Medication Medication Discussion Discussion GroupGroup

Kathlyn DavisKathlyn DavisJulie FortJulie Fort

Thomas Jefferson UniversityThomas Jefferson UniversityNU 425 Community Health NursingNU 425 Community Health Nursing

Pathways to Housing is a Pathways to Housing is a non-profit organization non-profit organization founded in 1992 by Dr. Sam founded in 1992 by Dr. Sam Tsemberis (from Columbia Tsemberis (from Columbia University, NY)University, NY)

TThe mission of Pathways to he mission of Pathways to Housing is to transform Housing is to transform individual lives by ending individual lives by ending homelessness and homelessness and supporting recoverysupporting recovery

The The Pathways Housing FirstPathways Housing First program is based on the program is based on the belief that housing is a basic human right. People belief that housing is a basic human right. People should not have to prove that they are deserving of a should not have to prove that they are deserving of a home by first participating in treatment or by being home by first participating in treatment or by being clean and sober. Instead, Pathways to Housing moves clean and sober. Instead, Pathways to Housing moves people who are homeless and suffer from psychiatric people who are homeless and suffer from psychiatric disabilities directly from the streets into apartments of disabilities directly from the streets into apartments of their own, instantly integrating them into the their own, instantly integrating them into the community. Once living arrangements are stabilized, community. Once living arrangements are stabilized, they are able to take part in the variety of services they are able to take part in the variety of services that are available to help them recover and to be a that are available to help them recover and to be a productive/valuable members of society productive/valuable members of society (Pathways to (Pathways to Housing, 2010)Housing, 2010)

Location: 4040 Market Street, Philadelphia, 19104Location: 4040 Market Street, Philadelphia, 19104

NU424 Community Health NU424 Community Health Project: “Meducation” Project: “Meducation” Discussion GroupDiscussion Group

• Medication discussion forumMedication discussion forum• Objectives:Objectives:

• To increase participants’ knowledge of their To increase participants’ knowledge of their prescribed medicationsprescribed medications

• To help participants organize their daily To help participants organize their daily medicationsmedications

• To assist participants in identifying To assist participants in identifying strategies to adhere to their medication strategies to adhere to their medication regimensregimens

The Target DemographicThe Target Demographic

Pathways to Housing program Pathways to Housing program participantsparticipants– Men and womenMen and women– Formerly homeless PhiladelphiansFormerly homeless Philadelphians– > 18 years of age> 18 years of age– Chronically mentally illChronically mentally ill– Many have substance abuse disordersMany have substance abuse disorders– Many have co-morbid conditions Many have co-morbid conditions

hypertension, diabetes, CHF, arthritis, asthma, HIV/AIDS`hypertension, diabetes, CHF, arthritis, asthma, HIV/AIDS`

Facts about Medication Facts about Medication Compliance in Mentally IllCompliance in Mentally Ill

Poor adherence to psychiatric medication regimens is a Poor adherence to psychiatric medication regimens is a major obstacle to the effective care of persons who have major obstacle to the effective care of persons who have chronic mental illness chronic mental illness (Magura, Laudet, Mahmood, Rosenbloom, and (Magura, Laudet, Mahmood, Rosenbloom, and Kinght, 2002)Kinght, 2002)

55% of people with schizophrenia who do not take 55% of people with schizophrenia who do not take antipsychotic medication will relapse over the course of a antipsychotic medication will relapse over the course of a year compared to only 14% of those who adhere to year compared to only 14% of those who adhere to medication medication (Scott, 2000)(Scott, 2000)

60% of patients admitted with mania had failed to adhere to 60% of patients admitted with mania had failed to adhere to medication in the month prior to hospitalization medication in the month prior to hospitalization (Scott, 2000)(Scott, 2000)

In unipolar disorders, the 1-year relapse rates are 80% in In unipolar disorders, the 1-year relapse rates are 80% in patients not taking antidepressants and 30% for those who patients not taking antidepressants and 30% for those who adhere, yet 60% of patients stop their medication within 3 adhere, yet 60% of patients stop their medication within 3 months of beginning treatment months of beginning treatment (Scott, 2000)(Scott, 2000)

