Journal of Gerontological Nursing

CNE Article 

Improving Medication Management Among At-Risk Older Adults

Delinda Martin, DNP, RN; Sunil Kripalani, MD, MSc; V.J. DuRapau, Jr., PhD

Abstract

Low health literacy is common among Medicare recipients and affects their understanding of complex medication regimens. Interventions are needed to improve medication use among older adults, while addressing low health literacy. Community-dwelling older adults in this study were enrolled at an inner-city adult day center. They completed a baseline measure of health literacy, medication self-efficacy, and medication adherence. They were provided with a personalized, illustrated daily medication schedule (PictureRx™). Six weeks later, their medication self-efficacy and adherence were assessed. Among the 20 participants in this pilot project, 70% had high likelihood of limited health literacy and took an average of 13.20 prescription medications. Both self-efficacy and medication adherence increased significantly after provision of the PictureRx cards (p < 0.001 and p < 0.05, respectively). All participants rated the PictureRx cards as very helpful in terms of helping them remember the medication’s purpose and dosing. Illustrated daily medication schedules improve medication self-efficacy and adherence among at-risk, community-dwelling older adults.

Click here for a Letter to the Editor about this article.

Abstract

Low health literacy is common among Medicare recipients and affects their understanding of complex medication regimens. Interventions are needed to improve medication use among older adults, while addressing low health literacy. Community-dwelling older adults in this study were enrolled at an inner-city adult day center. They completed a baseline measure of health literacy, medication self-efficacy, and medication adherence. They were provided with a personalized, illustrated daily medication schedule (PictureRx™). Six weeks later, their medication self-efficacy and adherence were assessed. Among the 20 participants in this pilot project, 70% had high likelihood of limited health literacy and took an average of 13.20 prescription medications. Both self-efficacy and medication adherence increased significantly after provision of the PictureRx cards (p < 0.001 and p < 0.05, respectively). All participants rated the PictureRx cards as very helpful in terms of helping them remember the medication’s purpose and dosing. Illustrated daily medication schedules improve medication self-efficacy and adherence among at-risk, community-dwelling older adults.

Click here for a Letter to the Editor about this article.

Dr. Martin is Assistant Professor of Nursing, Department of Nursing and Allied Health, Our Lady of Holy Cross College, New Orleans, Louisiana, Dr. DuRapau is Professor Emeritus, Department of Mathematics, Xavier University of Louisiana, New Orleans, Louisiana, and Dr. Kripalani is Chief of Hospital Medicine and Associate Director of the Effective Health Communication Program, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee.

Drs. Martin and DuRapau disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Dr. Kripalani is a consultant to and holds equity in PictureRx, LLC. The terms of this agreement were reviewed and approved by Vanderbilt University in accordance with its conflict of interest policies.

Address correspondence to Delinda Martin, DNP, RN, Assistant Professor of Nursing, Department of Nursing and Allied Health, Our Lady of Holy Cross College, 4123 Woodland Drive, New Orleans, LA 70131-7399; e-mail: demartin@olhcc.edu.

Received: October 11, 2011
Accepted: January 27, 2012
Posted Online: May 18, 2012

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (Institute of Medicine [IOM], 2004). Low health literacy adversely affects health and health care utilization and contributes to health disparities (IOM, 2004). Limited health literacy is associated with a substantial increase in mortality among community-dwelling older adults (Sudore et al., 2006) and is a factor in predicting all-cause mortality and cardiovascular death in older adults (Baker et al., 2007).

Low health literacy is prevalent among Medicare enrollees (Gazmararian et al., 1999) who experience a large burden of chronic illness (Gazmararian, Williams, Peel, & Baker, 2003; Gazmararian et al., 1999; Hoffman, Rice, & Sung, 1996). Forty-two percent of Medicare recipients read at lower than a sixth-grade level (National Network of Libraries of Medicine, 2011), which is a determinant in understanding health instruction, such as dosing schedules, and can lead to medication errors (Davis et al., 2006; Davis, Michielutte, Askov, Williams, & Weiss, 1998), as older adults take two to three times the amount of prescribed medications as does the general public (Kutner, Greenburg, & Baer, 2005). In one large study, 54.3% of Medicare enrollees with limited health literacy skills were unable to understand a relatively simple medication instruction such as, “take on an empty stomach,” and 47.5% of the sample erroneously described medication dosing (Gazmararian et al., 1999).

