Patient Counselling & Adherence

Effective patient counselling is a core pharmacist competency. The NZ Pharmacy Council competence framework explicitly requires pharmacists to communicate effectively with patients, support adherence, and identify and resolve medicine-related problems. This lesson covers motivational interviewing, the teach-back method, adherence barriers, polypharmacy reconciliation, medicines use review (MUR), and dose administration aids (DAAs).

Motivational Interviewing (MI) in Pharmacy

Motivational interviewing is a patient-centred, directive counselling style developed by Miller and Rollnick (1991). It aims to explore and resolve ambivalence about behaviour change by eliciting the patient's own motivation. MI is particularly valuable in pharmacy for adherence counselling, smoking cessation, and lifestyle modification.

Core MI Principles (RULE)

• *Resist* the righting reflex — avoid lecturing or prescribing behaviour
• *Understand* the patient's intrinsic motivation
• *Listen* with empathy and reflection
• *Empower* the patient to change

OARS Techniques

• *Open-ended questions*: "Tell me about how you've been getting on with your blood pressure tablets."
• *Affirmations*: "It sounds like you've been doing your best in a difficult situation."
• *Reflective listening*: Repeating or paraphrasing to demonstrate understanding and elicit elaboration.
• *Summaries*: Collecting and reflecting back key points to consolidate change talk.

Change Talk and Sustain Talk

MI practitioners listen for "change talk" (statements indicating desire, ability, reasons, or need to change — DARN) and "commitment language" (intention, activation, taking steps — CATs). When a patient says "I know I should probably take it more regularly," this is change talk that the pharmacist should amplify with reflection and open questions.

Conversely, "sustain talk" (arguments for the status quo) should be met with empathic reflection rather than counter-argument, which typically increases resistance.

MI in Practice: Adherence Scenario

Patient: "I keep forgetting my metformin."

Poor response: "You really need to take it — your HbA1c is too high."

MI response: "It sounds like remembering is a challenge. What usually gets in the way?" [open question] → "That makes sense. When it has worked for you in the past, what was different?" [elicit past success] → "So if you had a reminder by your breakfast, that might help?" [summarise, closed question for commitment].

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Teach-Back Method

Teach-back (also called "closing the loop" or "show-me") is an evidence-based health literacy tool. The pharmacist asks the patient to explain the medication instructions in their own words to confirm understanding.

Teach-Back vs Test-Back

The goal is to confirm the pharmacist's communication was clear — not to test the patient. If the patient cannot recall the information accurately, the pharmacist adjusts their explanation, not the patient's grade.

Example Phrasing

• "I want to make sure I've explained this clearly. Can you tell me back how you'll take this new inhaler?"
• "Just so I know I covered everything, what will you do if you miss a dose?"

Evidence

A Cochrane review (Berkman et al., 2011) found that teach-back improved medication adherence in patients with low health literacy by up to 25%. The New Zealand Health Literacy Alliance supports universal precautions for health literacy — treating all patients as potentially having low health literacy — rather than relying on identifying "at-risk" patients.

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Adherence Barriers

Medication non-adherence is estimated to cost the NZ health system hundreds of millions of dollars annually through preventable hospitalisations and disease progression. Non-adherence rates average 50% for chronic disease medicines.

Taxonomy of Non-Adherence

• *Intentional non-adherence*: Deliberate decision not to take medicine (side effects, cost, disbelief in need).
• *Unintentional non-adherence*: Forgetting, confusion about regimen, practical barriers (childproof caps, swallowing difficulty).

Common Barriers in NZ Context

1. *Cost*: Community Services Card (CSC) holders pay $5 per item; full-charge patients pay up to $15 per item (2025 rates). High-cost regimens (e.g., biologics before PHARMAC subsidy) create significant financial barriers. Patients may "share" tablets or take alternate-day doses without informing the prescriber.
2. *Health literacy and language*: 60% of NZ adults have low health literacy (Ministry of Health, 2010). Patients from Pacific Island or Māori communities may have additional cultural considerations around medicine use.
3. *Side effects*: Statin-associated myalgia, SSRI sexual dysfunction, and ACEi cough are leading causes of self-discontinuation.
4. *Regimen complexity*: Multiple daily dosing, food restrictions, storage requirements, and large pill burden reduce adherence.
5. *Beliefs and health models*: Explanatory models of illness that do not map onto biomedical frameworks (e.g., spiritual or traditional medicine constructs) may lead patients to use alternatives or discontinue.
6. *Stigma*: Mental health medicines, HIV antiretrovirals, and opioid substitution therapies carry stigma that patients may wish to conceal, leading to non-attendance at pharmacy for refills.

