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

2. Study Purpose  To improve medication adherence in patients with limited health literacy.  To assess economic impact of increased refill adherence and decreased use of health care services.  To measure secondary outcomes (pt self- reported adherence, med understanding)  Uses a systems approach

3. Study Phases Phase 1: Assessment of the pharmacy Phase 2: Implementation of a 3 “P” intervention Phase 3: Outcome evaluation of intervention

4. Phase 1: The Assessment A health literacy assessment can help your pharmacy to meet the needs of your limited-literacy patients by: Raising staff awareness Detecting barriers to effectively using your services Identifying opportunities for improvement

5. What Does a Pharmacy Health Literacy Assessment Involve?  This assessment tool includes 3 parts: Part 1: Pharmacy assessment tour Part 2: Pharmacy staff survey Part 3: Patient focus groups  This tool was adapted from Literacy Alberta’s Health Literacy Audit Kit 3 3. Literacy-Alberta. The Literacy Audit Kit. Calgary: Literacy Alberta; 1997.

6. Before Conducting a Health Literacy Assessment  Obtain staff support  Consider demographic information about the staff and patient populations  Consider adding or deleting assessment items

7. Part 1: Assessment Tour  Objective assessors identify existing barriers in these areas: Promotion of Services Print Materials Clear Verbal Communication  Will take 20-30 minutes to complete  Should be completed during both busy and less busy times in the pharmacy

8. Part 1: Assessment Tour Who Should Conduct the Assessment?  Assessment will be conducted by trained, objective assessors who are: Familiar with the principles of clear health communication Not pharmacy staff or patients Able to blend in with patients who use the pharmacy  At least 2 per pharmacy  Should be trained together

10. Part 1: Assessment Tour Conducting the Assessment  Full guide available at: http://www.ahrq.gov/qual/pharmlit/ http://www.ahrq.gov/qual/pharmlit/

11. Part 2: Survey of Pharmacy Staff  Staff members help create the environment within the pharmacy and have a unique perspective  Evaluates staff opinions of pharmacy’s sensitivity to the needs of limited-literacy patients in three areas: Print Materials Clear Verbal Communication Sensitivity to Literacy  Will take about 20 minutes to complete

12. Who Should Complete the Pharmacy Staff Survey?  Small staff: all staff members can complete the survey  Large staff: select a representative, random sample  Emphasize importance of completing the survey thoroughly!

13. Part 3: Pharmacy Patient Focus Groups  Ask pharmacy patients about their personal experiences in 4 areas: Physical Environment Care Process and Workforce Paperwork and Written Communication Culture  Conduct 2 focus groups of 10-12 patients, 2 hours each

14. Part 3: Who Should Participate in the Focus Groups?  Recruit patients directly from pharmacy  Patients should use the pharmacy regularly and manage their own medications

15. Why is it Important to Use a 3-Part Assessment Tool?  Mixed method approach more comprehensive than a single method approach Limitations resulting from the use of only one method often produce bias 4, 5  Pharmacists underreport counseling events when self-reporting compared to counseling events documented by observers 6,7  Pharmacy patient recall bias decreases reporting of specific counseling activities 4. De Young M. A Review of the Research on Pharmacists' Patient-Communication Views and Practices. Am.J. Pharm. Educ. 1996;60:60-77. 5. Laurier C, Poston J. Perceived levels of counseling among Canadian pharmacists. J Soc. Admin. Pharm. 1992;9:104-113. 6. Kirking DM. Pharmacists' perceptions of their patient counseling activities. Contemp Pharm Pract. 1982;5(4):230-238. 7. Raisch D. Patient counseling in community pharmacy and its relationship with prescription payment methods and practice settings. Ann Pharmacother. 1993;27:1173-1179.

16. Results from an Assessment of a Public Hospital Pharmacy  Assessment conducted in February - March 2006  Used as a baseline measure before implementing a health literacy intervention in the pharmacy

17. Results from an Assessment of a Public Hospital Pharmacy Patient Counseling: What the Pharmacists Said 65.5% of pharmacists felt confident in their ability to counsel patients with numerous questions 55.2% felt that they could effectively counsel patients when time was limited

18. Results from an Assessment of a Public Hospital Pharmacy Patient Counseling: What the Patients Said “I try not to ask any questions unless it’s absolutely necessary…I get the feeling that they already overworked and whatever and they really don’t feel like answering questions.” “[Counseling time] is enough because I already should know something about [my medicines] and that pamphlet can tell me a lot more than he can tell me.”

