Impact statements
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Teach-back medication counselling at hospital discharge increases patients’ satisfaction and confidence regarding medication knowledge.
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Providing written information about medications alongside verbal teach-back counselling from pharmacists is important for patients, and acts as a useful reference point after hospital discharge.
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Pharmacists found this teach-back counselling technique is feasible to deliver at hospital discharge, but the time requirements may necessitate additional staffing.
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Having a finalised discharge medication plan is key before providing teach-back medication counselling prior to hospital discharge.
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This study’s standardised teach-back procedure and the details regarding training should help guide the development of future medication counselling services.
Introduction
Aim
Ethics approval
Method
Study context and setting
Study design
Intervention development, patient recruitment, and data collection
Pharmacist training on intervention
Prioritisation criteria
Patient eligibility and recruitment
Data collection
Standardised intervention
Intervention evaluation
Patient telephone survey
Pharmacist survey
Data analysis
Results
Patient characteristics
Descriptor | n (%) |
---|---|
Gender | |
Female | 22 (68.8) |
Male | 10 (31.3) |
Age in years, mean (SD; range): 56.5 (18.3; 19–91) | |
Age categories | |
< 45 years | 10 (31.3) |
45–64 years | 10 (31.3) |
≥ 65 years | 12 (37.5) |
Length of stay in days, mean (SD; range): 10.3 (7.6; 0–34) | |
Previous hospital admission within 1 year | 11 (34.4) |
Co-morbidities, mean (SD; range): 2.7 (2.1; 0–8) | |
Co-morbidities prior to admission, | |
0 | 5 (15.6) |
1 | 6 (18.8) |
2 | 5 (15.6) |
3–4 | 10 (31.3) |
≥ 5 | 6 (18.8) |
Charlson Comorbidity Index, mean (SD; range): 3 (2.4; 0–8) | |
Medical Specialty | |
Gastroenterology | 8 (25) |
Respiratory | 5 (15.6) |
Rheumatology | 5 (15.6) |
Age-related healthcare | 4 (12.5) |
Endocrinology | 4 (12.5) |
Acute medical unit | 3 (9.4) |
Haematology | 2 (6.3) |
Neurology | 1 (3.1) |
Prioritisation criteria | |
High-risk medication | 19 (59.4) |
Priority education medication | 19 (59.4) |
Multiple changes to prescription | 14 (43.8) |
Polypharmacy | 7 (21.9) |
Medication administration education | 7 (21.9) |
Professional judgement | 5 (15.6) |
Other | 4 (12.5) |
Complex medication regimen | 2 (6.3) |
Compliance Issues | 1 (3.1) |
Medication counselling components discussed with patients | |
Medication Name | 31 (96.9) |
Dose | 31 (96.9) |
Frequency | 32 (100) |
Duration | 30 (93.8) |
Indication | 32 (100) |
Side effects | 32 (100) |
Special Instructions | 30 (93.8) |
Reason for medication changes | 26 (81.3) |
Written Resources provided to patients | |
Changes to my medication list | 32 (100) |
Anticoagulant card† | 15 (46.9) |
Patient information leaflet for a medication† | 13 (40.7) |
Anticoagulant book† | 11 (34.4) |
Steroid card | 5 (15.6) |
Stroke booklet | 2 (6.3) |
Asthma Society of Ireland Respimat® information | 1 (3.1) |
Epipen® booklet† | 1 (3.1) |
Gabapentin information for menopausal symptoms | 1 (3.1) |
Latent tuberculosis information from HSE | 1 (3.1) |
Thrombosis Ireland apixaban information leaflet | 1 (3.1) |
Discharge medication counselling
Medication type (Anatomical Therapeutic Chemical Classification) | n (% of total patients) |
---|---|
Antithrombotic agents (B01) | 22 (68.8%) |
Apixaban (B01AF02) | 6 |
Rivaroxaban (B01AF01) | 5 |
Clopidogrel (B01AC04) | 3 |
Aspirin (B01AC06) | 3 |
Edoxaban (B01AF03) | 3 |
Warfarin (B01AA03) | 1 |
Enoxaparin (B01AB05) | 1 |
Drugs for peptic ulcer and gastro-oesophageal reflux disease (A02B) | 8 (25%) |
Pantoprazole (A02BC02) | 5 |
Omeprazole (A02BC01) | 1 |
Lansoprazole (A02BC03) | 1 |
Sucralfate (A02BX02) | 1 |
Beta blocking agents (C07) | 7 (21.9%) |
Bisoprolol (C07AB07) | 5 |
Metoprolol (C07AB02) | 1 |
Nebivolol (C07AB12) | 1 |
Calcium Channel Blockers (C08) | 5 (15.6%) |
Lercanidipine (C08CA13) | 3 |
Amlodipine (C08CA01) | 2 |
ACE inhibitors (C09A) | 5 (15.6%) |
Ramipril (C09AA05) | 4 |
Perindopril (C09AA04) | 1 |
Vitamin Preparations (A11) | 4 (12.5%) |
Multivitamin (A11AA03) | 1 |
Vitamin B Complex (A11BA) | 1 |
Thiamine (A11DA) | 1 |
Pyridoxine (A11HA02) | 1 |
Blood Glucose Lowering Drugs (A10B) | 4 (12.5%) |
Gliclazide (A10BB09) | 2 |
Metformin (A10BA02) | 1 |
Sitagliptin (A10BH01) | 1 |
