Real World Health Care Blog

Tag Archives: medication adherence

With Great Health Comes Great Responsibility

Accountability. As children, we are taught that our actions have consequences and that we must be responsible for our own behaviors if we are to live as free and independent adults.

Linda Barlow

Linda Barlow

This simple life lesson has been shaping the healthcare landscape for some time now as hospitals, individual clinicians and other healthcare providers face increasing requirements to participate in Accountable Care Organizations and provide performance measures indicating accountability for patient outcomes—efforts that have successfully improved the quality of care for many. But what about the patients themselves?

“The greatest untapped resource in healthcare is the patient,” says Don Kemper, MPH, Founder and CEO of Healthwise, a non-profit organization with a mission to help people make better health decisions. “The time has come for people to ask more of themselves in managing their health.”

According to the authors of a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, patient participation and engagement are integral to the success of any treatment plan–a position echoed by the American Medical Association and the Institute of Medicine.

So how can we, as consumers of healthcare services, be more accountable for our own care? The authors of the ACC/AHA report suggest that “the general framework of shared accountability is predicated on partnerships between patients and clinicians, in which patients play an active role in setting goals, making treatment decisions and assessing outcomes. Ideally, patients would be aware of what to watch for, contact their clinicians when symptoms arise, learn about their condition and what they can do to improve their health, implement agreed-on treatment plans and lifestyle changes, and follow up with their clinicians to assess outcomes and adjust the treatment plan.”

“Developing a trusted relationship is key,” adds Nancy Carteron, M.D., HealthWell board member, rheumatologies, and autoimmune disease specialist at California Pacific Medical Center in San Francisco and Associate Clinical Professor at the University of California at San Francisco. “Patients need to feel heard, but from a physician’s standpoint, the limited time they have with patients can make that hard to accomplish, especially for complex illnesses. It may require the provider to restructure its practice. And if the patient does not feel their best interest is being served, they should try another provider or system.”

Healthwise’s Kemper suggests that patients focus on “patienthood”—the self-management behavior that ensures we either give to ourselves or get from others the care we need to best manage our health risks and medical problems.

“Each of us falls somewhere on the continuum of patienthood,” Kemper says. “The extremes can range from annual tooth brushing to self-surgery, but most of us fall well in the middle. And for most of us, it’s possible to do more for ourselves, especially with the right information, tools and expectations.”

“We should feel accountable for asking questions anytime we don’t understand our options, anytime we think something may not be right with our care, and anytime we have an idea for how we might contribute to the care,” Kemper adds. “And we should be accountable for adhering to any self-care plan we have agreed to follow—or to report why we have veered away from it.”

Are you someone who has started to take more personal accountability for your own care? Tell us what you’ve done to be a healthier, more involved patient. Are you a healthcare provider who has seen an improvement in patient outcomes when the patient is highly involved in his or her own care? Share your stories with us in the comments section.

Personal Connections with Pharmacists Drive Medication Adherence Outcomes

With nearly half of all patients in the US not taking their medications as prescribed, medication non-adherence remains a dangerous and expensive problem that costs the health care system $329 billion annually (Express Scripts Drug Trend Report), meaning more hospitalizations and visits to the emergency room (ER).

Paul DeMiglio

Paul DeMiglio

So what’s the good news? Effective, comprehensive solutions are emerging to reverse this trend by involving the pharmacist to improve medication adherence rates through a personal connection with patients.

Recent stories underscore how pharmacists are uniquely positioned to engage patients in conversations that help them understand why treatments are prescribed and why meds should be taken as directed.

A report released on June 25 by the National Community Pharmacists Association (NCPA), for example, illustrates how interpersonal relationships between pharmacists and patients boost adherence. Authors of the report found that a patient’s sense of connectedness with one’s pharmacist or pharmacy staff was the survey’s “single strongest individual predictor of medication adherence.”

“Pharmacists can help patients and caregivers overcome barriers to effectively and consistently follow medication regimens,” NCPA CEO B. Douglas Hoey, RPh, MBA, said in a statement. “Indeed, independent community pharmacists in particular may be well-suited to boost patient adherence given their close connection with patients and their caregivers.”

