Workshop 4 Pharmacovigilance: What do we know? Objectives To - PowerPoint PPT Presentation

Barriers Facilitators Predictors Improvement strategies - lack of knowledge of ADRs - Adequate - Consultant job - Increasing physicians awareness - Lack of ADRs reporting awareness - Adequate and knowledge of ADR reporting. process - Hospital support Awareness - Uncertainty between ADRs - Patient safety -Ample and drug concerns knowledge of - Busy schedules, time - Professional ADRs, and constraints responsibility training Health system-related Barriers: - Reactions of a - Continuous professional Lack of access to patient serious nature development programs and Records, Fear of litigation, Lack of - Unusual reactions reinforcing theoretical and practical clear reporting guidelines, Lack reactions to a new knowledge in undergraduate of financial rewards/incentives product pharmacy curriculum. Individual pharmacist-related - Access to patient’s medical record Barriers: and introducing electronic reporting Knowledge and clinical systems competence ; Inability to establish - Feedback from the relevant Causality , Lack of understanding authorities the responsibility of reporting ADRs, How/where to report, Attitudes toward reporting ADRs: Self-guilt of harming Patients, Lack of interest, Lack of time

Knowledge Skills Beliefs about Motivation and Environmental Social influence consequences goals constraints - Lack of - Lack of skills - Fear of - Lack of - workload - Lack of knowledge of in punishment feedback - incentives teamwork what should be differentiating and criticism - Lack of - human - Lack of active reported ADRs and MEs motivation resources support by - Lack of - time for hospital knowledge of reporting management and definitions - Complicated other colleague - Lack of yellow card knowledge of - Complicated guideline administrative reporting procedure - Lack of reporting facilities - Lack of Clinical pharmacists . Improvement strategies - Information - Provide - Provide - Provide more - Provide - Training to change delivery methods education to education on feedback such as information about group processes adopted to improve consequences timely alerts impact of - Organize social individual needs competency reporting, social influence (provide influence (e.g., support ) provide a role model), time management, incentives , establish Drug safety department,

Results from the ADR studies

Research Studies and findings Systematic review of Adverse Drug Reactions in Middle East Evaluating the Quality, Quantity and Nature of Adverse Drug Reactions using Vigigrade and VigiBase tools. Frequency and nature of Adverse Drug Reactions reported at Hamad Medical Corporation, Qatar “A study knowledge, attitude and practice characteristics of pharmacists in HMC towards Adverse Drug Reaction Reporting”

Phase1 Systematic Review Phase 4 Phase 2 Questionnaire. Women's Hospital Study (HMC ADR study Pharmacists) Phase 3 Corporate ADR Study

What is happening in Qatar & the region? In Hamad Medical Corporation? In Women's Hospital?

Qatar - WHO Programme member Image obtained from UMC - WHO Programme members website

Systematic Review • The review included 12 out of 581 articles. • The incidence varied between 0.7% at a university teaching hospital to 52.8% in medical ward of a 600-bedded hospital. • Majority of the studies used definition from World Health Organization (WHO). • The most common medication to cause ADRs are Non-steroidal anti- inflammatory drugs (NSAIDs), followed by antibiotics, vaccines and streptokinase. • The most common reactions were GI bleeding, renal toxicity, extrapyramidal side effects, skin rashes and itching. • Six (6/12) studies performed severity assessment, most these reported ADRs to be severe. • Only three (3/12) studies have mentioned about the strategies to reduce/prevent the ADRs • Only one study was included from Qatar.

Findings - WH ADR study • Retrospective • Data collection – 4 year ADR reports (2013 – 16) • Quality (completeness using Vigigrade), Quantity, nature (Causality, Preventability, Severity). • 133/187 ADRs were included. • Antibiotics were the most common class (39%), anti-inflammatory (9%), Gastro intestinal (7%). • Skin and subcutaneous tissues disorders were the most commonly affected organ system (56%), respiratory (19%). • 84% of the reactions were MILD while 2% caused SEVERE HARM. • Majority of the ADRs were NON PREVENTABLE (82%). • More than half (52 %) were categorized as “POSSIBLE” • The reports achieved a cumulative score of 0.74, that shows reports were of good quality although the numbers were low.

