Case scenario

You have been asked to complete a Home Medicines Review (HMR) with your regular patient, Asma. She is a 60-year-old female with a complex medicine regimen. Over the years, you have built a positive rapport with Asma and look forward to speaking with her. Recently, she has been diagnosed with type 2 diabetes (T2DM). You recently completed some reading on communication and the importance of shared decision-making and wish to put this into practice during your review.

After reading this article, pharmacists should be able to:

  • Discuss the importance of patient involvement in healthcare decision-making 
  • Describe strategies to manage communication challenges when conducting a medicines review
  • Discuss the concept of active listening
  • Describe tools and resources which can be used to aid in communication between pharmacists and patients during medicines reviews.

Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.2, 2.3, 2.4, 3.1, 3.5

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Introduction

Comprehensive medication management reviews aim to identify, resolve and prevent medicine-related problems, and optimise medicines safety in partnership with medical practitioners and patients. This process occurs in consultation with the patient, and in collaboration with a medical practitioner and other healthcare providers. In addition to pharmacists who offer reviews in the community setting, pharmacists embedded in general practice, residential aged care facilities (RACFs), disability services and Aboriginal Community Controlled Health Organisations (ACCHOs) may conduct comprehensive medication management reviews as part of their role.

Good communication skills, supported by evidence-based information, are essential for quality outcomes from collaborative medication reviews.

The PSA’s Guidelines for Comprehensive Medication Management Reviews highlight that communication with the patient is an important part of the service.1 When communicating with patients, pharmacists need to be sensitive to, and aware of, different perspectives, expectations, levels of understanding and cultural views.

HMR and Residential Medication Management Review (RMMR) services are ideal environments in which to discuss the patient’s health-related concerns, beliefs, attitudes and preferences about their medicines, health and wellness.

By establishing good patient communication, the pharmacist has an opportunity to build trust, enhance the patient’s satisfaction with the service, and achieve better health outcomes overall.

Patient-centred care and shared decision-making

Patient-centred care involves respectful and responsive consideration of patient preferences and individual circumstances. The central tenet of patient-centred care should be guided by the patient’s knowledge, experience, need and preferences, and not just driven by
clinical guidelines. The importance of involving the patient cannot be overestimated, as medicines optimisation is largely determined by patient goals and preferences.2

There is convincing evidence that patients who actively participate in their health management have better outcomes than passive patients.3 The benefits of shared decision-making include4:

  • increases patients’ knowledge
  • increases clinicians’ understanding of their patients’ needs
  • helps ensure patients have realistic expectations from their treatment options
  • stimulates patients to be more active in decision-making
  • helps patients clarify their preferences
  • increases overall patient engagement, autonomy and empowerment
  • creates a structured approach to reviewing options and outcomes
  • increases agreement between providers and patients
  • increases patients’ satisfaction with consultations.

Shared decision-making is particularly important in the context of deprescribing due to inherent uncertainties. Deprescribing should consider the patient’s care goals, current level of functioning, life expectancy, values and preferences.5

While every encounter with a patient will vary, the basic steps of shared decision-making involve6:

  1. defining the problem and identifying the decision to be made
  2. presenting options
  3. discussing the potential benefits and risks
  4. identifying patient values and preferences
  5. exploring patient ability
  6. presenting recommendations
  7. checking understanding
  8. making/deferring the decision and arranging for follow-up.

Utrecht’s Model for Patient Centred Communication in the Pharmacy (UMPA-model) emphasises 3 main elements7:

  1. building a therapeutic relationship with the patient
  2. defining the problem together with the patient
  3. agreeing to a shared decision on a medication management plan.

Initial establishment of a therapeutic relationship with the patient is essential for an effective patient-centred consultation.7 Trust is an important aspect of this therapeutic relationship.

The shared problem-defining process involves exploring and understanding the patient’s view through the following steps7:

  • Start the conversation – encourage the patient to be involved and to express their concerns and problems.
  • Explore the patient’s perspective – use active listening and summarising.
  • Consider the patient’s situation and share expert opinion.

The patient must be given time to process information and to ask questions.

