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Module 5, Part 1. Communication Essentials: Tips for Patient and Care Giver Communication

HOW DOES PATIENT COMMUNICATION IN MTM DIFFER FROM BASIC PHARMACIST–PATIENT COUNSELING?

Pharmacists are trained in patient counseling and communicating health information to the public. Medication therapy management (MTM) offers a chance to provide patient counseling at a higher level, with greater opportunity for give-and-take dialogue. Interactions with the patient during MTM go beyond the product-oriented counseling pharmacists provide on a daily basis. 

When engaging in counseling with patients, pharmacists often want to pass along their own ideas or suggestions to the patient. In MTM, the idea is to find out what the patient's goals are and to look for ways to address that individual's unique needs and problems. The process is more of an interactive collaboration between the patient and the pharmacist, rather than simply delivering information. To start, the pharmacist should think in terms of two basic questions for the patient:

  • If there is one issue we can address related to your medicines, what would it be? 
  • What is the most important thing you want to get out of our visit today? 

Table 1 illustrates the different stages of patient-pharmacist communication, from basic transfer of information (first column) to a more interactive level of communication with MTM counseling (column on far right).

Table 1. Stages of Patient-Pharmacist Communication
  Information Transfer Information Exchange Patient 
Education		 MTM
Level of information Brief, non-individualized Detailed, individualized Comprehensive: may be group or individualized Detailed information exploration and guidance
Spontaneous or planned Spontaneous, i.e., related to filling a prescription Spontaneous or planned Planned Planned
Goal/objective Basic information needed to use medication as directed (monologue)  Pharmacist responds to and asks questions about medication 
(dialogue)		 Collaborative learning environment (conversation) Guidance that assists in fulfilling needs for managing a medical condition (discussion)
Benefit to patient Safe, proper use of a medication or product Patient receives more individualized information about use of medication Increases condition-specific knowledge about proper use of medications Enhances problem-solving skills and assists with management of condition
Nature of relationship Passive instruction Active exchange of information Interactive learning Interactive collaboration and discussion
Adapted from: United States Pharmacopeia (USP) Medication Counseling Behavior Guidelines.

Product counseling vs. MTM 

At the pharmacy counter, patients frequently answer "No" when asked if they have any questions about new or renewed medications. People often answer "no" for two reasons: 1) because they are usually asked the question in a closed-ended manner (yes/no) and 2) they don't recognize how the added insight about their medication could help them to manage their medical condition.

Patients may not have insight into how well their medications are working for them. Most patients do not know enough about medications to ask the right kinds of questions, and thus rely on the pharmacist or other health professional to inform them.1 In addition, it is difficult or impossible to isolate a medication effect (such as drowsiness) from other potential causes. Unlike MTM, most "product counseling" opportunities are specific and targeted to issues with one medication. Generally, they do not include a comprehensive evaluation of the whole patient and the entire medication regimen (Figure 1).

Figure 1. Medication Therapy Management (MTM) Vs. Other Forms of Pharmacist Counseling

Patients who are unclear about the benefits of single-product counseling are also likely to be uncertain about a comprehensive MTM visit. However, when questions about a medication are put into the context of a person's own lifestyle, the rationale for MTM becomes clearer. Issues that MTM can help bring to light include:

  • Do you sometimes forget to take this medication?
  • What complications do your medications cause? 
  • Do you have side effects that cause you to use it in a different way than as directed?
  • Do you have concerns about the possible long-term effects of this medicine?
  • Are high copayments or lack of coverage preventing you from filling the prescription?
  • Do you cut pills in half, cut back on doses, or otherwise alter the prescription to fit your schedule, lifestyle, or budget?

Introducing the goals and benefits of MTM

To begin an MTM session, it may be helpful to very briefly explain to the patient the purpose of the MTM process and why it is worth their time and attention. Table 2 contains "Frequently Asked Questions" that can be used or adapted to share with patients about the goals, benefits, and steps of MTM.

Table 2. Frequently Asked Questions About Medication Therapy Management (MTM)

What is MTM?
Medication therapy management (MTM) is a service provided by a healthcare professional (often a pharmacist) to help patients gain the best possible benefits from their medications. This is usually done during a meeting between the pharmacist and the patient or a caregiver. A main goal of MTM is to identify, prevent, and resolve medication-related problems.

Why do I need MTM?
Almost anyone who receives medical therapy for a chronic illness can benefit from MTM. Usually, MTM is offered for people who have multiple medical conditions or are taking several medications. MTM can be helpful after a person has been hospitalized or has a change in medical care. People who have problems taking their medicines correctly can be helped by MTM services.

What should I expect during an MTM counseling session?
It is best to have a face-to-face meeting with the MTM provider. If that is not possible, phone or videoconferencing may be used. The pharmacist or other MTM provider will tell you what you need to bring to the meeting. At a minimum, you should bring all of your medications with you to the first visit (over the counter and prescription). During the meeting, you will have a chance to sit down with the pharmacist to discuss your questions and problems. You may talk about your health, your medicines, and ongoing needs. This may be different from what you have done with your doctor, because it is more focused on medications and how to use them correctly.

