The PILL Study

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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
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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

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Study Phases

• Phase 1
• Assessment of the pharmacy
• Phase 2
• Implementation of a 3 P intervention
• Phase 3
• Outcome evaluation of intervention

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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

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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 Albertas
  Health Literacy Audit Kit3

3. Literacy-Alberta. The Literacy Audit Kit.
Calgary Literacy Alberta 1997.
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Before Conducting a Health Literacy Assessment

• Obtain staff support
• Consider demographic information about the staff
  and patient populations
• Consider adding or deleting assessment items

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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

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Part 1 Assessment TourWho 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

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Part 1 Assessment TourConducting the Assessment

• Full guide available at http//www.ahrq.gov/qual/
  pharmlit/

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Part 2 Survey of Pharmacy Staff

• Staff members help create the environment within
  the pharmacy and have a unique perspective
• Evaluates staff opinions of pharmacys
  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

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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!

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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

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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

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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 bias4, 5
• Pharmacists underreport counseling events when
  self-reporting compared to counseling events
  documented by observers6,7
• 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. 19966060-77. 5.
Laurier C, Poston J. Perceived levels of
counseling among Canadian pharmacists. J Soc .
Admin. Pharm. 19929104-113. 6. Kirking DM.
Pharmacists' perceptions of their patient
counseling activities. Contemp Pharm Pract.
19825(4)230-238. 7. Raisch D. Patient
counseling in community pharmacy and its
relationship with prescription payment methods
and practice settings. Ann Pharmacother.
1993271173-1179.
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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

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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

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Results from an Assessment of a Public Hospital
Pharmacy

• Patient Counseling What the Patients Said
• I try not to ask any questions unless its
  absolutely necessaryI get the feeling that they
  already overworked and whatever and they really
  dont 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.

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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

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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.

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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

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Hospital Signage
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Results from an Assessment of a Public Hospital
Pharmacy

• As results show, people in different roles
  (staff, patients, outside observers) have
  different perspectives.

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Weve Assessed, Now What?

• Launch the Intervention
• 3 P Approach
• Reminder Phone calls
• Pharmacist Training
• Picture Prescription

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Participants

• 1600 adult, English-speaking patients who get
  their medication filled at Grady Hospital
• Participants must have received regular pharmacy
  services atGrady for a minimum of6 months

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Telephone Reminder System

• Integrated into the existing refill call line
• Calls 5-8 days before a script is due for refill

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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

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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

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Using Plain LanguageWhat could we say instead
of

• Adverse reaction
• Hypoglycemia
• Ophthalmic use only
• PRN
• Suppository
• Topical

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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.

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PictureRx

• Based on research and practice at Grady
• Further developed for Grady and PILL study
• Automated solution to facilitate counseling
• Displays patients 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.
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Perceived Value of anIllustrated Medication
Schedule
Helped patients remember
Kripalani et al, Prev Med 2004
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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

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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

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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
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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

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Your Action Steps

• How can you
• use these tools
• in your organization?