- Creating personal patient relationships and fostering communication can help to improve medication adherence and make chronic disease management programs more successful, says clinical pharmacist and diabetes coach Chuck Riepenhoff, RPh, CDE.
When pharmacists get involved in the engagement process, they are able to develop medication therapy management (MTM) plans that prioritize the patient’s individual challenges, opportunities, and needs.
“Instead of only being able to spend 45 or 60 seconds with the patient talking about the basic things, in these MTM programs we’re sitting there talking to that patient for 45 to 60 minutes,” explained Riepenhoff, who practices at The Pharmacy Counter, a ProMedia pharmacy. “When you spend that much time talking to the patient, you’re finding out a lot more details, some very valuable information.”
During MTM program meetings, Riepenhoff uses the pharmacy’s database to identify signs of potential medication non-adherence. If the patient does not fill prescriptions in his pharmacy, he asks them to bring all of their medications with them and inspects fill dates and the number of pills left in the bottle.
Because MTM programs allow Riepenhoff to forge deeper patient relationships, they have led him to better assess levels of medication non-adherence.
Does the patient consistently neglect the same drug, or is it a different one each month? Is she filling the prescription, but not taking the pills once she’s home? Through detailed conversations with patients and a look at their medications, Riepenhoff has identified three main categories to watch.
First, there are patients who consistently miss the same medication monthly. Second, there are patients who sporadically miss different medications from month to month. Third are those who mismanage several different aspects of their medication treatments, regularly missing refills for multiple different drugs.
By identifying which category each patient belongs in, Riepenhoff can target his patient engagement strategies, ensuring he meets specific patient needs.
Neglecting the same drug monthly
The core to engaging this first category is robust patient education, Riepenhoff said.
“For category one, more times than not it’s as simple as a lack of knowledge of what that medication is for, or a lack of appreciation for what the medication is for,” he said, citing statins for diabetes patients as an example.
“Maybe [patients] just don’t seem as committed to taking this statin month in and month out. That could be because they heard it’s a cholesterol med, but they think ‘my doctor checked my cholesterol and it’s fine. I don’t understand why my doctor added this statin,’” he explained.
Providers should take time to explain the importance of statin medications in order to address this issue, and should answer any questions about why a diabetic may need a heart medication.
“We have to reinforce the importance that this is a part of the American Diabetes Association guidelines that a person with diabetes is just naturally at higher risk of heart complications and heart events such as stroke and heart attack,” Riepenhoff said.
“So even though your doctor checked cholesterol levels, and that’s great that your doctor is keeping an eye on it, and even though your levels were overall okay, by guidelines it’s a benefit for you.”
Pharmacists may need to increase education on drug-related side effects, too. Many patients often express concern that a statin will cause muscle pain or “ruin their muscles,” Riepenhoff said. Family, friends, and even commercials can reinforce these fears, causing the patients to resist taking the drug even more.
“We as pharmacists need to reassure the safety of the medication,” Riepenhoff asserted. “We also try to tie in the importance of the medication and reinforce the overall benefit of the medication outweighs the potential risk.”
“That doesn’t mean you should ignore the potential side effects,” he continued. “You need to be aware of it, but you should feel comfortable moving forward and giving the medication a try.”
The final potential cause for non-adherence in this category is complex dosing, particularly twice-a-day dosing.
“Most patients will have a good routine in the morning. Part of that routine is taking the morning meds,” Riepenhoff said. “Then there’s that second dose. It’s that second dose that is missed more times than not.”
In those cases, pharmacists must work to better understand patient health habits to determine a better path forward. Determining the obstacles that keep patients from remembering that second dose is critical in improving her adherence level.
Typically, patients don’t take their second dose because their drugs are disorganized, Riepenhoff said. Pharmacists should work with the patient to determine where they should store their medication, if they should utilize a phone alarm, or if they should download a medication adherence app to keep them on track with their second dose.
Missing a different drug each month
The second non-adherence category includes patients who miss filling different drugs each month.
“For that patient, this comes from pill burden,” Riepenhoff stated. “That patient has ten, twelve, fifteen meds, and it’s simply too much to keep track of.”
At a certain point, patients have too many medications to manage and it is time for the pharmacist to intervene. Through a medication sync program, outside resources such as pharmacy technicians can act as the medication ordering manager and ensure that all of the medications are up for refill at the same time.
“We find that med sync is a valuable tool because what it does is it takes the burden of ordering and organizing the medication away from the patient,” Riepenhoff explained.
“It synchronizes the fill dates so it will simplify things in terms of some of their medications running out in the beginning of the month, some in the middle, and others running out at the end of the month. Instead they are now all due at the same time of the month, or ‘synced up.’”
Alleviating this burden is a significant organizational help, Riepenhoff wrote. Patients will now have their medications managed and filled for them, and they can then go forward by taking their pills at the correct doses on their own.
Regularly missing multiple drugs, not taking doses
The final category includes patients who do not refill multiple different drugs each month. These patients also don’t take the medications that they do refill. These complex patients require significant intervention, Riepenhoff asserted.
First, pharmacists should enroll these patients in med sync programs.
“This is where, the same as that med sync patient, they need us to take over,” he said. “It would be of benefit if they did not have to worry about having to order and organize their own medications.”
These patients may also benefit from a better organization system. Pharmacists should work with these patients to identify their barriers to taking their medications, and create strategies for overcoming them. For example, patients who miss a nightly medication should try storing the drug where their nightly routine takes place, such as their bathroom or bedroom.
Pharmacists can take organization a step further by using better packaging. At Riepenhoff’s pharmacy, he deploys SureMed cards that group medication doses together to make it easier and more convenient for patients to know what they are taking and when.
“It’s like med sync, but taking it a step further by placing their medications into multi-dose cards, which comes to the patient pre-organized by the time of day they are supposed to take them,” he explained.
While medication sync and different packaging indeed removes burden from the patient, they ultimately helps put the patient in control. By offering different levels of support – education, organization, or dosing help – pharmacists can activate patients to improve their medication adherence.
However, in order to for these strategies to be successful, pharmacists must move past their traditional role, Riepenhoff said.
“The value of a community pharmacist is no doubt filling the prescription and making sure the prescription we’re filling is the right med at the right dose, and that there are no negative potential drug interactions,” Riepenhoff concluded. “But we are also able to give that patient some very valuable information to take home with them about their medication.”