“The pharmacist of tomorrow is going to be unrecognizable to most of us. He might not be a vending machine, but he’s not going to be that quiet old white-haired guy up behind the counter, either.”  –  Jim Ammen

Part of the team… 

Harnessing the power of a pharmacist’s knowledge and expertise to control healthcare costs and improve patient outcomes has been a difficult process. Those promoting the transformation of the role of the pharmacist from the traditional dispenser of medications to a dispenser of information have always been confronted with the question of “who will pay for these services”. Fortunately, since the implementation of Medicare-D, the value of pharmacists providing cognitive services, including medication therapy management MTM services, has become more widely recognized.

But even with this increased recognition, the profession of pharmacy is still facing a sort of ‘identity crisis’. “Pharmacists see themselves as having nine different identities” according to a recent @ChemistDruggist article, thus suggesting they play a ‘flexible role’ in healthcare but remain uncertain of the future.

It’s been a long time coming…

The decade long push for recognizing pharmacists as healthcare providers is finally seeing results. Recent legislation in California became law when Governor Jerry Brown signed the pharmacist provider status bill (SB 493) recognizing pharmacists as healthcare providers. I’m sure other states will be looking at similar legislation in the near future. But will the new legal recognition as providers get pharmacists a seat at the healthcare team table?

“Pharmacists are working more closely with patients and healthcare colleagues in hospitals, outreach teams, patients’ homes, residential care, team graphichospices, and general practice” reports the Royal Pharmaceutical Society @rpharms in ‘Now or Never: Shaping Pharmacy for the Future’. In the U.S. the team based care approach continues to get a foothold with pharmacists participating in patient centered medical home models, accountable care organizations and in collaborative arrangements with other healthcare providers. But we have a long road ahead until we’ll actually see a majority of pharmacists participating as a member of the healthcare team on this level.

It all makes sense…

There are areas where it’s been shown pharmacists can contribute as a first string member of the healthcare plan team. Take medication non-adherence for example. The cost of non-adherence and compliance to prescribed medication therapy has been reported to be well over $290 billion annually in the United States. This is often a direct reflection of the lack of a patient’s understanding of their particular disease state and how their medication therapy can control or improve their particular condition. This is a great example where having a pharmacist on the care plan team makes a great deal of sense, especially at any point of transitional care.

A major component of the patient care plan consists of properly treating the patient’s disease state with appropriate drug therapy. When there is a breakdown, pause or discontinuation of medication therapy by a patient, i.e. lack of medication adherence or compliance, one can almost always predict a breakdown in overall patient care. This can result in increased hospital re-admissions, lack of disease control, increased complications and of course, increased healthcare costs.

Including a pharmacist in the patient care plan process can improve patient outcomes, especially during transitional care. About 1 in 5 Medicare patients who leave the hospital are readmitted withing 30 days. “We know that people who have medication discrepancies, or are not adhering to what the health care team thought they were adhering to, have at least double the risk of becoming a readmission” reports Jane Brock, MD, of the Colorado Foundation for Medical Care. 

Pharmacists should be given the role of patient care managers and  should be performing services such as medication reconciliation, checking for potential adverse drug reactions, performing patient education and other patient oriented services such such as MTM whenever there is a transition inlogo_white medical care. They should also be directly involved with follow-up services to ensure adherence and compliance to drug therapy and report this back to the patient care plan team. Compliance to drug therapy is critical in chronic diseases such as diabetes, hypertension or heart disease and community pharmacists are in an ideal position to fulfill this role. 

Moving forward…

I’ve written before on the topic of pharmacists “being the healthcare provider”. As PROVIDERS of services (including MTM services) and EDUCATORS to help patients understand their medications and medical conditions, pharmacists will be recognized as a resource to ensure continuity through the transitions of healthcare, thus changing patient’s lives, improving outcomes and saving healthcare dollars.

So again I say “Be the Provider” and take an active roll as part of the patient care planning team.

MORS and SMORS — more than a sweet treat

I’m going out on a limb here and betting many of you have not heard of MORS and SMORS. For your information, they may be one of the best solutions around to improve medication adherence, compliance and patient safety.

Medication Organizer Reminder Systems MORS and Secure Medication Organizer Reminder Systems SMORS are a group of products designed to organize patient medications and provide audible and/or visual alerts to remind patients to take their medication on time, every time.