According to the American Pharmacists Association (APhA), one effective method pharmacists can use to improve adherence is medication therapy management (MTM) services for patients taking more than one drug for multiple chronic medical conditions. In addition to therapy reviews, pharmacotherapy consults, anticoagulation management, immunizations, health and wellness programs and other clinical services, MTM involves the following elements:

  • Comprehensive medication review, including a personal medication report that lists all the medications the patient is taking.
  • Medication action plan.
  • Education and counseling or other resources to enhance understanding about using the medication and to improve adherence.
  • Coordination of care, including documenting MTM services, providing the documentation to other providers, and referring patients to other providers as needed.

Pharmacists can also leverage a variety of practical tips to help patients improve adherence that include:

  • Discussing the appropriateness of each medication and its impact on their multiple medical conditions.
  • Evaluating the effectiveness and safety of each medication.
  • Assessing whether some medications may be unnecessary and should be discontinued.
  • Discussing the need to change medications or doses if problems arise.

The implications of improved adherence will help lower the cost of treating chronic conditions, decrease hospitalizations, reduce ER visits and by extension lower the risk of treatment failures, serious adverse reactions and deaths too.

“Studies have repeatedly recorded the cost-saving effect of MTM,” said Kevin Schweers, Senior Vice President, Public Affairs, NCPA. “One Minnesota study found a 12:1 return-on-investment for MTM.  In North Carolina, Kerr Drug reports that MTM programs for seniors produced a 13:1 return. Improved adherence would likely help reduce hospitalizations as well. So many prescription drugs are intended to treat chronic conditions, such as heart disease, that can result in hospitalization. In addition, hospital re-admissions can result from the failure to stick to a prescribed medication regimen.”

Joel Zive, adjunct clinical faculty, University of Florida College of Pharmacy, underscored the need for patients to cultivate relationships with their pharmacists.

“While MTM services are quite important in helping adherence, getting to know your pharmacist’s name is helpful in establishing a relationship with your pharmacist,” he said. “Pharmacists are trained to pick up clinical clues from patients.  This is why if you are having unusual reactions medications, speaking to your pharmacist is an option.”

Although MTM services are an effective way to increase adherence, greater participation among patients and pharmacists is needed according to the APhA and the National Council on Patient Information and Education (NCPIE).

In addition to leveraging tips and strategies to boost adherence, pharmacists can also draw on a number of resources for patients, referring them to the NCPIE wallet card and to a brochure made available by NCPIE and the Agency for Healthcare Research and Quality (AHRQ), “Your Medicine: Be Smart. Be Safe.”

What else can pharmacists do to engage patients? How can stakeholders in health care, government, academia and the private sector collaborate to improve dialogue among pharmacists and patients around strategies that increase adherence?

Striking the Right Balance for Better Patient Outcomes

A recent article in Health Affairs reports that ChenMed – which serves low-to-moderate income elderly patients primarily through the Medicare Advantage program – is achieving better health outcomes for Medicare-eligible seniors, including those living with five or more major and chronic health conditions.  Dozens of Chen and JenCare Neighborhood Medical Centers are helping tens of thousands of seniors live better, longer: 

chris_chen

Dr. Christopher Chen, ChenMed CEO

  • Total hospital days per 1,000 patients at ChenMed in 2011 were 1,058 for the Miami area in comparison with 1,712 total US hospital days per 1,000 patients in the same year (Centers for Medicare and Medicaid Services Office of the Actuary).
  • Just one year prior, according to Dartmouth Atlas of Health Care, the Miami Hospital Referral Region was above the 90th percentile in inpatient hospital days.

Why is ChenMed so successful?

Dr. Christopher Chen, CEO of the organization, says its patient care model integrates cutting-edge medical expertise in a way that empowers physicians to ensure patients receive personalized attention and optimal care.

“People always ask, ‘What is your secret?’ There really is no secret,” he says. “It comes down to having the right incentives, the right physician and staff culture, and the right philosophy of care. My goal at the end of the day is to be cost-effective through improvement of outcomes by changing the philosophy of care. We care about results.”

