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Pharmacist provision of patient medication education groups Lisa W. Goldstone, Shannon N. Saldaña, and Amy Werremeyer
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n the United States, medication nonadherence accounts for 10% of all hospital admissions and 33–69% of medication-related admissions, resulting in direct costs of $100–$289 billion annually. 1-6 Inadequate information about medication and a lack of understanding are barriers to adherence for many patients. 7-11 Pharmacist-provided medication education that targets adherence-related factors is necessary to help reduce these hospitalizations. This is a critical area in which pharmacists are well positioned to have a significant impact. There is growing documentation of the benefits of pharmacist-provided medication education, including fewer adverse drug reactions,12 decreased emergency department visits and hospital readmissions,12-15 increased patient satisfaction,16 and cost savings.14 However, pharmacists do not routinely provide medication education to the majority of patients. A 2012 national survey found that only 22% of patients deemed “at risk” received pharmacist-provided education in a hospital setting and that only 9% received pharmacist followup by telephone after hospital discharge.17 The frequency of medication education provided to patients by pharmacists in the community pharmacy setting may be higher than
in the hospital, yet fewer than 50% of patients are reached. Pharmacists at community chain pharmacies in various U.S. metropolitan areas provided at least one item of information for a new prescription just 43% of the time.18 The relatively low percentage of patients who routinely receive medication education from pharmacists may be due to the competing clinical demands on pharmacists’ time and work-force limitations. Consequently, there is an important and unmet need to develop and refine practices to provide and extend the benefits of pharmacist-led medication education to larger numbers of patients. Pharmacist delivery of education about medications to groups of patients has the potential to meet this need. The patient medication education group (PMEG) is an intervention in which education is provided to two Lisa W. Goldstone, M.S., Pharm.D., is Assistant Professor, Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson. Shannon N. Saldaña, Pharm.D., M.S., is Pharmacy Clinical Specialist, Psychiatry, Intermountain Primary Children’s Hospital, Salt Lake City, UT, and Adjunct Assistant Professor of Psychiatry, School of Medicine, University of Utah, Salt Lake City. Amy Werremeyer, Pharm.D., is Vice Chair and Associate Professor, Department of Pharmacy Practice, College of
or more patients about medications or issues related to medication use, with content tailored to the needs of patients in each group. The education may encompass any or all of the content items described in the ASHP Guidelines on PharmacistConducted Patient Education and Counseling 19 and may meet the ASHP pharmacy practice survey definition of patient medication education and counseling.20 PMEG has been defined by the Medication Education Task Force of the College of Psychiatric and Neurologic Pharmacists as follows: The PMEG is an intervention separate from the act of pharmacist-provided individual education at the time the patient receives the medication and may incorporate group dynamics and peer-to-peer interaction. The PMEG is also a distinctly different intervention from a psychoeducational group, in terms of the expertise and training of the group leader in the area of pharmacotherapy. The primary focus of PMEGs is medication and issues related to pharmacotherapy. Examples of issues related to pharmacotherapy may include nutrition, substance abuse, stress management, or sleep hygiene. Finally, the PMEG
Pharmacy, Nursing and Allied Sciences, North Dakota State University, Fargo. Address correspondence to Dr. Goldstone ([email protected]). The authors have declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0302-0487. DOI 10.2146/ajhp140182
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is a specific intervention that may be included as part of a treatment plan to address drug-therapy problems identified by a pharmacist and/or other members of the patient care team.21
Although PMEG is a relatively new term, pharmacists have provided medication education to groups of patients, incorporating some of the elements of the PMEG, for over 30 years.22 As the pharmacist’s role as a member of the healthcare team has evolved, these groups have become a more formalized part of the treatment plan in recent years, especially in the area of mental health. Although limited data are available describing the practice and outcomes of these pharmacist-led groups, some studies have specifically examined outcomes related to patient attendance of these groups. In a 2012 literature review, six studies containing outcomes from pharmacistled or co-led medication education groups were identified. 23 These studies indicated that pharmacistled medication education groups resulted in improved cardiovascular risk factors in patients with diabetes mellitus,24 improved ability to manage diseases in children and adolescents,25 decreased outpatient psychiatric costs,22 and increased adherence in elderly patients and patients with respiratory diseases.26-28 More-recent studies evaluating the outcomes of group medication education also demonstrated positive results including decreased acute psychiatric hospital readmissions due to medication nonadherence29 and increased medication adherence in patients admitted to a geriatric inpatient psychiatry unit.30 The results from these initial studies are promising, and additional research is needed to quantify the positive outcomes conferred by PMEGs. This form of patient education occurs in practice and is in demand by some health systems, most notably in the area of mental health. Results 488
obtained from a voluntary survey of 72 psychiatric and neurologic pharmacists (65% response rate) revealed that 41 (87%) of 47 respondents provided PMEGs.31 The pharmacists indicated that they incorporated a number of strategies in these groups, including the provision of written material, and that the groups were provided to patients in a variety of healthcare settings. Further, over 50% of respondents reported that nonpharmacists provided medication education to groups of patients in their institutions, similar to the percentage found in a 2009 national survey, which revealed that 89% of one-on-one medication education in hospitals was provided by nursing staff.20 Interestingly, 40% of the survey respondents indicated that they had been asked to begin a new PMEG service in their institution but had not yet initiated it; the barriers to implementing the requested services were not investigated. 31 The psychiatric and neurologic pharmacist survey results suggest that institutions serving the psychiatric population recognize the value of the PMEG. At present, pharmacist-provided medication education for patients on an individual basis may be difficult in some settings due to staffing constraints.32 Medication education provided through pharmacist-led PMEGs may be a solution to reach a greater number of patients to improve medication- and disease-related outcomes. It is essential that core components (i.e., knowledge and skills of the provider, practice settings and execution, group content, documentation, and communication with the healthcare team) be established to ensure consistency in practice and quality for patient care and to facilitate more-comprehensive evaluations of PMEG outcomes. Knowledge and skills of the pharmacist provider. Earning a doctor of pharmacy degree, maintaining board certification in a pharmacy specialty, or having experience does