My interest in MORS and SMORS, (which always reminds me of a good time around a campfire), began nearly three years agosmores 3 when I first started researching medication adherence and compliance.

Although the causes and proposed solutions to the medication adherence/compliance problem vary widely and are often debated, it seems one thing can be agreed upon by all… it is a very costly healthcare problem in the U.S. today. The cost of non-adherence was estimated to be $290 billion annually by the New England Healthcare Institute NEHI in 2009. It’s now estimated by some to be in the neighborhood of $330 billion or more annually.

When you add in the additional costs of adverse drug reactions, medication misuse, lack of control of diseases like hypertension, diabetes, etc., additional physician, hospital and emergency department visits, this figure approaches nearly a half trillion dollars annually.  And this does not even take into consideration the loss of life from inappropriate medication use estimated to be over 125,000 deaths annually.

MORS and SMORS can help patients improve their medication compliance which in turn will improve control of their particular disease and reduce healthcare costs in the long run.

Opening doors for pharmacists –

I recently presented information on April 17th, 2013, to the Oregon Board of Pharmacy on the topic of medication adherence and compliance, the costs associated with the problem and the patient safety issues that arise when patients don’t take medications as prescribed. Pharmacists need to understand and utilize the available technology, including MORS and SMORS, to improve patient outcomes and help reduce healthcare costs.

But at this time the Oregon BOP does not allow pharmacists to dispense, fill or set up medications for use in medication organizer reminder systems. Pharmacy rules for medication labeling and packaging currently prevent pharmacists from doing so as they are not compliant with Board rules and guidelines. Several other states, including neighboring Washington State, have moved forward and adopted rules to allow pharmacists to utilize this technology to improve patient care and safety.

The Board responded favorably to my request by proposing additions to the customized patient medication packaging rule (Oregon 855-041-1140) to provide a waiver for approved medication organizer reminders systems not meeting regular labeling and packaging guidelines. After the recent rulemaking hearing, the Board will now move forward and vote on the new rule and, hopefully, implement this change in Oregon pharmacy law at their August 2013 meeting.

Patient safety is the issue –

The proposed rule change is based on improving patient safety as well as improving medication adherence. Allowing pharmacists to be involved with filling or dispensing medications for use in medication organizer reminder systems will have a positive impact on medication adherence, compliance and medication safety. Do you see the opportunity for pharmacists here?

The real solution –

The impact of the proposed rule changes are not based solely on the use of medication organizer reminder systems. The real solution to the adherence dilemma is getting pharmacists involved with their patients.

A recent report published by the National Community Pharmacy Association NCPA identified what I believe to be the biggest factor for combating the medication adherence problem:

  • The biggest predictor of medication adherence was patients’ personal connection (or lack thereof) with a pharmacist or pharmacy staff. Patients of independent community pharmacies reported the highest level of personal connection (89 percent agreeing that pharmacist or staff “knows you pretty well”), followed by large chains (67 percent) and mail order (36 percent).

“This predicting factor was followed in order of importance by: affordability of medications; continuity in health care usage; how important patients feel it is to take their medication as prescribed; how well informed they feel about their health; and medication side effects.”

Enter here… The Door is OPEN –

The door is now open for pharmacists to seize this opportunity to get involved with medication organizer reminder systems and assist their patients who may be struggling with medication adherence problems.

It’s the perfect addition to patient counseling or medication therapy management MTM to improve patient medication compliance and patient safety.

If your state Board of Pharmacy rules need to be changed for you to get involved, you need to BE THE CHANGE. Address the topic with your state Board and urge them to move the profession of pharmacy forward.

Feel free to contact me for assistance and advice on how to move forward with this in your state.

Can you hear me now?

You can call it selective hearing, being preoccupied or just not interested in listening to somebody when they’re trying to tell you something. In my case, it was also losing my hearing in the frequency range of my wife’s voice. never listenShe would often complain that I never listen to her. She returned one evening from a craft fair or bazaar with a painted block of wood, wrapped with a ribbon, and handed it to me. It had the following inscription:

“My wife says I never listen to her… at least I think that’s what she said.” 

Later I discovered our lack of communication was only partially due to my progressive hearing loss. I say “partially” because I now know I was guilty of not giving her my full attention when she spoke to me. I struggled with my hearing (and listening) until a few years later when I suffered profound loss of hearing in both ears.