Questionnaire survey of Pharmacist at HMC • A descriptive questionnaire-based methodology was used to evaluate the knowledge, attitude and practice of pharmacists and pharmacy technicians working at HMC. • Of 700 pharmacists and pharmacy technicians, 300 (~43%) respondents completed the questionnaires. • ~62% of the participants did not report an ADR over the last 12 months and more than 90% never received a feedback after reporting an ADR. • 78% knew how to report an ADR, while 60% said they havent reported any ADR in the last 12 months. • In terms of knowledge questions, respondents showed a high understanding of the concept of pharmacovigilance. Almost three quarters (72%) responded correctly when asked about the purpose of pharmacovigilance. • However, majority (70%) of the respondents never attended any course or training on pharmacovigilance and almost 80% of them were not aware if there is any pharmacovigilance center existing in Qatar. • Majority of the pharmacists and technicians were also not aware about different scales used to analyse ADRs (eg. Naranjo, Hartwig, Schumocks).

• Although most of the respondents were aware of their important role towards ADR reporting, only a few reported any ADR over the last 12 months. • Several factors such as lack of training, time and feedback, and complex reporting process were presumably associated with low reporting. Hence, the authors recommend several interventions to enhance ADR reporting including training and educational activities on pharmacovigilance, and providing appropriate feedback to ADR reporters.

ADR assessment scales • Naranjo Causality Assessment

Hartwig’s Severity Assessment

Preventability criteria according to Schumock and Thornton scale

Hands on Training!!!

ADR Causality assessment

Way forward • Research opportunities  to improve HCP reporting of ADR  to explore patients awareness of ADR’s and ADR’s reporting • Research opportunities to improve different patient safety aspects.

References • Edwards IR, Aronson JK. Adverse drug reactions: definitions, diagnosis, and management. The lancet. 2000 Oct 7;356(9237):1255-9. • Wester K, Jönsson AK, Spigset O, Druid H, Hägg S. Incidence of fatal adverse drug reactions: a population based study. British journal of clinical pharmacology. 2008 Apr 1;65(4):573-9. • Bouvy JC, De Bruin ML, Koopmanschap MA. Epidemiology of adverse drug reactions in Europe: a review of recent observational studies. Drug safety. 2015;38(5):437. • Waller P, Harrison-Woolrych M. An introduction to pharmacovigilance. John Wiley & Sons; 2017. • The Yellow Card Scheme: guidance for healthcare professionals: available at https://www.gov.uk/guidance/the- yellow-card-scheme-guidance-for-healthcare-professionals • Pharmacovigilance: available at http://www.who.int/medicines/areas/quality_safety/safety_efficacy/pharmvigi/en/ • World Health Organization. The use of the WHO-UMC system for standardized case causality assessment. Uppsala: The Uppsala Monitoring Centre. 2005:2-7. • Bakhsh TM, Al-Ghamdi MS, Bawazir SA, Qureshi NA. Barriers, Facilitators, Strategies, and Predictors for Reporting Adverse Drug Reactions in three General Hospitals in Jeddah, 2013. British Journal Medicine & Medical Research. 2016;17(4):1-3. • Mirbaha F, Shalviri G, Yazdizadeh B, Gholami K, Majdzadeh R. Perceived barriers to reporting adverse drug events in hospitals: a qualitative study using theoretical domains framework approach. Implementation Science. 2015 Aug 7;10(1):110. • Ioannidis JP, Mulrow CD, Goodman SN. Adverse Events: The More You Search, the More You FindAdverse Events: The More You Search, the More You Find. Annals of internal medicine. 2006 Feb 21;144(4):298-300. • Hadi MA, Neoh CF, Zin RM, Elrggal ME, Cheema E. Pharmacovigilance: pharmacists’ perspective on spontaneous adverse drug reaction reporting. INTEGRATED PHARMACY RESEARCH AND PRACTICE. 2017 Jan 1;6:91-8. • Mann RD, Andrews EB, editors. Pharmacovigilance. John Wiley & Sons; 2007 Feb 6. • Edwards R, Lindquist M, editors. Pharmacovigilance: Critique and Ways Forward. Springer; 2016 Oct 27.

