Intervention

Protocol

This protocol has been designed for early-career occupational therapists (i.e. occupational therapy students) and has several features included to facilitate clinical reasoning. Additionally, several logistical steps (i.e. retieving clients from the waiting room) have been included to ensure consistency between interventionist and again to facilitate early-career occupational therapists. The intervention protocol has 13 steps. Five steps are logistical, and eight steps are content driven skilled services. Each step will be denoted as skilled or logistical. The interventionist must cover all 13 steps in every intervention, but interventions will be tailored to the client. This means that clients may spend different amounts of time on each part of the intervention. Further, different strategies may be endorsed. For example, three clients may discuss assistive technology, but one may choose to try a pillbox, another may use a smartphone app, and a third may engage their watch alarm.

Step 1: Chart Review & Conceptualize treatment (Skilled)

The first step is to better understand the client and to create an initial treatment plan. The Pre-Intervention Worksheet will prompt the interventionist to think through a series of questions to develop the occupational profile and treatment plan. Interventionists must fill out the Pre-Intervention worksheet for each client, prior to intervention. Click here to download the Pre-Intervention Worksheet.

The occupational profile evaluates "the client's needs, problems, and concerns about performance" in medication management (AOTA, 2014, p. S13). The client's responses to the Occupational Profile Interview. To conceptualize the occupational profile, think about the following points:

The client's health condition, symptoms, and medication side effects and their effects on medication management
Complexity and frequency of medication dosing schedule
Client's current strategies for medication management and their effectiveness
Client's home environment
Client's social support
Strengths supporting medication adherence
Weaknesses limiting medication adherence

Once you understand the client's current situation, develop a preliminary intervention plan. You should also look for themes across assessments. For example, does the client have trouble reading medication labels in the Pillbox Test and the Medication Knowledge Assessment? The plan should include...

Specific intervention categories (discussed below) and strategies anticipated to be effective
Environmental factors that would change the intervention (e.g. children)
Anticipated barriers to a successful intervention

Once the occupational profile and preliminary intervention plan are complete, you are ready to begin the intervetnion.

Step 2: Reports Client's Current Adherence (Skilled)

Tell the patient about his or her current level of adherence (i.e. the percentage). You may determine the client's adherence level by looking at the pill count or based on his/her responses to the Adherence to Refills and Medications Scale.

Translate the adherence percentage into a more tangible number. For example, you may talk about the number of pills or doses a client misses each month or week. The goal of translating the percentage is to make the number more meaningful to the client.

Ask the client to verify their adherence information. This will give your some indication as to the client's insight and may help incorporate client buy-in.

Example Dialogue:

"So in this study we are looking at how well people take their medications. We asked you to keep a diary of your medications to look at how well you take your medications on a daily basis. Can you show me your medication diary?

So it seems like you are taking about 60% of your pills. So in a typical week you are supposed to take about 56 pills and this means that you are missing about 22 pills a week. Because you seem to take about 4 or 5 pills at a time that means you are skipping about or about 4-5 doses of your medication in a week. Does that seem about right to you?"

Step 3: Elicit a Commitment to Change (Skilled)

Once the medication adherence deficit has been identified, you must next get the client's buy-in to change behavior. This step highly leverages the motivational interview technique. Remember that it is preferable for the client to self generate ideas. Therefore, attempt to ask open ended questions to get the client to commit to better taking their medications.

For clients who do not believe their medications are effective may have difficulties with choosing to increase their medication adherence and may need a series of probing questions to problem solve through this process.

Here are some examples of probing questions and statements that you might use in this stage:

"Do you think it is important to take your medications?"

"Do your medications help you to feel better?"

"Do your medications help to control your [health condition]?"

"So it seems like you are having some difficulty taking all of your medications. I wonder if there is anything we could do about that?"

"On a scale of 0-10 with 10 being really confident, how confident are you that you can better take your medications?"

"Do you think you can try to take more of your medications?"

"The last time you met with us, you were telling us about your [insert health condition symptoms here - e.g. edema], does that change at all when you take your medication?"

"It seems like you are starting and stopping your medication, I wonder what would happen it you were on it consistently?"

"Did you know that your medications are really important and can protect you from having a stroke or heart attack?" [Would need to tailor to clients medication regimen].

Step 4: Goal Setting (Skilled)

Once the client commits to making a change, ask them to set a specific goal related to talking their medication The goal should be Specific, Measurable, and Time-Bound. The goal should be realistic and client-centered. Therefore, a client with a baseline adherence a 50% may have a different goal than another client whose baseline adherence is 70%.