Approaches to improve medication understanding and use among older adults are needed. Such efforts should address the pervasive issue of low health literacy in this population. In this article, we describe a quality improvement pilot project to provide at-risk, community-dwelling older adults with illustrated medication instructions. We evaluated the effect of this intervention on their confidence in managing their medications, as well as their self-reported adherence.

Method

Overview

The quality improvement project was conducted through an adult day center, which uses an evidence-based model of care and is located in an inner-city health facility sponsored by Catholic Charities Archdiocese of New Orleans. The project followed the Evidence-Based Practice Improvement Model: problem description, formulation of the clinical question, review and appraisal of the literature for evidence, and development of the aim/goal for change (Levin et al., 2010).

Medication errors resulting from misunderstanding instructions were identified as a problem among the facility’s population. In medical appointments at the facility, patients expressed difficulty understanding which medications to take and at what time to take each one (S. Smith, personal communication, March 4, 2010).

A needs assessment was conducted to identify the scope of the problem. After a literature review, it was decided to provide the adult day care center’s participants with PictureRx illustrated medication instructions. The goal was to facilitate understanding of medication instructions and improve medication safety.

The conceptual framework is based on the IOM (2004) health literacy framework, which places health literacy as the supporting entity for understanding and expressing health needs. Health contexts, culture and society, health systems, and education systems are individualized components that can determine health outcomes and service utilization costs; intervention strategies at these points can improve health outcomes.

Prior to project initiation, a risk analysis was conducted using the SWOT method to identify strengths, weaknesses, opportunities, and threats (Lewis, 2005). Project strengths included the plan to address an identified need by providing medication health education, as well as support from organizational management. A potential weakness/threat was interruption of nurse case managers’ and social workers’ scheduled activities, as the lead author planned to work primarily with these health professionals prior to and during project implementation. A potential opportunity was the dissemination of best practice, with measureable outcomes, to other health care entities supported by Catholic Charities, New Orleans.

The change process in a system usually encounters some kind of resistance; therefore, it is important to identify strategies to overcome the anticipated barriers to change (Lighter, 2011). Three staff development sessions were conducted using the American Medical Association (AMA, 2007) health literacy toolkit to instruct staff in evidence-based communication strategies, use of plain language, and “teach-back” (i.e., asking patients to repeat back their understanding of instructions to confirm comprehension) (AMA, 2007; Egbert & Nanna, 2009; Marcus, 2006; Oates & Paasche-Orlow, 2009). Additionally, a focus group was conducted with the nurse case managers and social workers to actively listen to any concerns or issues. Potential benefits of the project were clearly articulated: improved patient safety through a clearer understanding of medication instructions.

The project was approved by the facility’s executive director and medical director. Project implementation began in June 2010 and ended in October 2010.

Screening and Enrollment

Nurse case managers and social workers identified potential participants from those who regularly attended the health center. Exclusion criteria included non-English speaking and documented diagnosis of severe dementia. Severe dementia was defined as severe impairment or loss of intellectual capacity, per the adult day care center’s criteria (S. Smith, personal communication, March 4, 2010). Participation was voluntary.

The project was introduced to potential participants through a face-to-face meeting at the day center. For older adults who expressed interest, a letter of project introduction and intent to participate was sent home for patient consideration and to family members or caregivers, requesting agreement or declination. If the patient and family member and/or caregiver agreed to the project, an additional individual meeting was held with the potential participant to review project methodology. Twenty older adults provided written consent. One participant’s family member was involved in the project from initiation to completion.