Is MTM a one-time meeting, or a longer-term process?
In order to be effective, MTM services should include a follow-up plan. How often you will meet with the pharmacist or exchange information will vary for each individual. A main goal of MTM is to produce changes that can benefit the person over a long-term period. 

How does my doctor find out about changes in medical care determined during an MTM session?
The pharmacist providing the MTM services will follow up with your physician and/or other healthcare providers. Certain changes may need to be authorized by your doctor. It is important that the doctor's records match with yours and those of the pharmacist. It can sometimes be helpful to let your doctor know that you have participated in an MTM consultation and request his or her cooperation with the process.

Benefits of MTM to patients are shown in Figure 2.

Figure 2. Informing Patients About MTM Benefits

HOW TO IMPROVE COMMUNICATION SKILLS FOR PATIENT COUNSELING

Communicating clearly with patients has been part of the educational curriculum for pharmacists for decades, but studies of real life pharmacist–patient encounters suggest that many pharmacy professionals need to improve or enhance their communication skills.2,3 Changing communication behaviors involves:4

  • Awareness (knowing what should be done differently)
  • Practicing new skills (using the new strategy)
  • Assessing the approach (determine what went well and what needs to be improved)

Assessments of pharmacist communication practices have shown that the most effective interactions occur when the pharmacist is demonstrating a certain skill (such as how to use an inhaler device) or answering medication-specific questions (such as what side effects a medication might cause). Initiating an open-ended conversation about the patient's needs and customizing the message to fit the individual are areas where the most improvements may be needed.1 Communication and interviewing skills for pharmacists often mirror those taught to physicians and other healthcare professionals. The American Association of Medical Colleges (AAMC) provides the mnemonic, SEGUE, to summarize core competencies in patient communication (Table 3).5

Table 3. Core Competencies in Patient Communication

The "SEGUE" framework for teaching and assessing communication skills

Set the Stage

  • Greet the patient appropriately
  • Establish the reason for visit
  • Outline the agenda for visit
  • Make a personal connection
  • Maintain privacy
Elicit Information
  • Elicit the patient's view of health problems and/or progress
  • Explore physical/physiological factors
  • Explore psychosocial/emotional factors
  • Discuss previous treatments
  • Discuss how health problems affect the patient's life
  • Discuss lifestyle issues/prevention strategies/health risks
  • Avoid directive/leading questions
  • Give the patient opportunity/time to talk
  • Listen and give the patient your undivided attention
  • Check/clarify information
Give Information
  • Explain rationale for diagnostic procedures
  • Teach the patient about his/her own body and situation
  • Encourage the patient to ask questions
  • Adapt to the patient's level of understanding
Understand the Patient's Perspective
  • Acknowledge the patient's accomplishments/progress/challenges
  • Acknowledge waiting time
  • Express caring, concern, empathy
  • Maintain a respectful tone
End the Encounter
  • Ask if there is anything else the patient would like to discuss
  • Review next steps with the patient
Source: American Association of Medical Colleges (AAMC). Communication in Medicine.5

The pharmacist can use steps in the Segue Framework to collect information. Techniques such as asking a patient’s about their understanding of the condition, asking permission to provide information, giving the patient new information, then asking to confirm patient understanding (Ask–Tell–Ask) can be used to ensure that information has been communicated in a clear and patient centered manner.

MOTIVATIONAL INTERVIEWING TECHNIQUES

Motivational interviewing is a counseling method that helps address people's unwillingness or inability to change something about themselves. In MTM, this technique can be used to help patients improve medication adherence and overcome resistance to a new or difficult medication or healthcare procedure.

In MTM, the patient interview should begin with open-ended questions ("Tell me how you take this," not "So, you're taking this twice a day?") and progress to closed-ended questions in order to clarify or fine-tune certain points. The pharmacist should be open to letting the patient talk openly—addressing the patient's chief concerns first—while steering the person back on track if needed. Some concepts of motivational interviewing applicable to MTM include:6

  1. Ask open-ended questions "How does this medicine make you feel?" NOT: "Do you feel nauseated when you take the medicine?"
    "What would you like to get out of this session today?" NOT: "I think you might be able to benefit from...."
  2. Reflect back what the person has said: "It sounds like the stress you're experiencing is making it harder for you to manage your pain." NOT: "You can't let the stress stop you from taking care of yourself."
  3. Periodically sum up what has been said: "So, in the morning you might skip a dose because you feel the medicine upsets your stomach."

More information on motivational interviewing can be found in this certificate program in Module 14, Adherence.

Active listening

Active listening refers to the ability of a listener to not only hear another person's words, but to understand the complete message being sent.7,8 Much of the listening we do is actually spent tuning out the speaker, making our own inferences about the message, and jumping ahead to plan our own responses. Healthcare consumers often feel their voices are not being heard. This is backed by data—in a recent study of clinician–patient interviews on shared decision-making, the clinician interrupted the patient in 67% of cases, after a median of only 11 seconds.9

The principles of active listening can be taught—and practiced—in order to improve communication in the context of MTM. The 5 key elements of active listening are outlined in Table 4.

