[CASE HERE]



Title

A Small Group Simulated Patient Telehealth Session on Taking a Medication History

Authors

Maria H. van Zuilen, PhD1

Corresponding Author – rzuilen@med.miami.edu

Marlena Fernandez, MD3

Laura V Chamorro Dauer, MD2

Corinne B. Ferrari, BA1

Michael J. Mintzer, MD3

Affiliations

1Division of Geriatrics and Palliative Medicine, University of Miami Miller School of Medicine

2Department of Pediatrics, University of Miami Miller School of Medicine

3Geriatric Research Education and Clinical Center (GRECC), Miami VAHCS

Note: In response to the COVID-19 pandemic, we adapted and expanded the materials for an in-person clinical skills session so we could effectively deliver it online. The original session is available on MedEdPORTAL: Mintzer MJ, et al. (2008). The medication history: A small group session on interviewing a patient regarding medication use. MedEdPORTAL; Available from: publication/1112

The materials include

Facilitator’s Guide and Session Materials

Appendix A – Obtaining a Medication History: Student Study Guide

Appendix B – PowerPoint Slides for Session Facilitators

Table 1 – Session Evaluation with results

Facilitator’s Guide and Session Materials

Session Overview

This is a 45-60 minute interactive small group simulated patient session designed for groups of 4-6 medical students. We modified an existing in-person small group session and converted it to a tele-health session that can be completed via Zoom or other online learning platform. A facilitator simulates the role of a patient who is scheduled for a telehealth visit. An attending has instructed the students on the service to begin by visit by completing the medication history. The students are instructed to complete 3 tasks in the time allotted: 1) take a medication history; 2) identify problems with the medication use and formulate a plan to improve medication use; and 3) communicate the plan to the patient. After the 3 tasks are completed, the facilitator will conduct a formative feedback session. An overall session facilitator provides a brief overview of the session and reviews the learning objectives and general structure. Then the students are divided into breakout rooms on the online platform in groups of 4-6. The individual group facilitators conduct the remainder of the session and there is no need for groups to reconvene in the original large group. Even though suggested timelines are included, this enables each group to progress and finish at their own pace.

Learning Objectives

Students will:

1. Take a medication history to gather information regarding the:

a. patient’s understanding of their medications (indications, dosing and side effects)

b. problems and factors influencing adherence

2. Outline a plan to the patient with steps that can be taken to reduce medication problems and obstacles to adherence

Materials needed for the session

1. Facilitator’s guide to be emailed ahead of time so the individual facilitators can familiarize themselves with the patient scenario and script.

2. Student study guide to be emailed ahead of time (optional, see Appendix)

3. PowerPoint presentation with 5 slides: 1) title slide; 2) learning objectives, 3) session outline and instructions; 4) patient information, and 5) medication labels

(Note: labels are included below. Dates will need to be modified to coincide with the scheduled instructional activity. The labels were formatted for sessions occurring in late July and early August 2020)

4. Performance checklist for the facilitator to complete for each group

Advance Preparation

This small group instructional activity can be inserted into your curriculum after students have received instruction on taking a medication history.

Your Role as the Simulated Patient

You are a simulated patient (Mr. or Mrs. Pat Parsec) with the illnesses and medications listed in the table below. The students will conduct a medication history. Students need to ask the general questions about medication use (names of medications, doses, etc.) as well as important questions in the physical, psychological and socioeconomic domains of care that can impact medication adherence. You will complete a performance checklist that includes the questions students should ask; medication issues they should discover; and recommendations they can give to the patient. The information from this checklist will help you give targeted formative feedback to the group at the end of the session.

Please familiarize yourself with the script. During the interviewing stage (Task #1) your role is to answer questions without giving answers to questions NOT ASKED. For example, if a student asks, “What medications do you take,” you will show the slide with the labels and say “here are my medications” without going into further detail. If a student asks if you are taking any other medications say, “These are the ones my doctors prescribed,” but do not tell them about the OTCs, the vitamin, and the herbal supplement unless students ask about each separately.

Instructions to be read to the group of students

Show Slide 1: Session Scenario and learning objectives

Scenario - You are medical students on the Geriatrics team participating in the telehealth clinic. Your first patient is Pat Parsec whose previous primary care physician, Dr. Baker, is retiring. Your attending, Dr. Smith, is assuming care for Pat at the same clinic. Dr. Smith has asked you to start the visit by taking a medication history. Your goals are to: (1) take a medication history so at the end of the interview you understand “my” use of medicines; (2) review the medication regimen and formulate recommendations to improve “my” use of medications; (3) effectively communicate your recommendations to “me.”

