Pharmacy Intervention for Limited Literacy PILL Kara L. Jacobson, MPH, CHES Julie A. Gazmararian, PhD, MPH Sunil Kripalani, MD, MSc Karen J. McMorris, BA Sarah Blake, MA

To improve medication adherence in pharmacy patients with limited health literacy To use a systems-level approach to improving patient adherence Purpose of HL Tools

Phases of the Study Phase 1: Health literacy assessment of the pharmacy environment Phase 2: Implementation of a 3 “P” intervention Phase 3: Outcome evaluation of intervention

Study Phase 1: Assessment Evaluated the extent to which the existing pharmacy environment accommodated patients with limited health literacy Included 3 parts: Part 1: Pharmacy assessment tour Part 2: Pharmacy staff survey Part 3: Patient focus groups Adapted from Literacy Alberta’s Health Literacy Audit Kit Literacy-Alberta. The Literacy Audit Kit. Calgary: Literacy Alberta; 1997.

Part 1: Assessment Tour Objective assessors identified existing barriers in these areas: Promotion of Services Print Materials Clear Verbal Communication Assessment conducted by trained, objective assessors who were: Familiar with the principles of clear health communication Not pharmacy staff or patients Able to blend in with patients who use the pharmacy

Part 2: Survey of Pharmacy Staff Evaluated staff opinions of pharmacy’s sensitivity to the needs of limited-literacy patients in three areas: Print Materials Clear Verbal Communication Sensitivity to Literacy

Part 3: Pharmacy Patient Focus Groups Pharmacy patients discussed their personal experiences in 4 areas: Physical Environment Care Process and Workforce Paperwork and Written Communication Culture

Interested in Conducting a Health Literacy Assessment? Assessment guide developed during the PILL study is available at

Study Phase 2: Intervention PILL Study intervention involved a “3-P” approach: 1. Pharmacist training in clear health communication 2. Picture Rx (or “pill cards”) 3. Automated reminder phone calls

Intervention Part 1: Pharmacist Training Training kit includes: PowerPoint slide set Handouts for use Hands-on practice activities Available at:

Intervention Part 2: Pill Card Patients called this their “pill card” Created automatically through a software program Personalized for each patient New card was created each time the patient picked up meds

Pill Card Name: Sarah Smith Date Created: 12/15/07 Pharmacy phone number: NameUsed ForInstructionsMorningAfternoonEveningNight Simvastatin 20mg Cholesterol Take 1 pill at night Furosemide 20mg FluidTake 2 pills in the morning and 2 pills in the evening Insulin 70/30 Diabetes (Sugar) Inject 24 units before breakfast and 12 units before dinner 24 units12 units

Interested in Creating a Pill Card? To learn how to create a pill card using a word processor, please view the guide created during the PILL study at: pillcard.htm pillcard.htm

Intervention Part 3: Automated Reminder Phone Calls Calls were placed through an automated system using a script written for a low-literate audience The reminder system was linked to the existing medication refill system to allow patients to refill their prescriptions right away

Interested in Using Automated Reminder Phone Calls with a Low- Literate Population? To view the phone call script developed during the PILL study, please visit:

Phase 3: Outcome Evaluation Patients felt that the card presented their medicines and dosing schedules in a way that was accessible to them: “You know what, my pill card made me excited about knowing about my medicines, it excited me because I didn’t understand my medicines. I took it because the doctor told me to take it but I am proud of the pill card... I love my pill card. That’s the only reason… because I’m excited about the pill card.”