Molly Ekstrand, RPh AE-C CDE Mom and Medication Management Pharmacist

1. Health Care Burden and the Medication Experience: Engaging our medically complex learners and families Molly Ekstrand, RPh AE-C CDE Mom and Medication Management Pharmacist Certified Asthma and Diabetes Educator Park Nicollet Clinic, St Louis Park, MN

2. How many times have you heard…? “I (we) can control this myself, without medication” “Do I really need 3 prescriptions for…” “What do all these chemicals do in my body?” “I think I felt better before all these drugs” “My whole life revolves around drugs and doctors” “We can’t afford her medications.”

3. “Drugs don’t work in people who don’t take them.” C. Everett Koop, MD For 88% of chronic and complex diseases, drugs are a first choice for medical intervention Medco Data Presented 2010

4. Medication Experiences and MTM • Understand how 'The Medication Experience' can impact decision making about medication use. • Implement strategies to engage and support learners and families to balance medical needs with academic success.

5. Questions to run on How often do you engage your patients in a conversation about their medication? • How many times a day are your patients taking their medicines? • How many different ways are your patients administering their medication? • How often do they visit their pharmacy or pharmacies? These can be signs of healthcare burden!

6. We’re not making progress… 60 50 40 30 20 10 0 Medication non-adherence rates 1979-2011 33-50% of patients adhere to chronic regimens 1980 1990 2000 2010 Claxton, et al. A Systematic Review of the Associations Between Dose Regimens and Medication Compliance. Clinical Therapeutics 2001, 23:1296-1310.

7. 24% of e-prescriptions sent were never filled within 6 months of the written date

8. Claxton, et al. A Systematic Review of the Associations Between Dose Regimens and Medication Compliance. Clinical Therapeutics 2001, 23:1296-1310. Direct association between dosing frequency and medication adherence

9. Did someone say…?

10. Asthma Stepwise Approach 2007 Asthma Guidelines. www.nhlbi.gov

11. ADHD Guidelines and Algorithm

12. Diabetes Algorithm

13. The Conundrum Evidence Based Medicine and Treatment Guidelines vs. The Patient’s Medication Experience

14. The Medication Experience • Patient’s subjective experience of taking a medication in daily life • Gained expertise with a medication in his own body • May include positive or negative bodily effects • Alter the way they take their own medication Uncovering, understanding and utilizing these experiences in practice represent an effective way to improve the medication outcomes of patients. Shoemaker SJ, Ramalho de Oliveira D. The meaning of medications for patients: the medication experience. Pharm World Sci 2008;30:86–91.

15. Medication Experience Themes • Meaningful Encounter • Signs of losing control • Signs of getting older • Cause questioning • Meeting with Stigma • Social Stigma with drugs/diseases Shoemaker, S.J.; Ramalho de Oliveira, D.; Alves, M.R.; Ekstrand, M.J. Patient EducCouns. 2011 Jun;83(3):443-50. Epub 2011 Mar 23.

16. More Medication Experience Themes • Bodily Effects • Magic Elixir • Negative Effects • Unremitting Nature • Chronic medication use, day in and day out • Exerting Control • Changing meds to fit with lifestyle Shoemaker, S.J.; Ramalho de Oliveira, D.; Alves, M.R.; Ekstrand, M.J. Patient Educ Couns. 2011 Jun;83(3):443-50. Epub 2011 Mar 23.

17. What do I do now? • Strategies were identified to help providers tailor their care to overcome medication experience barriers. Motivational Interviewing meets Medication Counseling

18. Callie, 13yo • Social History: 2nd oldest, family of 4 kids. Married parents, dad travels a lot. • Current Medical Issues • Asthma and allergies since ~4yo, no hospitalizations. Frequents the health office for coughing and wheezing. Seen in Urgent Care last week, URI. • Just finishing her antibiotic and prednisone course. • More comfortable with her albuterol. Also prescribed ICS/LABA combo which she admits ‘I keep forgetting’ Sometimes I feel like my voice gets funny.

19. Callie, 11yo, continued • Presents in clinic with mom, urgent care follow-up • Mom surprised that Callie hasn’t been using her controller regularly. • Callie feels ashamed that she forgets • Mom feels ashamed that she hasn’t paid closer attention • Callie admits that when she does use it regularly, her voice changes. ‘I sound funny.’ • Our Goals: Better asthma control! Ideally use controller regularly • Family Goals: Better asthma control! Fit meds in with life, minimize side effects.