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not necessarily ensure that pharmacists have or utilize the knowledge and skills necessary to effectively lead a PMEG. A pharmacist leading such a group must also have skills, knowledge, and experience in (1) teaching (including techniques to aid in active learning), (2) effective communication techniques, and (3) group process (including dynamics among group members).32 Pharmacists who provide PMEGs must demonstrate proficiency in teaching skills, such as organizing material so it is presented clearly and concisely and is beneficial to patients’ learning.33 Pharmacists must also consider cultural factors in the delivery of material and actively involve all patients in the learning process.34 Lecturing by the pharmacist should be kept to a minimum, with active learning strategies employed as much as possible.35 Multiple teaching approaches should be incorporated to engage all learning styles (i.e., visual, auditory, reading and writing, and kinesthetic).36 In addition, extensive knowledge of the material being presented is crucial for the success of the group. Therefore, it is optimal to have PMEGs provided by pharmacists who specialize in the diseases and medications included in the group education. Effective communication techniques include active listening, clarification of patients’ statements, and reflection of patients’ thoughts.35,37-39 Understanding how people, including the group facilitator, relate to each other, as well as how to manage nonproductive group behaviors such as conflict, is key in facilitating an effective group.40 Remaining flexible about the topics discussed, taking into account both individual patient needs as well as group needs, helps to ensure material is relevant to the individual patients in attendance.38 Finally, the ability to assist the patient in processing feelings that occur as a result of the group dynamics is not required in order to
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lead PMEGs and, in fact, should be reserved for those healthcare professionals who are trained to provide psychotherapy. Practice settings and execution. A PMEG is separate from the act of medication dispensing, in time and space, and is a focused educational intervention.41-43 PMEGs generally occur in community centers, ambulatory care clinics,44,45 and inpatient units26,46-48 but may be conducted in other healthcare settings. Regardless of the setting, this educational intervention should be conducted in a conference room, auditorium, or other space that comfortably holds the attendees and is private and free from distractions. Generally, group participants gather around a conference table or in classroom-type seating, but other comfortable or practical spaces can be used. For example, sitting in a circle on the floor in a living room or community room setting may be suitable for pediatric patient groups. In our experience, the use of a bulletin board, blackboard, or computer with projector or other media for communicating visual information is often helpful to enhance understanding. The PMEG represents a patient encounter that may address the plan for an individual patient’s care or help direct a patient’s ongoing or future care plan. A recommendation for participation in one or more PMEGs can be written into the care plan of a patient for a variety of reasons. For example, a recommendation for a PMEG may be appropriate for a patient in the following circumstances: • Medication nonadherence is suspected or discovered, • The patient misunderstands the recommended duration of therapy or another aspect of medication treatment, or • The patient has unrealistic expectations of the expected outcomes from medications.
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In each of these situations, education about a medication and its role in the treatment of disease, involving both pharmacist and peer experiences, can be a powerful means to identify and address medication-related issues. In our experience, a patient’s participation in one or more PMEG sessions often leads to opportunities for additional interventions that may enhance the pharmacotherapy or overall plan of care. For example, a patient who learns via a group discussion that sexual dysfunction is an adverse effect of therapy with many antidepressants and is concerned that this adverse effect is present may be referred back to the prescriber for alteration of therapy aimed at addressing that effect. Without the PMEG, the patient may not have been adherent to antidepressant therapy or may have carried an unnecessary adverse-effect burden, potentially resulting in poorer quality of life. Perhaps most importantly, a PMEG can and should be used proactively to prevent medication-related issues. Hence, patients may benefit from PMEG attendance before initiating medication therapy and need not have any preidentified medicationrelated problems or concerns. PMEG content. The content of PMEG sessions may touch on any or all of the specific areas of information recommended in the ASHP Guidelines on PharmacistConducted Patient Education and Counseling.19 However, the setting and time allotted to a PMEG often allow for more in-depth exploration of medication information and connection of concepts with practical application to the patient than is possible at the time of dispensing. For example, in a PMEG session, the pharmacist and participants may discuss how a medication works to treat the disease and use this to explain the recommended duration of therapy or time to onset of medication efficacy.28 This enhanced explanation, often augmented by patients’
experiences, may more effectively relate the medication to the disease, symptoms, and expected goals of treatment. The content of PMEG sessions is generally tailored to address the needs of participants. For example, a group composed mostly of patients with diabetes mellitus may focus on self-monitoring of blood glucose and insulin administration, while a group composed mostly of patients undergoing cardiac rehabilitation may focus on recognizing the signs of bleeding associated with antiplatelet agents or dealing with b-blocker-induced fatigue. However, not all PMEGs are composed of patients with similar conditions or medications. In these instances, the discussion of general principles such as encouraging patient engagement in medication decision-making, emphasizing medication adherence, or relating questions to ask about new medications is recommended. Teaching patients to play an active role in resolving medication-related problems may also be useful, especially for patients at high risk for readmission or with a history of medication nonadherence.49,50 Often in PMEG sessions, participants are encouraged to share their experiences, ask questions, and seek information that will help them to use medications effectively.25 As participants ask questions or share medication experiences, others in the PMEG session may be prompted to expound on their related experiences, potentially leading to the effective delivery of information that neither the patients nor the pharmacist recognized as educational gaps at the outset of the session. This affords the pharmacist an opportunity to clarify medication misconceptions or build on a preexisting understanding to enhance medication knowledge and acceptance by the patients. Some PMEGs are delivered as programs, composed of one to eight sessions, with each session having a specified topic (e.g., medication
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adherence, adverse effects and their management).24 Others are delivered as single one- or two-hour sessions with varied or flexible discussion topics.26 Still others feature interactive ways to increase patients’ knowledge and understanding of medication information, such as “medication jeopardy.”51 Documentation and communication with the healthcare team. Based on the documentation practices of other disciplines who conduct patient groups, we recommend that the documentation of a PMEG contains several elements: • Organization name, program name, and service location, • Patient name, • At least one patient identifier (e.g., medical record number, visit number, date of birth), • Service type or description, • Date of service, • Duration of group in minutes (or start and stop times), • Topics addressed and methods used (e.g., game, handout, discussion), • Level of participation in the group, including observed individual or group dynamics, • Assessment of learning, including any barriers to learning, • Response to the PMEG and progress toward goals, • Recommendations regarding the need for further education or other follow-up to improve the overall care of the patient, • Signature (electronic) of pharmacist, including credentials, and • Additional information as required by the payer or institution.