The following are the learning objectives for this small group:

1. You will take a medication history to gather information regarding the:

a. patient’s understanding of their medications (indications, dosing and side effects)

b. problems and factors influencing adherence

2. You will outline a plan to the patient with steps that can be taken to reduce medication problems and obstacles to adherence

You have learned about the medication interviewing process in the study guide emailed to you earlier. Now you can apply your learning and receive feedback.

Show Slide 2: Session outline

The overall session facilitator finishes by reviewing the session outline.

In a moment, we will assign you to breakout rooms in small groups. You will be given some patient information. Then you will have 15 minutes to ask questions and gather the history. The you will have 10 minutes to work as a group to discuss the medication concerns identified and develop a plan for each medication concern. Please identify a scribe for the group who will keep a record of the medication issues identified and recommendations made in the Zoom chat box. Finally, you will have 10 minutes to communicate the plan back to me as the patient. We will end with a brief feedback session. At the very end, we will provide a link to a brief evaluation (see Table 1). Please take a moment to provide us with some feedback on the session.

Assign students to their breakout room

Show Slide 3: Patient information

I will be playing the role of Pat Parsec, a patient who is scheduled for a telehealth visit with the Geriatrics clinic. Here is my patient information.

Take a moment to review the patient information on this slide (give the students 1-2 minutes to process this information). Now, each of you will take turns asking me (the patient) a few questions (2 or 3) regarding my medications. We will continue until the group has no more questions or time has run out. This format will give each of you an opportunity to ask multiple questions.

[After the students have reviewed the patient information slide, ask:”] “Are there any questions?” [Answer questions only about the logistics of the session not the content of the case.]

You now have 15 minutes to complete Task 1. Who wants to begin? [Students should self-select; if they cannot decide, you may have to choose someone to begin. You could decide the order ahead of time]

[START TIMING: 15 MINUTES]

Show Slide 4: Medication Labels only after the first student asks what medications you take

[Before Task 2, read the following:]

You now have 10 minutes, as a group, to review the medication regimen, discuss amongst yourselves any medication concerns, and formulate a comprehensive list of recommendations. Since there are a number of issues you have probably already identified by now, do not spend too much time on any one issue. The scribe can record each medication issue with its related recommendation in the Zoom chat box. This will help with the next step in which you will communicate your concerns and recommendations back to me as the patient.

Any questions? Please begin.

[START TIMING: 10 MINUTES]

[Before Task 3, read the following:]

You now have 10 minutes to communicate your recommendations to me as your patient. Please take turns using the information the scribe typed in the chat box.

Any questions? Please begin.

[START TIMING: 10 MINUTES]

[THIS IS THE END OF THE INSTRUCTIONS TO BE READ TO THE GROUP OF STUDENTS.]

Show Slide 5: Link to session evaluation

Feedback session discussion points

• Use the patient information sheet as you guide to feedback component

• Comment on whether or not the students discovered the medications from multiple physicians, the medication prescribed for a neighbor and the expired medication. Reinforce the importance of examining the medication bottles.

• Ask what are some of the other things a doctor might find? Possible answers: unlabeled medications, medications not the same as the label says, medications mixed in the same bottle, or empty bottles.

• Review the students performance on the general questions (e.g., what medications do you take;” “how (or when) do you take your medications; and how long have you been taking (or using) this medication; do your medicines help, or not). Could the dosing regimen be simplified? What were the important issues that were missed? There is no medical indication for the digoxin and there is no longer an indication for the Tylenol #3.

• There were medical, social and economic issues that could directly affect adherence: side effects, the patient’s dependency on the son to pick up their medications, and medication cost. Several medications are causing side effects. The son is also inappropriately using the patient’s Tylenol #3.

Physical domain

• Did the students recognize the potential impact of vision, hearing and arthritis on the proper use of medications?

Psychological domain

• Did the students ask if the patient had problems remembering to take their medications?

• Did the students ask how the patient kept track of their medication doses?

Social and Economic

• Did the students ask if the patient had any trouble (delivery, pick-up) getting the medications?

• Did the students ask if the patient needed any help with their medications?

• Did the students ask if the patient had any problems buying their medications?

Recommendations

• Review how the students linked their recommendations with the specific information they learned from the medication history and examination of the bottles

• Ask the students what additional recommendations they might make now

• You can reinforce some of the specific medication issues again: large number of medications and complex schedule, multiple sources of medications, therapeutic duplication, medication without indication, medication side effects (timing of symptom onset in relation to the initiation of a medication), costly brand name drug compared to generic, use of neighbor’s medication, son using the pain medication, issues that impact adherence (cost, side effects, and functional impairments), etc.