Baseline data were collected, including age, sex, race, educational level, cognitive function, medical comorbidities, number of prescribed medications, and health literacy. Educational level was assessed as completion of grade school (grades 1 to 5), junior high school (grades 6 to 8), high school (grades 9 to 12), some college, or college graduate. Measurements of cognitive function, using the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975), were extracted through chart reviews.

Health literacy was assessed using the Newest Vital Sign (NVS; Weiss et al., 2005). The NVS measures prose literacy and numeracy by the respondent answering six structured questions after reading a nutrition label; one point is awarded for each correct answer. A score of 4 or greater indicates adequate literacy skills, a score of less than 4 indicates the possibility of limited health literacy, and a score of less than 2 indicates high likelihood (50% or more) of limited health literacy.

At baseline and at a follow-up visit 6 weeks after delivery of the intervention, participants completed measures of medication adherence and self-efficacy. For each measure, the lead author read the questions aloud, and participants responded from the available answer choices, referring to answer cards printed in large font for ease of reading. Adherence was measured using the Adherence to Refills and Medications Scale (ARMS; Kripalani, Risser, Gatti, & Jacobson, 2009). The 12-item instrument was reduced to 10 items after removal of 2 items not applicable to this population; scores on the reduced instrument can range from 10 to 40, with lower scores indicating better adherence. The ARMS has high internal consistency reliability (Cronbach’s alpha coefficient = 0.81) and has previously shown a significant correlation with the Morisky Medication Adherence Scale (Morisky, Green, & Levine, 1986) (Spearman’s rho = −0.651, p < 0.01), as well as refill adherence calculated from pharmacy claims data (p < 0.01). Lexile analysis found that the reading level required for the ARMS is below eighth grade.

Self-efficacy was measured pre- and post-intervention using the Self-Efficacy for Appropriate Medication Use Scale (SEAMS; Risser, Jacobson, & Kripalani, 2007); scores on the 13-item measure range from 13 to 39, with higher scores indicating greater self-efficacy. The scale has high internal consistency reliability (Cronbach’s alpha coefficient = 0.89) and also correlates significantly with self-reported adherence.

Intervention

Participants received an illustrated depiction of their daily medication schedule: PictureRx ( http://www.picturerxcard.com; Figure). This educational aid shows the patient’s medications pictorially, uses plain language for instructions, and has icons to help patients understand the purpose and dosing schedule. Previous studies show that concise language in medication instructions is better understood, especially among patients with limited health literacy (Davis et al., 2006, 2009). Prior research showed that the tool was rated as very helpful by patients and pharmacists (Blake, McMorris, Jacobson, Gazmararian, & Kripalani, 2010) for clarifying and reinforcing medication instructions.

Sample PictureRx™ illustrated daily medication schedule.

Figure. Sample PictureRx™ illustrated daily medication schedule.

To make the PictureRx cards, each participant’s medication regimen was first reconciled by a clinic pharmacist, referring to the facility’s pharmacy database. The lead author then used a web-based interface to make the PictureRx cards for each participant. The cards were printed in color on letter-sized paper using a laser printer and enclosed in a clear plastic sleeve for protection. Patients were briefly oriented to the card, and they received educational instruction regarding the picture icons and dosing instructions, ending with a teach-back to confirm understanding (Walker, Pepa, & Gerard, 2010). The participants used their PictureRx cards for 6 weeks and then were surveyed to reassess their self-efficacy and adherence, as well as their perceptions about the usefulness of the PictureRx cards.

Statistical Analysis

Descriptive statistics of means, standard deviations (SD), percentages, and frequencies were calculated. The related-samples Wilcoxon signed-rank test was used to evaluate ARMS and SEAMS responses. Analysis was performed using SPSS version 19.0 for Windows®.