Other information that should be considered for documentation, when applicable, includes adverse effects reported by the patient, difficulties with adherence, therapeutic preferences, and symptoms described by the patient or observed by the pharmacist during the group session. PMEG should be documented as 490
part of the individual patient’s medical record in a place that is accessible to all healthcare members caring for the patient. Barriers and gaps to implementation. There are multiple barriers or gaps that delay the provision of pharmacist-led PMEGs, including inadequate pharmacist staffing, lack of training, and inability to pay pharmacists for these services. Staffing issues are a common theme across pharmacy settings. Lack of funding is often an obstacle to adding new positions for many pharmacy departments, and it can be especially difficult to justify additional positions or services that do not increase revenue. 32 Although preliminary evidence strongly demonstrates the value of the pharmacist-provided PMEG, more in-depth investigation is needed to clearly elucidate PMEG practices and outcomes. Therefore, it is imperative that all pharmacists conducting PMEGs gather outcomes data to demonstrate the impact on patient-related outcomes, including costs. Until this occurs, other disciplines with billing capabilities (e.g., nursing, social work) but with lessextensive knowledge of medications and medication-related issues may continue to be the healthcare providers who most often deliver medication education to groups of patients. There is a lack of formal training in effectively designing and leading a PMEG. Group dynamics and group facilitation with patients are not skills included among the required standards of doctor of pharmacy or postgraduate residency training programs.52,53 Although some pharmacy students and residents may receive some exposure to this intervention during professional rotations, that alone may not be adequate to render a pharmacist qualified to facilitate a PMEG. Dynamics in a group differ from those in one-on-one education, and a pharmacist must have knowledge of these dynamics to be an effective group leader. As a profession, it is
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necessary to ensure that current and future pharmacists providing direct patient care are adequately trained to provide PMEGs. Pharmacists’ abilities to bill for a PMEG are limited. Although Current Procedural Terminology (CPT) codes for pharmacists exist for medication therapy management, there are no codes that allow for services provided in a group format. There is potential for billing under education and training for self-management group codes (98961 and 98962). However, these codes are only valid for this service if it is prescribed by a physician, uses a standardized curriculum, and is provided by a qualified nonphysician healthcare professional. Although a pharmacist may fall under the category of a qualified nonphysician healthcare professional, many insurance companies do not currently credential pharmacists; therefore, pharmacists would be unable to receive payment under these codes. The inability to receive payment for a PMEG by third parties remains a major obstacle to PMEG implementation. However, with the increasing emphasis on payments for bundled services, this point may become moot. Next steps and conclusion. The PMEG allows pharmacist-provided medication education to reach larger numbers of patients in a variety of settings. Although this document provides our recommendations regarding the core components of the PMEG, additional steps must be taken in several areas to support PMEGs as a routine pharmacist-provided service. These areas, in no particular order, are as follows: 1. Training. Pharmacists who are already skilled in providing PMEGs should be identified and assist with didactic or experiential training. Ideally, trainees would receive classroom training on the provision of PMEGs, with subsequent opportunities to apply their knowledge through an actual PMEG
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during doctor of pharmacy student practice experiences and residency training. For pharmacists currently in practice, strategies such as modeling and feedback provided by an experienced group leader may be used for training.38 2. Assessment for implementation. For settings in which a PMEG is not being provided, an assessment should determine the feasibility of implementing such a service. The information presented herein should be used to evaluate the setting and the skills of the pharmacists who will provide the service. This commentary may also be useful in the basic design and implementation of a PMEG. 3. Outcomes. For pharmacists providing PMEGs, data pertaining to therapeutic, safety, humanistic, and economic outcomes should be collected and disseminated to illustrate the value of the PMEG as part of a patient treatment plan. These outcomes are essential to demonstrate the value of this service to stakeholders and leaders who delineate pharmacist staffing and responsibilities. 4. Payment. It is imperative to develop consistent billing models for PMEGs. With the development of patientcentered medical homes and the emphasis on value-based payment for care, pharmacist payment is most likely to occur as part of the bundled services payment made to the healthcare team or the physician. Although a separate CPT code for the pharmacistprovided PMEG may be appealing to some, a system that allows for the provision of PMEGs without requiring interaction with the patient care team may be counterproductive to a collaborative team-based approach and, as a result, less beneficial to the patient.
