Addressing low health literacy with "Talking Pill Bottles": A pilot study in a community pharmacy setting.

OBJECTIVES: To test the effect of "Talking Pill Bottles" on medication self-efficacy, knowledge, adherence, and blood pressure readings among hypertensive patients with low health literacy and to assess patients' acceptance of this innovation. DESIGN: Longitudinal nonblinded randomized trial with standard treatment and intervention arms. SETTING AND PARTICIPANTS: Two community pharmacies serving an ethnically diverse population in the Pacific Northwest. Participants were consented patients with antihypertension prescriptions who screened positive for low health literacy based on the Test of Functional Health Literacy Short Form. Participants in the intervention arm received antihypertensive medications and recordings of pharmacists' counseling in Talking Pill Bottles at baseline. Control arm participants received antihypertensive medications and usual care instructions. MAIN OUTCOME MEASURES: Comparison and score changes between baseline and day 90 for medication knowledge test, Self-Efficacy for Appropriate Medication Use Scale (SEAMS), Morisky Medication Adherence Scale (MMAS-8), blood pressure, and responses to semistructured exit interviews and Technology Acceptance Model surveys. RESULTS: Of 871 patients screened for health literacy, 134 eligible participants were enrolled in the trial. The sample was elderly, ethnically diverse, of low income, and experienced regarding hypertension and medication history. In both arms, we found high baseline scores in medication knowledge test, SEAMS, and MMAS-8 and minimal changes in these measures over the 90-day study period. Blood pressure decreased significantly in the intervention arm. Acceptability scores for the Talking Pill Bottle technology were high. CONCLUSION: Our results suggest that providing audio-assisted medication instructions in Talking Pill Bottles positively affected blood pressure control and was well accepted by patients with low health literacy. Further research involving newly diagnosed patients is needed to mitigate possible ceiling effects that we observed in an experienced population.

Redesigning pictographs for patients with low health literacy and establishing preliminary steps for delivery via smart phones.

BACKGROUND: Pictographs (or pictograms) have been widely utilized to convey medication related messages and to address nonadherence among patients with low health literacy. Yet, patients do not always interpret the intended messages on commonly used pictographs correctly and there are questions how they may be delivered on mobile devices. OBJECTIVE: Our objectives are to refine a set of pictographs to use as medication reminders and to establish preliminary steps for delivery via smart phones. METHODS: Card sorting was used to identify existing pictographs that focus group members found "not easy" to understand. Participants then explored improvements to these pictographs while iterations were sketched in real-time by a graphic artist. Feedback was also solicited on how selected pictographs might be delivered via smart phones in a sequential reminder message. The study was conducted at a community learning center that provides literacy services to underserved populations in Seattle, WA. Participants aged 18 years and older who met the criteria for low health literacy using S-TOFHLA were recruited. RESULTS: Among the 45 participants screened for health literacy, 29 were eligible and consented to participate. Across four focus group sessions, participants examined 91 commonly used pictographs, 20 of these were ultimately refined to improve comprehensibility using participatory design approaches. All participants in the fifth focus group owned and used cell phones and provided feedback on preferred sequencing of pictographs to represent medication messages. CONCLUSION: Low literacy adults found a substantial number of common medication label pictographs difficult to understand. Participative design processes helped generate new pictographs, as well as feedback on the sequencing of messages on cell phones, that may be evaluated in future research.

Redesigning pictographs for patients with low health literacy and establishing preliminary steps for delivery via smart phones

Background: Pictographs (or pictograms) have been widely utilized to convey medication related messages and to address nonadherence among patients with low health literacy. Yet, patients do not always interpret the intended messages on commonly used pictographs correctly and there are questions how they may be delivered on mobile devices. Objective: Our objectives are to refine a set of pictographs to use as medication reminders and to establish preliminary steps for delivery via smart phones. Methods: Card sorting was used to identify existing pictographs that focus group members found «not easy» to understand. Participants then explored improvements to these pictographs while iterations were sketched in real-time by a graphic artist. Feedback was also solicited on how selected pictographs might be delivered via smart phones in a sequential reminder message. The study was conducted at a community learning center that provides literacy services to underserved populations in Seattle, WA. Participants aged 18 years and older who met the criteria for low health literacy using S-TOFHLA were recruited. Results: Among the 45 participants screened for health literacy, 29 were eligible and consented to participate. Across four focus group sessions, participants examined 91 commonly used pictographs, 20 of these were ultimately refined to improve comprehensibility using participatory design approaches. All participants in the fifth focus group owned and used cell phones and provided feedback on preferred sequencing of pictographs to represent medication messages. Conclusion: Low literacy adults found a substantial number of common medication label pictographs difficult to understand. Participative design processes helped generate new pictographs, as well as feedback on the sequencing of messages on cell (AU)

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Silos to systems: three models for developing geriatric interprofessional education.