Closing the session

• Review the learning objectives. Ask if students feel they have had an opportunity to practice the skills defined in the learning objectives.

• Copy the link to the session evaluation form in the zoom chat box and ask students to complete the evaluation.

Simulated Patient Information and Script

The following table gives you a list of Pat Parsec’s medications, the “special conditions” we have created for the session, and scripted answers to the “what,” “how,” and “how long” questions (see headings for columns 3, 4 and 5). DO NOT give away the special conditions unless the students ask a specific question. They should be discovering these on their own through inspection of the medication labels and specific questions during the interview. Your medications include: 1) medications prescribed by your previous primary care physician, Dr. Baker (one is expired); 2) medications prescribed by other physicians (Dr. Sharma and Dr. Levitts); and 3) a medication that was prescribed for a neighbor (Pat Squire). The list DOES NOT contain the OTCs, herbals, and vitamins you use.

|Medication |Special conditions |If asked: |If asked: |If asked: |

| | | | | |

| | |“What you are taking the |“How you are taking this |“How long you have been |

| | |medications for” |medication” |using this medication |

|HCTZ 25 mg daily |potential therapeutic |It’s for my blood pressure |In the morning |Five years |

|(hydrochlorothiazide) |duplication with | | | |

| |furosemide | | | |

|Furosemide 10 mg q6h prn |prescribed by a different|I take it when my legs are swollen|Most of the time, I take two a day|Two years |

| |MD | | | |

| |can cause dizziness and | | | |

| |blurred vision | | | |

|Procardia XL 90 mg daily |expired date |It’s for my blood pressure |In the morning |Three years |

|(nifedipine extended | | | | |

|release) |can cause leg swelling | | | |

|Ibuprofen 400 q6h prn |Causes upset stomach if |It helps my knees |Usually twice a day, but 3 or 4 |Two years |

| |not taken with food | |when my knees are bad | |

|Digoxin 0.125 mg daily |No indication |I am not sure exactly what it is |In the morning |5 months ago (It was |

| |Can cause fatigue |for | |started before my hernia |

| | | | |operation) |

|Tylenol #3 q6h prn |Prescribed by a different|That was for the pain. I used it |I haven’t taken it since I started|5-6 months ago (It was |

|(acetaminophen 300 mg plus|MD |when the Tylenol alone didn’t work|the ibuprofen; my son takes it |started after my hernia |

|codeine 30 mg) | | |when his back hurts |operation) |

|Valium 5 mg q12h prn |Neighbor’s name on bottle|It’s supposed to help me feel |Once or twice a day, but I am |About two weeks |

|(diazepam) | |better |almost out | |

|Benadryl |OTC–not in bag of |It helps me sleep |Mostly at night |About 2-3 years |

|(diphenhydramine) |medicines | | | |

|Multivitamin daily |OTC–not in bag of |Aren’t we all supposed to be |When I eat my breakfast |For at least 10 years |

| |medicines |taking these | | |

|Ginkgo biloba 1 tablet |OTC/herbal–not in bag of |It is supposed to help me think |With breakfast |About 3 months |

|daily |medicines |better | | |

Script Guidelines

* * Remember, students will likely ask questions in a different order * * *

The Interview (Task #1)

Please answer the students in keeping with the guidelines outlined in the above table and the script cues given below. However, feel free to improvise as needed.

GENERAL QUESTIONS

Students should begin with general questions like:

“What medicines do to use,” and

“What are your medicines for,” and

“Do your medicines help,” and

“Do your medicines cause any problems?”

Script cues – suggested responses

When asked, “What medicines do you take?”

• Show the slide with the medication labels and say “Here are my medicines, Doc”. - Students should examine the medications and from just looking at the labels, they SHOULD (but might not) discover that there is 1 expired medication, 2 medications prescribed by different physicians, and 1 medication prescribed for someone else.

If asked do you take your medicines on schedule, say:

• Pretty much. Sometimes I fall asleep in my chair so I might forget a dose

• [NOTE: this is an adherence issue. There are safety concerns with taking medication at a time not recommended]

If asked if you knew 1 medicine was expired, say:

• No, I didn’t

• [NOTE: Procardia XL is expired. You have found this to be a very expensive medicine. You sometimes take it every-other-day to “stretch” it. Also, on months when money is tight, you will delay buying this medication. This is an adherence issue based in the socioeconomic domain. See below.]