Results

Participant characteristics are described in Table 1. The mean age was 75.25 (SD = 8.77; age range = 59 to 89). Participants’ highest educational level was grade school (55%), high school (25%), some college (15%), and college graduate (5%). MMSE scores ranged from 18 to 30 (mean = 24.55, SD = 3.50). Per chart review, 25% of the participants were diagnosed with dementia. NVS results revealed that 70% of participants had a high likelihood of limited health literacy, while 25% had the possibility of limited health literacy. One participant’s score revealed adequate health literacy skills. The number of prescribed medications ranged from 4 to 21 (mean = 13.20, SD = 4.72).

Participant Characteristics (N = 20)

Table 1: Participant Characteristics (N = 20)

At pretest, patients commonly reported medication nonadherence, such as forgetting to take their medications or skipping doses intentionally. After provision of the PictureRx cards, participants less often reported such forms of nonadherence. Overall, ARMS scores improved significantly after receipt of the intervention (pretest mean = 13.3, SD = 3.2; posttest mean = 11.1, SD = 3.1; p = 0.046 (Table 2).

Adherence to Refills and Medications Scale Results (N = 20)

Table 2: Adherence to Refills and Medications Scale Results (N = 20)

At pretest, self-efficacy for taking medications correctly was relatively low, with a mean score of 28.4 (SD = 9.1) of a possible 39. Patients commonly expressed lack of confidence with taking their medications, for example, when they had many medications to take, multiple times of day at which to take them, or had a change in their regimen or routine. After the intervention, confidence improved in each of these areas. Overall, SEAMS scores improved significantly after the intervention (posttest mean = 35.8, SD = 5.8; p < 0.001) (Table 3).

Self-Efficacy for Appropriate Medication Use Scale Results (N = 20)Self-Efficacy for Appropriate Medication Use Scale Results (N = 20)

Table 3: Self-Efficacy for Appropriate Medication Use Scale Results (N = 20)

In the assessment of participants’ opinions, the PictureRx cards were rated as very easy to understand (Table 4); 100% of participants rated the cards as very helpful. The cards were felt to be most helpful in remembering what the medicines are for (40%), what time to take each medicine (30%), and the names of the medicines (25%). Several participants requested an updated PictureRx card for use after the pilot project ended. Two participants revealed that they took their card to an appointment with a cardiologist and requested the physician continue using this kind of medication instruction.

Use and Perceived Utility of PictureRx CARDS (N = 20)Use and Perceived Utility of PictureRx CARDS (N = 20)

Table 4: Use and Perceived Utility of PictureRx CARDS (N = 20)

Discussion

In this pilot project, we demonstrated that illustrated medication schedules (PictureRx cards), along with educational instruction using the teach-back method, significantly improved medication-related self-efficacy and adherence among community-dwelling older adults. Participants rated the educational tool highly and used it regularly. The results of this study are consistent with other published literature, which shows that illustrated medication instructions significantly increase patient satisfaction, understanding, recall, and adherence (Katz, Kripalani, & Weiss, 2006).

The fact that self-efficacy improved in this population with multiple comorbidities, including dementia, is significant. The patients had substantial prior experience in taking medications, yet were unsure of how to do so. Provision of illustrated medication schedules improved their confidence with taking medications daily. For example, confidence in taking several medications each day improved from 30% to 75%; confidence in taking mediations more than once per day improved from 40% to 75%.

Patients with limited health literacy and who have chronic diseases benefit from focused education, as comorbidities require complex medication and disease management (Fang, Machtinger, Wang, & Schillinger, 2006; Schillinger et al., 2002). In this study, participants had hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, and dementia, resulting in complex daily medication regimens. Medication nonadherence is a risk factor for morbidity and mortality (Simpson et al., 2006) and is frequently found among patients with cardiovascular and associated diseases (Ho, Bryson, & Rumsfield, 2009).

The NVS proved to be a straightforward tool for assessing health literacy. It was created for use in clinical settings (Johnson & Weiss, 2008; Weiss et al., 2005) and has been shown to be reliable and valid (Osborn et al., 2007; Weiss et al., 2005). Health literacy screening took approximately 3 minutes per patient, similar to the time reported in previous studies (Johnson & Weiss, 2008; Monachos, 2007; Shah, West, Bremmeyr, & Savoy-Moore, 2010; VanGeest, Welch, & Weiner, 2010).