Though my total loss of hearing was devastating when it happened, regaining my hearing through the process of receiving a cochlear implant has taught me some very important lessons about the difference between hearing and listening.

Hearing is not the same as listening.

The rehabilitation process of regaining my hearing through the miracle of a cochlear implant was hard work. I would struggle to hear at times, knowing I needed to understand the words being said.

But because I was concentrating so much on hearing the words in a conversation, I found myself lacking in the area of listening to the conversation. My brain was so focused on hearing that I didn’t have time to listen at first. Likewise, if our minds and concentration are focused elsewhere, we’re going to miss most of the conversation.

Using more than just your ears.

Listening is not only hearing what is being said, but what is not being said or only partially being said. There are so many nuances to a conversation that one can’t hear unless they truly engage in listening. Body language, facial expression, verbal and non-verbal messages can only be pick up if one is fully engaged, both hearing and listening.

So now you might be asking yourself “what does this have to do with healthcare?”

Time allotted:  8 minutes per patient.

The New York Times recently published an article referencing a study which confirmed “new doctors are spending less time with patients than ever before.” I’m sure this translates over to many of the physicians who’ve been in practice for a number of years as well. Physicians (and pharmacists for that matter) are being bogged down in paperwork and other tasks not directly associated with patient care.

Pharmacists have been under this pressure for years. Even With OBRA mandating patient counseling on all new prescriptions, most pharmacists find it difficult to  get 30 seconds to counsel a patient at times. And I’m sure that physicians and pharmacists are not the only healthcare professionals who are lacking the time to spend listening to patients.

“The opposite of talking isn’t listening. The opposite of talking is waiting…”
~ Fran Lebowitz

So here’s a few tips that would improve the delivery of healthcare from a listening perspective:

  • Stop talking – let your patients tell their story
  • Get ready to listen – remove distractions (including laptops, etc.)
  • Be patient – put them at ease and let them share their concerns
  • Listen for what’s not being said – listen with your eyes as well
  • Be empathetic – try to understand the patient’s point of view

Unless we put forth the effort to prepare ourselves to listen it probably isn’t going to happen.

No time, no time, no time…

One might argue the case of  this new generation of healthcare practitioners being different than past generations due to time constraints. Circumstances may change over time. But the framework for building good relationships with other people hasn’t changed much, if at all, for centuries.

If we want to improve healthcare we must improve the communication and interaction with patients… many who are more informed and engaged in their health and medical conditions than ever before.

So what happened to the sign?

It still sits on our kitchen windowsill, over 15 years later, as a daily reminder to us all.

Remember the Reminders… the medication reminders, that is.

Considering the scope of the medication adherence and compliance problem in the U.S. it just makes good sense to use any means possible to help patients improve their compliance with prescription drug therapy. If you’ve read any of my recent blog posts or follow healthcare news at all you’re well aware of the extentstring-around-finger of the problem, the cost of which is now reported to be over $300 billion annually in the U.S. alone.

I’m now seeing other effects of non-compliance with information suggesting the medication compliance problem may be putting the public at even greater risk. There is evidence showing over 50% of drug clinical trial patients do not report missed doses to the clinical trial study team. This could result in problems experienced later by the public after the FDA has approved the sale of new drug products in the market place.

Finding the right fit -

So how do medication reminders fit into the scheme of things and what reminder tools or devices should be used?

There are many medication reminder tools and devices available ranging from simple pill boxes or organizers and reminder caps on pill bottles to smart phone apps and automated pill dispensers. The choice of medication reminder tools or devices would also depend on the needs of the patient with special considerations given for high risk patients who may be living in environments with little or no supervision by family or outside healthcare services.

Direct or indirect patient contact through text messages, email or telephonic messages will also influence patient compliance. But even with the plethora of medication reminder devices and techniques available we cannot discount the influence of direct patient education and encouragement from healthcare professionals.

Patient education coupled with the right reminder tools or device will produce the greatest dividends towards combating the medication adherence and compliance problem that exists today.

