1. Patient Counseling DMC Pharmacy Department Competency July 2005
Dale Tucker RPh, BCPS
Terry Dunn Pharm. D.
Albert Bajjoka Pharm. D., BCPS
July 2005

2. Goals and Objectives
Goal: To review with the pharmacist the steps and importance of effective patient counseling
Objective: To obtain actual practice in counseling patients in order for the pharmacist to become a more effective counselor

3. Outline WHO should be counseled? WHY should counseling be performed?
HOW should counseling be performed?

4. WHO to Counsel
DMC has a Tier 2 policy (MED 112) requiring pharmacists to counsel all patients taking warfarin (Coumadin®) and dieticians to counsel all patients on MAOIs
Other patient medication counseling could include patients with solid-organ transplant, asthma, COPD, new onset diabetes mellitus, CHF, the elderly, discharge medications for any patient, or if requested by physician.

5. Outline WHY should counseling be performed? WHO should be counseled?
HOW should counseling be performed?

6. WHY Counsel?
To promote adherence to medications and avoid treatment failure and future hospital admissions
Helps patients cope with their disease and any medication side effects that might occur
Important to avoid potential drug interactions with OTC, herbal, and prescription medications

7. Outline HOW should counseling be performed? WHO should be counseled?
WHY should counseling be performed?
HOW should counseling be performed?

8. HOW to Counsel Be aware of barriers to counseling
Disease state: dementia, stroke
Language: verify primary language
Hearing/vision problems
Environmental: noise, lack of privacy
Educational level (reading ability)
Patient motivation: disinterest in learning
Lack of pharmacist training/time

9. Minimize Barriers: Effective Communication Skills
Proper environment
Private, quiet
Free of distractions, e.g., patient should have pain controlled, ask patient to lower volume on the TV etc.
Introduce yourself
Greet the patient
Explain your purpose
Ask the patient’s permission to counsel

10. Minimize Barriers: Effective Communication Skills
Know your audience
Educational level: tailor talk for understanding
Use appropriate language
Religious or ethnic beliefs
e.g. need to avoid blood products or specific foods

11. Minimize Barriers: Effective Communication Skills
Be specific
Name of medication (brand/generic), dose, dosage form, schedule
List precautions: e.g., use sunscreen, avoid milk
How to administer (Sub-Q, PO, IM etc.)
Special directions and precautions
Necessary lab tests

12. Minimize Barriers: Effective Communication Skills
Be selective
Cover major / common side effects
Cover major / common drug interactions
Cover patient specific indication
Emphasize benefits of medication
What to do if dose(s) missed
Duration of therapy
Provide written information
Summarize key points

13. Minimize Barriers: Effective Communication Skills
Be sensitive/empathetic
Listen to the patient
Speak distinctly and clearly
Return later if patient indisposed, not alert, distracted, has visitors etc.

14. Minimize Barriers: Effective Communication Skills
Elicit feedback to assess understanding
Improves coping if side effects occur
Increases adherence to improve health
Verifies patient’s comprehension
Ask open ended questions
Ask if any final questions

15. Assess Patient’s Understanding
“Just to make sure I did not leave anything out, could you tell me…[examples]
What is the medication used for?”
When are you going to take the medication?”
What side effects might you experience?”
What will you do if that occurs?”
What will you do if you miss a dose?”

16. Example: Warfarin CounselingDO
Address patients formally
Ask what the patient knows about warfarin or Coumadin®
DON’T
Address patients by their first names
Assume the patient knows all or nothing about the drug

17. Example: Warfarin CounselingDO
Explain that warfarin is used to slow the blood clotting process to prevent unwanted blood clots
Ask patients to call their doctor if they notice bleeding that they don’t normally have
DON’T
Explain that warfarin is an anticoagulant
Explain that warfarin works by inhibiting the vitamin K dependent clotting factors and that it is an emergency situation if they see any blood

18. Example: Warfarin CounselingDO
Identify the specific reason the patient is taking it and how long they might be expected to take it
DON’T
List every reason anyone might be on warfarin

19. Example: Warfarin CounselingDO
Explain the signs and symptoms of bleeding such as bloody nose, blood in the urine, a stool that changes color or darkens, bruises that never go away or increase in size
DON’T
Give the patient the impression that they are going to bleed to death

20. Example: Warfarin CounselingDO
Ask the patient to tell all their doctor/ dentist etc. all the medications they are taking including nonprescription ones (e.g., pain medications, vitamins, herbal products)
DON’T
Assume the patient realizes the need to notify all health care providers concerning all the medications they are on; OTCs are often not considered medications

21. Example: Warfarin CounselingDO
Ask the patient to avoid taking OTC pain medications such as aspirin, Aleve®, Motrin®, or Advil® unless they have discussed it first with their physician
Recommend Tylenol® as the OTC pain reliever of choice with their physician’s knowledge as well
DON’T
Indicate that the only good pain medications are those found on prescription

22. Example: Warfarin CounselingDO
Tell the patient what to do if he or she forgets a dose
Ask the patient to inform their physician or anticoagulation clinic if a dose is missed
DON’T
Tell the patient to double up on their next dose if they miss one

23. Example: Warfarin CounselingDO
Stress the need for follow-up appointments and blood draws
Indicate that it is normal for doses to change from time to time
DON’T
Minimize the importance of follow-up by an anticoagulation clinic or a physician

24. Example: Warfarin CounselingDO
Ask the patient to eat a constant and moderate diet where they eat vegetables and salads in a consistent manner and neither over do nor stop eating what they normally eat
DON’T
Limit or forbid the patient to eat salads or vegetables, though a renal diet used by an ESRD patient may include some restrictions

25. Example: Warfarin CounselingDO
Summarize key points covered
Ask if the patient has any other questions
Ascertain that the patient understands the information
Thank the patient and leave written information
Ask them to view the in-house educational TV program if available
Document as required
DON’T
Assume the patient has no final questions
Assume the patient has understood all you have discussed
Forget to leave a note in the chart

26. Warfarin Counseling Summary
Reason for being on anticoagulation
Side Effects ( major and minor with expected frequency)
Signs of major bleeding
Anticipated duration of therapy
Adding or discontinuing medications
Dietary considerations
Arrangements for future blood draws

27. Documentation of Counseling Session
When counseling is completed
Write note or use counseling sticker in progress note.
Include assessment of patient and/or care giver understanding.

28. Summary Prepare prior to counseling Introduce yourself and your topic
Use language the patient understands
Present information in logical order
Summarize key points
Verify patients’ understanding
Allow final questions from patient
Give written information to patient
Place a note in the chart