Patient Engagement A strategy for Improving medication Safety 17/07/2017 49

Patient Engagement: A strategy for Improving medication Safety Presented by : Pharmacist Mohd A/Wahid Facilitators : Pharmacist Asma A/Azziz : Pharmacist Hiba Khairy 17/07/2017 50

Objectives  Discuss Patient Engagement (PE)/Patient activation (PA) concepts  Strategies to improve PE/PA  Roles and responsibilities of HCP/patients in promoting patient engagement (PE)  Identify patient barriers to medication adherence. •  Describe the consequences of medication non-adherence  Discuss communication strategies to improve medication adherence and medication reconciliation 17/07/2017 51

Agenda  Introduction  Overview of Medication Errors  Patient Engagement  Patient Engagement & Medication Safety  Rationale  Adherence  Levels of engagement  Group Activity (Medication  Benefits of patient Adherence Scenarios) engagement  Medication Reconciliation  Patient Activation  Patient activation measure  Summary (PAM)  Implications of PAM score  Interventions to promote  Questions patient activation 17/07/2017 52

Introduction  Medication use has become increasingly complex in recent times  ADE’s account for 25% of all medical errors  ADE’s occur in approximately 4% of hospital admissions.  Medication Errors account for US$ 42 billion annually. (WHO)  75% of these errors are preventable. 17/07/2017 53

Introduction  Medication safety is defined as freedom from preventable harm with medication use (ISMP Canada, 2007). [1,2]  " A medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labelling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use” (NCCMERP) [3] 17/07/2017 54

Factors that may influence medication errors  Factors associated with health care professionals  Factors associated with patients  Work environment factors  Factors associated with medicines  Factors associated with tasks  Factors associated with computerized information systems 17/07/2017 55

“ First do no harm ” 17/07/2017 56

Traditional Error Prevention Strategies  changing provider behavior  encouraging inter-professional collaboration  enhancing the culture of safety 17/07/2017 57

Dimensions of healthcare quality 2001 “Crossing The Quality : A New Health System For The 21 st Century ” [9]  The six dimensions of Patient &Family Centered Care is defined as; healthcare quality  Safe "care that is respectful of and  Effective responsive to individual  Patient centered patient preferences, needs,  Timely and values and that patient  Efficient values guide all clinical  Equitable decisions" (Institute of Medicine, 2001). 17/07/2017 58

Patient Engagement  Patient engagement is defined as “Actions individuals must take to obtain the greatest benefit from the health care services available to them” [10]  The patient is not just at the center of care but is part of the team . [10]  Engagement means doing things WITH patients not just for them. [43] 17/07/2017 59

Patient & Family Engagement Patient Engagement continuum Levels of Consultation Involvement Partnership & shared Engagement decision-making Direct patient Patients receive Patients are asked about their Treatment decisions are made care information about a preferences in treatment plan based on patients’ diagnosis preferences, medical evidence, clinical judgement. Organizational Organization surveys Hospital involves patients as Patients’ co -lead hospital design & patients about their care advisers or as advisory safety & quality improvement governance experiences council members committees Policy-making Public agency conducts Patients’ recommendations Patients’ have equal focus groups with patients about research priorities are representation on agency to ask questions about used by public agency to committee that makes healthcare issues make funding decisions decisions about how to allocate resources to health programs 17/07/2017 60

Patient & Family Engagement Patient Engagement continuum Levels of Consultation Involvement Partnership & shared Engagement decision-making Direct patient Patients receive Patients are asked about Treatment decisions are care information about a their preferences in made based on patients’ diagnosis treatment plan preferences, medical evidence, clinical judgement. 17/07/2017 61

Rationale for Patient Engagement  Patients who are more actively involved in their health care experience better health outcomes and incur lower costs. [11]  15 million patients with long-term condition (LTC) in UK.  People with LTCs account for [12]:  about 50 per cent of all GP appointments,  64 per cent of all outpatient appointments and  over 70 % of all inpatient bed days  70% of health expenditure 17/07/2017 62

Rationale for Patient Engagement  Patients with Long Term Conditions (LTCs) spend less than 1% of their time with healthcare professionals  Patients with LTCs manage their health on a daily basis. [13]  60 to 70% of premature deaths caused by health risk behaviors. [12] 17/07/2017 63

Patient Activation  “An individual’s knowledge, skill, and confidence for managing their health and health care” (Hibbard et al 2005).  links to all the principles of person-centered care,  Enables the delivery of personalized care  Supports people to develop their capability to manage their own health and care.  Activated patients experience better health outcomes at lower costs. [13] 17/07/2017 64