If asked where you got the valium (or who Pat Squire is) say:

• From my neighbor, he said it would perk me up some

OR

• Oh, that’s my neighbor, he said it would perk me up some

If asked how long you have been on these medications, say:

• Most of them I have been taking for several years (students may then ask about each one – answer based on the information in the table)

• [Note: do not offer that the digoxin and Tylenol #3 have only been used for 5 months since the time of an elective surgery or that the ginkgo is relatively new unless the students ask very directed questions about them.]

If asked if you have recently started any new medication, say:

• I have been taking the Valium only for a couple of weeks

If asked about OTCs or if you take any medications not prescribed by your doctor, say:

• I take Benadryl [DO NOT say anything about the multivitamin or ginkgo unless students ask specifically about vitamins or herbals)

If asked about vitamins, say:

• I take a multivitamin

If asked about herbals/alternative/complimentary medication, say:

• I take ginkgo biloba – it’s supposed to help me with my brain

If asked if all of your doctors know about the other medications (shared, OTC, herbal and vitamin), say:

• They never asked about anything except what the doctor’s gave me

If asked if your medications make you feel better, say:

• They seem to be helping – I can’t always tell.

If asked if any of your medications make you feel worse or have side effects, you can say:

• My legs started swelling up after I began taking the Procardia (After this, a dermatologist, Dr. Sharma, started the Lasix because you mentioned the swelling during an appointment. This resulted in therapeutic duplication with the patient being on 2 diuretics)

• Also, if I don’t take the ibuprofen with food, it really does a number on my stomach

[NOTE: regarding the timing of new medications and the onset of symptoms, the blurred vision started about two years ago after the Furosemide was prescribed, and the fatigue started after the patient was started on Digoxin. Provide this information when specifically asked]

If asked about your dizziness, you can say:

• I occasionally feel a little dizzy, especially if I get up too quick in the morning. This has been going on for a few years.

If asked about problems with sleep, you can say:

• Sometimes I feel a bit drowsy but I don’t know if it’s the medicines I take or just not getting enough sleep. I have to get up to go to the bathroom and then can’t always get a good night sleep.

• [NOTE: the patient is using the OTC Benadryl for sleep and has a “hangover” effect because of the longer half-life in older adults . There are many other issues that could be interfering with sleep in this patient including the diuretics but do not make the scenario too complicated for students]

IN THE PHYSICAL DOMAIN (Including functional)

If asked if you have any difficulty reading your medicine bottles [or your written directions for taking the medication], say:

• My eyes are getting really bad and I have to hold the bottles really close or use a magnifying lens to read them

Did you have any problems hearing or understanding the instructions when these medicines were prescribed?

• I think I heard it all right. The doctor did not say all that much.

Do you have any problems opening medication bottles?

• Sometimes the arthritis in my hands flares up. When that happens I take an ibuprofen and wait a little while. Sometimes I ask my neighbor to open the bottles and I just leave the tops on loosely for a couple of days until my hands feel good again.

IN THE PSYCHOLOGICAL DOMAIN

If asked if you have any problems remembering to take your medicines or ever forget to take your medications, say

• Sometimes, I loose track of time [If asked what you do then, say you take the pills as soon as you remember

If asked how you keep track of your medications or if you have a method to help you remember when to take you medications (e.g., a pill box), say:

• I just keep the bottles on the kitchen table so I am reminded every time I walk in there.

IN THE SOCIAL AND ECONOMIC DOMAINS

If asked how you get your medications, who helps you get them, and if you ever have trouble getting your medications, say:

• My son drives me to the pharmacy, but a few weeks ago I had to wait more than a week to get the refill on one of my meds because he was out of town

• [You can intimate that your son is unreliable; you don’t like some of his friends or activities. You need his help so you have to compromise (e.g., you are refilling the Tylenol #3 only to keep your son happy and helpful. He takes if for “back pain”).]

If asked, if anyone helps you put out your medications or helps you remember to take your medications, say:

• No, I take care of it myself.

If asked how you pay for your medications or if you have any difficulty paying for your medications, say:

• I am on Medicare but this new drug plan is really confusing and I still end up spending a lot on co-payments. [See note on Procardia XL below]

If asked specifically if you cannot afford to pay for a medication or do not get your prescription refilled because of the cost, say:

• I got a couple of medications for my blood pressure so, if I am really tight for money, I don’t get the Procardia XL; it costs the most.