The results of this pilot project were presented to administrative and clinical staff. The nurse case managers noted increased awareness of the scope and effects of limited health literacy as a result of staff development using the AMA (2007) health literacy toolkit. Communication strategies and the teach-back method are now being used by the nurse case managers as advocated by the AMA, The Joint Commission, and the Centers for Medicare and Medicaid Services (CMS). For example, the case managers verbalized that health instruction of dosing is now given in plain language: “BID” dosing is now verbalized as “Take in the morning and at night,” rather than “Take one twice daily.” Medication instruction also now includes a focused discussion of intent and purpose, using the teach-back method. The purposeful dialogue is an important factor in medication safety.

A limitation of this study is that it was conducted as pilot project, with a pretest-posttest evaluation using a small convenience sample of Medicare patients in a single health facility. These factors limit the generalizability of the findings. A second limitation is that 25% of the participants had clinical documentation of dementia, and this may have affected the validity of the self-report responses. However, we do not believe this to be the case, as each participant was able to complete the informed consent process and was able to teach back medication instructions. Additional research is warranted to confirm this experience, as well as assess the effect of such an intervention on clinical outcomes.

These limitations notwithstanding, this project suggests a valuable model for improving medication use in clinical practice. Individualized health instruction, performed in a shame-free environment with illustrated medication instructions and teach-back, promotes patient safety. The Joint Commission (2007) recommends using the teach-back method of communication, as well as illustrations to communicate health instruction. The CMS (2010) advocates a reader-centered strategy in written health instruction for older adults who may experience decreased cognitive skills. Clear communication is a health initiative of the National Institutes of Health (2012).

Dissemination of scientifically based best practices with stakeholders, including sharing non-successes during the change process with other health care professionals, can increase patient safety in health care (Levin et al., 2010). Mancuso (2009) conducted a review of literature from 1991–2006 to identify psychometric properties of health literacy screening tools, noting that all articles and a majority of citations were from medical, not nursing, journals. Professional nurses, and gerontological nurses specifically, should more often publish health literacy and quality improvement research in professional nursing journals to contribute to best practices, thus improving patient safety.

Baccalaureate nursing education includes provision of knowledge and skill sets in quality improvement and patient safety, as these are essential components of professional practice (American Association of Colleges of Nursing, 2008). Incorporating health literacy awareness in curricula to prepare nursing students to address the needs of the population they serve is an important task of nurse educators (Cormier & Kotrlik, 2009; Owens & Walden, 2007; Scheckel, Emery, & Nosek, 2010). As a nurse educator, the lead author will integrate health literacy awareness and related issues into the curriculum for undergraduate senior nursing students to promote patient-centered communication.

Conclusion

Limited health literacy is a prevailing factor among Medicare enrollees as this population experiences a substantial burden of chronic illnesses and complex medication management. Medication nonadherence is a risk factor for morbidity and mortality. A lack of self-confidence in understanding purpose, intent, numeracy, and dosing schedules can result in nonadherence, as well as medication errors. This quality improvement project identified psychometric properties of health literacy skill and the patients’ perspective of medication management. PictureRx illustrated pill cards facilitated understanding of instruction, resulting in improved adherence and self-efficacy.

Dissemination of project results among health care professionals may increase understanding of effects of limited health literacy among older adults, leading to further research and quality improvement studies. Specifically, nurses are the forefront of patient education in all areas of practice. Therefore, it is critical for nurse educators to purposefully incorporate properties of health literacy into nursing curricula to promote patient safety.