Why is Patient Activation Important?  As activation levels increase, individuals become: [14,15,16]  More adherent to medications & medical advise  More likely to engage in positive health behaviors  More likely to have better health outcomes  More likely to engage in health information seeking behaviors  Increased readiness-to-change to live a healthier lifestyle.  More likely to attend screenings, regular check-ups and immunizations, 17/07/2017 65

Behaviour associated with low activation  Feeling overwhelmed  Little confidence in their ability to have a positive impact on their health  Passive - less likely to ask questions or to offer information  Less likely to follow clinical advice or follow recommendations  Higher hospitalisation; readmissions.  More likely to delay seeking medical help. [15,17] 17/07/2017 66

Patient Activation Measure (PAM)  Patient activation measure (PAM), assesses an individual's knowledge, skill, and confidence for self- management.  Appropriately designed interventions can increase patients’ levels of activation, with associated health benefits. [12,14] 17/07/2017 67

What is the Patient Activation Measure (PAM)?  “patient activation measure”— a validated survey that scores the degree to which someone sees himself/herself as a manager of his or her health and care.  PAM questionnaire consists of 13 items  Based on PAM score, patients are categorized into four levels of the individual’s likelihood of effective self-management 17/07/2017 68

13-items PAM Strongly agree, Agree, Disagree, Strongly disagree Source: University of Oregon, 2010 17/07/2017 69

Patient Activation is 52 53 Developmental Level-4 50 51 51 Level-3 Individuals have 42 43 44 44 45 47 adopted many of the Level-2 behaviors needed to Individuals appear to be support their health but 39 40 taking action but may still may not be able to Level-1 lack the confidence and maintain them in the Individuals may lack the skill to support their face of life stressors. knowledge and confidence to behaviors. manage their health. Individuals tend to be passive and feel overwhelmed by managing their own health. They may not understand their role in the care process. 1 2 3 4 5 6 7 8 9 10 11 12 13 17/07/2017 70

Why Measure Patient Activation?  To know who needs more support & tailor interventions based their needs.  To track progress over time  25 and 40 percent of the population have low levels of activation (levels 1 and 2). [13] 17/07/2017 71

Patient Activation Interventions  Effective interventions can help to increase people’s activation levels and their confidence in managing their health .[13]  Patients need to believe that they have a sense of control over events related to their health and healthcare- Partnership vs Compliance  Building confidence through small steps is the key strategy for increasing activation.  People with lower levels of activation are likely to need more in-depth one to one support  Those who are least activated make the most progress when given appropriate support. [18] 17/07/2017 72

Tailoring support to patient activation levels Level4 Achieve/exceed life style behavior Level3 guidelines, develop Skills development, techniques to pursue guideline prevent relapse behaviors Level2 Increase in knowledge, initial skills development, Grow confidence Level1 Build knowledge – base, self- awareness, & initial confidence 17/07/2017 73

Patient Activation Interventions Examples of interventions for patients at the lowest level of activation include :[12]  Focus on one change at a time  Focus on what is important to the patient  Reinforce the importance of patient participation  Encourage small steps with encouragement  Revisit behavioral goals  Show empathy  Build on strengths  Develop problem solving skills 17/07/2017 74

Patient Engagement & Medication Safety 17/07/2017 75

Medication Adherence  " the degree to which the person's behavior corresponds with the agreed recommendations from a health care provider .“[ 20] No of Pills Absent in Time X X 100 ≥ 80%% No of Pills Prescribed for Time X  Acceptable Adherence rate ranges from 80 -95% [21] 17/07/2017 76

Magnitude of the Medication Non- Adherence Problem  20 to 30 percent of new prescriptions are never filled.  50% of prescribed medication is not taken as prescribed  Adherence is lowest among patients with chronic diseases, • Source: Centers for Disease Control and Prevention (CDC) 17/07/2017 77

Forms of Medication Non-Adherence [46]  Medication nonadherence, either willful or inadvertent, can include:  Failing to fill/refill a prescription  Omitting a dose or more  Prematurely discontinuing medication  Taking a dose at the wrong time  Taking a medication prescribed for someone else  Taking a dose with prohibited foods, liquids, and other medications  Taking outdated/damaged medications  Storing medications improperly  Improperly using medication administration devices (e.g., inhalers). 17/07/2017 78

Health Consequences of Non- Adherence [22,23]  Increased hospitalization- 33-69% medication related admissions.  Poor health outcomes  Increased costs- $289 Billion/year  Decreased quality of life  Patient death- 125,000 Mortalities annually 17/07/2017 79