Reasons for Non-AdherenceReasons for Non-Adherence

• The single most significant reason why individuals The single most significant reason why individuals who suffer from mental illness fail to take their who suffer from mental illness fail to take their medication is because of their lack of awareness of medication is because of their lack of awareness of their illnesstheir illness

• Concurrent alcohol or drug abuse Concurrent alcohol or drug abuse

• Poor relationship between psychiatrist and patientPoor relationship between psychiatrist and patient

• Troublesome medication side effects Troublesome medication side effects

Medication adherence is often a key clinical goal in Medication adherence is often a key clinical goal in assertive community treatment within a broad-based assertive community treatment within a broad-based and vigorous program to deliver relevant psychiatric and vigorous program to deliver relevant psychiatric and rehabilitative services and rehabilitative services (Zygmunt, Olfson, Boyer & (Zygmunt, Olfson, Boyer & Mechanic, 2002)Mechanic, 2002)

Working Toward a ResolutionWorking Toward a Resolution

Increased efforts to facilitate adherence among Increased efforts to facilitate adherence among patients who live in the community are beneficial, patients who live in the community are beneficial, because better adherence is associated with less because better adherence is associated with less severe psychiatric symptoms and less need for severe psychiatric symptoms and less need for expensive interventions, such as hospitalization expensive interventions, such as hospitalization (Magura, Laudet, Mahmood, Rosenbloom, and Kinght, 2002)(Magura, Laudet, Mahmood, Rosenbloom, and Kinght, 2002)

Project DevelopmentProject Development

Wiki site Wiki site created created – Provided a place forProvided a place for

Convenient, organized communication Convenient, organized communication between group membersbetween group members

BrainstormingBrainstorming Delegation of tasksDelegation of tasks Storage Storage

– journal articlesjournal articles– project documentsproject documents

General Cultural ConsiderationsGeneral Cultural Considerations

It is important to become familiar with the characteristics It is important to become familiar with the characteristics and customs of most ethnocultural groups that we will and customs of most ethnocultural groups that we will be working with and sensitive to any differences be working with and sensitive to any differences (Pederson, 2008)(Pederson, 2008)

Some examples of how cultures differ:Some examples of how cultures differ: Eye contact varies across cultures (from conveying Eye contact varies across cultures (from conveying

respect in African American culture to disrespect in respect in African American culture to disrespect in Asian culture)Asian culture)

Men and women play different roles across cultures Men and women play different roles across cultures – Arab Americans: Men make most of the decisionsArab Americans: Men make most of the decisions– Asian Americans: Fathers and eldest sons make most of the Asian Americans: Fathers and eldest sons make most of the

decisionsdecisions– African Americans: Decision-making extends to extended African Americans: Decision-making extends to extended

familyfamily– Mexican Americans: Decision-making is shared by men and Mexican Americans: Decision-making is shared by men and

womenwomen The use of silence may convey distrust in some culturesThe use of silence may convey distrust in some cultures

Examples of Cultural Examples of Cultural Considerations in Mental Considerations in Mental HealthHealth African AmericansAfrican Americans

– Often distrustful of therapy and mental health servicesOften distrustful of therapy and mental health services May seek therapy because of child-focused concernsMay seek therapy because of child-focused concerns

– Seek help and support through “the church,” which provides a sense of Seek help and support through “the church,” which provides a sense of belonging and communitybelonging and community

– Therapy is for crazy peopleTherapy is for crazy people Mexican AmericansMexican Americans

– Church often provides supportChurch often provides support– Folk healers (curanderos) may be consulted for problems such as: evil Folk healers (curanderos) may be consulted for problems such as: evil

eye (mal de ojo) and fright (susto)eye (mal de ojo) and fright (susto) Puerto RicansPuerto Ricans

– Nominally Catholic, most value the spirit and soulNominally Catholic, most value the spirit and soul– Many believe in spirits that protect or harm and the value of incense and Many believe in spirits that protect or harm and the value of incense and

candles to ward off the “evil eye” candles to ward off the “evil eye” – Often underutilize mental health services, and therapist needs to Often underutilize mental health services, and therapist needs to

understand that expectations about outcome may differunderstand that expectations about outcome may differ Asian AmericanAsian American