Based on our experiences, we expect that progress in the above areas will facilitate the integration of the PMEG as a consistent and standard pharmacy practice in the provision of patient care. The medical literature suggests that PMEGs improve
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patient outcomes and may meaningfully reduce overall healthcare costs, especially costs related to medication nonadherence. PMEGs extend the benefits of pharmacist-provided medication education to more patients than are practically reached with one-on-one education in most settings. Moreover, PMEGs offer a simultaneous advantage of enhancing understanding through group interactions. References 1. McDonnell PJ, Jacobs MR. Hospital admissions resulting from preventable adverse drug reactions. Ann Pharmacother. 2002; 36:1331-6. 2. Senst BL, Achusim LE, Genest RP et al. Practical approach to determining costs and frequency of adverse drug events in a health care network. Am J Health-Syst Pharm. 2001; 58:1126-32. 3. Levy G, Zamacona MK, Jusko WJ. Developing compliance instructions for drug labeling. Clin Pharmacol Ther. 2000; 68:586-91. 4. Berg JS, Dischler J, Wagner DJ et al. Medication compliance: a healthcare problem. Ann Pharmacother. 1993; 27(suppl 9):S1-24. 5. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005; 353:48797. 6. Peterson AM, Takiya L, Finley R. Metaanalysis of trials of interventions to improve medication adherence. Am J Health-Syst Pharm. 2003; 60:657-65. 7. Barker A, Shergill S, Higginson I et al. Patients’ views towards care received from psychiatrists. Br J Psychiatry. 1996; 168:641-6. 8. Gray R, Rofail D, Allen J et al. A survey of patient satisfaction with and subjective experiences of treatment with antipsychotic medication. J Adv Nurs. 2005; 52:31-7. 9. Brown MT, Russell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011; 86:304-14. 10. Berk L, Hallam KT, Colon F et al. Enhancing medication adherence in patients with bipolar disorder. Hum Psychopharmacol Clin Exp. 2010; 25:1-16. 11. Bushnell CD, Olson DM, Zhao X et al. Secondary preventive medication persistence and adherence 1 year after stroke. Neurology. 2011; 77:1182-90. 12. Schnipper JL, Kirwin JL, Cotugno MC et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006; 166:565-71. 13. Dudas V, Bookwalter T, Kerr KM et al. The impact of follow-up telephone calls to patients after hospitalization. Am J Med. 2001; 111:26S-30S.
14. Jack BW, Chetty VK, Anthony D et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009; 150:178-87. 15. Al-Rashed SA, Wright DJ, Roebuck N et al. The value of inpatient pharmaceutical counseling to elderly patients prior to discharge. Br J Clin Pharmacol. 2002; 54:657-64. 16. Clancy CM. Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction. Am J Med Qual. 2009; 24:344-6. 17. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2012. Am J Health-Syst Pharm. 2013; 70:787-803. 18. Flynn EA, Barker KN, Berger BA et al. Dispensing errors and counseling quality in 100 pharmacies. J Am Pharm Assoc. 2009; 49:171-80. 19. American Society of Health-System Pharmacists. ASHP guidelines on pharmacistconducted patient education and counseling. Am J Health-Syst Pharm. 1997; 54:431-4. 20. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2009. Am J Health-Syst Pharm. 2010; 67:54258. 21. College of Psychiatric and Neurologic Pharmacists. March 2014 update: CPNP supports the following definition of patient medication education group. http://cpnp.org/resource/mhc/2013/03/ medication-education-task-forceproviding-valuable-resources-cpnpmembers (accessed 2014 Mar 19). 22. Gray DR, Namikas EA, Sax MJ et al. Clinical pharmacists as allied health care providers to psychiatric patients. Contemp Pharm Pract. 1979; 2:108-16. 23. Norman S, Davis E, Goldstone LW. Impact of pharmacist-led or co-led medication education groups on patient outcomes: a literature review. http:// cpnp.org/resource/mhc/2012/10/impactpharmacist-led-or-co-led-medicationeducation-groups-patient-outcomes (accessed 2014 Mar 5). 24. Martin OJ, Wu W, Taveira T et al. Multidisciplinary group behavioral and pharmacologic intervention for cardiac risk reduction in diabetes: a pilot study. Diabetes Educ. 2007; 33:118-27. 25. Hunter KA, Bryant BG. Pharmacists provided education and counseling for managing pediatric asthma. Patient Educ Couns. 1994; 24:127-34. 26. Hawe P, Higgins G. Can medication education improve the drug compliance of the elderly? Evaluation of an in hospital program. Patient Educ Couns. 1990; 16:151-60. 27. Gallefoss F, Bakke PS. How does patient education and self-management among asthmatics and patients with chronic
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obstructive pulmonary disease affect medication? Am J Respir Crit Care Med. 1999; 160:2000-5. Gallefoss F, Bakke PS, Kjaersgaard P. Quality of life assessment after patient education in a randomized controlled study on asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999; 159:812-7. Arterbury A, Bushway A, Goldstone LW. Effect of a pharmacist-led medication education group on hospital readmissions due to medication non-adherence for patients with previous inpatient psychiatric admissions. J Pharm Pract. 2014; 27:279. Abstract. Davis E, Biglow M, Pinkhasov A, Cohen H. A pharmacist-led medication education group and the effect on medication compliance in a geriatric psychiatric unit. J Pharm Pract. 2014; 27:290. Abstract. Werremeyer A, Saldana SN, Goldstone LW et al. Medication education task force providing valuable resources to CPNP members. http://cpnp.org/resource/ mhc/2013/03/medication-educationtask-force-providing-valuable-resourcescpnp-members (accessed 2014 Mar 5). Goldstone LW, Kennedy AK, Clark JS et al. Developing and evaluating clinical pharmacy services. In: Chisholm-Burns MA, Vaillancourt AM, Shepherd M, eds. Pharmacy management, leadership, marketing and finance. 2nd ed. Burlington, VT: Jones and Bartlett Learning; 2014:199-215. Moore PM, Rivera Mercado S, Grez Artiques M, Lawrie TA. Communication skills training for healthcare professionals working with people who have cancer. Cochrane Database Syst Rev. 2013; 3:CD003751. Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. Substance abuse treatment: group therapy—treatment improvement protocol (TIP) series, no 41. Rockville, MD: Department of Health