Non-Adherence increases the total cost of healthcare Source: Smith DL. The effect of patient non-compliance on health care costs. Medical Interface 1993:April; 74-84 17/07/2017 80

Factors Contributing to Non- Adherence  Many factors may influence patients’ adherence to medication therapy regimen [24,25,29,39]  Patient/provider communication  Cognitive impairment  Limited language proficiency  Complexity of the medication regimen  Duration of treatment  Frequent changes to medications  Adverse drug effects & Drug interactions  Comorbidities  Lack of symptoms  No perceived benefit of medicine  Cost 17/07/2017 81

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Interventions to improve Adherence Predictors of non-adherence [44]  Low literacy  Lack of belief in benefit of treatment  Homelessness  Belief that the drug is not  Depression important or is harmful  Psychiatric disease  Complexity of medication  Substance abuse regimen  Lower cognitive function  Side effects  Forgetfulness  Cost of medication,  Anger, psychological stress,  Inadequate follow-up anxiety  Missed appointments  Lack of insight into illness 17/07/2017 84

Interventions to Improve Adherence  Patient Engagement: [25,30]  Engaged patients are 2.57 times more likely to stay adherent with their medication regimens.  Basic patient engagement techniques :  sending reminders 7-10 days prior to appointments,  meeting with patients face-to-face to review their medications and answer questions. 17/07/2017 85

Interventions to improve adherence [45]  Linking with daily  Simple regimens activity  Formulations  Compliance-aids  Prompts/reminders  Specialized labels  Medilist (medication  Involve caregivers list)  Behavioural counseling  Family members  Patient education  Alarm beepers  Goals/systematic plan  Mixing with foods  Rewards  Administration aids 17/07/2017 86

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Patient Engagement & Medication Safety: Medication Adherence  There is no universal solution to improve adherence [27]  Combining approaches that are tailored to address a patient’s specific adherence barriers [27]  Education-based interventions that focus on teaching individuals about their medications are Less effective than interventions that focused on changing the behavior of patients. [34] 17/07/2017 88

Interventions to Improve Adherence [33]  For short-term treatments, counselling and written information may be effective in the short term.  More complex interventions needed to improve adherence in the long term, including various combinations of:  Convenient care,  Information,  Counselling,  Reminders,  Self-monitoring,  Reinforcement,  Family therapy, 17/07/2017 89

Group Activity 17/07/2017 90

Scenario 1: Ms. D, a 65-year-old woman with hypertension and diabetes, presented to your office for a routine appointment. Her most recent hemoglobin A1C was 9.0. On examination, her vital signs were normal with the exception of BP, which was 165/85. Her medications included zestoretic and pioglitazone. On questioning, she revealed that she has not been able to buy her medications because they are too expensive.  What are your concerns for medication compliance for this patient?  How would help Ms. D better comply with medication regimen? 17/07/2017 91

Scenario 1: Ms. D, a 65-year-old woman with hypertension and diabetes, presented to your office for a routine appointment. Her most recent hemoglobin A1C was 9.0. On examination, her vital signs were normal with the exception of BP, which was 165/85. Her medications included zestoretic and pioglitazone. On questioning, she revealed that she has not been able to buy her medications because they are too expensive.  Concerns :  Cost of medications  Knowledge about the disease  Asymptomatic disease  Interventions: :  Switch to generics.  Counseling about the long-term consequences of not appropriately managing her hypertension and diabetes 17/07/2017 92

Scenario 2: An 83 year old female has multiple chronic conditions, including diabetes, iron deficiency anemia, and gastroesophageal reflux disorder. She is prescribed metformin (to be taken with meals, morning and evening), glipizide (to be taken with food), ferrous sulfate (to be taken on an empty stomach), and omeprazole (to be taken 1-2 hours before the iron supplement). All of these directions about the timing of medications with meals are confusing to the patient, so she just takes them all once a day, right before breakfast.  What are your concerns for medication compliance for this patient?  How would help the patient better comply with medication regimen? 17/07/2017 93