OBJECTIVE: To describe three interprofessional education (IPE) programs in geriatrics and to encourage senior care pharmacists' innovation and participation in IPE teaching. DESIGN: Description of three geriatric IPE programs showing how pharmacy faculty along with colleagues in other health professions established, conducted, and evaluated their respective IPE programs. SETTING: Schools of pharmacy and their affiliated interprofessional geriatric clerkship sites. PROGRAM DESCRIPTION AND MAIN OUTCOME MEASUREMENTS: Reported are program histories, participating health professions, teaching objectives, program designs and operations, outcomes, funding sources, challenges and barriers encountered, and strategies to overcome problems. Learning activities to enable students to achieve competencies recommended by the Institute of Medicine and the Partnership for Health in Aging are described for each of the three IPE programs. RESULTS: All three programs provide learning activities that help students achieve core interprofessional competencies. The two programs in which students, with preceptor supervision, have provided direct patient care services have long histories, despite challenges and barriers. The third program has established curriculum plans that will be implemented upon resolution of challenges. CONCLUSION: Successful geriatric IPE programs can be established and conducted in various practice settings. Program sustainability requires participation and interaction of faculty, site preceptors, and students of multiple health professions; administrative and funding support of collaborating partners; and a curriculum that fosters teamwork, shared responsibilities, and joint decision-making while delivering patient-centered care. Senior care pharmacists need to be proactive partners in establishing and conducting IPE in geriatrics.

A pilot study to assess cognition and pillbox fill accuracy by community-dwelling older adults.

OBJECTIVE: To assess pillbox fill accuracy and cognition among community-dwelling older adults. DESIGN: A descriptive, cross-sectional study. SETTING: Retail pharmacy. PARTICIPANTS: Convenience sample of English-speaking adults older than 60 years of age without dementia, taking more than four medications, and naive to Mediset use. INTERVENTIONS: In face-to-face interviews, subjects provided demographic, medical, and medication information, completed the Mini-Cog and Medi-Cog (combination of Mini-Cog and medication-transfer screen [MTS]), and filled their own medications in a pillbox. Data were analyzed using descriptive statistics and stepwise regression analysis with correctly filled pill count (PC) as the dependent variable and the cognitive screens as independent variables. MAIN OUTCOME MEASURES: Accuracy of the Mini-Cog, MTS, and Medi-Cog in predicting PC. RESULTS: Among 50 subjects (58% female, mean age 76.4 years), only one subject failed to pass the Mini-Cog and two failed to reach the criterion level of correctly filled PC. The mean (standard deviation) Mini-Cog score for the sample was 4.38 (0.81), MTS score was 4.1 (1.31), Medi-Cog score was 8.48 (1.82), and the mean PC was 97% (8%). The Mini-Cog and MTS individually accounted for about 30% of the variance (P < 0.001); the Medi-Cog accounted for 44% of the variance (P < 0.001), indicating strongest PC prediction. CONCLUSION: Nearly all study participants filled pillboxes accurately. The Medi-Cog was the strongest predictor of pillbox fill accuracy. Future studies of medication self-management abilities among community-dwelling older adults should include representative samples of this population, comprehensive assessment of health status, cognitive screening, pillbox fill accuracy, and the utilization of medications in filled pillboxes.

Telepharmacy services in an urban community health clinic system.

OBJECTIVE: To describe telepharmacy-related services and outcome. SETTING: Suburban western Washington State during 2007 to 2008. PRACTICE DESCRIPTION: Five network clinics without in-house pharmacies are remotely connected to a central pharmacy to provide telepharmacy services. PRACTICE INNOVATION: Automated drug dispensing system (ADDS) units, webcams, and electronic medical charts were used to provide remote medication order processing/dispensing, patient counseling, refill authorizations, and medication assistance referral services. MAIN OUTCOME MEASURES: Patient demographics; numbers of dispensed medications, patient consultations, refill authorizations, and service referrals; pharmacist feedback; and workflow changes. RESULTS: At five network sites, 12,000 patients received 3,282 new prescriptions per month with webcam-enabled consultations, 589 monthly refill prescriptions, 2,800 pharmacist-provided refill authorizations, and 250 medication assistance referrals. Antibiotics were the most frequently dispensed medications. Pharmacists commented that webcam-enabled interviews provided better privacy and longer counseling duration. Six new staff members (one pharmacist and five pharmacy technicians) were added. Workspace and staff responsibilities were reassigned to facilitate medication prepackaging and ADDS prescription processing. CONCLUSION: Expanded application of telepharmacy technology can improve patient access to pharmaceutical care beyond remote medication dispensing to include point-of-care refill authorization and medication assistance referrals. Further research to explore patient-focused services and to assess economic, humanistic, and clinical outcomes of telepharmacy services is needed.

Assessing medication consultations, hypertension control, awareness, and treatment among elderly Asian community dwellers.