Adherence-Enhancing Strategies

• Simplify regimens: Once-daily formulations where available (e.g., extended-release metformin, once-daily bisoprolol).
• DAAs: Blister packs, Webster-pak, or electronic pill dispensers.
• SMS reminders and smartphone apps.
• Synchronisation of refills to reduce pharmacy visits.
• Patient education using plain language, visual aids, and translated materials.

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Polypharmacy Reconciliation

Polypharmacy is defined as the concurrent use of five or more medicines. In New Zealand, approximately 15% of adults aged over 65 take five or more prescribed medicines; in residential aged care, average medicine counts exceed eight per resident.

Problems Associated with Polypharmacy

• Increased drug–drug and drug–disease interaction risk.
• Pill burden contributing to non-adherence.
• Cascade prescribing: A side effect is treated with a new drug, which itself causes another side effect, generating further prescriptions.
• Prescribing inertia: Medicines started in hospital continue indefinitely without review.

Medication Reconciliation

Reconciliation involves comparing the patient's current medicine list against prescriptions from all sources (GP, specialists, over-the-counter, complementary/herbal) to identify discrepancies. In NZ, the Medicines Use Review (MUR) service and the Hospital Medicines Reconciliation project under Health NZ are the primary frameworks.

Deprescribing

Deprescribing is the planned, supervised reduction or cessation of medicines that are no longer indicated or where risk outweighs benefit. Common targets include:

• PPIs (if started empirically and no ongoing indication)
• Anticholinergics (contribute to falls, cognitive impairment in elderly)
• NSAIDs (GI/renal risk in elderly)
• Benzodiazepines (falls, dependence)

The STOPP/START criteria and Beers Criteria provide evidence-based frameworks for identifying potentially inappropriate medicines in older adults.

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Medicines Use Review (MUR)

MUR is a funded pharmacy service in New Zealand under the Primary Health Organisation (PHO) contract framework. It involves a structured review of the patient's medicines by an accredited pharmacist, typically lasting 20–30 minutes.

MUR Eligibility

Patients who benefit most: those on four or more regular medicines, recently discharged from hospital, recently changed to a new medicine, or those with adherence difficulties.

MUR Process

1. Appointment scheduling (patient consent required).
2. Systematic review of all current medicines using an MUR template.
3. Identification of adherence issues, side effects, drug interactions, and monitoring gaps.
4. Written MUR report provided to patient and sent to GP with recommendations.
5. Follow-up at 3–6 months.

Outcomes of MUR

Studies in NZ (including the MUR pilot with Canterbury PHO) demonstrated reductions in hospital readmission rates and improved patient-reported confidence with medicines management following pharmacist-led MUR.

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Dose Administration Aids (DAAs)

DAAs are devices or packaging systems that organise medicines into pre-dispensed compartments corresponding to specific dose times. In New Zealand, DAAs include:

• Blister (Webster-pak) packaging: Medicines packed in individually sealed compartments for AM, NOON, PM, and BED for each day of the week, supplied as a one- or four-week supply.
• Dosette boxes: Reusable or single-use divided pill organisers filled by the patient, carer, or pharmacist.
• Electronic DAAs: Automated dispensing devices (e.g., Pivotal Alert, MedMinder) that beep or flash at dose times and may lock other compartments.

Eligibility for DAA Service in NZ

PHARMAC-funded DAA packaging is available for patients with a demonstrated adherence need, as assessed by the pharmacist. A written prescription is not required to supply a DAA, but a current medicine list must be obtained from the prescriber.

Limitations of DAAs

• Cannot accommodate medicines requiring specific storage (e.g., refrigeration, light protection) or medicines with complex preparation (e.g., inhalers, topical preparations, insulin).
• Packaging process itself introduces risk — incorrect packing by technician or pharmacist is a source of medication error. A second pharmacist check of all DAA packs is best practice.
• Once blister-packed, identification of individual tablets may be difficult if a query arises.

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Summary

Effective patient counselling integrates communication skills (MI, teach-back), adherence knowledge, systematic medicines review (MUR), and practical tools (DAAs). Pharmacists are the most accessible health professionals in NZ (no appointment needed), placing them in a unique position to address adherence proactively and prevent medication-related hospitalisations.