The PILL Study Pharmacy Intervention for Limited Literacy Kara L. Jacobson, MPH, CHES Julie A. Gazmararian, PhD, MPH Sunil Kripalani, MD, MSc Karen J

The PILL Study

Pharmacy Intervention forLimited Literacy

Kara L. Jacobson, MPH, CHESJulie A. Gazmararian, PhD, MPH

Sunil Kripalani, MD, MScKaren J. McMorris, BA

Sarah Blake, MACindy Brach, MPP

Study Purpose

To improve medication adherence in patients with limited health literacy.

To assess economic impact of increased refill adherence and decreased use of health care services.

To measure secondary outcomes (pt self-reported adherence, med understanding)

Uses a systems approach

Study Phases

Phase 1:Assessment of the pharmacy

Phase 2:Implementation of a 3 “P” intervention

Phase 3:Outcome evaluation of intervention

Phase 1: The Assessment

A health literacy assessment can help your pharmacy to meet the needs of your limited-literacy patients by:

Raising staff awareness Detecting barriers to effectively using

your services Identifying opportunities for

improvement

What Does a Pharmacy Health Literacy Assessment Involve?

This assessment tool includes 3 parts: Part 1: Pharmacy assessment tour

Part 2: Pharmacy staff survey

Part 3: Patient focus groups

This tool was adapted from Literacy Alberta’s Health Literacy Audit Kit3

3. Literacy-Alberta. The Literacy Audit Kit. Calgary: Literacy Alberta; 1997.

Before Conducting a Health Literacy Assessment

Obtain staff support

Consider demographic information about the staff and patient populations

Consider adding or deleting assessment items

Part 1: Assessment Tour

Objective assessors identify existing barriers in these areas: Promotion of Services Print Materials Clear Verbal Communication

Will take 20-30 minutes to complete

Should be completed during both busy and less busy times in the pharmacy

Part 1: Assessment TourWho Should Conduct the Assessment?

Assessment will be conducted by trained, objective assessors who are: Familiar with the principles of clear health

communication Not pharmacy staff or patients Able to blend in with patients who use the

pharmacy

At least 2 per pharmacy

Should be trained together

Part 1: Assessment TourConducting the Assessment

Full guide available at: http://www.ahrq.gov/qual/pharmlit/

Part 2: Survey of Pharmacy Staff

Staff members help create the environment within the pharmacy and have a unique perspective

Evaluates staff opinions of pharmacy’s sensitivity to the needs of limited-literacy patients in three areas: Print Materials Clear Verbal Communication Sensitivity to Literacy

Will take about 20 minutes to complete

Who Should Complete the Pharmacy Staff Survey?

Small staff: all staff members can complete the survey

Large staff: select a representative, random sample

Emphasize importance of completing the survey thoroughly!

Part 3: Pharmacy Patient Focus Groups

Ask pharmacy patients about their personal experiences in 4 areas: Physical Environment Care Process and Workforce Paperwork and Written Communication Culture

Conduct 2 focus groups of 10-12 patients, 2 hours each

Part 3: Who Should Participate in the Focus Groups?

Recruit patients directly from pharmacy

Patients should use the pharmacy regularly and manage their own medications

Why is it Important to Use a 3-Part Assessment Tool? Mixed method approach more

comprehensive than a single method approach Limitations resulting from the use of only

one method often produce bias4, 5

Pharmacists underreport counseling events when self-reporting compared to counseling events documented by observers6,7

Pharmacy patient recall bias decreases reporting of specific counseling activities

4. De Young M. A Review of the Research on Pharmacists' Patient-Communication Views and Practices. Am.J. Pharm. Educ. 1996;60:60-77.

5. Laurier C, Poston J. Perceived levels of counseling among Canadian pharmacists. J Soc . Admin. Pharm. 1992;9:104-113.

6. Kirking DM. Pharmacists' perceptions of their patient counseling activities. Contemp Pharm Pract. 1982;5(4):230-238.

7. Raisch D. Patient counseling in community pharmacy and its relationship with prescription payment methods and practice settings. Ann Pharmacother. 1993;27:1173-1179.

Results from an Assessment of a Public Hospital Pharmacy

Assessment conducted in February - March 2006

Used as a baseline measure before implementing a health literacy intervention in the pharmacy


Patient Counseling: What the Pharmacists Said

65.5% of pharmacists felt confident in their ability to counsel patients with numerous questions

55.2% felt that they could effectively counsel patients when time was limited


Patient Counseling: What the Patients Said

“I try not to ask any questions unless it’s absolutely necessary…I get the feeling that they already overworked and whatever and they really don’t feel like answering questions.”