The group practice’s popularity also attests to its effective one-stop-shop approach to patient-centered care through multi-specialty services. Smaller physician panel sizes of 350-450 patients spur intensive health coaching and preventive care, and prescriptions are given to patients during their visits at all Chenand JenCare Neighborhood Medical Centers.

This aspect of ChenMed’s model makes the biggest difference in boosting medication adherence, followed by strong one-on-one doctor-patient relationships that help to change habits for the better. Receiving meds within 3-5 minutes of ordering drugs not only means patients don’t have to wait for the treatment they need, but that they receive their medications while having face-to-face interactions with their primary care doctors.

“In our model we aren’t looking for high-income patients,” Dr. Chen says. “People ask, ‘Are you saying that patients like you because you give more attention to them and provide more access to doctors than those who pay for concierge service?’ I would say yes.”

ChenMed continuously employs top specialists from a variety of fields to conveniently provide fully integrated medical services to patients.  It effectively combines services like acupuncture into its portfolio of care, and improves outcomes and patient experience with customized end-to-end technologies enhancing its daily operations. For example, all the medical assistants and staff are equipped with iPads and can offer physician support tailored to each patient. This fuels collaboration, enabling doctors to work side by side with patients and providing a significant convenience to all parties as a result.

Primary care physicians at Chen and JenCare Neighborhood Medical Centers also meet three times a week, engaging in thoughtful ongoing discussions that generate numerous enhancements to care and delivery for better outcomes.

“We discuss whether a hospitalization could be improved through better outpatient care. We ask, ‘What can we do to improve patient outcomes while the patient is in the hospital?’ We innovate to improve outcomes and can achieve great things for patients because of our small panel sizes. These meetings have saved many lives and continue to do so,” explains Dr. Chen.

When interviewing prospective doctors to work at ChenMed, they are asked whether they like spending time with patients and whether they love the complexity of medicine. If they say no to either of those questions, then this group is probably not the best place for them, Dr. Chen says, underscoring that:

“We want you to practice medicine the way you thought you would when you graduated from medical school. It’s not about how many patients you see, how many procedures you do, or how much you bill. You should want to be a doctor to make people feel better.” 

ChenMed, through its Primary Management Resources subsidiary, also provides behind-the-scenes consulting services to enhance medical practice operations nationwide.  Physicians interested in end-to-end solutions that streamline operations while enhancing patient health outcomes and the patient experience should contact ChenMed at (305) 628-6117 or go to ChenMed.com.

With a Little Help from My Friends, Family… And Apps

“Drugs don’t work in patients who don’t take them.” – C. Everett Koop, former Surgeon General

It was an idea born of near tragedy: an elderly, diabetic father who double-dosed on his insulin therapy and suffered a medical emergency. His two sons realized that if they were more involved in reviewing their father’s daily medication and insulin regimens, it could change his behavior for the better and help him get healthier.

MedicineCabinet (5)

Photos courtesy of NextGen Healthcare

So Omri and Rotem Shor co-founded the MediSafe Project, a free mobile app that makes it easier for families and friends to give the support needed to help their loved ones get healthier and integrate healthier behavior modification into their everyday lives. In the first four months after its launch, users reported medication adherence rates of 79 percent (82.25 percent for statins) – well above the 50 percent average medication adherence rate reported by the World Health Organization.

The MediSafe Project provides an easy-to-use interface – an interactive pillbox of sorts — over iOS and Android mobile phones. Users input information about their meds by typing their names or photographing their National Drug Code numbers. The system stores the correct pharmaceutical name, manufacturer and dosage, ensuring an error-free medication list in the event of a medical emergency. Users signify taking their meds by dragging pills from the virtual pillbox into a mouth icon, which “swallows” the pills.

Users receive alerts before medication courses are completed, allowing them to order refills in a timely manner. In addition to reminding users when it’s time to take their medication, the MediSafe Project sends alerts to selected family members, friends and caretakers when a loved one misses a dose. Users can also email a personalized list of adherence stats to their doctor, giving doctors better patient oversight between office visits. A prescription page feature lets doctors “prescribe” the MediSafe project to their patients to help better monitor medication adherence.