Improving patient outcomes – saving healthcare dollars -

Here are a few examples where medication compliance reminder tools or devices can be easily inserted into the healthcare delivery process:

  • reminder devices provided through hospital discharge planning and follow up of high risk patients to prevent re-admissions
  • reminder devices provided during counseling sessions by pharmacists, home health or home care agencies
  • reminder devices provided before leaving the physician’s office with a new prescription for maintenance medications
  • reminder devices provided in conjuction with special clinical monitoring including anti-coagulation clinic therapy or other similar outpatient services
  • reminder devices provided by pharmaceutical companies marketing products and drug therapies to improve product recognition, acceptance and compliance
  • reminder devices provided as an adjunct to monitoring patients participating in clinical trials
  • reminder devices provided by insurance, 3rd party payers or self insured businesses to reduce expenses related to medication non-compliance in patients taking maintenance medications
  • reminder devices provided to residents of independent living or retirement communities

A liberal dose of medication reminders -

For the most part we can’t control a patient’s healthcare decisions. We can’t make people take their medications if they’ve decided not to. We can, however, help steer them in the right direction with proper education and encouragement. Adding a liberal dose of medication reminder devices to the patient’s drug therapy regimen along with patient education has the greatest chance of improving compliance with prescription medication therapy.

Put on your thinking caps -

I challenge you to think of other ways to incorporate medication reminder devices into the healthcare delivery process. I look forward to your thoughts and ideas and encourage you to comment or contact me directly via email at dave.walker@medtime-compliance.com

For the most part people go to their physician or healthcare provider to get help or treatment for a medical problem. But some people are so stubborn they’ll wait until the last minute, suffering with an ache, pain or other uncontrolled symptom of disease or condition until they have no other recourse but make an appointment to see their doctor. It’s often only when they get to this virtual point of no return are they willing to give in, seek advice and visit their ‘healer’ of choice.

Similarly, due to stubborness, the desire to follow doctor’s orders seems to disappear for many patients as soon as the prescribed treatment or therapy relieves the pain or symptoms they were suffering from. This happens all too often with antibiotic therapy where patients stop taking their medication when symptoms subside, terminating the therapy before the full course of treatment has ended. It’s also evident when a patient is prescribed a maintenance medication to control a disease or chronic condition such as hypertension, cardiovascular disease, COPD or diabetes, often leading to uncontrolled symptoms, progression of disease state or even death.

What can we do to increase patient adherence and compliance with their prescribed medication regimen?

Lack of medication adherence… America’s other drug problem-

MedTime cartoon

medication compliance cards, not clubs…

Adherence and compliance to medication therapy or prescription drug regimen seems to be an ever looming problem, adding over $300 billion in healthcare expense annually in the U.S. alone. Recent statistics posted by Express Scripts indicate 69% of non-adherence to drug therapy is behavioral in nature resulting from forgetfulness or procrastination. So what’s it going to take to get people to take their medications?

No Wooden Clubs or 2 by 4’s -

Pharmacists are continually frustrated with this problem. I’m sure physicians and other prescribers are as well. Because, for the most part, we can’t “make” a patient take their medication if they don’t want to. Even when we spend the extra time to educate patients about their disease state and prescribed medications we can’t compel anybody to be compliant if they’re unwilling to do so.

$331 billion is at stake-

Improving medication adherence and ensuring timely medication use are the greatest opportunites to cutting the nearly one-half trillion dollars of avoidable healthcare costs worldwide. Any measures taken to reduce this expense and advance the responsible use of medicines  will lead to improved health outcomes as well.

What we can do, and should do, is to continue to educate, offer encouragement and provide medication reminder devices and tools to help patients who need to improve their medication compliance.

There are many tools available ranging from simple pill boxes and reminder caps on pill bottles to smart phone apps and automated pill dispensers. Some of the most unique, innovative and easy to use reminders devices are the medication compliance cards from Med Time Compliance. These devices can be designed for specific needs ranging from their iRemindHer once a day oral contraceptive compliance card and multiple daily dosing reminder cards to unique products designed for complex dosing regimens such as growth hormone injections or chemotherapy medication regimens with variable dosing schedules.

A simple thing-

As healthcare providers we should all adopt the slogan, “Remember the Reminders” to help improve medication adherence and compliance. Adding reminders to the patient education process will undoubtedly become one of the simplest, least expensive ways to improve medication adherence and compliance in the future.

We have a drug adherence problem in the United States contributing well over $300 billion each year toward the escalation of unnecessary medical expenditures.

And you may be part of the problem!  

“Three out of four Americans don’t take their medication as prescribed while one-third doesn’t even pick up their medication,” says Rebecca Burkholder, vice president of Health Policy at the National Consumers League.