“[Counseling time] is enough because I already should know something about [my medicines] and that pamphlet can tell me a lot more than he can tell me.”


Print Materials: What the Pharmacists Said

57.1% indicated that prescription bottle labels and warning labels are easy for their limited-literacy patients to understand

42.9% agreed that prescription informational inserts are easy for adults with limited literacy skills to understand


Print Materials: What the Patients Said

Rely heavily on printed materials for information about their medicines:

“I love those [informational inserts].”

Find the print on these materials difficult to read:

“Little type, little print across there [the bottle label]. You can barely, hardly read it.”


Print Materials: What the Assessors Said

All agreed that the pharmacy could make improvements in providing clearly written information inserts

None felt that the information inserts were easy to understand

All agreed that the pharmacy could make improvements in providing clearly written bottle labels

Hospital Signage


As results show, people in different roles (staff, patients, outside observers) have different perspectives.

We’ve Assessed, Now What?

Launch the Intervention3 “P” Approach

Reminder Phone calls Pharmacist Training Picture Prescription

Participants:

1600 adult, English-speaking patients who get their medication filled at Grady Hospital

Participants must have received regular pharmacy services atGrady for a minimum of6 months

Telephone Reminder System

Integrated into the existing refill call line

Calls 5-8 days before a script is due for refill

Pharmacist Training

All Grady pharmacists received training in clear health communication

When patients pick up their prescriptions, they should be counseled on their medications by pharmacists trained to communicate with limited-literacy patients

PILL Pharmacist Training

Explain things clearly in plain language Focus on key messages and repeat Use a “teach back” or “show me”

technique to check understanding Effectively solicit questions Use patient-friendly educational materials

to enhance interaction

Using Plain Language:What could we say instead of…

Adverse reaction

Hypoglycemia Ophthalmic use

only PRN Suppository

Topical

Side effectLow sugarPut in your eyes

When you need itPill that goes in your

bottom/behindOn skin

PictureRx

When study patients pick up their prescriptions, they will receive a pill card.

The card will provide: list of all of the patients’ medications pictures of the pills information on what the medication is for graphic instructions on how/when to take

it.

PictureRx

Based on research and practice at Grady Further developed for Grady and PILL study Automated solution to facilitate counseling Displays patient’s regimen in picture form Explains regimen, also reminds patient Easy to understand, take-home aid Punch-out wallet card

Disclosure: Dr. Kripalani is a consultant to and holds equity in PictureRx, LLC. He is entitled to revenues from future product sales. He will not receive any compensation from Grady or Emory through the PILL study.

Perceived Value of anIllustrated Medication Schedule

80%

94%

72%

78%

87%

71%

0% 20% 40% 60% 80% 100%

At least one of above

Timing

Dosage

Purpose

Names

What to take

Helped patients remember…

Kripalani et al, Prev Med 2004

Phase 3: Outcome Measures

Through one-on-one interviews, the study assessed participants’: Understanding of their medications Medication adherence as measured through refill

compliance Confidence in their ability to correctly take their

medicines Health status, social support, and health literacy Level of satisfaction with pharmacy services

received during the study

What Resources Can Help Make a Pharmacy More Literacy-Friendly?

AHRQ Tools Strategies To Improve Communication

Between Pharmacy Staff and Patients: Training Program for Pharmacy Staff

Introduce pharmacists to the problem of low health literacy in patient populations

Identify the implications of this problem for the delivery of health care services

Explain techniques that pharmacy staff members can use to improve communication with patients who may have limited health literacy skills

http://www.ahrq.gov/qual/pharmlit/pharmtrain.htm


AHRQ Tools How to Create a Pill Card

Guide to help users create an easy-to-use "pill card" for patients, parents, or anyone who has a hard time keeping track of their medicines

Step-by-step instructions, sample clip art, and suggestions for design and use will help to customize a reminder card

http://www.ahrq.gov/qual/pillcard/pillcard.htm


Automated Telephone Reminders: A Tool to Help Refill Medicines On Time

Easy-to-understand telephone script Automated refill reminder calls to patients remind

them to refill their prescriptions Calls also allow patients to order the refill on the

phone

http://www.ahrq.gov/qual/callscript.htm

Your Action Steps

How can youuse these tools

in your organization?

Documents

The PILL Study Pharmacy Intervention for Limited Literacy Kara L. Jacobson, MPH, CHES Julie A. Gazmararian, PhD, MPH Sunil Kripalani, MD, MSc Karen J