The impact of non-adherence on the outcomes of patients with cardiovascular diseases is one example that underscores why it is so critical to implement strategies and utilize technologies that improve medication adherence.

“Medication non-adherence is a problem that costs U.S. hospitals billions of dollars every year,” says Omri “Bob” Shor, CEO, MediSafe. “An American dies every nineteen minutes from skipping or taking medication incorrectly. Our goal is to help combat this problem and encourage healthy habits among users and their support systems with easy-to-use technology.”

The MediSafe Project isn’t the only app on the medication adherence scene. The free NextGen® MedicineCabinet app lets users create and update a list of medications, including dosing and schedule information, thus creating their own “personal” medication record.

Notifications are sent for each medication and users can confirm adherence. The app was designed, in part, to improve adherence and proper use of medication by enhancing patients’ understanding of how to correctly take their medication and to recognize adverse reactions. According to the company, it also equips health care professionals with all the relevant information they need, in a way they like to view it.

“Mobile patient engagement is at the forefront of today’s changing health care environment,” said Ike Ellison, executive vice president of business development for NextGen Healthcare, in a statement. “Providing consumer technology that encourages members to control and lead healthier lifestyles is a key factor in improving outcomes.”

Michael Paquin, vice president, business development for NextGen Healthcare, added “One of our users commented on the way that she was able to, for the first time, be able to share her medication lists easily with family, friends and all her physicians. It has saved this particular patient hours of time on a monthly basis.”

Technology-based solutions like the MediSafe Project and the NextGen Medicine Cabinet are among the latest patient-directed tools that improve medication adherence.

However, providers still play an important role in assisting patients in maintaining healthy behaviors like medication adherence. The American College of Preventive Medicine offers a SIMPLE approach on how providers can help their patients take their medications as prescribed.

Barriers to medication compliance abound, with memory issues, lack of support, and lack of education just being a few. What is behind these barriers? How can patient behaviors and motivations be changed?

MedicineCabinet2 (2)

Categories: Access to Care

New Drug Delivery Options that Help the Medicine Go Down

David Sheon

David Sheon

The water cooler talk for us at RWHC is frequently about improving treatment adherence (a patient’s ability and willingness to take his or her medicine consistently, as directed).  OK, so we don’t have the most exciting water cooler discussions.  But this happens to be important – for all of us because when patients stay on treatment, they get better faster.  This is almost universally true, regardless of the therapeutic category.

In some cases, improving adherence not only saves the life of the patient, but it can benefit an entire community.  In HIV, for example, taking antiretrovirals not only helps the patient to manage his or her viral load (the amount of HIV circulating in the blood), but it also lowers that patient’s ability to transmit the virus to someone else.

Sometimes, adherence can be improved by using a different delivery system.  This is the first post in a series on how drug delivery helps adherence.

Remember the first time you took a breath strip that dissolved on your tongue? The technology was invented in the 1970s, but only since July 2012 have pharmaceutical companies been able to win marketing approval to put a drug on the strip.  Two products have been cleared by the FDA.

Zuplenz (ondansetron) oral soluble film is an anti-nausea and vomiting product used by cancer patients who experience nausea and vomiting as a result of receiving chemotherapy and/or radiation as well as for the prevention of postoperative nausea and vomiting.

“We know from market research that patients who are nauseated don’t necessarily like swallowing pills or using suppositories and that sometimes taking pills with water contributes to their nausea,” said John V. Aiken, M. Ed., Vice President, Corporate Operations, Marketing, and Training, Praelia Pharmaceuticals, Inc.  “Since launching the product in December 2012, a number of doctors are telling us that their patients prefer the dissolving strip.”

The second drug now available on an oral dissolving strip is Suboxone (Buprenorphine and Naloxone), from Reckitt Benckiser Pharmaceuticals Inc.  For more information on this product, click here.

If the dosing is standardized and absorption is as good as more typical drug delivery methods, we see only an upside in terms of patient adherence to oral dissolving strips.  Please tell us what you think.  Also, if you know of a new drug delivery option that you’d like to see us cover, let us know!