Scenario 2: Concerns & Interventions An 83 year old female has multiple chronic conditions, including diabetes, iron deficiency anemia, and gastroesophageal reflux disorder. She is prescribed metformin (to be taken with meals, morning and evening), glipizide (to be taken with food), ferrous sulfate (to be taken on an empty stomach), and omeprazole (to be taken 1-2 hours before the iron supplement). All of these directions about the timing of medications with meals are confusing to the patient, so she just takes them all once a day, right before breakfast.  Concerns:  Complexity of therapy  Forgetfulness  Chronic conditions  Information overload  Interventions:  Simplify the dosing regimen (e.g., switch to extended release metformin)  Use a pill box to dosing times.  Counseling about which medications can be taken together and what is an allowable window of medication administration. 17/07/2017 94

Scenario 3: 66 year old male with type II diabetes mellitus works as a business executive in a fast-paced environment. He has been taking metformin since being diagnosed with diabetes 10 months ago. At first, he had no problem remembering to take his metformin. However, recently he has begun to notice that he sometimes cannot remember whether he took his metformin amid his busy schedule.  What are your concerns for medication compliance for this patient?  How would help the patient better comply with medication regimen? 17/07/2017 95

Scenario 3: Concerns & Interventions A 66 year old male with type II diabetes mellitus works as a business executive in a fast-paced environment. He has been taking metformin since being diagnosed with diabetes 10 months ago. At first, he had no problem remembering to take his metformin. However, recently he has begun to notice that he sometimes cannot remember whether he took his metformin amid his busy schedule.  Concerns:  Lack of symptoms  Interventions  Use pill-boxes, mobile apps, PC-Based software, clocks, etc. 17/07/2017 96

Scenario 4: An 82 year old female is prescribed furosemide 20mg by mouth once daily for symptomatic treatment of her heart failure. She was recently hospitalized for a CHF exacerbation and has since had monthly follow- up visits with her primary care physician (PCP). Since she does not notice any improvement in her symptoms and experiences some urinary frequency since starting the furosemide, she occasionally skips her dose. However, in the days before her clinic appointments, she takes her furosemide exactly as prescribed. When her PCP asks her is she is taking her medications appropriately at the visit, she responds affirmatively. After a couple months, she is hospitalized again for a CHF exacerbation after a period of 10 days without furosemide.  What are your concerns for medication compliance for this patient?  How would help the patient better comply with medication regimen? 17/07/2017 97

Scenario 4: Concerns & Interventions An 82 year old female is prescribed furosemide 20mg by mouth once daily for symptomatic treatment of her heart failure. She was recently hospitalized for a CHF exacerbation and has since had monthly follow-up visits with her primary care physician (PCP). Since she does not notice any improvement in her symptoms and experiences some urinary frequency since starting the furosemide, she occasionally skips her dose. However, in the days before her clinic appointments, she takes her furosemide exactly as prescribed. When her PCP asks her is she is taking her medications appropriately at the visit, she responds affirmatively. After a couple months, she is hospitalized again for a CHF exacerbation after a period of 10 days without furosemide.  Concerns:  Perceived benefit of the treatment  Knowledge about the disease  Treatment:  Counseling patient about the importance of taking her medications as prescribed 17/07/2017 98

Scenario 5: Mr. T is an 80-year-old Chinese man, wheelchair bound with diabetes mellitus, hypertension, chronic kidney disease, peptic ulcer disease, and anemia, presents to the clinic with recurrent admissions for poor diabetes control and hyperkalemia. He is on 17 different medications and tells you that he is having difficulty managing medications at home.  What are your concerns for medication compliance for this patient?  How would help Mr. T better comply with medication regimen? 17/07/2017 99

Scenario 5: Concerns & Interventions Mr. T is an 80-year-old Chinese man, wheelchair bound with diabetes mellitus, hypertension, chronic kidney disease, peptic ulcer disease, and anemia, presents to the clinic with recurrent admissions for poor diabetes control and hyperkalemia. He is on 17 different medications and tells you that he is having difficulty managing medications at home.  Concerns:  Complexity of medication regimen  Cost of medications  Limited language proficiency  Cognitive impairment  Duration of treatment  Interventions  Assess if he is able to understand his condition and, if he has the right belief and knowledge about his medications and health.  Include the pharmacist to:  consider doing a medication reconciliation service to assist in reduction of polypharmacy  Pack his medications in suitable storage containers for ease of consumption.  Provide a medication schedule so that other clinicians will not add on to his pill burden unnecessarily.  Refer to the medical social worker to understand his financial and social conditions  Use a translator to better understand his situation.  Assign a case manager to coordinate between multiple providers 17/07/2017 100