Session Outline

Breakout rooms of 4-6 students with a facilitator who will be the patient

Review the patient information

Task 1 (15 min):

• Take a medication history so at the end of the interview you understand your patient’s use of medicines. Use this time to ask the patient questions.  

Task 2 (10 min):

• As a group, review the medication concerns and formulate recommendations to improve your patient’s use of medications. Designate a note taker to record your concerns and recommendation in the chat box (Please consider all domains of function/self-care.)  

Task 3 (10 min):

• Using the information you documented in the chat box,” communicate your recommendations to your patient – Pat Parsec.

Case discussion and feedback

Patient Information

Information

Name: Pat Parsec (Male or Female)

Age: 75

Occupation: Retired elementary school teacher

Marital status: Widowed, spouse 6 years ago

Residence: Lives alone in a small cottage rented from a neighbor

Family: Son lives nearby and helps around the house

Income: Social security

Medical Insurance: Medicare

Medical illnesses: High blood pressure, Arthritis in my knees and hands

Other problems: Trouble falling asleep. Feeling tired. Occasional leg swelling. Mild dizziness. Slightly blurred vision.

Medication bottle labels (Dates listed are for an August 10, 2020 session)

| | |

|MVK Healthcare Clinic Dr. S. Baker |MVK Healthcare Clinic Dr. S. Baker |

|(305) 555-1234 |(305) 555-1234 |

|RX: ****** 7/1/20 |RX: ****** 7/1/20 |

|Pat Parsec |Pat Parsec |

| | |

|(Hydrochlorothiazide) |Ibuprofen 400 mg TAB Qty: 120 |

|HCTZ 25 mg TAB Qty: 30 | |

| |Take 1 tablet by mouth every 6 hrs as needed for pain |

|Take 1 tablet by mouth every morning | |

| |Refills: 3 Expires: 1-Jul-21 |

|Refills: 3 Expires: 1-Jul-21 | |

| | |

|MVK Healthcare Clinic Dr. B. Sharma |MVK Healthcare Clinic Dr. S. Baker |

|(305) 555-2789 |(305) 555-1234 |

|RX: ****** 7/1/20 |RX: ****** 7/1/20 |

|Pat Parsec |Pat Parsec |

| | |

|Furosemide 10 mg TAB Qty: 60 |Digoxin 0.125 mg TAB Qty: 30 |

| | |

|Take 1 tablet by mouth every 6 hrs |Take 1 tablet by mouth every morning |

| | |

|Refills: 2 Expires: 1-Jul-21 |Refills: 6 Expires: 1-Jul-21 |

| | |

|MVK Healthcare Clinic Dr. S. Baker |MVK Healthcare Clinic Dr. J. Levitts |

|(305) 555-1234 |(305) 555-8903 |

|RX: ****** 7/1/19 |RX: ****** 2/15/20 |

|Pat Parsec |Pat Parsec |

| | |

|(Nifedipine extended release) |(Acetaminophen 300 mg with Codeine 30 mg) |

|Procardia XL 90 mg TAB Qty: 30 |Tylenol #3 TAB Qty: 90 |

| | |

|Take 1 tablet by mouth every morning |Take 1 tablet by mouth every 8 hrs as needed for pain |

| | |

|Refills: 1 Expires: 1-Jul-20 |Refills: 3 Expires: 15-Feb-21 |

|MVK Healthcare Clinic Dr. S. Baker | |

|(305) 555-1234 | |

|RX: ****** 5/7/20 | |

|Pat Squire | |

| | |

|(Diazepam) | |

|Valium 5 mg TAB Qty: 60 | |

| | |

|Take 1 tablet by mouth every 12 hrs as needed for stress | |

| | |

|Refills: 0 Expires: 7-May-21 | |

Facilitator’s Checklist: Medication Use

|During the Patient Interviewing (Task 1) and Group Discussion (Task| |During the Patient Counseling Session (Task 3) the Students |

|2) the Students Elicited or Discovered: | |Recommended: |

| |The patients’ understanding of their prescription | |Talk to your doctor/ pharmacist to make sure you understand | |

| |medications (indications/dosing) | |indications and dosing for all medications | |

| |The patient is taking an OTC | |Inform all doctors of all OTC, vitamins and/or herbal | |

| | | |medications | |

| |The patient is taking a multivitamin | | | |

| |The patient is taking an herbal | | | |

| |Different doctors prescribed meds | |Inform your primary care doctor of all prescribed | |

