Tips for Patient Discharge Counseling from the Hospital Setting; Improving Adherence
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Psychiatric pharmacists make a constant effort to improve patient’s psychiatric outcomes while minimizing the untoward side effects that can occur as a result of taking psychiatric medications. Once patients show an adequate response, and ultimately remission, of psychiatric symptoms, many may conclude that patients will continue improvement for the foreseeable future. Those who have experience with psychiatric pharmacotherapy know otherwise. Medication adherence is the ultimate long term goal in both the medical and psychiatric populations in order to maintain sustained illness remission; however, it is known that adherence rates are far below what is optimal.1 It has been estimated that approximately 50% of patients become non-adherent with medications within a short period of time.2 The reasons for this vary. Some of the reasons are economic, lack of insight into illness, misunderstanding of care goals, or even stigma of mental illness.3, 4, 5 Each of these can facilitate medication non-adherence, leading patients to discontinue medications, remain ill, or seek readmission to the acute hospital unit.
Pharmacists have provided patients with pharmaceutical care for years. Helping patients understand their medications’ role in their recovery from illness, while simultaneously educating them on possible side effects and the management of these effects, are some of the services that pharmacists frequently participate in.6 In recent years, the concept of medication therapy management has been introduced, expanding the traditional pharmacist roles with the addition of patient follow-up and ongoing care management.7 While medication provision and counseling encompass the primary care roles of the pharmacist, there are many facets of care that a psychiatric pharmacist must incorporate into patient interactions in order to afford the best opportunity for long-term treatment success and positive outcomes.
When counseling patients prior to discharge, medication adherence is paramount to positive outcomes. Yet there are both medication as well as non-medication related issues that should be articulated and emphasized with patients to improve overall patient care outcomes in the psychiatric populations. Performing these tasks at or prior to discharge can aid in transitioning the patient from a controlled hospital environment to success in the outpatient setting.
- Describe the incidence and relative severity of specific adverse effects of medications and suggest methods of management. Some of the drug information provided to patients by their pharmacy as a result of the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) may be overwhelming and confusing. Lists of possible adverse effects, while comprehensive, may intimidate patients and lead to possible non-adherence. Provide patients with a brief handout which reviews the most common side effects, management strategies, and the incidence of their occurrence. These effects can be further divided into two categories; one that requires immediate physician notification, and the other which should be discussed at the next visit. Providing perspective and clarity to the relative risks of side effects may calm patient apprehension regarding psychiatric medications and improve adherence.
- Emphasize the need for long term monitoring, including laboratory tests and psychiatric evaluation. Psychiatric symptomatology may wax and wane over time with the introduction of life or physiologic stressors. Accentuating the need for adherence to follow-up psychiatric and physical assessment on a scheduled basis is essential. This may seem elementary, but patients should be aware of their next appointment with their psychiatrist and have that information reiterated by the pharmacist at discharge. In addition to psychiatric assessment, the patient should be reminded that some of their medications require periodic laboratory testing to avoid adverse events or insure that serum drug levels are appropriate. Educating the patient on the periodic need for these tests gives an opportunity for pharmacists to allay patient apprehensions, disarming a potential reason for non-adherence.
- Counsel patients on any prescribed long-acting antipsychotic injections prior to discharge. Don’t forget about these! Patients may have prescriptions for oral medications upon hospital discharge, but forgetting about outpatient administration of long-acting injections may bring about serious consequences for the patient, leading to potential non-adherence and possible rehospitalization. Since the depot injection may have been administered during the acute hospital admission, the importance of attending the next scheduled injection needs to be discussed. Patients may or may not have an actual prescription for this type of medication when discharged. Pharmacists should investigate the administration date and location during hospital admission and proactively counsel the patient prior to discharge. Discussion on these medications should include the date and place of the next administration as well as management of the potential unique side effects of these drugs.