Table 4. Five Key Elements of Active Listening7-9
1. Focus on giving the speaker your undivided attention 
DO:
  • Acknowledge the message
  • Look directly at the speaker 
  • Put aside distracting thoughts 
 DON'T:
  • Mentally prepare a response 
  • Tune in to outside distractions such as other conversations 
2. Give cues to show that you are listening
DO:
  • Use both nonverbal (body language) and verbal cues 
  • Nod occasionally, smile, use other facial expressions to convey attention 
  • Adjust posture to convey an inviting, open message 
 DON'T:
  • Use "negative" facial cues, such as eye-rolling or yawning 
  • Fidget (e.g., play with a desk accessory) 
3. Provide verbal and nonverbal feedback
DO:
  • Give speaker occasional indicators that you understand what is being said. 
  • Reflect back, paraphrasing what speaker has said. Use phrases like "What I'm hearing is..."
  • Ask questions to clarify the speaker's intent. "What do you mean when you say...?"
  • Ask for examples: "Can you give me an example of what you mean when you say you feel lousy?"
 DON'T:
  • Interrupt the speaker 
  • Go off on a tangent when the goal is to validate what the person is saying 
4. Avoid being judgmental
DO:
  • Keep in mind that the speaker's point of view may not reflect your own. 
  • Allow a person to vent frustrations about the healthcare system or a chronic disease 
 DON'T:
  • Present counter-arguments when the speaker is telling his or her point of view
  • Cast blame. Instead of "I can't believe he did that," one could say, "That must have been frustrating for you." 
5. Respond appropriately
DO:
  • Be candid, open, and honest 
  • Assert opinions and advice thoughtfully. Try "I would like to suggest..." rather than "This is what you should be doing." 
 DON'T:
  • Over-state what you have heard 

BARRIERS AND PITFALLS IN PATIENT COMMUNICATION

"The single biggest problem in communication is the illusion that it has taken place." —George Bernard Shaw

Few MTM sessions go "by the book." It is more likely that the pharmacist will encounter a number of communication challenges or barriers with each patient encounter, as outlined in Figure 3.

Figure 3. Barriers and Challenges in Patient Communication

More detailed discussion on overcoming barriers, including literacy and health literacy issues, is provided in the upcoming module (Module 14) on Adherence. 

TELEPHONE/VIDEOCONFERENCING FOR MTM 

Telephone and videoconferencing are becoming a more common way to conduct MTM interventions. As many as 92% of MTM encounters occur over the telephone, while 40% of plans also provide the opportunity for face-to-face visits.10 Important considerations in a successful telephone encounter are shown in Figure 4.

SUMMARY AND CONCLUSIONS

Education about how to communicate better with patients is a part of the pharmacist's training but should be an ongoing process. As this module highlights, the need for sensitive, empathetic, and effective communication with patients and caregivers is heightened during the process of MTM, because there is a much greater need for give-and-take of information. Communication skills such as using open-ended questions and active listening are an important part of MTM, but the pharmacist also needs to hone the skills of keeping the communication exchange focused and goal-oriented. 

REFERENCES

  1. Wuliji T, Airaksinen M. Counselling, Concordance, and Communication: Innovative Education for Pharmacists. International Pharmaceutical Federation. 2005.
  2. Boesen KP, Herrier RN, Apgar DA, et al. Improvisational exercises to improve pharmacy students' professional communication skills. Am J Pharm Educ. 2009;73(2):35.
  3. Kimberlin CL. Communicating with patients: skills assessment in US colleges of pharmacy. Am J Pharm Educ. 2006;70(3):67.
  4. Beardsley RS, Kimberlin CL, Tindall, WN. Communication Skills in Pharmacy Practice. 6th ed. Philadelphia: Wolters Kluwer Health; 2011.
  5. Association of American Medical Colleges. Report III. Contemporary Issues in Medicine: Communication in Medicine. 1999. Washington, D.C.
  6. Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol. 2009;64(6):527-537.
  7. Robertson K. Active listening: more than just paying attention. Aust Fam Physician. 2005;34(12):1053-1055.
  8. Fassaert T, van Dulmen S, Schellevis F, et al. Active listening in medical consultations: development of the Active Listening Observation Scale (ALOS-global). Patient Educ Couns. 2007;68(3):258-264.
  9. Ospina NS, Phillips KA, Rodriguez-Gutierrez R, et al. Eliciting the patient’s agenda: secondary analysis of recorded clinical encounters. J Gen Intern Med. 2019;34(1):36-40.
  10. Centers for Medicare & Medicaid Services (CMS). 2018 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet: Summary of 2018 MTM Programs. August 20, 2018. Available at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/CY2018-MTM-Fact-Sheet.pdf

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