1

Pharmacist Patient Care Process and Introduction

to Patient Counseling

Dr. Hindu Rao, PharmD, APh, BCACP

Dr. Neeloufar Fakourfar, PharmD, APh, BCACP

Learning Objectives

1. Describe the Pharmacist Patient Care Process (PPCP)

2. Review the goals and steps for effective patient counseling

3. Review effective ways to navigate challenging patient encounters

4. Practice patient counseling with peers

The Pharmacist Patient Care Process

1. Process for consistent delivery of patient care across the profession

2. Applicable to any practice setting where pharmacists provide patient care and for any patient care service provided by pharmacist

3. Patient centered approach, in collaboration with other providers on the health care team, to optimize patient health and medication outcomes

4. Uses principles of evidence based practice

5. SOAP note is a tool used to guide through the process of working up patients

Patient Counseling

“The pharmacy profession has accepted responsibility for providing patient education and counseling in the context of pharmaceutical care to improve patient adherence and reduce medication-related problems.” - ASHP Guidelines on Pharmacist-Conducted

Patient Education and Counseling

https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/pharmacist-conducted-patient-education-counseling.ashx

Steps to Patient Counseling

Modified Calgary-Cambridge Approach

Build patient relationship

Develop rapport

Involve the patient

Use appropriate non-verbal cues

1. Initiate the interview (preparation, opening discussion)

2. Collect information

3. Assess

4. Plan and implement

5. Close encounter: monitor and follow up

Goals for Patient Counseling

Effective patient interviewing and counseling is a core clinical skill

Goals:

• Collect accurate health history from a patient

• Come up with an assessment and plan

• Implement: provide successful consultation

• Include instructions for follow up

To be successful at the goals above, you must develop a good patient relationship using effective communication skills

Steps to Patient Interview

Modified Calgary-Cambridge Approach

Build patient relationship

Develop rapport

Involve the patient

Use appropriate non-verbal cues

1. Initiate the interview (preparation, opening discussion)

2. Collect information

3. Assess

4. Plan and implement

5. Close encounter: monitor and follow up

Initiate the Interview

Understand your setting

• Pharmacy counter, pharmacy aisle, clinic, hospital, blood pressure screening, immunization delivery

Establish initial rapport

• Greet the patient, identify and confirm the patient’s name, check how the patient prefers to be called.

• Introduce yourself, clarify your role, if appropriate give the patient an outline of what you intend

• Engage the patient, use open ended questions, assess their understanding

Steps to Patient Interview

Modified Calgary-Cambridge Approach

Build patient relationship

Develop rapport

Involve the patient

Use appropriate non-verbal cues

1. Initiate the interview (preparation, opening discussion)

2. Collect information

3. Assess

4. Plan and implement

5. Close encounter: monitor and follow up

Collect Information

Identify the problem or problems (s)

Consider all aspects of the patient’s illness experience

• Social, psychological, biomedical

It is important to have an organized approach on how to gather information

If you collect information through an organized and comprehensive approach, the rest of the encounter will be smoother

Key Components of Health History

• Identification of the Problem(s)/Chief Complaint (CC)

• History of Present Illness (HPI)

• Past Medical History (PMH)

• Current Medications/Medication History

• Allergies

• Family History (FH)

• Social History (SH)

• Review of Systems (ROS)/Physical Exam Findings

• Laboratories/Studies

Steps to Patient Interview

Modified Calgary-Cambridge Approach

Build patient relationship

Develop rapport

Involve the patient

Use appropriate non-verbal cues

1. Initiate the interview (preparation, opening discussion)

2. Collect information

3. Assess

4. Plan and implement

5. Close encounter: monitor and follow up

Assess

Use information gathered to evaluate the patient’s needs

• What medications are they currently taking?

• Are they starting a new medication?

• Are there specific patient needs that are unmet?

• How are the current conditions being managed?

Steps to Patient Interview

Modified Calgary-Cambridge Approach

Build patient relationship

Develop rapport

Involve the patient

Use appropriate non-verbal cues

1. Initiate the interview (preparation, opening discussion)

2. Collect information

3. Assess

4. Plan and implement

5. Close encounter: monitor and follow up

Plan and Implement

• Determine a course of action

• Focus on resolving task at hand (e.g. new medication being counseled on, screening patient for health condition, educating and answering patient’s questions)

• Highlight any other important health needs

• Explain to the patient course of action

• If counseling on a medication, focus on providing key topics for your drug (directions for use, highlighting potential side effects, managing side effects when possible, etc)

• Make sure to answer patient questions and engage them

If patient is picking up a new prescription medication, use the 3 PRIME QUESTIONS to direct your counseling session

1. What did your health care provider tell you the medication was for?

2. How did your health care provider tell you to take the medication?

3. What did your health care provider tell you to expect?

“Fill in the Gaps”

Using an open-ended question-and-answer process, the pharmacist must address specific points:

• Name/class/purpose of medication

• Open vial/pour in lid

• Directions for use

• Side effects and precautions

• Duration of use/refill info

• Storage

• Missed dose instructions

Steps to Patient Interview

Modified Calgary-Cambridge Approach

Build patient relationship

Develop rapport

Involve the patient

Use appropriate non-verbal cues

1. Initiate the interview (preparation, opening discussion)

2. Collect information

3. Assess

4. Plan and implement

5. Close encounter: monitor and follow up

Final Verification of Patient Understanding

• “I want to make sure I explained everything clearly. Please summarize for me how you will take this medication.”