For a patient to actively participate, pharmacists should check the patient’s information needs, give clear explanations, and encourage questions while keeping the individual’s comprehension in mind. The ‘teach-back’ method can be used to confirm the patient has understood the information exchanged.8 Effective use of the teach-back technique involves asking the patient to explain in their own words what they have been told. It helps to ensure understanding, identify misunderstandings and enhance patient engagement.8

Both therapeutic options and patient preferences need to be considered.7 Strategies that solely provide information and/or education may be effective in improving knowledge, but they appear to be ineffective in improving adherence or clinical outcomes.9 Finally, the patient and pharmacist should reach an agreement on any proposed changes to therapy, concordant with the patient’s values.7

Decision aids to help facilitate shared decision-making

Patient decision aids are commonly used to facilitate shared decision-making. Decision aids help to support patients when they need to consider the benefits and risks of treatment, as well as no treatment. These tools support patients in making evidence-informed choices, especially with ‘grey zone’ treatments that rely on the patient’s judgement of associated benefits and harms.10

Decision aids increase the patient’s knowledge on expected outcomes and improve risk perception accuracy while incorporating personal values. Using decision aids in a medication review consultation can lead to greater patient activation through shared
decision-making.10

A Cochrane review found that the use of patient decision aids leads to10:

  • greater knowledge
  • more accurate risk perceptions
  • informed, values-based choice
  • greater comfort with decisions
  • greater participation in decision-making
  • no increase in anxiety
  • improved patient–practitioner communication.

In the context of deprescribing, estimating treatment benefit-harm trade-offs can be enabled using prediction tools, evidence tables and decision aids that estimate absolute disease risk (carethatfits.org/tools), and absolute treatment benefit and harm for various conditions (gpevidence.org and pain-calculator.com). Practical guidance on how to safely taper and cease medicines in older people has recently been updated (primaryhealthtas.com.au/resources/deprescribing-resources).

Patient activation

Patient involvement is an essential aspect of health management. Understanding each patient’s readiness to take an active part in managing their health is important for the pharmacist to ascertain.

Patient activation is defined as patients’ preparedness to manage and participate in their own healthcare based on their knowledge, skills, confidence and motivation.11 Patients who are highly activated are more likely to adhere to medication regimens, seek health information, self-manage their chronic conditions and maintain a healthy lifestyle.9 People with higher activation levels report significantly better health outcomes and significantly lower GP and emergency department visits.12

Patient activation can be adversely influenced by symptoms of fatigue, anxiety, stress and cognitive impairment.13

There are 4 stages of patient activation14:

  1. believes active role is important
  2. confidence and knowledge to take action
  3. taking action
  4. staying the course under stress.

Careful discussion in a medication review consultation can identify the level of activation.15 The initial HMR consultation can start with establishing rapport, providing patient education and setting goals through the medication management plan. Follow-up visits can assess positive changes to adherence, response to therapy and progress to target goals (e.g. HbA1c, BP, weight loss).

The patient activation measure (PAM) is a tool that can be used to measure patient empowerment.16 The short version, containing 13 items, is a reliable and valid measure for different chronic conditions.11 PAM measures patient activation for self-management, including beliefs, knowledge, skills and confidence in managing their personal health or illness on a 5-point scale.17 PAM scores can provide insight into possible strategies for supporting activation along the continuum.18 For example, low scores may indicate the need to focus on self-awareness and improve knowledge about their conditions. Patients with higher scores may need to increase their self-efficacy and confidence to maintain positive behaviour change.

PAM can be used with patients across many common diseases, including diabetes, chronic kidney disease, atrial fibrillation, depression, rheumatoid arthritis and COPD.18

Active listening

Active listening is a way of listening and responding to the patient to improve mutual understanding. It is important to assess patient comprehension, willingness to manage their health, and to address any misconceptions.

Active listening together with empathy, compassion and caring lead to effective rapport with the patient. Letting the patient ‘tell their story’ at the start of the home consultation can build rapport. The ICE mnemonic can be used effectively to explore the patient’s ideas, concerns and expectations,6 together with simple open-ended questions. Listening for
5–10 minutes, allowing the patient to complete statements without interruption, and picking up on non-verbal cues, can identify information that can be further discussed throughout the interview.