| | | |medications you take; bring all medications to the office | |

| | | |for review | |

| | | |Make a complete list of medications to take to all | |

| | | |physicians you see | |

| |A medication is expired | |Discard any expired medication and get an up-to-date | |

| | | |prescription | |

| |A medication has no indication | |Ask your doctor if this medication is needed | |

| |The patient is taking a medication prescribed for someone | |Do not take someone else’s medication – it is not safe | |

| |else | | | |

| |Someone else uses one of the patient’s medications | |Do not allow someone else to use your medication – it is not| |

| | | |safe | |

| |The patient is taking several medications for one condition | |Talk to your doctor about possibly reducing the number of | |

| | | |medications | |

| |Medication side effects | |Talk to your doctor/ pharmacist/ office nurse about your | |

| | | |side effects | |

| |Medication schedule/dosing regimen is complicated | |Talk to your doctor about simplifying the dosing schedule | |

| |The patient’s adherence problems | |Take your medication as prescribed | |

| |If the patient has a way to organize their medications | |Use a pillbox/ calendar to keep track | |

| | | |Ask someone to fill a pillbox | |

| |How the patient gets their refills | |Use mail delivery; ask for help from neighbors; ask for a | |

| | | |90-day supply | |

| |The patient has difficulty paying for one of their | |Talk to your doctor/ pharmacist about replacing Procardia XL| |

| |medications | |with a generic | |

| |The patient occasionally has difficulty opening their pill | |Ask the pharmacist for regular caps | |

| |bottles | | | |

| |The patient has difficulty seeing the labels | |Ask the pharmacist for large-print labels | |

| | | | | |

|Other issues identified | |Other recommendations made |

| | | | | |

| | | | | |

Appendix A: Obtaining a Medication History: Student Study Guide

Developed by Michael J. Mintzer MD and Maria H. van Zuilen, PhD

Objectives

Students will be able to:

1. Take a medication history to gather information regarding the:

– Patients’ understanding of all their medications (indications, dosing and side effects)

– Problems and factors influencing adherence

2. Outline a plan to the patient with steps that can be taken to reduce medication problems and obstacles to adherence

Background

• The elderly are the highest users of prescription medication. Although they represent about 15% of the population they account for 35% of prescribed medications.

• The safe use of medication is an important issue in medical care. Adverse drug events (falls, fractures, delirium, etc.) cause 17% of hospital admissions in the elderly – 88% of them are preventable!

• Intoxication by medication is the #1 cause of delirium in the elderly.

• 40-50% of over-the-counter (OTC) drugs are used by the elderly.

Medication History: Getting Started

Often the medication history is obtained as one component of the complete history. The completeness of the information obtained allows the physician to anticipate and link medications to illnesses and issues already described by the patient. There are times when history-taking is abbreviated. For example, there are many occasions when an illness does not present a diagnostic challenge (e.g., a fractured wrist suffered during a softball game at the family reunion, a URI, an earache). In such cases detailed history-taking is not needed but it is important to develop the habit of asking the patient for a summary of the current illnesses when obtaining a medication history.

I. Look At the Bottles

• Examine the medication bottles! Look for:

– Patient’s name (not someone else’s name!)

– Drug name, dose, directions, and number of refills

– Prescribing doctor(s)

– Dates: dispensed and expired

– Number of pills remaining (an estimate of adherence)

– “Co-mingled” pills (potential safety hazard)

• This information provides a quick overview of patient illnesses, physicians, possible duplicate medications, borrowing, adherence and complexity of medication schedule.

II. General Questions and Strategies

General questions are designed to give you a quick overview of the patient’s use and tolerance of medications past and present. The following questions (or variations thereof) will help to identify important information about medication use problems.

1. ARE YOU ALLERGIC TO ANY MEDICATION?

2. HAVE ANY MEDICINES EVER CAUSED YOU ANY PROBLEMS?

Ask about allergies or “bad reactions” (i.e., side effects) to any medications and record the response in the medical record. Allergies include itching, rashes, wheezing, etc., whereas “bad reactions” are often common side effects such as headaches, dizziness, nausea, etc. Patients often DO NOT distinguish between allergies and side effects.

These are important questions because they raise issues of adherence and adverse events.

• If there is an allergy or side effect, it is often the reason for non-adherence. Patients stop the medication but may not tell you … unless you ask (e.g., codeine causing constipation, cortisone causing weight gain).

• Some patients experience an allergy or side effect but continue the medication because it is “good for them” (e.g., antibiotic causing diarrhea). They can develop more serious adverse events (antibiotic induced colitis).

