[CASE HERE] - POGOe



[pic]

* FACILITATOR’S GUIDE *

The Medication History

A Small Group Session on

Interviewing a Patient Regarding

Medication Use

Authors

Michael J. Mintzer, MD

Maria H. van Zuilen, PhD

Marie A. Cordero, PharmD

Robert M. Kaiser, MD

Geriatrics Institute

University of Miami Miller School of Medicine

Developed with support from the Donald W. Reynolds Foundation

January 2008

Session Overview

This is a 45-60 minute small group session designed for 4-8 medical students. The facilitator will simulate the role of a patient and bring to the session a “brown bag” with medications. The students will be required 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 with the students.

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. Paper bag for medications

2. 8 bottles of medication labeled according to the script. Bottles can be filled with jelly beans or other candies (NOTE: labels are included below. Dates will need to be modified to coincide with the scheduled instructional activity)

3. Instructions to the student to be read by the facilitator

4. Mr. Parsec’s completed information sheet

5. Blank paper for students to record information gained through history

6. Medication recommendation worksheet

7. A watch for keeping track of time

Advance Preparation

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

Your Role as the Simulated MALE Patient

You are a simulated patient (Mr. 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 “Mr. Parsec.” 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 the student asks, “What medications do your take,” you will NOT give a list of all your medicines, instead you will hand them a bag of all the medicines you brought with you. Also, if students ask 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 unless the student asks about each separately.

Instructions to be read to the group of students

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

[Continuing reading the following Task 1 instructions:]

This small group activity will assess your readiness to take a medication history. You have learned the medication interviewing process in a previous instructional activity. Now you can apply your learning and receive feedback.

I will be playing the role of Mr. Pat Parsec, a man who is coming to your medication review station at the health fair. 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.”

Mr. Parsec has been asked to complete an information sheet ahead of time. Please review this information [each student gets a copy of the “Patient Information Summary Sheet”]. One of you will ask questions for about 1-2 minutes; then the next student will ask questions for about 1-2 minutes and so on 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 sheet, 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.]

[START TIMING: 15 MINUTES]

[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. Please use the “Medication Recommendation Worksheet” provided and choose a note-taker to record the recommendations.

Any questions? Please begin.

[START TIMING: 10 MINUTES]

[Before Task 3, read the following:]

You now have 10 minutes to communicate you recommendations to “me.” Take turns giving recommendations.

Any questions? Please begin.

[START TIMING: 10 MINUTES]

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

Feedback session discussion points

• Use the patient information sheet as you guide to feedback

• 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.

• 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 Darvocet.

• There were medical, social and economic issues that could directly affect adherence: side effects, his dependency on his son to pick up his medications, and medication cost. Several medications are causing side effects. His son is also inappropriately using his Darvocet.

• Try not to get into what recommendations they made yet – that will come a little later

Physical domain

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

Psychological domain

• Did the students ask if he had problem remembering to take his medications?

• Did the students ask how he kept track of his mediation doses?

Social and Economic

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

• Did the students ask if he needed any help with his medications?

• Did the students ask if he had any problems buying his 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, 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.

• Ask students to complete the session evaluation form

Simulated Patient Information and Script

The following table gives you a list of Mr. 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 bottles and specific questions during the interview. Your medication bag contains: 1) medications prescribed by your primary care physician, Dr. Baker (one is expired); 2) medications prescribed by others physicians (Dr. Sharma and Dr. Levitts); and 3) a medication that was prescribed for a neighbor (Pat Squire). The bag 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 |

| |duplication with | | | |

| |furosemide | | | |

|Furosemide 20 mg bid prn |prescribed by a |I take it when my legs are swollen|Most of the time, I take two a day|Two years |

| |different MD | | | |

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

| | | | | |

| |Causes leg swelling | | | |

|Terazosin 2mg hs | |This one is for my prostate and my|Mostly at night, but sometimes in |Five years |

| | |blood pressure |the morning | |

|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 |

| | |for | |started before my hernia |

| | | | |operation) |

|Darvocet q6h prn |Prescribed by a |That was for the pain. I used it |I haven’t taken it since I started|5 months ago (It was |

| |different MD |when the Tylenol didn’t work |the ibuprofen; my son takes it |started after my hernia |

| | | |when his back hurts |operation) |

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

|prn) |bottle |better |almost out | |

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

| |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.

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?”

• Hand over the bag and say something general (e.g., “Here’re 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 (see images below).

[pic][pic]

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

• Pretty much. Sometimes I fall asleep at night in my chair so I don’t take my “prostate medicine” until the next morning.

• [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. Mr. Parsec has found this to be a very expensive medicine. He sometimes takes it every-other-day to “stretch” it. Also, on months when money is tight, he 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 Darvocet have only been used for 5 months since the time of an elective surgery, and 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 them.]

If asked about vitamins, say:

• I take a multivitamin

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

• I take ginkgo biloba

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 they prescribed

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

• They seem to be helping

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

NOTE: DO NOT offer all of these answers at once. The students should be asking you about side effects for each medicine or asking, “Are any other medicines causing side effects.”