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and Human Services, 2005; DHHS publication no. (SMA) 05-3991. American College of Clinical Pharmacy, O’Connell MB, Korner EJ et al. Cultural competence in health care and its implications for pharmacy. Part 1. Overview of key concepts in multicultural health care. Pharmacotherapy. 2007; 27:1062-79. Prithishkumar IJ, Michael SA. Understanding your student: using the VARK model. J Postgrad Med. 2014; 60:183-6. Boykins AD. Core communication competencies in patient-centered care. ABNF J. 2014; 25:40-5. Maguire P, Pitceathyly C. Key communication skills and how to acquire them. BMJ. 2002; 325:697-700. Eames C, Daley D, Hutchings J et al. The impact of group leaders’ behaviour on parents acquisition of key parenting skills during parent training. Behav Res Ther. 2010; 48:1221-6. Perraud S, Farran CJ, Loukissa D et al. Alzheimer’s disease caregiving information and skills, part III: group process issues and concerns. Res Nurs Health. 2004; 27(2):110-20. Tankel K. Therapeutic interactions in a medication education group. Using the psychopharmacology RACE. J Psychosoc Nurs Ment Health Serv. 2001; 39:22-30. Davidhizar E, Powell MJ. Patient medication education groups. Hosp Top. 1987; 65:21-4. Esposito L. The effects of medication education on adherence to medication regimens in an elderly population. J Adv Nurs. 1995; 21:935-43. Tang TS, Funnell MM, Anderson RA. Group education strategies for diabetes self-management. Diabetes Spectr. 2006; 19:99-105. Rickheim PL, Weaver TW, Flader JL et al. Assessment of group versus individual diabetes education. Diabetes Care. 2002; 25:99-105. Abdulwadud O, Abramson M, Forbes A et al. Evaluation of a randomized
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controlled trial of adult asthma education in a hospital setting. Thorax. 1999; 54:493-500. Robinson GL, Gilbertson AD, Litwack L. The effects of a psychiatric patient education to medication program on post-discharge compliance. Psychiatr Q. 1986; 58:113-8. Kavanaugh K, Duncan-MacConnell D, Greenwood K et al. Educating acute inpatients about their medication: is it worth it? An exploratory study of group education for patients on a psychiatric intensive care unit. J Ment Health. 2003; 12:71-80. Velligan DI, Weiden PJ, Sajatovic M et al. Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the expert consensus guidelines. J Psychiatr Pract. 2010; 16:306-24. Dolder CR, Lacro JP, Leckband S et al. Interventions to improve antipsychotic medication adherence: review of recent literature. J Clin Psychopharmacol. 2003; 23:389-99. Gavin L, Frey T. Assessment of a pharmacist-run medication education group for inpatient psychiatric patients. http://cpnp.org/resource/mhc/2012/10/ assessment-pharmacist-run-medicationeducation-group-inpatient-psychiatric (accessed 2014 Jun 19). Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. www.acpea cc re d i t . o r g / d e a n s / s t a n d a rd s . a s p (accessed 2014 Jun 19). American Society of Health-System Pharmacists, College of Psychiatric and Neurologic Pharmacists. Required educational outcomes, goals, and objectives for postgraduate year two (PGY2) pharmacy residencies in psychiatry. http://cpnp. org/sites/default.files/PGY2_Residency_ Standards.pdf (accessed 2014 Nov 21).
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Pharmacist provision of patient medication education groups Lisa W. Goldstone, Shannon N. Saldaña, and Amy Werremeyer
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n the United States, medication nonadherence accounts for 10% of all hospital admissions and 33–69% of medication-related admissions, resulting in direct costs of $100–$289 billion annually. 1-6 Inadequate information about medication and a lack of understanding are barriers to adherence for many patients. 7-11 Pharmacist-provided medication education that targets adherence-related factors is necessary to help reduce these hospitalizations. This is a critical area in which pharmacists are well positioned to have a significant impact. There is growing documentation of the benefits of pharmacist-provided medication education, including fewer adverse drug reactions,12 decreased emergency department visits and hospital readmissions,12-15 increased patient satisfaction,16 and cost savings.14 However, pharmacists do not routinely provide medication education to the majority of patients. A 2012 national survey found that only 22% of patients deemed “at risk” received pharmacist-provided education in a hospital setting and that only 9% received pharmacist followup by telephone after hospital discharge.17 The frequency of medication education provided to patients by pharmacists in the community pharmacy setting may be higher than
in the hospital, yet fewer than 50% of patients are reached. Pharmacists at community chain pharmacies in various U.S. metropolitan areas provided at least one item of information for a new prescription just 43% of the time.18 The relatively low percentage of patients who routinely receive medication education from pharmacists may be due to the competing clinical demands on pharmacists’ time and work-force limitations. Consequently, there is an important and unmet need to develop and refine practices to provide and extend the benefits of pharmacist-led medication education to larger numbers of patients. Pharmacist delivery of education about medications to groups of patients has the potential to meet this need. The patient medication education group (PMEG) is an intervention in which education is provided to two Lisa W. Goldstone, M.S., Pharm.D., is Assistant Professor, Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson. Shannon N. Saldaña, Pharm.D., M.S., is Pharmacy Clinical Specialist, Psychiatry, Intermountain Primary Children’s Hospital, Salt Lake City, UT, and Adjunct Assistant Professor of Psychiatry, School of Medicine, University of Utah, Salt Lake City. Amy Werremeyer, Pharm.D., is Vice Chair and Associate Professor, Department of Pharmacy Practice, College of
or more patients about medications or issues related to medication use, with content tailored to the needs of patients in each group. The education may encompass any or all of the content items described in the ASHP Guidelines on PharmacistConducted Patient Education and Counseling 19 and may meet the ASHP pharmacy practice survey definition of patient medication education and counseling.20 PMEG has been defined by the Medication Education Task Force of the College of Psychiatric and Neurologic Pharmacists as follows: The PMEG is an intervention separate from the act of pharmacist-provided individual education at the time the patient receives the medication and may incorporate group dynamics and peer-to-peer interaction. The PMEG is also a distinctly different intervention from a psychoeducational group, in terms of the expertise and training of the group leader in the area of pharmacotherapy. The primary focus of PMEGs is medication and issues related to pharmacotherapy. Examples of issues related to pharmacotherapy may include nutrition, substance abuse, stress management, or sleep hygiene. Finally, the PMEG
Pharmacy, Nursing and Allied Sciences, North Dakota State University, Fargo. Address correspondence to Dr. Goldstone ([email protected]). The authors have declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0302-0487. DOI 10.2146/ajhp140182
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is a specific intervention that may be included as part of a treatment plan to address drug-therapy problems identified by a pharmacist and/or other members of the patient care team.21