• A patient may NOT associate a specific side-effect with a medication (e.g. diuretics causing weakness from hypokalemia). It is the physician’s job to make the link!

III. Specific Questions

When the physician begins to ask about current medication use, it is wise to use open-ended questions such as:

3. ARE YOU TAKING ANY MEDICINES?

This question gathers information on all medications prescribed and not prescribed from all sources. Ask about all medicines:

a. Prescribed by the primary doctor

b. Prescribed by all “other” doctors

c. Obtained over-the-counter (OTC) including vitamins and herbal remedies

d. “Borrowed and traded”

4. WHAT DO YOU TAKE AND WHAT IS IT FOR?

This question gathers information on ALL the types (pills, creams, patches, etc.) of medications and why the medications are needed.

a. The patient should be able to describe the reason for each medication – what disease or process is it treating (e.g., heart, blood pressure, diabetes, cholesterol, prevent blood clots, etc.)

b. If there is no indication for a medication, it should be stopped

5. “HOW” MUCH DO YOU TAKE?

This question gathers information on the number of times and doses a medication is taken (used) daily.

6. “HOW LONG” HAVE YOU BEEN TAKING IT?

This question gathers information on how many days, weeks, months or years a patient has been using a medication.

a. NOTE: If new symptoms (side effects) have occurred within the past 90 days, any new medication or dose adjustments should be considered strongly as the possible cause.

7. “HOW HELPFUL” IS IT?

The patient should be able to give some assessment of the effectiveness of each medication, even if it is a qualitative statement such as “I think it makes me feel better.” Patients are often able to describe a specifically recognizable benefit (e.g., breathing better, heart not racing, blood sugar is down, redness is going away, etc.)

IV. Geriatric Factors and Factors Beyond the Physical Domain

Elderly patients often have problems that affect the ease and reliability of medication use (visual and hearing impairments, arthritis). In addition, they often have problems or issues beyond the physical such as psychological (depression, anxiety, memory loss) and/or socioeconomic (changing family relationships, fixed income) problems. These problems can affect adherence and safe use of medication. Specific questions can be used to survey potential problems in these domains.

V. Physical Domain: Function And Limitations

8. DO YOU HAVE ANY DIFFICULTY:

• READING (SEEING) THE PRINT ON YOUR MEDICINE BOTTLES [OR YOUR WRITTEN DIRECTIONS FOR TAKING THE MEDICATION]?

• WITH VERBAL INSTRUCTIONS (HEARING) YOU GOT WHEN THE MEDICINES WERE PRESCRIBED?

• OPENING MEDICATION BOTTLES?

9. WOULD IT BE BENEFICIAL IF SOMEONE HELPED YOU WITH YOUR MEDICINES?

10. WOULD IT BE BENEFICIAL IF YOU USED A PILL BOX OR WRITTEN SCHEDULE TO HELP YOU ORGANIZE YOUR DAILY MEDICATION DOSES?

VI. Psychological Domain (Addresses Mood, Memory, Anxiety)

11. DO YOU HAVE ANY PROBLEMS:

• REMEMBERING TO TAKE YOUR MEDICINES?

• WITH TAKING YOUR MEDICINES LATER THAN USUAL BECAUSE YOU FORGET TO TAKE THEM ON TIME?

• OR CONFUSION ABOUT HOW OR HOW OFTEN TO TAKE YOUR MEDICINE?

12. DOES TAKING ANY OF YOUR MEDICINES MAKE YOU FEEL ANXIOUS OR SAD?

VII. Social and Economic Domains

13. DO YOU HAVE ANY DIFFICULTY:

• BUYING YOUR MEDICATION?

• GETTING OR REFILLING YOUR PRESCRIPTIONS?

14. DO YOU USE ANYONE ELSE’S PRESCRIBED MEDICATION?

15. DOES ANYONE ELSE USE YOUR PRESCRIBED MEDICATION?

VIII. Strategies and Recommendations

1. Address allergies and side effects

– Report all problems that may (or may not) be associated with medication use to the physician

2. Simplify the dosing schedule (physician’s instructions)

– Consider coordinating the dosing schedule (e.g., try to eliminate concurrent BID, TID, and QID dosing)

– (see Economic problems below)

3. Simplify the process of taking medications (patient’s organization)

– Functional aids (pillbox can be filled weekly, often by a family member or friend)

– Memory aids (calendar or schedule, pillbox)