– Six predictors of mental health problems are: 1) employment/financial Six predictors of mental health problems are: 1) employment/financial status, 2) gender (women more vulnerable), 3) old age, 4) social status, 2) gender (women more vulnerable), 3) old age, 4) social isolation, 5) recent immigration, and 6) refugee premigration experiences isolation, 5) recent immigration, and 6) refugee premigration experiences and postmigration adjustment and postmigration adjustment (Pederson, 2008)(Pederson, 2008)

Education/Grade Level Education/Grade Level ConsiderationsConsiderations

Health LiteracyHealth Literacy

In the report In the report Healthy People 2010Healthy People 2010, , Health literacy is defined as: Health literacy is defined as: "The degree to which "The degree to which individuals have the capacity individuals have the capacity to obtain, process, and to obtain, process, and understand basic health understand basic health information and services information and services needed to make appropriate needed to make appropriate health decisions.”health decisions.”

Skills Required for Health Skills Required for Health Literacy:Literacy:– Analyzing information for Analyzing information for

validity and accuracy validity and accuracy – Determining risks and benefitsDetermining risks and benefits– The ability to calculate The ability to calculate

dosagesdosages– Understanding test resultsUnderstanding test results

Vulnerable Populations at Risk Vulnerable Populations at Risk Include:Include:– Elderly (age 65+) Elderly (age 65+) – Minority populations Minority populations – Immigrant populations Immigrant populations – Low income Low income

Approximately half of Approximately half of Medicare/Medicaid recipients Medicare/Medicaid recipients read below the fifth-grade level (read below the fifth-grade level (http://http://www.medicarerights.org/mainconwww.medicarerights.org/maincontentstatsdemographics.htmltentstatsdemographics.html))

– People with chronic mental People with chronic mental and/or physical health conditions and/or physical health conditions

Recommendation for Education Recommendation for Education Material:Material:– Materials must be visually Materials must be visually

appropriate for visually impairedappropriate for visually impaired– Educational materials should not Educational materials should not

exceed 4th or 5th grade levelexceed 4th or 5th grade level– Graphics and language must Graphics and language must

meet need of diverse populationmeet need of diverse population

MCES ProgramMCES Program

Montgomery County Emergency Service, Montgomery County Emergency Service, Inc. served as foundation for our programInc. served as foundation for our program

Documents were obtained during Documents were obtained during previous community health rotationprevious community health rotation

Group Discussion ActivitiesGroup Discussion Activities

One hour open discussionOne hour open discussion– Why medications are Why medications are

importantimportant– How to better adhere to a How to better adhere to a

medication regimenmedication regimen Staying organizedStaying organized Tips for remembering to take Tips for remembering to take

medicationsmedications– Benefits and troublesome side Benefits and troublesome side

effects of psychotropic effects of psychotropic medicationsmedications

– Completion of wallet cardCompletion of wallet card– Presentation of medication Presentation of medication

binderbinder

Components of DiscussionComponents of Discussion

Open format of questions and answersOpen format of questions and answers– Some examples of questions:Some examples of questions:

What side effects of your medications are troublesome? What side effects of your medications are troublesome? Do you talk to your doctor about the side effects of your Do you talk to your doctor about the side effects of your medications? (social skills training)medications? (social skills training)

Where do you store your medications?Where do you store your medications? How do you remember to take your medications? How do you remember to take your medications?

(behavioral tailoring)(behavioral tailoring)– Reminders, self-monitoring tools, cues (pill box), and Reminders, self-monitoring tools, cues (pill box), and

reinforcementsreinforcements What do you do if you forget to take your medications?What do you do if you forget to take your medications? What stressful life events might affect your motivation or What stressful life events might affect your motivation or

ability to continue taking your medications?ability to continue taking your medications? Do you have someone who can support you in Do you have someone who can support you in

remembering to take your medications? How can you remembering to take your medications? How can you help your peers to remember to take their medications? help your peers to remember to take their medications? (peer counseling)(peer counseling)

Wallet CardWallet Card Long-Term Goal: For every PTH program participant to Long-Term Goal: For every PTH program participant to

complete onecomplete one

Medication BinderMedication Binder

To be stored in the library at PTHTo be stored in the library at PTH Includes information for 20 commonly prescribed psychotropic medications including:Includes information for 20 commonly prescribed psychotropic medications including:

Trade and generic name of medicationTrade and generic name of medication Photograph for easy identificationPhotograph for easy identification Side effectsSide effects ““What you should know”What you should know”

We believe that this binder would be a great project for future nursing interns to expand uponWe believe that this binder would be a great project for future nursing interns to expand upon

CELEXA (CITALOPRAM)CELEXA (CITALOPRAM)SIDE EFFECTS:SIDE EFFECTS:

Nausea, diarrhea, Nausea, diarrhea, vomiting, stomach pain, vomiting, stomach pain,

drowsiness, drowsiness, excessive tiredness, excessive tiredness,

uncontrollable shaking of a part ofuncontrollable shaking of a part of the body, excitement the body, excitement

nervousness , dry mouthnervousness , dry mouthmuscle or joint pain, muscle or joint pain, excessive sweating, excessive sweating,

changes in sex drive or ability, changes in sex drive or ability, loss of appetite loss of appetite

What you should know:Take your medicine the same time everydayReport any side effects to your doctorCall your doctor if you have any questionsCall if you lose your medicine

FlyerFlyer

RecruitmentRecruitment

One young woman at PTH, CS, is One young woman at PTH, CS, is incredibly organized when it comes to incredibly organized when it comes to her medications. Every week, she her medications. Every week, she presents her list of medications, with presents her list of medications, with how many pills/refills are left, to her how many pills/refills are left, to her team leaderteam leader– We asked CS to come to the meeting to We asked CS to come to the meeting to

share her story with her peers. She gave share her story with her peers. She gave many good tips for how to stay adherent to a many good tips for how to stay adherent to a medication regimen. She was well received!medication regimen. She was well received!

EvaluationEvaluation Simple evaluation Simple evaluation

tool was developed tool was developed to receive feedback to receive feedback from participantsfrom participants– Based on MCES Based on MCES

programprogram

ReflectionReflection

Reaction from clientsReaction from clients– Mostly positiveMostly positive– Receptive to learningReceptive to learning

What workedWhat worked– Having food Having food – Talking about side effectsTalking about side effects

What did not workWhat did not work– Staying too general was not interesting enough for some Staying too general was not interesting enough for some

of the more anxious participants; they wanted very of the more anxious participants; they wanted very specific information about their medicationsspecific information about their medications

What we would change for next timeWhat we would change for next time– 30 minute session instead of 1 hour and make ongoing30 minute session instead of 1 hour and make ongoing– Ask higher functioning program participants to attend to Ask higher functioning program participants to attend to

balance out the energy in the environmentbalance out the energy in the environment

ReferencesReferences

Magura, S., Laudet, A., Mahmood, D., Rosenbloom, A., Magura, S., Laudet, A., Mahmood, D., Rosenbloom, A., and Kinght, E. (2002). Adherence to medication and Kinght, E. (2002). Adherence to medication regimens and participation in dual-focus self-help regimens and participation in dual-focus self-help groups. groups. Psychiatric Service, 53Psychiatric Service, 53(3). 310-316.(3). 310-316.

Montgomery County Emergency Service, Inc. (2004). My Montgomery County Emergency Service, Inc. (2004). My action plan for relapse prevention.action plan for relapse prevention.

Pathways to Housing. (2010). Our model. Retrieved from Pathways to Housing. (2010). Our model. Retrieved from http://pathwaystohousing.org/http://pathwaystohousing.org/

References References

Pederson, D. (2008). Psych notes: Clinical pocket guide Pederson, D. (2008). Psych notes: Clinical pocket guide (2(2ndnd ed.). F.A. and Company: Philadelphia. ed.). F.A. and Company: Philadelphia.

Scott, A. (2000). Predicting medication adherence in Scott, A. (2000). Predicting medication adherence in severe mental health disorders. severe mental health disorders. Acta Pyschiatrica Acta Pyschiatrica Scandinavica, Scandinavica, 101, 119-124.101, 119-124.

Zygmunt, A., Olfson, M., Boyer, C., Mechanic, D. (2002). Zygmunt, A., Olfson, M., Boyer, C., Mechanic, D. (2002). Interventions to improve medication adherence in Interventions to improve medication adherence in schizophrenia. schizophrenia. American Journal of Psychiatry, American Journal of Psychiatry, 159(10). 1653-1654.159(10). 1653-1654.