OBJECTIVE: To describe blood pressure (BP) and medication-related findings of a pharmacist-conducted hypertension (HTN) monitoring program. STUDY DESIGN: Retrospective post hoc analysis. SETTING: Community site. PATIENTS: Multiethnic, community-dwelling, Asian older adults. INTERVENTIONS: Medication consultation/BP records from 1998-2005 were reviewed. Participants' mean baseline BP readings were classified using guidelines from the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) and stratified into three groups: < or =70, 71-79, and > or =80 years of age. Medication consultations were grouped into: lifestyle/general medication review, adherence assessment, non-HTN medication consults, and specific consults, which included pharmacist-provided, medication-related recommendations. Participants with specific consults and subsequent self-reported changes in HTN therapy were identified. Their mean BP readings at six months, before and after the self-reported changes, were assessed for differences, using paired t-test, P < or =0.05 was significant. MAIN OUTCOME MEASURES: Baseline HTN treatment/awareness rates, age-stratified HTN control, number/types of HTN medications used, adherence problems, consultations provided, BP changes in participants who self-reported changes in medication therapy. RESULTS: Among 414 participants (averaged 74.2 +/- 8.5 years of age, 34.1% male), baseline HTN rate, awareness rate, and treatment rates were 51.9%, 37.9%, and 24.9%, respectively. Baseline BP worsened with increasing age. Overall, 258 participants received 651 consultations. The most prevalent non-adherent behavior reported was self-adjustment of medication dosing. Among 65 participants who received HTN medication-related advice, 52/65 (80%) reported changes in medication therapy and showed significant improvement in BP at six months before and after the self-report. CONCLUSION: HTN awareness/treatment rates were low in the entire population. HTN control was worst among the oldest individuals. Implementing initiation or adjustments in medication therapy can potentially improve BP control.

Establishing an on-site influenza vaccination service in an assisted-living facility.

OBJECTIVE: To describe the establishment, implementation, and economic outcomes of a pharmacist-conducted on-site influenza vaccination service in an assisted-living facility (ALF). DESIGN: Retrospective descriptive report. SETTING: 75-unit senior housing complex in the International District of Seattle, WA, during the 2004 flu season. PATIENTS: 58 indigent, multiethnic, older Asian adult patients, of whom 44 were ALF residents and 14 were adult day health (ADH)/independent-dwelling clients. INTERVENTION: Patient charts were reviewed for contraindications, vaccines were administered, and postvaccination satisfaction surveys were conducted. MAIN OUTCOME MEASURES: Number of residents vaccinated, satisfaction survey results, time spent by a pharmacist and an assistant and their salary rate, cost of vaccines, cost of supplies, and reimbursement data. Service outcomes included vaccination rate and resident satisfaction. A cost analysis reflects the economic outcome. RESULTS: In two 2-hour sessions, 58 ALF residents and ADH clients (age 83.5 +/- 7.7 years [range 65-98]) were vaccinated. The immunization rate in the population improved from 64% in the previous year to 83% with the on-site service. Both the clients and the facility staff rated the service highly. The pharmacist spent a total of 22 hours and the assistant 4 hours providing vaccination services. A net income of $13 per vaccination was realized after making adjustments for costs (vaccines, supplies, and salaries). CONCLUSION: An on-site pharmacist-conducted influenza vaccination service in the ALF setting expanded the scope and economic outcome of pharmacist-provided pharmaceutical services. Influenza vaccination rates were improved, and patients and staff were highly satisfied with the service.

A cross-sectional comparison of prevalent diagnoses and medication profiles for residents in an assisted living facility at two time periods.

OBJECTIVES: Describe the prevalence of diagnoses and prescribed medications in an assisted living facility for one month in 2001 and 2004. DESIGN: A descriptive, cross-sectional report. SETTING: An assisted living facility in Seattle, Washington. PARTICIPANTS: Assisted living facility residents. INTERVENTIONS: In March 2001 and January 2004, charts of all the assisted living facility residents were reviewed. Cross-sectional comparisons of demographics, total and average numbers of charted diagnoses, and prescribed medications were conducted. Prevalent diagnoses and medications used were identified. Among the residents present in both periods, longitudinal comparisons of treatment outcomes for hypertension (HTN) and diabetes mellitus (DM) were assessed. MAIN OUTCOME MEASURES: Changes in demographics, diagnoses, medications, and blood pressure and blood glucose readings. RESULTS: Charts of 52 (2001) and 54 (2004) residents were reviewed. HTN, DM, and gastrointestinal (GI) disease were the most prevalent diagnoses during both time periods, although the prescribed medications for these conditions were different in 2001 and 2004. The per-resident numbers of diagnoses and medications averaged 7.2 +/- 3.3 and 9.1 +/- 4.7, respectively, in 2004, compared with 5.1 +/- 1.9 and 6.4 +/- 3.6 in 2001. Among 11 residents who lived in the assisted living facility during both data-collection months, the per-resident averages were 5.2 +/- 2.2 diagnoses and 8 +/- 3.9 medications in 2001, compared with 7.9 +/- 2.9 and 11.1 +/- 5.1, respectively, in 2004. The average blood pressure readings among these residents improved in 2004 over those in 2001, though no improvement was seen in the average blood glucose readings. CONCLUSION: To address the changing needs of assisted living facility residents over time, active ongoing monitoring and assessment of residents' medication therapies by pharmacists are indicated.