Step 5: Discuss Strategies to Reach Goal (Skilled)

Once a client has decided to change their behavior and has verbalized his or her goal, the next step is to figure out strategies to help the client reach the goal. Counseling the client about their health condition, medications, and basic health literacy are commonly used interdisciplinary strategies that will be applied in this intervention. In addition to these general counseling strategies, this intervention will also provides services unique to occupational therapy. Interventionist will help clients develop activity-based cues, alter the environment, provide assistive technology, and work to develop an effective system to ensure timely refills.

Overall there are six different strategies. Interventionist must review all six strategies with each client in some capacity. The amount of time spent on each strategy and the order of presentation is up to the interventionist based on their clinical reasoning after reviewing the participants initial evaluation. Within each strategy there are sub-strategies. For example, within the assistive technology strategy there is the sub-strategy of using low tech notes and checklists and the sub-strategy of using smartphone apps. While each strategy must be discussed, the sub-strategies should only be discussed when it makes sense based on the clinical reasoning of the interventionist. For example, only clients with smartphones should discuss the sub-strategy of using apps.

When you and the client decide on a new intervention strategy to try, be sure to use the teach-back method before moving on to the next type of intervention strategy. So for example, ask the client to tell you about about the information they learned in the education strategy prior to moving on to talking about health literacy.

Example Dialogue:

“So we talked a little bit about why taking medications is important and your goal in taking medications for the next two months, now lets think about some strategies for helping you reach your goal.”

Click on the buttons below to learn more about each strategy, to review handouts, and identify specific intervention techniques.

Welcome to the intervention protocol page. In this page, you will learn about the background of the intervention, basic skills used throughout the intervention, and the protocol for implementing the intervention. Briefly, in the intervention the researcher discusses the client's current medication adherence level, asks the client to improve their adherence by setting a goal and identifying strategies to reach his or her goal. While this intervention seems simple, as you will see it is supprisingly complex to implement.

Background

This section discusses how the intervention was developed and why it is anticipated to be effective.

How was the intervention developed?

The intervention was developed after a thorough review of the medication adherence literature and is based on best practices in occupational therapy and the PI’s clinical experiences. As this intervention is intended for occupational therapy practitioners, Sanders and Van Oss's 2013 recomendations to the profression have been highly utilized to develop this intervention. In their article, the authors recommended that occupational therapists complete interventions that "develop specific, individualized, concrete plans for integrating medication into daily routines." This intervention fulfills all of those recomendations.

Why is this intervention anticipated to be effective?

This intervention leverages techniques shown to be effective in other studies. The Cochrane Review on medication adherence is one of the largest in the Cochrane database. The PI reviewed all of the interventions included in the Cochrane review to find themes consistent in effective interventions. In general, effective interventions...

Are complex (i.e. they address several deficits)
Are tailored to the clients needs
Are delivered by allied health professionals
Include education
Include motivational interviewing
Have follow-ups

This intervention includes all of the above characteristics of effective interventions.

Basic Skills Used Throughout the Intervention

There are four basic occupational therapy skills that are leveraged in this intervention, client-centered care, complex interventions, motivational interviewing, health literacy. These are intervention techniques that are not a specific step in the protocol, but are used throughout the intervention. This section highlights each of the four basic skills.

Client-Centered Care (i.e. Tailored)

American Occupational Therapy’s Practice Framework defines client-centered care as an “approach to service that incorporates respect for and partnership with clients as active participants in the therapy process. This approach emphasizes client’s knowledge and experience, strengths, capacity for choice, and overall autonomy” (AOTA, 2014). Commonly, other medication adherence interventions use a one-size-fits-all approach. In this intervention however, the client is in the driver’s seat and the interventionist is there to help guide the client through the process. Further, because of the thorough initial evaluation, the interventionist can better understand the client’s current knowledge and past experiences to better tailor the intervention to “meet clients where they’re at.”

Complex Interventions

Too often, current interventions for medication adherence are one-dimensional and, for example, function on one domain (such as education). As occupational therapist’s know, occupation (such as medication adherence) is a multidimensional issue and barriers across domains can affect a client’s performance in this activity. Specifically, the Occupational Therapy Practice Framework states that occupational performance (i.e. managing medications) is the result of a “dynamic interaction among client factors, performance skills, performance patterns, and context and environments, along with the activity demands of the occupation being performed” (p. S11). Similarly, the World Health Organization (2003) posits that medication adherence is a complex activity that is affected by 5 factors:

1. Social & Economic factors – e.g. socioeconomic status, poverty, illiteracy, education, employment etc.

2. Health Care Related Factors – e.g. patient-provider relationship, provider training on working with chronic conditions, time spent with the client, etc.

