help use acknowledge?

RECOGNIZE patient strengths

ACKNOWLEDGE behaviors that lead in the direction of positive change, no matter how big or small

What do Affirmations emphasize during Motivational Interviewing?

What is required for them to be Effective?

EMPHASIZE past experiences that demonstrate strength and success

To be EFFECTIVE, must be GENUINE and congruent

What are four examples of how we can use Affirmations during Motivational Interviewing?

1. I appreciate you being here today.

2. Your honesty is very encouraging.

3. Thank you for your hard work today.

4. You have accomplished so much in a short amount of time.

When does Resistance occur?

Occurs when:

- Patient feels a conflict between their views of the problems + their solutions and those of their pharmacist

- Patient feels their freedom is being impinged upon

What does Rolling with Resistance allow us to do during Motivational Interviewing?

Allows us to avoid direct head-on arguments and allows the patient to define the problem and develop their own solution, which leaves little room for them to resist

What is Self-Efficacy?

Belief in one's capabilities to organize and execute the course of action required to make a change / accomplish a goal

How can we support Self-Efficacy during Motivational Interviewing?

Focus on previous successes

Highlight skills and strengths the patient already possesses

Help patients define small steps toward change

Reinforce patient statements that reflect positive attitudes and optimism about the ability to change

What is Change Talk?

Statements by the patient revealing consideration of, motivation for, or commitment to change

What does Eliciting and Reinforcing Change Talk do to help with Motivational Interviewing?

Allows us to discuss a range of steps that could be taken to get closer to health goals, rather than promoting an All-or-Nothing thinking

How does Change Talk differ from Commitment Talk?

Change Talk - DARN vs. Commitment Talk - CAT

Change Talk:

D - Desire

A - Ability

R - Reasons

N - Need

Commitment Talk:

C - Commitment

A - Activation

T - Taking Steps

What do SMART Goals stand for?

SPECIFIC - goal is direct, detailed, and meaningful

MEASURABLE - quantifiable; we are able to track progress or success

ATTAINABLE - realistic; you have the tools and / or resources to attain it

RELEVANT - aligns with the end outcome

TIME-BASED - nothing gets done without a deadline

What are the four values when talking about Behavior Change?

1. Safety and Rapport

2. Respect for Autonomy

3. Understanding and Compassion

4. Collaborative Learning

What is Compliance?

What does it imply?

Extent to which a patient's behavior matches the prescriber's recommendations

Implies PATIENT PASSIVITY

What is Adherence?

What does it imply?

Patient's ability and willingness to take a therapeutic regimen recommended by their prescriber

Implies patient ACTIVELY participates in decision about medication regimen

What is Concordance?

Agreement reached after NEGOTIATION between a patient and health care professional that respects the beliefs and wishes of the patient

What are the two types of Nonadherence?

1. Intentional

2. Unintentional

What are the three types of reasons for Nonadherence?

1. Patient-Related

2. Provider-Related

3. Health System-Related

What are some examples of Patient-Related reasons for Nonadherence?

Perception of the Medication

Perception of the Severity of the Illness

Value of the Treatment

Confidence in their Own Ability to Adhere

Lack of Social Support

Negative Patient Mood

What are some examples of Provider-Related reasons for Nonadherence?

Pill Burden

Negative Patient-Provider Relationship

What are some examples of Health System-Related reasons for Nonadherence?

Lack of Access to Medication

Lack of Resources to Afford Medication

What are five techniques we use to establish new behaviors?

1. Integrate new behaviors into current habits

2. Reminder aids

3. Patient self-monitoring

4. Monitor use on ongoing basis

5. Connect to other resources / refer

What are seven examples of false assumptions we are prone to making when talking about Medication Taking Behavior?

1. Directions are easy to understand

2. Understanding = Doing

3. Patient just does not care

4. Patients take meds consistently

5. Prescriber will follow up

6. Patient will know when to ask questions

7. Prescriber already discussed how to take the medication

What are six techniques we use to improve understanding for patients?

1. Emphasize Key Points

2. Give Reasons for Key Advice

3. Give Specific Instructions

4. Repeat Key Information

5. Give Opportunity to Provide Feedback

6. Supplement Counseling with Written Information

What four main examples exist to prove why pharmacists should be included in interprofessional collaboration?

1. Reduced medication errors and overall costs

2. Improved adherence

3. MD-PharmD management of Hypertension leads to more consistent and higher rates of BP control

4. Pharmacist collaboration in diabetes treatment leads to better A1C control

What are five critical behaviors within collaborative partnerships?

1. Similar Agendas

2. Non-Hierarchical Relationships

3. Consideration of Patient Perspectives

4. Trust and Shared Vision

5. Demonstration of Respect

What are Collaborative Practice Agreements?