Although PMEG is a relatively new term, pharmacists have provided medication education to groups of patients, incorporating some of the elements of the PMEG, for over 30 years.22 As the pharmacist’s role as a member of the healthcare team has evolved, these groups have become a more formalized part of the treatment plan in recent years, especially in the area of mental health. Although limited data are available describing the practice and outcomes of these pharmacist-led groups, some studies have specifically examined outcomes related to patient attendance of these groups. In a 2012 literature review, six studies containing outcomes from pharmacistled or co-led medication education groups were identified. 23 These studies indicated that pharmacistled medication education groups resulted in improved cardiovascular risk factors in patients with diabetes mellitus,24 improved ability to manage diseases in children and adolescents,25 decreased outpatient psychiatric costs,22 and increased adherence in elderly patients and patients with respiratory diseases.26-28 More-recent studies evaluating the outcomes of group medication education also demonstrated positive results including decreased acute psychiatric hospital readmissions due to medication nonadherence29 and increased medication adherence in patients admitted to a geriatric inpatient psychiatry unit.30 The results from these initial studies are promising, and additional research is needed to quantify the positive outcomes conferred by PMEGs. This form of patient education occurs in practice and is in demand by some health systems, most notably in the area of mental health. Results 488
obtained from a voluntary survey of 72 psychiatric and neurologic pharmacists (65% response rate) revealed that 41 (87%) of 47 respondents provided PMEGs.31 The pharmacists indicated that they incorporated a number of strategies in these groups, including the provision of written material, and that the groups were provided to patients in a variety of healthcare settings. Further, over 50% of respondents reported that nonpharmacists provided medication education to groups of patients in their institutions, similar to the percentage found in a 2009 national survey, which revealed that 89% of one-on-one medication education in hospitals was provided by nursing staff.20 Interestingly, 40% of the survey respondents indicated that they had been asked to begin a new PMEG service in their institution but had not yet initiated it; the barriers to implementing the requested services were not investigated. 31 The psychiatric and neurologic pharmacist survey results suggest that institutions serving the psychiatric population recognize the value of the PMEG. At present, pharmacist-provided medication education for patients on an individual basis may be difficult in some settings due to staffing constraints.32 Medication education provided through pharmacist-led PMEGs may be a solution to reach a greater number of patients to improve medication- and disease-related outcomes. It is essential that core components (i.e., knowledge and skills of the provider, practice settings and execution, group content, documentation, and communication with the healthcare team) be established to ensure consistency in practice and quality for patient care and to facilitate more-comprehensive evaluations of PMEG outcomes. Knowledge and skills of the pharmacist provider. Earning a doctor of pharmacy degree, maintaining board certification in a pharmacy specialty, or having experience does
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not necessarily ensure that pharmacists have or utilize the knowledge and skills necessary to effectively lead a PMEG. A pharmacist leading such a group must also have skills, knowledge, and experience in (1) teaching (including techniques to aid in active learning), (2) effective communication techniques, and (3) group process (including dynamics among group members).32 Pharmacists who provide PMEGs must demonstrate proficiency in teaching skills, such as organizing material so it is presented clearly and concisely and is beneficial to patients’ learning.33 Pharmacists must also consider cultural factors in the delivery of material and actively involve all patients in the learning process.34 Lecturing by the pharmacist should be kept to a minimum, with active learning strategies employed as much as possible.35 Multiple teaching approaches should be incorporated to engage all learning styles (i.e., visual, auditory, reading and writing, and kinesthetic).36 In addition, extensive knowledge of the material being presented is crucial for the success of the group. Therefore, it is optimal to have PMEGs provided by pharmacists who specialize in the diseases and medications included in the group education. Effective communication techniques include active listening, clarification of patients’ statements, and reflection of patients’ thoughts.35,37-39 Understanding how people, including the group facilitator, relate to each other, as well as how to manage nonproductive group behaviors such as conflict, is key in facilitating an effective group.40 Remaining flexible about the topics discussed, taking into account both individual patient needs as well as group needs, helps to ensure material is relevant to the individual patients in attendance.38 Finally, the ability to assist the patient in processing feelings that occur as a result of the group dynamics is not required in order to
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lead PMEGs and, in fact, should be reserved for those healthcare professionals who are trained to provide psychotherapy. Practice settings and execution. A PMEG is separate from the act of medication dispensing, in time and space, and is a focused educational intervention.41-43 PMEGs generally occur in community centers, ambulatory care clinics,44,45 and inpatient units26,46-48 but may be conducted in other healthcare settings. Regardless of the setting, this educational intervention should be conducted in a conference room, auditorium, or other space that comfortably holds the attendees and is private and free from distractions. Generally, group participants gather around a conference table or in classroom-type seating, but other comfortable or practical spaces can be used. For example, sitting in a circle on the floor in a living room or community room setting may be suitable for pediatric patient groups. In our experience, the use of a bulletin board, blackboard, or computer with projector or other media for communicating visual information is often helpful to enhance understanding. The PMEG represents a patient encounter that may address the plan for an individual patient’s care or help direct a patient’s ongoing or future care plan. A recommendation for participation in one or more PMEGs can be written into the care plan of a patient for a variety of reasons. For example, a recommendation for a PMEG may be appropriate for a patient in the following circumstances: • Medication nonadherence is suspected or discovered, • The patient misunderstands the recommended duration of therapy or another aspect of medication treatment, or • The patient has unrealistic expectations of the expected outcomes from medications.