Not taking your medications correctly can contribute to long term UncleSame_takeyourmedshealth problems, especially for patients who have chronic disease such as diabetes, asthma, hypertension, COPD or heart disease.

So how do you know if you’re “part of the problem”?

Do you ever-

  • forget to take your medication on time, every time?
  • have trouble staying “on track” with your medication schedule?
  • skip doses or cut doses in half to save money?
  • forget to refill your prescriptions on time?
  • take the wrong medication?
  • fail to fill new prescriptions your doctor gives you?

If you answered “yes” to any of the above questions you are not being fully compliant with your prescription drug therapy.  Your failure, or non-compliance to taking your medications correctly can lead to:

  • additional physician office visits
  • progression of disease state
  • emergency room visits
  • hospital admissions

As a matter of fact -
If you’re not taking your medication correctly your medical condition will most likely worsen. It will result in increased inconvenience for you, increased healthcare costs and increased chance for a shortened lifespan or premature death.

Steps you can take -

  1. talk to your pharmacist about your medications in depth so you understand what they do and when to take them.
  2. consult with your pharmacist and healthcare provider if you have concerns about side effects from your medications.
  3. find out if there are ways to save money on your medication expenses if you have trouble affording them.
  4. fill your prescriptions in a timely manner, both new prescriptions and refills
  5. Utilize medication management and reminder tools to help you remember to take your medications each and every day.

Pharmacists are considered THE most accessible of any healthcare providers in the U.S. Use the availability of their counsel and expertise to your advantage to improve your health.

Dag-nabbit! 

Walter Brennan was a familiar character in many of the western movies and television shows, including “The Real McCoys”, we watched growing up as a kids in my parent’s home. I always remember when he was angry or just really emphatic he used the word dag-nabbit often in these shows.

I was recently reminded that Walter Brennan played the role of Murph, a pharmacist, in the 1947 movie “Driftwood”. I don’t remember if he used the word “dag-nabbit” in Driftwood or not. But I can imagine him as a pharmacist using it when frustrated with patients who don’t take their medication as prescribed.

Physicians and pharmacists dedicate their lives to helping patients manage their various disease states with the help of prescription drugs. Whether it is hypertension, diabetes, COPD, Parkinson’s or any other chronic disease a patient may have… if patients don’t take their medication as prescribed their disease will progress and they may find themselves in the emergency room at the local hospital.

$300 billion dollar a year problem: 

And dag-nabbit, we’ve got a medication adherence problem in the U.S. that increased healthcare costs by over $300 billion last year! Failure to take medications correctly decreases the quality of life for these individuals and it’s estimated that failure to take prescription medications as prescribed results in over 125,000 deaths each year.  So why don’t people take their medications as prescribed?

barriers to medication adherence

There are a number of reasons people don’t take their medications correctly. Communication barriers, socio-economical barriers and motivational barriers all contribute to the medication non-adherence problem.

Forgetfulness, poor understanding of disease or illness, concerns about medication costs are all contributing factors to the non-compliance issue. So how do we work towards solving the medication adherence problem?

Solving the medication adherence problem: 

Healthcare professionals need to step up efforts to engage and educate patients to the importance of taking medication correctly. Physicians, nurses and pharmacists should increase efforts to enhance patient’s understanding of their disease and how they will benefit from taking their prescription medications appropriately. Pharmacist medication therapy management MTM has also been shown to increase adherence resulting in improved patient outcomes and reduce healthcare costs.

There are a number of organizations like Script Your Future that provide information and tools to improve medication compliance. Those who care for the elderly can also assist patients with reminders to take their medications as prescribed.

Technology can help with medication reminders and tools that improve medication adherence. Text messaging and reminders via phone are available to give personal medication reminders. There are many ‘pill reminder’ devices and systems available that have audible alarms or visual cues to remind patients it’s time to take their medication.

The LCD Compliance Card is the most accepted and used compliance device in the world. More than 10 million units have been distributed globally in several health care fields including both physician and veterinary practices.

The functions of the Compliance Card are all pre-programmed. There are no user settings. Users start the device at the desired time of day by depressing one button. There are variations of the Compliance Card that adapt to multiple regimens including daily, twice a day, or once a week.

So dag-nabbit – there really shouldn’t be any excuses not to take your medicines as prescribed!

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