Patients’ perceptions of being heard during an HMR consultation can lead to improved patient-reported outcomes.18 Patients value being heard without judgement and being given the opportunity to address their concerns and questions about their medicines in
the privacy of their home.17

Active listening techniques include19:

  • simple open-ended questions
  • listening and encouraging with verbal and non-verbal prompts
  • clarifying and summarising
  • empathetic responding
  • paraphrasing
  • reflective listening.

Other tools and resources

There are many tools and guides available to pharmacists and other healthcare professionals to help them structure or plan their communication with patients during medicine reviews. Some additional examples are included below.

UK ‘7 Steps’

The UK 7 Steps to Appropriate Polypharmacy clearly highlights communication as an integral component in medicines reviews and provides a 7-step guide for structuring these conversations.20

These 7 steps include20:

  1. establishing what matters to the patient
  2. identifying essential drug therapy
  3. establishing if the patient takes unnecessary drug therapy
  4. confirming that therapeutic objectives are being achieved
  5. checking if the patient is at risk of adverse drug reactions (ADRs) or is experiencing actual ADRs
  6. confirming if the drug therapy is cost-effective for the patient
  7. establishing if the patient is willing and able to take drug therapy as intended.

The guide includes practical advice and information within each step to ensure each of the above is achieved during a medicine review. The detailed guide can be found online (rightdecisions.scot.nhs.uk/polypharmacy-guidance/7-steps).

Medicines conversation guide – pharmacist toolkit

This is an Australian-based resource prepared for pharmacists, developed by clinicians and researchers from the University of Sydney. It is a practical tool to help aid communication and shared decision-making between pharmacists and older patients taking multiple medicines.

The toolkit consists of the Medicines Conversation Guide (the Guide), HMR summary table template, patient summary template and information about useful strategies for communication challenges. The Guide covers conversations about understanding of general health, preferences for medicines information, patient goals/priorities, views on important activities, patient concerns/fears and balancing benefits and harms. It can be found online (ses.library.usyd.edu.au).21

Navigating communication challenges

Numerous challenges can present during a medicines review, some of which may be related to the communication aspect. Table 1 discusses some examples of communication challenges and how they might be navigated by the pharmacist.

Other examples of general challenges that may affect communication include language, cultural or health literacy barriers. Strategies to help address some of these broader challenges may include22:

  • undertaking cultural competency training
  • use of translation services
  • modification of language to suit the patient
  • using teach-back methods to ensure understanding
  • use of pictograms to aid understanding of medicines.

Knowledge to practice

Communicating with patients about their experiences, needs and concerns regarding their health and medicines is essential to identify medication-related problems. Pharmacists must adapt their communication to a wide variety of patient needs to achieve patient- centred communication.

The success of a medication review is heavily influenced by the consultation skills and clinical acumen of the credentialed pharmacist. It is important to build trust and develop rapport with the patient from the outset. Pharmacists should seek to understand what matters to the patient and determine their level of understanding.

Conclusion

When conducting medication reviews, effective communication is crucial. Understanding a patient’s lived experience is an important principle of medication optimisation and shared decision-making. Communication strategies include using plain language, encouraging patients to ask questions, and actively listening to their concerns. Visual aids and decision tools can be used to enhance patient understanding and facilitate shared decision-making.

Case scenario continued

During the HMR, you make sure to employ active listening techniques to improve mutual understanding and explore Asma’s perspective on her recent diagnosis, other health conditions and current medicines. Given Asma’s recent diabetes diagnosis, she completes the PAM and achieves a high score, showing an increased level of patient activation.  You ask her about her perceptions and preferences on how her conditions are being managed. She explains that in times of stress, she can become overwhelmed with the dosing frequency of her medication throughout the day and would like to reduce this. You work together to reach an agreement for any proposed changes to the regimen (including deprescribing of unnecessary drug therapy and optimising timing of others) to help achieve this. 

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Key points

  • Good communication skills during medicines reviews are essential for positive health outcomes.
  • Active listening is a valuable communication skill for encouraging patients to tell their story.
  • Several resources are available to pharmacists to help aid communication with patients.