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Participant Characteristics (N = 20)

Characteristic Mean (SD), Range
Age (years) 75.25 (8.77), 59 to 89
MMSE score 24.55 (3.50), 18 to 30
Number of chronic illnesses 3.70 (1.38), 2 to 7
Number of prescribed medications 13.20 (4.72), 4 to 21
n (%)
Sex
  Women 13 (65)
  Men 7 (35)
Race/ethnicity
  African American 19 (95)
  Caucasian 1 (5)
Educational level
  Grade school 11 (55)
  High school 5 (25)
  Some college 3 (15)
  College graduate 1 (5)
Chronic illnessesa
  Hypertension 19 (95)
  Hyperlipidemia 14 (70)
  Diabetes mellitus 8 (40)
  Senile dementia 7 (35)
  Dementia 5 (25)
  Chronic kidney disease 4 (20)
  Cerebral vascular accident 3 (15)
Health literacy
  High likelihood (50% or more) of limited health literacy 14 (70)
  Possibility of limited health literacy 5 (25)
  Adequate health literacy 1 (5)

Adherence to Refills and Medications Scale Results (N = 20)

Reply of None of the Timea, n (%)
Item Pre-Intervention Post-Intervention
1. How often do you forget to take your medications? 9 (45) 18 (90)
2. How often do you decide not to take your medications? 15 (75) 18 (90)
3. How often do you forget to get prescriptions filled? 19 (95) 18 (90)
4. How often do you run out of medicine? 15 (75) 18 (90)
5. How often do you skip a dose of your medicine before you go to the doctor? 11 (55) 18 (90)
6. How often do you miss taking your medicine when you feel better? 12 (60) 18 (90)
7. How often do you miss taking your medicine when you feel sick? 12 (60) 18 (90)
8. How often do you miss taking your medicine when you are careless? 14 (70) 18 (90)
9. How often do you change the dose of your medication to suit your needs? 14 (70) 18 (90)
10. How often do you forget to take your medicine when you are supposed to take it more than once a day? 14 (70) 17 (85)

Self-Efficacy for Appropriate Medication Use Scale Results (N = 20)

Pre-Intervention Post-Intervention
Item n(%) n(%)
1. When you take several different medicines each day?
Not confident 3 (15) 0 (0)
Somewhat confident 11 (55) 5 (25)
Very confident 6 (30) 15 (75)
2. When you have a busy day planned?
Not confident 3 (15) 0 (0)
Somewhat confident 9 (45) 5 (25)
Very confident 8 (40) 15 (75)
3. When you are away from home?
Not confident 3 (15) 0 (0)
Somewhat confident 9 (45) 5 (25)
Very confident 8 (40) 15 (75)
4. When no one reminds you to take the medicine?
Not confident 4 (20) 0 (0)
Somewhat confident 8 (40) 5 (25)
Very confident 8 (40) 15 (75)
5. When you take medicines more than once a day?
Not confident 4 (20) 0 (0)
Somewhat confident 8 (40) 5 (25)
Very confident 8 (40) 15 (75)
6. When the schedule to take the medicine is not convenient?
Not confident 4 (20) 0 (0)
Somewhat confident 8 (40) 5 (25)
Very confident 8 (40) 15 (75)
7. When your normal routine gets messed up?
Not confident 3 (15) 0 (0)
Somewhat confident 9 (45) 5 (25)
Very confident 8 (40) 15 (75)
8. When you get a refill of your old medicines and some of the pills look different than usual?
Not confident 4 (20) 0 (0)
Somewhat confident 9 (45) 5 (25)
Very confident 7 (35) 15 (75)
9. When you are not sure how to take the medicine?
Not confident 4 (20) 0 (0)
Somewhat confident 9 (45) 5 (25)
Very confident 7 (35) 15 (75)
10. When you are not sure what time of the day to take your medicine?
Not confident 4 (20) 0 (0)
Somewhat confident 9 (45) 5 (25)
Very confident 7 (35) 15 (75)
11. When your doctor changes your medicines?
Not confident 3 (15) 0 (0)
Somewhat confident 10 (50) 5 (25)
Very confident 7 (35) 15 (75)
12. When they cause some side effects?
Not confident 4 (20) 0 (0)
Somewhat confident 9 (45) 5 (25)
Very confident 7 (35) 15 (75)
13. When you are feeling sick (like having a cold or the flu)?
Not confident 4 (20) 0 (0)
Somewhat confident 10 (50) 5 (25)
Very confident 6 (30) 15 (75)