3. Condition Related Factors – e.g. symptom severity, level of disability, rate of profess, availability of effective treatments, etc.

4. Therapy Related Factors – e.g. complexity of the medication regimen, duration of treatment, effectiveness of treatment, immediacy of the beneficial effects, side effects, etc.

5. Patient Related Factors – e.g. client’s knowledge, beliefs, self-efficacy, motivation, etc.

No matter what framework is used, professional organizations are recognizing that medication adherence is a multidimensional issue. For this reason, this intervention has six different types of intervention strategies that work on all domains listed in the WHO and the OT frameworks.

Motivational interviewing

Motivational interviewing is a technique to help clients with behavior change. This technique is commonly used in OT (Shannon, 2009). Often, healthcare professionals are tempted to tell the clients the “right” answer, but the research shows that clients are more likely to be convinced by their own ideas than by being told by a therapist. Therefore, motivational interviewing is an alternative to “advice giving” education. In this intervention, motivational interviewing is blended throughout the session. It is assumed that the research assistants/interventionist have taken (or are enrolled in) the Therapeutic Communications course, where they have had time to practice this technique. Briefly though, motivational interviewing encourages the therapist to use the OARS:

Asking Open-ended questions
Affirming the patient
Reflective listening
Summarizing

For interventionist, if you need a refresher on motivational interviewing you can read “Motivational Interviewing: Enhancing Patient Motivation for Behavior Change” and/or you can watch this video of a physician using motivational interviewing in his practice.

Health Literacy

Several strategies for good health literacy have been included throughout the intervention. Information, particularly strategies for change, should presented verbally and with written notes or handouts. The written materials included in the intervention are composed at a Flesch-Kincaid Reading level of 6th-grade or lower in large easy to read font to ensure optimal readability for clients.

In addition to having written and verbal materials, the teach-back method will be used to check for client learning. Briefly, health literacy studies show that clients forget about half of the things health care providers tell them. The teach-back method is an evidence based strategy where clients repeat the information they just learned in their own words. This strategy gives the interventionist the opportunity to find out how well he or she has presented the information, and gives the client and interventionist the opportunity to go over areas where information has not been retained.

The teach-back method should be utilized after discussing intervention strategies and at the end of the session. To engage in the teach-back strategy ask the client to demonstrate understanding using their own words. Click here for more information on the teach-back method. Below are some example prompts that you may use to engage in the teach back process

“I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did?”
“We’ve gone over a lot of information. In your own words, please review what we talked about. How will you make these changes to your medication management strategies work at home?”

Step 6: Review Session, Check for Questions and Understanding (Skilled)

Once you have made it to this portion of the intervention, you and the client have probably talked about a number of different things. In this step you will summarize all of the different things that you and the client talked about and make sure that the client understood the discussion by using the teach back method.

Begin by providing a brief verbal description of what you discussed in the session. Be sure to include the following...

Clients current performance in taking medication
Clients goal related to talking medicaation
All of the strategies talked about during the session

Example Dialogue:"As we reach the end of our time here, I just want to review what we talked about. When we looked at you medication adherence we found that you were missing about 4-5 doses a week. You mentioned that you would like to get better at taking your medications and that your goal is to take 80% of your pills for the next two months. We talked about a number of different strategies such as putting your morning meds by the coffee maker, using a pill box, ... Does this sound about right to you?"

After you provide the summary, implement the teach back method and ask the client to provide a summary as well. Below is some example dialogue. Try to stick relatively close to this specific prompt.

Example Dialogue:"So I know we talked about a lot of information today. I just want to make sure we are on the same page. Can you tell me what changes you plan on making to your medication routine over the next few days?"

Be sure to address any inconsistencies or areas of poor understanding you see in the client's report.

Then ask the client if he or she has any questions before the end of the session.

Example Dialogue: "What questions can I answer before we end today?"

Remind the client that you will work with them to see how it is going and refine strategies in the future.

Step 7: Document Session (Skilled)

Document session and clinical reasoning in the Post-Intervention Worksheet. Click here to download the Post-Intervention Worsheet. This includes documentation of the following points...

Creating a problem list
Describing the client's goal adherence rate
Intervention strategies discussed for all six intevention strategy areas
Interventionist's reflections on the session

Step 8: Try Strategies for Two Weeks

After the intervention, the client is given two weeks to try the strategy out at home. This allows the client to see how easy or hard it is to implement various strategies. No action is needed from the interventionist.

Step 9: Follow-up

During the follow-up, the interventionist should inquire about all of the strategies agreed upon during the initial evaluation. If a client has not yet implemented a strategy or if a client started using a strategy, but was not able to continue with it, then use motivational interviewing to help the client adjust or modify the plan.