Diuretics (C03) | 3 (9.4%) |
Bumetanide (CO3CA02) | 2 |
Spironolactone (C03DA01) | 1 |
Drugs for obstructive airway diseases (R03) | 3 (9.4%) |
Tiotropium bromide (R03BB04) | 1 |
Vilanterol, umeclidinium bromide, and fluticasone furoate (R03AL08) | 1 |
Formoterol and budesonide (R03AK07) | 1 |
Antiepileptics (N03) | 3 (9.4%) |
Sodium valproate (N03AG01) | 1 |
Gabapentin (N03AX12) | 1 |
Levetiracetam (N03AX14) | 1 |
Lipid Modifying Agents (C10) | 3 (9.4%) |
Atorvastatin (C10AA05) | 3 |
Corticosteroids (systemic)
(H02) | 3 (9.4%) |
Prednisolone (H02AB06) | 3 |
Antibacterials for systemic use (J01) | 3 (9.4%) |
Amoxicillin (J01CA04) | 2 |
Co-trimoxazole (J01EE01) | 1 |
Antihypertensives (C02) | 2 (6.3%) |
Doxazosin (C02CA04) | 2 |
Antipsychotics (N05) | 2 (6.3%) |
Levomepromazine (N05AA02) | 1 |
Quetiapine (N05AH04) | 1 |
Immunosuppressants (L04) | 2 (6.3%) |
Fingolimod (L04AA27) | 1 |
Methotrexate (L04AX03) | 1 |
Other | 15 (46.9%) |
Patient telephone survey
Statement | Agree | Undecided | Disagree |
---|---|---|---|
It is important to get information about changes to my medications before I leave hospital | 100% (n = 32) | - | - |
It is important to get information about possible side effects of my medications before I leave hospital | 96.9% (n = 31) | - | 3.1% (n = 1) |
Before I went home, the pharmacist spent enough time with me explaining my medications | 87.6% (n = 28) | 6.3% (n = 2) | 6.3% (n = 2) |
The pharmacist explained the purpose of my medications, in a way which I could understand | 93.7% (n = 30) | 3.1% (n = 1) | 3.1% (n = 1) |
The pharmacist explained how and when to take my medications at home, in a way which I could understand | 93.7% (n = 30) | 3.1% (n = 1) | 3.1% (n = 1) |
Possible side effects of my medications to watch out for when I went home were explained, in a way which I could understand | 90.6% (n = 29) | - | 9.4% (n = 3) |
Changes to my medications were explained to me in a way which I could understand | 93.7% (n = 30) | 3.1% (n = 1) | 3.1% (n = 1) |
The written or printed information I received in hospital (e.g., ‘Changes to my Medication list’) helped me to understand my medications when I went home | 93.7% (n = 30) | - | 6.3% (n = 2) |
I am more confident about my knowledge of my medication after my discussion with the pharmacist in hospital | 93.7% (n = 30) | - | 6.3% (n = 2) |
Theme | Comments |
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1. Clarity and understanding | |
Patients valued the information and clarity of explanation, which improved their understanding of medication use, indication, and side effects This helped reduce previous confusion, and provided reassurance and confidence to manage medication Some, however, still did not understand, even with the teach-back counselling | “I was given crystal clear instructions on how to take my new tablet… I found the advice given to me in hospital just brilliant…” [Patient 11] “Education is amazing for patients…” [Patient 23] “I understand all my medicines that I take at home now” [Patient 17] “…it was the first time I knew what my tablets were all about.” [Patient 9] “When I go home from hospital, I feel it is very important for me to be aware of the medication side effects and what medication interacts…” [Patient 12] “…made me aware of the reason I was put on Eltroxin®; I did not know was it for under- or over-active thyroid. I was confused until I was told.” [Patient 10] “I am confident to manage my tablets at home” [Patient 23] “ …The pharmacist put my mind at rest…” [Patient 27] “…needed to explain the information a bit more.” [Patient 18] “…I did not know that I had to take new tablets… I should have been told…” [Patient 21] |
2. Information provision before discharge | |
The importance of medication counselling before discharge was noted; some said it should be provided to all patients. The time provided was not sufficient for everyone, with community pharmacist involvement mentioned | “This is a great idea. I wish I could get all this information every time I visit the hospital.” [Patient 6] “People should be spoken to every time in hospital and explained why their tablets have changed.” [Patient 9] “When I went home to my chemist, I was not confused. I was able to tell them about the change to my Rx.” [Patient 11] “…I needed more time to be told about my tablets…my local chemist had to explain again…” [Patient 18] “I am very happy with the time
taken to advise me on my medication.” [Patient 22] |