4. Economic problems

– Consider cheaper medications with equal therapeutic effectiveness, change brand name drugs to generic, reduce dosing if possible, medications combined in a single pill, referring patients to lower cost pharmacies or reputable mail order refill services and government subsidized plans for the elderly (Medicare part D, State funded programs)

5. Special needs and support

– Large print labels (and instructions)

– Easy-open caps on bottles

– Pill box / organizer

– Assistance from family or friend(s)

– Transportation to pharmacy / prescriptions mailed to patient

6. List ALL Medications

– The patient should have an up-to-date list of ALL (prescriptions, OTCs, vitamins and herbals) their medications available to their primary physician and all the other providers

– Once the complete list of medications is known and recorded in the medical record, it becomes a very easy task to review the medication list on each visit and ask about new medications

7. Safety

– Discontinue medications that are not indicated

– Do not use expired medicines

– “Neither a borrower nor a lender be

– Call your doctor with any questions or concerns about medication

8. Involve other disciplines

– Other professionals can solve problems (e.g., pharmacist: drug info and education; social worker: cost and access problems)

Summary

• A complete and accurate medication history requires a deliberate, systematic, structured interviewing process

• Factors in multiple domains affect the proper use of medication and adherence

• Professionals from other disciplines (pharmacy, social service, nursing) often provide important medication information to patients

• In order to provide the best recommendations for adjusting a medication regiment, your medication history must be accurate and complete

15 Questions* To Ask After You Discover the Current Active Illnesses

1. ARE YOU ALLERGIC TO ANY MEDICATION?

2. HAVE ANY MEDICINES EVER CAUSED YOU ANY PROBLEMS?

3. ARE YOU TAKING ANY MEDICINES?

4. WHAT DO YOU TAKE AND WHAT IS IT FOR?

5. “HOW” MUCH DO YOU TAKE?

6. “HOW HELPFUL” IS IT?

7. “HOW LONG” HAVE YOU BEEN TAKING IT?

8. DO YOU HAVE ANY DIFFICULTY:

• READING (SEEING) THE PRINT ON YOUR MEDICINE BOTTLES [OR YOUR WRITTEN DIRECTIONS FOR TAKING THE MEDICATION]?

• WITH VERBAL INSTRUCTIONS (HEARING) YOU GOT WHEN THE MEDICINES WERE PRESCRIBED?

• OPENING MEDICATION BOTTLES?

9. WOULD IT BE BENEFICIAL IF SOMEONE HELPED YOU WITH YOUR MEDICINES?

10. WOULD IT BE BENEFICIAL IF YOU USED A PILL BOX OR WRITTEN SCHEDULE TO HELP YOU ORGANIZE YOUR DAILY MEDICATION DOSES?

11. DO YOU HAVE ANY PROBLEMS:

• REMEMBERING TO TAKE YOUR MEDICINES?

• TAKING YOUR MEDICINES LATER THAN USUAL BECAUSE YOU FORGET TO TAKE THEM ON TIME?

• OR CONFUSION ABOUT HOW OR HOW OFTEN TO TAKE YOUR MEDICINE?

12. DOES TAKING ANY OF YOUR MEDICINES MAKE YOU FEEL ANXIOUS OR SAD?

13. DO YOU HAVE ANY DIFFICULTY:

• BUYING YOUR MEDICATION?

• GETTING OR REFILLING YOUR PRESCRIPTIONS?

14. DO YOU USE ANYONE ELSE’S PRESCRIBED MEDICATION?

15. DOES ANYONE ELSE USE YOUR PRESCRIBED MEDICATION?

*Variations of these questions to obtain the same information are also acceptable

Appendix B: PowerPoint Slides for Session Facilitators

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Table 1. Student Evaluations of the Medication History Session

|Evaluation questions (1= strongly disagree, 5 = strongly agree) |N=174 |

|Please indicate the degree to which you agree with the following statements: |

|The objectives of the session were clearly defined |4.6 |

|The session was overall well planned and organized |4.7 |

|Each student was provided an opportunity to actively participate |4.7 |

|Please indicate the degree to which you agree that the learning objectives of this session were met: | |

|Demonstrate interviewing and information gathering techniques to identify: |4.7 |

|(a) patient understanding of their medications | |

|(b) factors influencing patient adherence | |

|Outline a plan to the patient with steps that can be taken to reduce medication problems and obstacles to adherence |4.8 |

|Please rate your facilitator on the following: | |

|Demonstrated medical knowledge/skill |4.9 |

|Made the session interesting and comfortable |4.9 |

|Explained concepts clearly |4.9 |

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Medication Use

Psychological

Socioeconomic

Physical

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