Bedside Medication Education with Pharmacy Students

 

As a student, I remember back to the first time I visited a patient in a hospital room to go over their discharge medications with them. I was doing my cardiac care unit rotation during my last year of pharmacy school and one of the preceptors let me know that a patient was being discharged in 20 minutes. I was asked to go pick up their meds in the pharmacy and take them up to the patient. Also, I was informed that I needed to pick up a weekly pill box and show the patient how to fill the medications in the container so he would remember to take his meds.

We had little instruction in this process so I did as best as I could. I recall I was a bit clumsy with the bottles and our discharge instruction conversation was mostly about what was already written on the prescription labels. This was a military teaching hospital so the patients were already use to young doctors, nurses and pharmacists coming and going from their room with a constant flow of inquiries, tests, information and education.

Thirty five years later, just the other day, I had the opportunity to visit with a group of 4 pharmacy students who were preparing to visit patients in their rooms for medication education and counseling prior to discharge. I practice in the outpatient pharmacy of a local community hospital in northern California. We are not specifically a teaching hospital; however, every hospital allows for some teaching.  Over the past 4 or 5 years I have had the opportunity to help develop, implement and participate in an evolving process of bedside education and transitions of care.

The plan was to help the students learn some tools they may implement when entering patients rooms so their conversation may be helpful and productive. This made me think back to when I first entered a patient's room, without any guidance other than the encouragement to hurry up and get there before the patient left for home. Like I said, I did the best I could; however, had I known then what I know now I feel as if it would have made a world of difference. With that thought in mind, I addressed this group of 4 pharmacy students with the hopes our talk may help them feel ready to enter a patients room and be equipped with the tools to deliver an educated discharge medication counseling session.

First we discussed why a hospital would want to take valuable pharmacist time to have them step into a patient's room to talk with them about their medication therapy for 20 minutes. Yes, pharmacists are medication educators and have an excellent understanding of medication therapy; however, what value will this bring to the hospital. 

In my opinion, there are 2 value based goals of having a pharmacist visit a patient prior to discharge to discuss medication therapy.

1. Patient satisfaction: Patients who are provided one-on-one medication education are more likely to feel they were treated with respect and dignity. With this, they will also be much more likely to provide positive ratings on discharge satisfaction surveys. Positive results on discharge surveys directly lead to positive hospital ratings and reimbursement.
2. Decreased readmission: Patients who understand their therapy are more likely to have increased positive outcomes and are less likely to be readmitted to the hospital. This includes patient, family and caregiver adherence counseling, medication education, teach-back, home medication management and many other potential education opportunities. Decreased patient readmissions save hospital dollars.

Next, we talked about what happens during the first half of our visit with the patient:

1. We enter the room, introduce our self, and let them know we are here to have a discussion with them about their medications. We want to help the patient understand their pharmacist is an important resource for them in their medication management.
2. As we address the patient we are actively assessing the situation. What level of understanding does this patient have and will we be talking with the patient, family member or a caregiver.
3. Next, ask the patient if they would please explain why they are here in the hospital. Do they have a reasonable understanding of their current diagnosis as well as any other current diagnosis'? During this time, it is important to be keeping notes about which medications they discuss so we may come back to them in the second half of the conversation where we review their medication list.
4. Have the patient describe how they manage their medications at home. What pharmacy do they use, how do they pay for their meds, how do they get them home from the pharmacy, do they use a pill box at home, and how do they remember to take them? During this session we need to sit up and pay attention. Specifically, what barrier to adherence are we able to identify during this part of the conversation?
• Patient related (health literacy, disability, family issues, moral issues, financial issues, forgetfulness)
• Medication related (side effects, cost, medication understanding, dosing regimen, perceived value)
• Provider related (language barrier, poor communication, cultural differences, transportation)
5. What specific adherence tools may benefit this specific patient:
• Virtual or Actual pill box
• Smart phone adherence apps
• Med card for wallet
• Family member participation
• Bubble packing or strip packing of medications
• Medication synchronization

During the second half of our visit we discuss their current medication therapy.

1. Review their current list of medications with them, checking to see what is new and what they have already been on at home. From our first 10 minutes of talking with the patient we have a relatively clear idea of how much information the patient, family or caregiver can work with. We need to gear our discussion about the medications specifically to the level of understanding of our audience.
2. Initially, pick 1 or 2 topics to cover, not an overwhelming amount of information. What are the 2 most important items to cover today?
3. Be open to adjusting the consult as necessary, directing the education toward the resolution of the important items on your agenda.
4. Be aware of the patient, acknowledge them regularly without letting them redirect the conversation to topics that, although interesting, may not be directly related to what we are talking about today.
5. Keep an eye open for any major medication dosing concerns, duplicate, un-necessary or missing therapy or critical drug interactions. Any important medication concerns need to be followed up directly with the prescriber immediately after the education session is complete.
6. Focus on the discharge medications, assuring the patient understands what each medication is for, what it is treating, and importantly what will happen if they don't take their medication.

When complete, remember to thank the patient for the opportunity to sit and discuss their medications with them. If any concerns are noted during the conversation, assure them we will be following up with their practitioner right away. Give them an opportunity to ask any last minute questions, and remind them to please contact their pharmacist, doctor or nurse if they have any more concerns or questions about their medications.

Please add the tools you use for bedside teaching in the comments below.

Steve