Too close to discharge may not be the most suitable time for counselling as patients may be unwell or distracted, and may find the information excessive | “Very rushed as I was waiting to be discharged (porter and my husband waiting for me). Therefore, I did not take in information and could not concentrate on what pharmacist was saying. I suggest to get advice about medicines earlier during stay and not at discharge.” [Patient 7] “I can't remember much of the pharmacist talking to me as I was a bit upside down in hospital…” [Patient 20] “I don't think it is important for me to learn about side effects of my tablets. This is too much information to take in…” [Patient 28] |
Written information was easy to understand and supported the verbal counselling. It was useful as a point of reference at home, especially with the possibility of forgetting | “The list of my new medication was very clear and easy to follow…” [Patient 22] “Excellent documentation helped me to understand new medication.” [Patient 4] |
“The form acted as a reminder how to take my tablets when I went home. I think everybody should get written information…” [Patient 5] | |
“The warfarin booklet is very useful to refer to.” [Patient 27] If I received no written sheet, I would be very confused. [Patient 6] | |
“…I did not refer to the leaflet, as I felt I knew enough about my tablets…” [Patient 7] | |
3. Pharmacist approach and performance | |
Patients were very satisfied with the service overall. They appreciated the value of teach-back and repeating instructions, and that the pharmacists took time to ensure understanding and answer any questions where needed | “Very happy with the service.” [Patient 2] “I am 100% satisfied with the advice”. [Patient 6] “…it was a "brilliant experience." [Patient 10] |
“…helped me to understand in a clever way, by checking and asking me to tell her in my own way…” [Patient 11] | |
“…made sure to check a number of times that I understood the information explained to me about my new medicine.” [Patient 15] | |
“I appreciate the time taken to explain my new medication”. [Patient 12] “The advice given was not rushed.” [Patient 9] | |
“The pharmacist was excellent; she answered all my questions…” [Patient 22] “I liked that I could ask questions without feeling stupid…” [Patient 27] | |
“I was made feel very important and the pharmacist had great respect for me as a patient…” [Patient 9] | |
Pharmacists were perceived as professional, helpful, friendly, and easy to talk to – but the importance of not using jargon was noted | “The pharmacist was very professional, very helpful, clear, and brilliant at her job…” [Patient 8] “…easy to talk to, she had a friendly manner.” [Patient 13] |
“She explained my new medication in layman's terms. I am very happy with the information as I never took a tablet in my life.” [Patient 8] | |
“She used jargon that professionals speak that I could not understand.” [Patient 18] |
Pharmacist survey
Theme | Comments |
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1. Implications for patient care | |
Potential to improve patients’ adherence, knowledge, and confidence with medication | “It was apparent that my counselled patients felt that the information provided was beneficial and they seemed more confident / knowledgeable on their medicines on discharge.” [Pharmacist 4] |
“It gives the opportunity to pharmacists to make a real difference around adherence…” [Pharmacist 3] | |
Patient gratitude with intervention | “Feedback received from patients was mostly positive… There were obvious gaps in her knowledge, even after applying teach-back.” [Pharmacist 5] |
“I found the people I educated to be so very grateful for the information, and I believe that the education will have a positive impact on their compliance and adherence in the future.” [Pharmacist 2] | |
Effective counselling method, and highlighted patients’ need for discharge counselling | “…was more of an effective method of counselling than current practice…” [Pharmacist 6] |
“This project proves there is a need for patient counselling on discharge…” [Pharmacist 5] | |
Some patients found it challenging | “The teach-back method seems useful, but for those patients who could not relay the information back it was very challenging.” [Pharmacist 3] |
Focus distracted by imminent discharge | “On one occasion, the patient’s NOK was downstairs waiting – it’s questionable as to how much the patient actually paid attention to the counselling session as she was very eager to leave.” [Pharmacist 5] |
2. Impact on pharmacist practice | |
Beneficial for pharmacists: learning new technique; increased job satisfaction; increased patient contact; highlights pharmacist's role | “It’s a great experience for pharmacists to learn a new counselling technique…” [Pharmacist 8] |