Patient medication education
In each of these situations, education about a medication and its role in the treatment of disease, involving both pharmacist and peer experiences, can be a powerful means to identify and address medication-related issues. In our experience, a patient’s participation in one or more PMEG sessions often leads to opportunities for additional interventions that may enhance the pharmacotherapy or overall plan of care. For example, a patient who learns via a group discussion that sexual dysfunction is an adverse effect of therapy with many antidepressants and is concerned that this adverse effect is present may be referred back to the prescriber for alteration of therapy aimed at addressing that effect. Without the PMEG, the patient may not have been adherent to antidepressant therapy or may have carried an unnecessary adverse-effect burden, potentially resulting in poorer quality of life. Perhaps most importantly, a PMEG can and should be used proactively to prevent medication-related issues. Hence, patients may benefit from PMEG attendance before initiating medication therapy and need not have any preidentified medicationrelated problems or concerns. PMEG content. The content of PMEG sessions may touch on any or all of the specific areas of information recommended in the ASHP Guidelines on PharmacistConducted Patient Education and Counseling.19 However, the setting and time allotted to a PMEG often allow for more in-depth exploration of medication information and connection of concepts with practical application to the patient than is possible at the time of dispensing. For example, in a PMEG session, the pharmacist and participants may discuss how a medication works to treat the disease and use this to explain the recommended duration of therapy or time to onset of medication efficacy.28 This enhanced explanation, often augmented by patients’
experiences, may more effectively relate the medication to the disease, symptoms, and expected goals of treatment. The content of PMEG sessions is generally tailored to address the needs of participants. For example, a group composed mostly of patients with diabetes mellitus may focus on self-monitoring of blood glucose and insulin administration, while a group composed mostly of patients undergoing cardiac rehabilitation may focus on recognizing the signs of bleeding associated with antiplatelet agents or dealing with b-blocker-induced fatigue. However, not all PMEGs are composed of patients with similar conditions or medications. In these instances, the discussion of general principles such as encouraging patient engagement in medication decision-making, emphasizing medication adherence, or relating questions to ask about new medications is recommended. Teaching patients to play an active role in resolving medication-related problems may also be useful, especially for patients at high risk for readmission or with a history of medication nonadherence.49,50 Often in PMEG sessions, participants are encouraged to share their experiences, ask questions, and seek information that will help them to use medications effectively.25 As participants ask questions or share medication experiences, others in the PMEG session may be prompted to expound on their related experiences, potentially leading to the effective delivery of information that neither the patients nor the pharmacist recognized as educational gaps at the outset of the session. This affords the pharmacist an opportunity to clarify medication misconceptions or build on a preexisting understanding to enhance medication knowledge and acceptance by the patients. Some PMEGs are delivered as programs, composed of one to eight sessions, with each session having a specified topic (e.g., medication
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Patient medication education
adherence, adverse effects and their management).24 Others are delivered as single one- or two-hour sessions with varied or flexible discussion topics.26 Still others feature interactive ways to increase patients’ knowledge and understanding of medication information, such as “medication jeopardy.”51 Documentation and communication with the healthcare team. Based on the documentation practices of other disciplines who conduct patient groups, we recommend that the documentation of a PMEG contains several elements: • Organization name, program name, and service location, • Patient name, • At least one patient identifier (e.g., medical record number, visit number, date of birth), • Service type or description, • Date of service, • Duration of group in minutes (or start and stop times), • Topics addressed and methods used (e.g., game, handout, discussion), • Level of participation in the group, including observed individual or group dynamics, • Assessment of learning, including any barriers to learning, • Response to the PMEG and progress toward goals, • Recommendations regarding the need for further education or other follow-up to improve the overall care of the patient, • Signature (electronic) of pharmacist, including credentials, and • Additional information as required by the payer or institution.
Other information that should be considered for documentation, when applicable, includes adverse effects reported by the patient, difficulties with adherence, therapeutic preferences, and symptoms described by the patient or observed by the pharmacist during the group session. PMEG should be documented as 490
part of the individual patient’s medical record in a place that is accessible to all healthcare members caring for the patient. Barriers and gaps to implementation. There are multiple barriers or gaps that delay the provision of pharmacist-led PMEGs, including inadequate pharmacist staffing, lack of training, and inability to pay pharmacists for these services. Staffing issues are a common theme across pharmacy settings. Lack of funding is often an obstacle to adding new positions for many pharmacy departments, and it can be especially difficult to justify additional positions or services that do not increase revenue. 32 Although preliminary evidence strongly demonstrates the value of the pharmacist-provided PMEG, more in-depth investigation is needed to clearly elucidate PMEG practices and outcomes. Therefore, it is imperative that all pharmacists conducting PMEGs gather outcomes data to demonstrate the impact on patient-related outcomes, including costs. Until this occurs, other disciplines with billing capabilities (e.g., nursing, social work) but with lessextensive knowledge of medications and medication-related issues may continue to be the healthcare providers who most often deliver medication education to groups of patients. There is a lack of formal training in effectively designing and leading a PMEG. Group dynamics and group facilitation with patients are not skills included among the required standards of doctor of pharmacy or postgraduate residency training programs.52,53 Although some pharmacy students and residents may receive some exposure to this intervention during professional rotations, that alone may not be adequate to render a pharmacist qualified to facilitate a PMEG. Dynamics in a group differ from those in one-on-one education, and a pharmacist must have knowledge of these dynamics to be an effective group leader. As a profession, it is
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necessary to ensure that current and future pharmacists providing direct patient care are adequately trained to provide PMEGs. Pharmacists’ abilities to bill for a PMEG are limited. Although Current Procedural Terminology (CPT) codes for pharmacists exist for medication therapy management, there are no codes that allow for services provided in a group format. There is potential for billing under education and training for self-management group codes (98961 and 98962). However, these codes are only valid for this service if it is prescribed by a physician, uses a standardized curriculum, and is provided by a qualified nonphysician healthcare professional. Although a pharmacist may fall under the category of a qualified nonphysician healthcare professional, many insurance companies do not currently credential pharmacists; therefore, pharmacists would be unable to receive payment under these codes. The inability to receive payment for a PMEG by third parties remains a major obstacle to PMEG implementation. However, with the increasing emphasis on payments for bundled services, this point may become moot. Next steps and conclusion. The PMEG allows pharmacist-provided medication education to reach larger numbers of patients in a variety of settings. Although this document provides our recommendations regarding the core components of the PMEG, additional steps must be taken in several areas to support PMEGs as a routine pharmacist-provided service. These areas, in no particular order, are as follows: 1. Training. Pharmacists who are already skilled in providing PMEGs should be identified and assist with didactic or experiential training. Ideally, trainees would receive classroom training on the provision of PMEGs, with subsequent opportunities to apply their knowledge through an actual PMEG
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during doctor of pharmacy student practice experiences and residency training. For pharmacists currently in practice, strategies such as modeling and feedback provided by an experienced group leader may be used for training.38 2. Assessment for implementation. For settings in which a PMEG is not being provided, an assessment should determine the feasibility of implementing such a service. The information presented herein should be used to evaluate the setting and the skills of the pharmacists who will provide the service. This commentary may also be useful in the basic design and implementation of a PMEG. 3. Outcomes. For pharmacists providing PMEGs, data pertaining to therapeutic, safety, humanistic, and economic outcomes should be collected and disseminated to illustrate the value of the PMEG as part of a patient treatment plan. These outcomes are essential to demonstrate the value of this service to stakeholders and leaders who delineate pharmacist staffing and responsibilities. 4. Payment. It is imperative to develop consistent billing models for PMEGs. With the development of patientcentered medical homes and the emphasis on value-based payment for care, pharmacist payment is most likely to occur as part of the bundled services payment made to the healthcare team or the physician. Although a separate CPT code for the pharmacistprovided PMEG may be appealing to some, a system that allows for the provision of PMEGs without requiring interaction with the patient care team may be counterproductive to a collaborative team-based approach and, as a result, less beneficial to the patient.
