Greetings colleagues:
I have a challenging problem, and I hope you can provide some feedback and resources that might be helpful.
Our state pharmacy society is working on refining some existing criteria that allows individuals to qualify for a Comprehensive Medication Review (CMR/A) coverage under Medicaid (based on being identified as having low health literacy). A CMR/A is a longer sit down with the pharmacist to go over the medication regime in detail.
Having "established low health literacy" is one of the qualifying criteria that is currently in place. However, at this time, some patients are being denied services under the current criteria -- because they are fairly specific, but not necessarily comprehensive at this time. Here are the criteria that currently exist:
Health Literacy Criteria* (requires prior authorization from payer):
· Requires the use of a trained medical translator
· Is unable to demonstrate pill count(s)
· Is familiar with personal medications by color only
· Is unable to read or is suspected to have very low literacy
· Is suspected to have adherence problems due to low literacy
· Takes medications obtained from another country
Our pharmacy society has asked that we assist with the task of refining this list. Their goal is to be as inclusive as possible.
We have spoken in detail about the Universal Precautions approach, and they are very supportive of this idea. My initial instinct was to advise them to use the Universal Precautions approach with all encounters, and then leave it up to the pharmacist's discretion whether the patient was able to demonstrate understanding or whether they would benefit from a CMR/A.
However, on a practical level, there are a few issues with this. One is that the pharmacists themselves are not universally aware of health literacy issues, and I am told that having a list of criteria would help raise pharmacist awareness of what to look for. The other issue is that pharmacists are being asked to call in to obtain prior authorization to conduct a CMR/A, and that the criteria for inclusion needs to be more concrete for approval decisions to be made.
I feel stuck because I think any list is potentially limiting, not to mention the issues with pharmacists trying to assess literacy levels in a clinical environment, but I think this is a situation where we can help more people by making sure some people with low health literacy have access to additional services, even if we leave some people out, which we are bound to do if we try to create a list.
Your thoughts/advice/resources would be greatly appreciated!
Thanks,
Erin
Comments
Sounds like you're doing a great job of educating your pharmacy board, Erin. You might find the resources in the AHRQ Pharmacy Health Literacy Center (URL currently http://www.ahrq.gov/legacy/pharmhealthlit/index.html but may change shortly due to Web site redesign) helpful as you continue those efforts.
The current criteria aren't too terrible. I'd make the following changes:
These changes would really allow the pharmacist to deliver CMR to anyone he or she feels needs it because of health literacy issues. If pharmacists were trained to ask all patients to show them how they'll take their medicine, you'd have made tremendous progress. (You can tell the Pharmacy Board about the health literacy curricula modules for pharmacist in the AHRQ Pharmacy Health Literacy Center.) Another important thing, however, would be to eliminate the requirement for pre-authorization. I suspect that decision is not in the hands of the pharmacy board, but rather the Medicaid agency or even the Medicaid health plans.
Keep up the good work and good luck!
Thanks for the feedback, Cindy! This was very helpful.
My experience at our local pharmacy is that the pharmacist is rarely (if ever) the front line employee. Pharm techs and other staff (often check out staff from other parts of the store) give me my prescription and check me out. They rarely ask if I want counseling, instead just saying "sign here".
My thoughts are that this role of assessing literacy is, then, one that all pharmacy employees should be trained on. Perhaps only the pharmacist should actually do the patient teaching, but the front line emoyees should have these assessment tools as part of their set of job skills.
The issue confidentiality also comes tO mind- I think it would be problematic for patients if their literacy level is assessed at the check out counter. It's not clear to me from your comments if both this issue and the amount of time this will take per patient are being considered and included as part of this work.
Erin,
Thanks for opening this up to the listserv.
To your resources, I'm going to suggest check out 10-secondMedSchool - which has examples of Rx directions open to interpreation.
To your point about pharmacists not realizing/knowing health literacy issues, there's so much that can be mis-interpreted by the patient/client/custormer/person:
The husband and wife who both took her birth control pills;
The woman who came with a bleeding rectum, saying 'I cant use these suppositories' and learning she hadn't removed the sliver wrapping.
Would that pharmacists had on display, for example (and nailed to the counter),
examples of teaspoon, tablespoon, drop and dropper-ful. List of what 'liquids' and illustrate what 'plenty' means when the instruction says: take with plenty of liquids.
Health literacy isn't just dependent on level of schooling or sophistication.
Kathy Kastner
blogger and curator
BestEndings.com
Ablity4Life.com