• “When you get home, how will you check your blood sugar?”

• “What side effects are you going to look for when taking this medication?”

Closing Discussion

• Provides the patient an opportunity to consider the information discussed during the session

• Time for patients to ask questions

• “What questions do you have for me?”

• Consider asking patient to repeat the most important information

• Reiterate and emphasize the most important counseling points as well as your contact information

• Thank patient for their time

Closing Discussion

• Provide patient the opportunity to voice any additional concerns and questions

• Provide patient with follow-up information• Follow-up with you

• Follow-up with another provider

• Appointment or time-frame for another visit

• Use written information to support counseling when appropriate• Written information has been shown to reinforce verbal instruction

• Don’t give before you start speaking because either you or the patient will start reading the paper during the verbal portion of the session

23

Patient Counseling Resources:1. “Communication Skills for

Pharmacists” by Bruce Berger2. ASHP Guidelines on

Pharmacist-Conducted Patient Education and Counseling

24

Example Counseling Video: https://youtu.be/_4iQOKRQrwA

25

Example Counseling Video:https://www.youtube.com/watc

h?v=TBqfu-uaRpU

Patient Case #1 - Information for Student Playing the Pharmacist

A patient presents to your community pharmacy to pick up a new prescription and needs counseling. The patient informed the technician they are hoping they do not need to take the medication long-term.

Patient Case #1 - Information for Student Playing the Pharmacist

https://www.urmc.rochester.edu/medialibraries/urmcmedia/medicine/general-medicine/patientcare/documents/Lisinopril_Brochure_URMC.pdf

You, Blake Anderson, are a new patient to this pharmacy. You were told to pick up a new prescription after being informed you have high blood pressure.

No known drug allergies

PMH: Seasonal allergies, newly diagnosed hypertension

Other medications: Claritin 10 mg once daily

Demeanor: Calm, curious

Question to ask pharmacist: Do I have to take this medication long-term?

Patient Case #1 - Information for Student Playing the Patient

29

Let’s practice!Do not advance to next slide without practicing!

Modified Calgary-Cambridge Approach

1. Initiate the interview (preparation, opening discussion)2. Collect information3. Assess4. Plan and implement5. Close encounter: monitor and follow up

Patient Case #1

Patient Case #1

Navigating Challenging Patient Cases

Adopted with permission from: Heidi Eukel, PharmD School of Pharmacy, College of Health Professions, North Dakota State University

• The patient• The provider• The disease state• The system

What can cause interactions to be challenging?

• Convey respect and non judgmental attitude towards patients• Listen to and engage with the patient• Use patient friendly language • Display appropriate body language and eye contact• Address patient’s concerns in a thoughtful and caring manner• Stay calm and professional at all times• Try your best to meet the patient’s needs• Set boundaries

Navigating Challenging Patient Cases

B.G., a 55 year old male, is picking up a new prescription for metformin, a medication for diabetes. He is overwhelmed that he has been recently diagnosed with diabetes. He feels that his health is changing rapidly at a young age and worries about his ability to take the medication every day at the same time.

He is very openly worried when the pharmacist starts to counsel on the new medication

Facts:✔ The patient has never used this medication before✔ The patient is not confident that he will be able to take a medication every day without

forgetting✔ The patient is concerned about his quality of life now that he has a new diagnosis of diabetes

Patient Case #2

38

Let’s practice!

Adopted with permission from: Heidi Eukel, PharmD School of Pharmacy, College of Health Professions, North Dakota State University

Patient Case #2

• What attitude(s) is this individual demonstrating? How is it different than the individual in patient case #1?

• What went well in this encounter?• What are other strategies for working with individuals that

are demonstrating this attitude?

J.B., a 16 year old female, is picking up 4 prescriptions – an oral contraceptive, a topical acne medication, an antibiotic for her newly-diagnosed gonorrhea, and an anti-anxiety medication. Her mother has called ahead and paid for her prescriptions so the pharmacist is asked to counsel the patient on all 4 new medications.

J.B. is extremely distracted by the use of her cell phone. She is talking on the phone, texting, and taking selfies constantly while waiting for the pharmacist. Prom is tonight so she has also picked out some condoms from the OTC area. She becomes very embarrassed when the pharmacist discusses the medication for her gonorrhea

Facts:✔ The patient has never used ANY medications before✔ There are 4 other patients in the pharmacy waiting for the pharmacist✔ The pharmacist has a call on hold on line 2

Adopted with permission from: Heidi Eukel, PharmD School of Pharmacy, College of Health Professions, North Dakota State University

Patient Case #3

41

Let’s practice!

Adopted with permission from: Heidi Eukel, PharmD School of Pharmacy, College of Health Professions, North Dakota State University

Patient Case #3

• What attitude(s) is this individual demonstrating?• What went well in this encounter?• What are other strategies for working with individuals that

are demonstrating this attitude?

Summary

1. Introduce yourself and your role2. Build rapport with the patient3. Gather additional information and ask questions to help make

patient-specific recommendations 4. Listen to and engage with the patient respectfully5. Ask open ended questions throughout your conversation6. Keep counseling organized using your 3 prime questions7. Be mindful of the patient’s demeanor and respectful of their needs8. Convey appropriate body language and non judgmental attitude

towards the patient9. Wrap up by having them “teach back” what they learned. Ask specific

questions during “teach back”10. Answer patient’s questions

44

Questions?