• My legs started swelling up after I began taking the Procardia XL

• [NOTE: the dermatologist, Dr. Sharma, started the Lasix because Mr. Parsec mentioned the swelling during an appointment. Dr. Baker DID NOT prescribe the Lasix. There is a potential danger from this therapeutic duplication of a patient using 2 diuretics simultaneously]

AND

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

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

• [NOTE: he is using the OTC Benadryl for sleep and has a “hangover” effect because of the longer half-life in the elderly. There are many other issues that could be interfering with sleep in this man 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

Did you have any problems hearing or understanding the instructions when this [these] medicine[s] was 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 like when you take the terazosin in the morning after you forgot it the night before.]

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 the one for my prostate 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 Darvocet only to keep your son happy and helpful. He takes if for “back pain”).]

If asked, if anyone helps you put out his 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; I just get the one for my prostate because my doctor said it would also help with the blood pressure.

Medication labels

Note: Dr. Baker is the primary care provider; Dr. Levitts is the general surgery who did the hernia operation; and Dr. Sharma is a dermatologist who does annual skin examinations. Also, the dates on the bottles must be completed to be believable within the small group scheduled time period.

NOTE: The dates on the prescription labels below are appropriate for a small group taking place in late October, 2007.

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

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

|RX: ****** 10/1/07 |RX: ****** 10/1/07 |

|Pat Parsec |Pat Parsec |

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

| | |

|HCTZ 25 mg TAB Qty: 30 |Ibuprofen 400 mg TAB Qty: 120 |

| | |

|Refills: 3 Expires: 1-Oct-08 |Refills: 3 Expires: 1-Oct-08 |

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

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

|RX: ****** 10/1/07 |RX: ****** 10/1/07 |

|Pat Parsec |Pat Parsec |

|Take 1 tablet by mouth before breakfast and supper |Take 1 tablet by mouth every morning |

| | |

|Furosemide 20 mg TAB Qty: 60 |Digoxin 0.125 mg TAB Qty: 30 |

| | |

|Refills: 2 Expires: 1-Oct-08 |Refills: 6 Expires: 1-Oct-08 |

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

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

|RX: ****** 10/1/06 |RX: ****** 8/15/07 |

|Pat Parsec |Pat Parsec |

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

| | |

|Procardia XL 90 mg TAB Qty: 30 |Darvocet N 100 mg TAB Qty: 90 |

| | |

|Refills: 3 Expires: 1-Oct-07 |Refills: 3 Expires: 1-Aug-08 |

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

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

|RX: ****** 10/1/07 |RX: ****** 8/1/07 |

|Pat Parsec |Pat Squire |

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

| | |

|Terazosin 2 mg TAB Qty: 30 |Valium 5 mg TAB Qty: 60 |

| | |

|Refills: 3 Expires: 1-Oct-08 |Refills: 0 Expires: 1-Aug-08 |

Patient Information Summary Sheet

You are a professional health care worker who has volunteered to participate in the AARP-sponsored community health fair. You have been assigned to the “Medication Review” station. People attending the health fair have been told they should bring their medicines with them and a “qualified professional” would review the medicines with them. The first person in your line is Mr. Pat Parsec. The following is the information that Mr. Parsec was asked to provide to help you during the medication review.

Information

Gender: Male

Age: 75

Occupation: Retired lawn maintenance worker

Marital status: Widowed, my wife died 6 years ago

Residence: I live alone in a small cottage I rent from my neighbor

Family: My son lives nearby and helps me keep the place up

Income: Social security

Medical Insurance: Medicare

Medical illnesses: High blood pressure

Arthritis in my knees and hands

Enlarged prostate

Other problems: I am having trouble falling asleep. When I do fall asleep, I wake up

3 or 4 times a night to go to the bathroom. I often feel tired all day.

Sometimes my legs swell up.

* * * REMEMBER * * *

You WILL NOT be ordering any changes to the medication regimen but you will be making recommendations that Mr. Parsec can take to Dr. Baker, his primary care physician. * * *

Task 1 (15 min):

Take a medication history so at the end of the interview you understand Mr. Parsec’s use of medicines. Use this time to ask him questions.

Task 2 (10 min):

As a group, review the medication regimen and formulate recommendations to improve Mr. Parsec’s use of medications. (Please consider all domains of function/self-care.)

Task 3 (No more than 10 min):

Using your “Recommendations Worksheet,” communicate your recommendations to Mr. Parsec.

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 his prescription medications | |Talk to your doctor/ pharmacist to make sure you understand | |

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

| |The patient is taking an OTC | |Inform your primary care doctor of all OTC, and/or 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 | |

| |Medications’ 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 his medications | |Use a pillbox/ calendar to keep track | |

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

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

| | | |90-day supply | |

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

| | | |with a generic | |

| |The patient occasionally has difficulty opening his 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 |

| | | | | |

| | | | | |

Medication Recommendation Worksheet

|Medication Issues |Recommendations |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download