What do they promote?

Formal relationship between a provider and a pharmacist in which defined activities are delegated and pharmacists are seen as under-utilized resources

Promotes team-based approach, as recommended by major health organizations

When are Collaborative Practice Agreements (CPAs) a more rational choice for treatment management?

Why?

In treatment of chronic illnesses

- Widespread prevalence

- Specific guidelines are available

What type of activities are conducted with Collaborative Practice Agreements (CPAs)?

Medication Modification

Interpretation and Ordering of Labs

Point-of-Care Testing

Refill Authorization

What are the ISBAR Steps?

INTRODUCE - introduce yourself and who you are

SITUATION - why are you communicating with the provider, based on patient history and current issue

BACKGROUND - medical history of patient and any other information that is relevant to current issue

ASSESSMENT - assessing what the issue might be and why it is happening

RECOMMENDATION - what you recommend within your clinical judgement

What are the various types of Telehealth?

What two types of timing in interaction can they be?

Various types include:

- Phone

- Video

- Secure Messaging (provider to provider, provider to patient)

- Remote Monitoring

Can be either SYNCHRONOUS (real-time) or ASYNCHRONOUS (not real-time; typically staggered)

What are the five main benefits to Telehealth?

1. Improved patient access

2. Insight into the home

3. Increased provider efficiency

4. Ability to avoid germs

5. Overall expansion of care

What are the five main challenges to Telehealth?

1. Technology (access, literacy)

2. Possible labs / point-of-care testing

3. Private and secure area for providers and patients

4. Visibility

5. Documentation must remain consistent

6. Security

7. Reimbursement

Describe the results of the two studies mentioned in lecture and how pharmacies are involved in Telehealth.

For Litke, et al.:

- Site?

- Staff?

- Intervention?

- Outcomes?

SITE - NC Veterans Affairs

STAFF - Clinical Pharmacists

INTERVENTION - 15 to 60 phone or video visits

OUTCOMES - significant drop in HbA1c and BP; significant increase in statin use and tobacco cessation

Describe the results of the two studies mentioned in lecture and how pharmacies are involved in Telehealth.

For Shively, et al.:

- Site?

- Staff?

- Intervention?

- Outcomes?

SITE - 2 community hospitals

STAFF - Residency- or ASP-trained pharmacists

INTERVENTION - 60 minute meetings 2 to 3 times per week

OUTCOMES - high rates of acceptance of ABX recommendations; ~$160k in cost savings

What types of services can be offered via Telehealth for Hospitals?

Providers?

Patients?

HOSPITALS:

- Medication Order Reviews

- Antimicrobial Streamlining

- Outpatient Antimicrobial Monitoring

PROVIDERS:

- Chart Review and Interventions

- Comprehensive Geriatric Assessments

PATIENTS:

- Counseling and Education

- Medication Histories and Reconciliation

In which situations is Telehealth typically appropriate?

General wellness visits

Management of chronic conditions

Discussion of test results

Dermatology

Counseling (prescriptions, mental health, diagnostic and therapeutic options)

In which situations is Telehealth typically inappropriate?

Procedures

Abdominal pain

Eye complaints

Dental complaints

Highly nuanced or multipl complex conditions

What are three reasons for pharmacists to document their care?

1. Provide a summary of relevant patient information

2. Provide an assessment and plan, including the rationale for it

3. Monitoring and follow-up

What is included in the Subjective section of the SOAP Note?

What overall section is that in?

Chief Complaint

History of Present Illness (Medication History)

Past Medical History

Allergies

Family History

Social History

Review of Systems

in the COLLECT Section

What is included in the Objective section of the SOAP Note?

What overall section is that in?

Vital Signs

Physical Exam (by body system)

Labs / Tests / Imaging

(if none, state none)

Current Medication List

in the COLLECT Section

What is included in the Assess section of the SOAP Note?

FOR EACH CONDITION:

Current Status

Goals of Therapy

Drug Therapy Problem(s) Identified

Plans to Resolve DTPs including therapeutic alternatives

Succinct rationale (guidelines, primary literature that guided decision making)

What is included in the Plan / Monitor and Follow-Up section of the SOAP Note?

PLAN: (for each condition)

- Start / Stop / Continue specific medication dose, route, frequency, and duration

MONITOR AND FOLLOW-UP: (for each condition)

- Monitoring parameters for efficacy, safety

- Follow-up (who, when, what)

What are the six main barriers to documentation by Pharmacists?

1. Time

2. Knowledge

3. Comfort Level

4. Lack of Reimbursement

5. Reports generated for workload analysis and accreditation

6. Papers Documenting = Inconsistent Reporting

What is the purpose of patient counseling?

Educate

Prepare

Build Relationship

Avoid Drug Therapy Problems