“I didn't expect that discharge counselling would increase my job satisfaction as a pharmacist; while some patients clearly benefit more than others, I feel that it is an important aspect of our role.” [Pharmacist 4] | |
“…I really enjoyed the additional contact time with patients… I do believe these are very worthwhile and gratifying activities for pharmacists… and also makes patients actually 'see' our input as opposed to always being invisible in the background!” [Pharmacist 3] | |
Need to focus on medication counselling in future practice balanced against workload | “I love the overall idea of using the teach-back method of communication… However, this is not very feasible with our workload at present… I was always stressed about not being on top of workload… …more focus is needed from the pharmacy side on counselling, as it is a crucial area for us as medical professionals, and would often help prevent readmissions or medical issues happening in the future for patients.” [Pharmacist 2] |
3. Environmental challenges | |
Time constraints, busy workload, and need for additional staffing for intervention | “…very time consuming getting leaflets together for discharge counselling…” [Pharmacist 1] |
“…undertaking discharge is time consuming and would require additional staffing.” [Pharmacist 4] | |
“Time constraints was another limitation, a heavy patient workload in addition to other responsibilities made it difficult to complete the tasks required.” [Pharmacist 5] | |
“The main limitation is time. It would be amazing to be in a position to counsel every patient on new medication on discharge but we don't currently have the time to do this for all patients, only high-alert medications such as anticoagulants.” [Pharmacist 8] | |
Need for finalised discharge medication plan and clear communication on this | “…medical team at times do not communicate effectively when patients are ready for discharge and discharge medications are not finalised for the pharmacists to know what to counsel on.…” [Pharmacist 7] |
“…counselling a patient without a discharge prescription in hand is inherently a risky process—diuretic doses often change last minute in CCF patients; decisions about whether to restart medications (e.g. antihypertensives withheld during an in-patient stay) will often be made at the last minute.” [Pharmacist 4] | |
“Patients were counselled immediately before discharge to ensure no further changes to the medications occurred.” [Pharmacist 5] | |
Discharge timing: patients discharged outside pharmacist working hours | “Great initiative but tricky to implement in practice. Found lots of patients discharged after pharmacist working hours and decisions still to be made about discharge medications meant that it was not feasible to counsel without concrete plan.” [Pharmacist
1] |
Difficulties in recruiting eligible patients or in completing the intervention with those eligible | “Locating patients posed problematic also. On numerous occasions, patients were enlisted into the project but due to unforeseen circumstances their discharge was postponed. This made the data invalid.” [Pharmacist 5] |
4. Suggestions for improvement | |
Need for discharge medication reconciliation | “…discharge counselling cannot be done fully without some element of pharmacist discharge medication reconciliation. In my view, both are quite interlinked unless counselling on just one medicine in isolation, but this is difficult as naturally enough patients often ask about other medications.” [Pharmacist 3] |
Pharmacist aiding with discharge prescription | “If pharmacists were undertaking medication reconciliation on discharge and / or generating the discharge prescription plus counselling as part of the discharge process, some of these issues may be ironed out.” [Pharmacist 4] |
Having patient carer/relative present | “It may be beneficial to have NOK/carer etc. present at the counselling when COVID restrictions are lifted.” [Pharmacist 3] |
Availability of generic counselling information Partnership with community pharmacists | “…risk of patient getting different brand on discharge and causing confusion. Wonder is it better to have generic information available or perhaps look at engaging community pharmacists on discharge counselling.” [Pharmacist 1] |
Synchronous/in-person pharmacist training | “A 'live' training might better upskill pharmacists on how to apply the teach-back method… I understand this was not possible with COVID.” [Pharmacist 3] |