Based on our experiences, we expect that progress in the above areas will facilitate the integration of the PMEG as a consistent and standard pharmacy practice in the provision of patient care. The medical literature suggests that PMEGs improve
Patient medication education
patient outcomes and may meaningfully reduce overall healthcare costs, especially costs related to medication nonadherence. PMEGs extend the benefits of pharmacist-provided medication education to more patients than are practically reached with one-on-one education in most settings. Moreover, PMEGs offer a simultaneous advantage of enhancing understanding through group interactions. References 1. McDonnell PJ, Jacobs MR. Hospital admissions resulting from preventable adverse drug reactions. Ann Pharmacother. 2002; 36:1331-6. 2. Senst BL, Achusim LE, Genest RP et al. Practical approach to determining costs and frequency of adverse drug events in a health care network. Am J Health-Syst Pharm. 2001; 58:1126-32. 3. Levy G, Zamacona MK, Jusko WJ. Developing compliance instructions for drug labeling. Clin Pharmacol Ther. 2000; 68:586-91. 4. Berg JS, Dischler J, Wagner DJ et al. Medication compliance: a healthcare problem. Ann Pharmacother. 1993; 27(suppl 9):S1-24. 5. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005; 353:48797. 6. Peterson AM, Takiya L, Finley R. Metaanalysis of trials of interventions to improve medication adherence. Am J Health-Syst Pharm. 2003; 60:657-65. 7. Barker A, Shergill S, Higginson I et al. Patients’ views towards care received from psychiatrists. Br J Psychiatry. 1996; 168:641-6. 8. Gray R, Rofail D, Allen J et al. A survey of patient satisfaction with and subjective experiences of treatment with antipsychotic medication. J Adv Nurs. 2005; 52:31-7. 9. Brown MT, Russell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011; 86:304-14. 10. Berk L, Hallam KT, Colon F et al. Enhancing medication adherence in patients with bipolar disorder. Hum Psychopharmacol Clin Exp. 2010; 25:1-16. 11. Bushnell CD, Olson DM, Zhao X et al. Secondary preventive medication persistence and adherence 1 year after stroke. Neurology. 2011; 77:1182-90. 12. Schnipper JL, Kirwin JL, Cotugno MC et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006; 166:565-71. 13. Dudas V, Bookwalter T, Kerr KM et al. The impact of follow-up telephone calls to patients after hospitalization. Am J Med. 2001; 111:26S-30S.
14. Jack BW, Chetty VK, Anthony D et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009; 150:178-87. 15. Al-Rashed SA, Wright DJ, Roebuck N et al. The value of inpatient pharmaceutical counseling to elderly patients prior to discharge. Br J Clin Pharmacol. 2002; 54:657-64. 16. Clancy CM. Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction. Am J Med Qual. 2009; 24:344-6. 17. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2012. Am J Health-Syst Pharm. 2013; 70:787-803. 18. Flynn EA, Barker KN, Berger BA et al. Dispensing errors and counseling quality in 100 pharmacies. J Am Pharm Assoc. 2009; 49:171-80. 19. American Society of Health-System Pharmacists. ASHP guidelines on pharmacistconducted patient education and counseling. Am J Health-Syst Pharm. 1997; 54:431-4. 20. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2009. Am J Health-Syst Pharm. 2010; 67:54258. 21. College of Psychiatric and Neurologic Pharmacists. March 2014 update: CPNP supports the following definition of patient medication education group. http://cpnp.org/resource/mhc/2013/03/ medication-education-task-forceproviding-valuable-resources-cpnpmembers (accessed 2014 Mar 19). 22. Gray DR, Namikas EA, Sax MJ et al. Clinical pharmacists as allied health care providers to psychiatric patients. Contemp Pharm Pract. 1979; 2:108-16. 23. Norman S, Davis E, Goldstone LW. Impact of pharmacist-led or co-led medication education groups on patient outcomes: a literature review. http:// cpnp.org/resource/mhc/2012/10/impactpharmacist-led-or-co-led-medicationeducation-groups-patient-outcomes (accessed 2014 Mar 5). 24. Martin OJ, Wu W, Taveira T et al. Multidisciplinary group behavioral and pharmacologic intervention for cardiac risk reduction in diabetes: a pilot study. Diabetes Educ. 2007; 33:118-27. 25. Hunter KA, Bryant BG. Pharmacists provided education and counseling for managing pediatric asthma. Patient Educ Couns. 1994; 24:127-34. 26. Hawe P, Higgins G. Can medication education improve the drug compliance of the elderly? Evaluation of an in hospital program. Patient Educ Couns. 1990; 16:151-60. 27. Gallefoss F, Bakke PS. How does patient education and self-management among asthmatics and patients with chronic
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