References 

  1. Pharmaceutical society of Australia. Guidelines for comprehensive medication management reviews. 2020. At: www.ppaonline.com.au/wp-content/uploads/2020/04/PSA-Guidelines-for-Comprehensive-Medication-Management-Reviews.pdf
  2. Weir K, Nickel B, Naganathan V, et al. Decision-making preferences and deprescribing: perspectives of older adults and companions about their medicines. J Gerontol B Psychol Sci Soc Sci 2018;73:e98–e107.
  3. Coulter A, Collins A. Making shared decision-making a reality: no decision about me, without me. 2011. At: https://assets.kingsfund.org.uk/f/256914/x/73b4098901/making_shared_decisions_making_reality_july_2011.pdf
  4. Hoffman TC, Legare F, Simmons MB, et al. Shared decision making: what do clinicians need to know and why should they bother. Med J Aust 2014;1:35–9.
  5. Scott IA, Hilmer SN, Reeve E, et al. Reducing Inappropriate polypharmacy: the process of deprescribing JAMA Intern Med 2015;175(5):827–34.
  6. Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns 2006;60(3):301–12.
  7. Wolters M, van Hulten R, Blom L, et al. Exploring the concept of patient centred communication for the pharmacy practice. Int J Clin Pharm 2017;39:1145–1156.
  8. Yen P, Leasure A. Use and effectiveness of the teach-back method in patient education and health outcomes. Fed Pract 2019;36:284–9.
  9. Ryan RE, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2014, Issue 4.
  10. Stacey D, Legare F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Systematic Reviews 2017, Issue 4.
  11. Hibbard JH, Greene J, Shi Y, et al. Taking the long view: how well do patient activation scores predict outcomes four years later? Med Care Res Rev 2015;72(3):324–37.
  12. John JR, Tannous WK, Jones A. Outcomes of a 12-month patient-centred medical home model in improving patient activation and self-management behaviours among primary care patients presenting with chronic diseases in Sydney, Australia: a before-and-after study. BMC Family Practice 2020;21(158).
  13. Newland P, Lorenz R, Oliver BJ. Patient activation in adults with chronic conditions: A systematic review. J Health Psychol 2021;26(1):103–14.
  14. Hibbard JH, Mahoney ER, Stockard J, et al. Development and testing of a short form of the patient activation measure. Health Serv Res 2005;40(6 pt 1):1918–30.
  15. Prochaska JO, DiClemente CC. Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change. J Consult Clin Psychol 1983;51:390-5.
  16. Hibbard JH, Stockard J, Mahoney ER, et al. Development of the ppatient activation measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res 2004;39(4 pt 1):1005–26.
  17. White L, Klinner C, Carter S. Consumer perspectives of the Australian Home Medicines Review Program: benefits and barriers. Res Social Admin Pharm 2012;8(1):4–16.
  18. Carter SR, Moles R, White L, et al. The impact of patients’ perceptions of the listening skills of the pharmacist on their willingness to re-use home medicines reviews: a structural equation model. Res Social Admin Pharm 2015;11:163–75.
  19. Robertson K. Active listening: More than just paying attention. Am Fam Physician 2005;34(12):1053–5.
  20. Healthcare Improvement Scotland. 7-Steps. 2024. At: https://rightdecisions.scot.nhs.uk/polypharmacy-guidance/7-steps/
  21. Weir K, Jansen J, Bonner C, et al. Medicines conversations guide. 2018. At: https://ses.library.usyd.edu.au/bitstream/handle/2123/18330/Pharmacist%20Toolkit%20-%20The%20Guide%20-%20102019.pdf
  22. Filmer T, Ray R, Glass B. Barriers and facilitators experienced by migrants and refugees when accessing pharmaceutical care: A scoping review. Res Social Adm Pharm 2023;19(7):977–88.

Our author

Debbie Rigby BPharm, GradDipClinPharm, AdvPracPharm, AdvDipNutrPharm, AACPA, FASCP, FPS, FACP, FAICD, FSHP, FANZCAP is an Advanced Practice Pharmacist
with postgraduate qualifications in clinical pharmacy, geriatrics and respiratory medicine. Her special interests include geriatrics, deprescribing, drug interactions, respiratory disease, communication and health behaviour change, and medicines information.

Our reviewer

Hana Numan (she/her) BPharm (NZ), PGDipClinPharm (NZ), MPS (NZ)

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