20. Strategy: Acknowledge Patient Choice • Patients have the ultimate choice in their health and utilization of medication. • Ask what their wishes are for their health. • Ask them to explain their thoughts, respect them. • Avoid the ‘Righting Reflex’ http://shareddecisions.mayoclinic.org

21. Strategy: Provide Tailored Education • Understand patient’s experiences and thoughts on health and medications • Train on inhalers to minimize side effects • Realities: • Preventive medicine is non-gratifying • Drugs have side effects • Drugs are expensive

22. Jacob, 8 yo • Social History: Oldest of 2 kids, married parents, engaged family, one parent works in healthcare • Current Medical Issues: • ADHD diagnosed beginning of first grade (1.5 years ago) • Adderall XR AM and Guanfacine twice daily. Fairly stable • Sees Specialist, Psychologist • Concussion/TBI after tree fall over spring break • 2 Night PICU at Childrens, • MANY follow up MD appointments, and tests. • Physical/Occupational therapy • Many activity and academic restrictions

23. …And you’re reading for at least 30 minutes too, right? Increasingly complex regimens Treatments | Monitoring Decreasing healthcare support Shift towards self-management Evidence-based guidelines are disease-specific Promotion of treatments Poor care coordination Increasing treatment burden Failure to cope Poor fidelity to the treatment program

24. Minimally disruptive healthcare Health care delivery designed to reduce the burden of treatment on patients while pursuing patient goals http://minimallydisruptivemedicine.org May CR, Montori VM, Mair FS. BMJ 2009; 339:b2803

25. Strategy: Empower and Prioritize • Motivational Interviewing Strategies • Ask open ended, non-confrontational questions • Tell me more about that. • How does that make you feel? • Let’s pick two things today… • Allow the patient to • Identify their health goals • Identify solutions to problems http://shareddecisions.mayoclinic.org

26. Annette, 17yo • Social history: Older brother left for college last fall, Parents divorced 3 years ago. ‘Things have been different around my house’ …’I don’t want to be different than my friends.’ • Current Medical Conditions: • Type1 Diabetes since 9yo. Had one severe hypoglycemic episode at school, fearful of hypoglycemia • Endocrinologist every 3 months • Depression/Anxiety: Sertraline, controlled now, had severe anxiety attacks when parents split • Counselor about once a month

27. What are Annette’s Med Experiences? • Exerting control • Unremitting Nature • Magic elixir • All of the above Answer: All of the above! Not taking her insulin at school, Magic elixir with the Sertraline, Unremitting nature with her complex regimen.

28. Strategy: Negotiation • Help patient utilize objective data to realize value of or need for drug therapy • Home glucose monitoring • Home blood pressure monitoring • Allow patient to set goal and timeframe. Hold them accountable.

29. Strategy: Building Trust • Build a relationship with your patient • 3 visits? The magic number? • Show them you’re on their side • Want to work with them • Explain your role: ‘Helping YOU get the most from your medications’ Reducing your health risks, Keeping your body safe.

30. Sam, 11yo • Social History: Parents divorced, Middle child, Half time with each parent. Differing parenting styles. • Current Medical Issues: • ADD diagnosed in second grade, poor test scores and teacher input, seemed to correlate with home struggles. • Concerta daily, better adherence at mom’s house • Dad feels he should be able to focus better, ‘He eats a ton of junk at Mom’s house, not mine.’ • Sam gets frustrated and tearful at school, feels in the middle

31. Strategy: Building Trust • Build a relationship with your patient/family • Understand family’s experiences and thoughts on health and medications • Show them you’re on their side • Want to work with them • Explain your role: ‘Helping Sam thrive academically’ Reducing potential risks of side effects. • Sam knew it helped, kept some in the nurse office.

32. Strategy: Backing Off • Set lifestyle goals with patient to achieve health goals, set follow-up and hold them accountable. • Focus on another health goal or drug therapy issue. Hopefully they will see progress and willingness to move forward.

33. Engage your patients in conversations about their medications. QUESTIONS?PLEASE CONTACT MEMOLLY.EKSTRAND@PARKNICOLLET.COM952-993-2087