19. Results from an Assessment of a Public Hospital Pharmacy Print Materials: What the Pharmacists Said 57.1% indicated that prescription bottle labels and warning labels are easy for their limited- literacy patients to understand 42.9% agreed that prescription informational inserts are easy for adults with limited literacy skills to understand

20. Results from an Assessment of a Public Hospital Pharmacy Print Materials: What the Patients Said Rely heavily on printed materials for information about their medicines:  “I love those [informational inserts].” Find the print on these materials difficult to read:  “Little type, little print across there [the bottle label]. You can barely, hardly read it.”

21. Results from an Assessment of a Public Hospital Pharmacy Print Materials: What the Assessors Said  All agreed that the pharmacy could make improvements in providing clearly written information inserts  None felt that the information inserts were easy to understand  All agreed that the pharmacy could make improvements in providing clearly written bottle labels

23. Hospital Signage

25. Results from an Assessment of a Public Hospital Pharmacy  As results show, people in different roles (staff, patients, outside observers) have different perspectives.

26. We’ve Assessed, Now What? Launch the Intervention 3 “P” Approach  Reminder Phone calls  Pharmacist Training  Picture Prescription

27. Participants:  1600 adult, English-speaking patients who get their medication filled at Grady Hospital  Participants must have received regular pharmacy services at Grady for a minimum of 6 months

28. Telephone Reminder System Integrated into the existing refill call line Calls 5-8 days before a script is due for refill

29. Pharmacist Training All Grady pharmacists received training in clear health communication When patients pick up their prescriptions, they should be counseled on their medications by pharmacists trained to communicate with limited- literacy patients

30. PILL Pharmacist Training  Explain things clearly in plain language  Focus on key messages and repeat  Use a “teach back” or “show me” technique to check understanding  Effectively solicit questions  Use patient-friendly educational materials to enhance interaction

31. Using Plain Language: What could we say instead of…  Adverse reaction  Hypoglycemia  Ophthalmic use only  PRN  Suppository  Topical  Side effect Low sugar Put in your eyes When you need it Pill that goes in your bottom/behind On skin

32. PictureRx When study patients pick up their prescriptions, they will receive a pill card. The card will provide:  list of all of the patients’ medications  pictures of the pills  information on what the medication is for  graphic instructions on how/when to take it.

33. PictureRx  Based on research and practice at Grady  Further developed for Grady and PILL study  Automated solution to facilitate counseling  Displays patient’s regimen in picture form  Explains regimen, also reminds patient  Easy to understand, take-home aid  Punch-out wallet card Disclosure: Dr. Kripalani is a consultant to and holds equity in PictureRx, LLC. He is entitled to revenues from future product sales. He will not receive any compensation from Grady or Emory through the PILL study.

36. Perceived Value of an Illustrated Medication Schedule Helped patients remember… Kripalani et al, Prev Med 2004

37. Phase 3: Outcome Measures Through one-on-one interviews, the study assessed participants’:  Understanding of their medications  Medication adherence as measured through refill compliance  Confidence in their ability to correctly take their medicines  Health status, social support, and health literacy  Level of satisfaction with pharmacy services received during the study

38. What Resources Can Help Make a Pharmacy More Literacy-Friendly? AHRQ Tools  Strategies To Improve Communication Between Pharmacy Staff and Patients: Training Program for Pharmacy Staff Introduce pharmacists to the problem of low health literacy in patient populations Identify the implications of this problem for the delivery of health care services Explain techniques that pharmacy staff members can use to improve communication with patients who may have limited health literacy skills http://www.ahrq.gov/qual/pharmlit/pharmtrain.htm

39. What Resources Can Help Make a Pharmacy More Literacy-Friendly? AHRQ Tools  How to Create a Pill Card Guide to help users create an easy-to-use "pill card" for patients, parents, or anyone who has a hard time keeping track of their medicines Step-by-step instructions, sample clip art, and suggestions for design and use will help to customize a reminder card http://www.ahrq.gov/qual/pillcard/pillcard.htm

40. What Resources Can Help Make a Pharmacy More Literacy-Friendly?  Automated Telephone Reminders: A Tool to Help Refill Medicines On Time Easy-to-understand telephone script Automated refill reminder calls to patients remind them to refill their prescriptions Calls also allow patients to order the refill on the phone http://www.ahrq.gov/qual/callscript.htm

41. Your Action Steps How can you use these tools in your organization?