- Obtain necessary medication prior authorizations. Since insurance plans may require prior authorizations for coverage of certain medications, failure to obtain these may lead to delays in obtaining medications upon discharge. This can be discouraging for patients. While waiting for an inadvertently missed authorization, patients may leave their pharmacy, causing unnecessary delays in care or avoidable non-adherence. If these medications are identified during admission, and prior authorizations obtained, patients can receive their medications in a timely manner in the community. This avoidable adherence issue, if not addressed, may cause psychiatric decompensation and subsequent rehospitalization.
- Reiterate the importance of non-pharmacologic means of care following discharge. Mental illnesses such as major depressive disorder and anxiety disorders (including OCD and PTSD) respond well to various forms of talk therapies. Adherence to these forms of treatment should be discussed during patient counseling sessions. Combination therapy with medications and CBT or other psychotherapies provide for more rapid resolution of symptoms in depressive disorders and anxiety disorders.8,9,10 Other therapies such as Interpersonal and Social Rhythm Therapy (IPSRT) are helpful in mood disorders. Failure to discuss the integrative role of these treatments with medications may prevent patients from achieving optimal outcomes. Thus, adherence to appointments with psychologists, therapists, or counselors should be included in patient counseling, and these appointment dates should be added to the patient’s outpatient care plan.
- If possible, have an initial supply of medications filled for patients at discharge. Having an ambulatory pharmacy in or near the hospital can help to facilitate this. Develop a system where faxing of prescriptions to the pharmacy and delivery of initial supplies can be accomplished. Discharge counseling for patients with the presence of their filled prescriptions is well accepted by patients and provides the patient with a visual learning experience prior to discharge. Filling an initial supply of psychiatric medications for patients helps to alleviate the opportunity for non-adherence by failing to fill prescriptions after discharge. Patients can then be discharged with their medications, not just a prescription.
Findings suggest that the addition of these key points to medication discharge counseling, coupled with providing the patient with filled prescriptions for their psychiatric medications immediately at discharge can decrease 30 day rapid readmission between 35 and 50%.11
Employing these tips can help to prevent rapid readmission to the hospital, encourage medication adherence in the initial acute phase of treatment following hospitalization, and give patients the opportunity to be treated in a less intrusive outpatient setting. Not only can these improve patient quality of life, but they can increase hospital bed availability, leading to better stewardship of precious acute care resources.
- Hayes,RB. NCPIE Prescription Month, October 1989.
- Akhunzada WA, Rahman RU, Dogar IA, Maqsood N. Depression and drug non-adherence. Professional Med J. Jun 2010;17(2):340-346.
- Sullivan G, Wells KB, Morgenstern H, Leake B. Identifying modifiable risk factors for rehospitalization: a case-control study of seriously mentally ill persons in Mississippi. Am J Psych. 152(12):1749-56.
- Lacro JP, Dunn LB, Dolder CR, Leckhand SG, Jeste DV. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of the recent literature. J Clin Psychiatry. 2002(10);63:892-909.
- Olfson M, Mechanic D, Hansell S, Boyer CA, et al. Predicting medication noncompliance after hospital discharge among patients with schizophrenia. Psychiatr Serv. 2000; 51(2):216-22.
- Hepler CD and Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. Mar 1990;47:533-43.
- American Pharmacists Association. Medication Therapy Management in Pharmacy Practice: Core Elements of and MTM Service Model. Available at http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf. Accessed 19 Oct 2012.
- Bowers WA. Treatment of depressed in-patients: cognitive therapy plus medication, relaxation plus medication, and medication alone.BJPsych.Jan.1990;156:73-78.
- Blom MB, Jonker K, Dusseldorp E, Spinhoven P, et al. Combination treatment for acute depression is superior only when psychotherapy is added to medication. Psychother Psychosom.2007;76(5):289-297.
- Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: . JAMA. 2000;283(19):2529-2536.
- Tomko JR, Ahmed N, Mukherjee K, Roma RS, DiLucente D, Orchowski K. Evaluation of a discharge medication program in an acute psychiatric unit. Hosp Phar (in press; accepted for publication).
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