Use and Perceived Utility of PictureRx CARDS (N = 20)

Item n(%)
1. How often did you use your pill card when you first got it?
Every day 20 (100)
Every few days (more than once a week) 0 (0)
Once a week 0 (0)
Every few weeks 0 (0)
Once a month or less often 0 (0)
Never 0 (0)
2. How often do you use your pill card now?
Every day 8 (40)
Every few days (more than once a week) 7 (35)
Once a week 5 (25)
Every few weeks 0 (0)
Once a month or less often 0 (0)
Never 0 (0)
3. How easy is it to understand the pill card, in terms of when and how to take your medicines?
Very easy 20 (100)
Somewhat easy 0 (0)
Not easy 0 (0)
4. Where did you keep your pill card most of the time?
On the refrigerator 1 (5)
In the bathroom 3 (15)
In my bedroom 2 (10)
Pocketbook, wallet, or pocket 0 (0)
Some other place where I keep my medicines 14 (70)
Other 0 (0)
5a. Has the pill card helped you remember which medicines you are supposed to take?
Yes 20 (100)
No 0 (0)
5b. Has the pill card helped you remember the names of the medicines?
Yes 20 (100)
No 0 (0)
5c. Has the pill card helped you remember what the medicines are for?
Yes 20 (100)
No 0 (0)
5d. Has the pill card helped you remember how many pills to take?
Yes 20 (100)
No 0 (0)
5e. Has the pill card helped you remember what time to take each medicine?
Yes 20 (100)
No 0 (0)
6. Which one of these has the pill card helped you with the most?
Remembering which medicines you are supposed to take 0 (0)
Remembering the names of the medicines 5 (25)
Remembering what the medicines are for 8 (40)
Remembering how many pills to take 1 (5)
Remembering what time to take each medicine 6 (30)
Other 0 (0)
7. Overall, how helpful is the pill card?
Very helpful 20 (100)
Somewhat helpful 0 (0)
Not at all helpful 0 (0)

Instructions

2.1 contact hours will be awarded for this activity. A contact hour is 60 minutes of instruction. This is a Learner-Paced Program. Vindico Medical Education does not require submission of quiz answers. A contact hour certificate will be awarded 4 to 6 weeks upon receipt of your completed Registration Form, including the Evaluation portion. To obtain contact hours:

  1. Read the article “Improving Medication Management Amont At-Risk Older Adults” by Delinda Martin, DNP, RN; Sunil Kripalani, MD, MSc; and V.J. DuRapau, Jr., PhD on pages 24–34, carefully noting the tables and other illustrative materials that are provided to enhance your knowledge and understanding of the content.

  2. Read each question and record your answers. After completing all questions, compare your answers to those provided at the end of the quiz.

  3. Type or print your full name, address, and date of birth in the spaces provided on the registration form.

  4. Indicate the total time spent on the activity (reading article and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity.

  5. Forward the completed form with your check or money order for $20 made payable to JGN-CNE. All payments must be made in U.S. dollars and checks must be drawn on U.S. banks. CNE Registration Forms must be received no later than June 30, 2014.

This activity is co-provided by Vindico Medical Education and the Journal of Gerontological Nursing.

Vindico Medical Education, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Activity Objectives

  1. Describe the components of health literacy as defined by the Institute of Medicine.

  2. Identify the percentage of Medicare recipients who read at lower than a sixth-grade level.

  3. Describe the goal of the quality improvement project conducted by the authors.

  4. Describe the methods used in the quality improvement project conducted by the authors.

  5. Discuss the findings of the quality improvement project.

Author Disclosure Statement

Drs. Martin and DuRapau disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Dr. Kripalani is a consultant to and holds equity in PictureRx, LLC.

Commercial Support Statement

All authors and planners have agreed that this activity will be free of commercial bias. There is no commercial support for this activity. There is no non-commercial support for this activity.

Keypoints

Martin, D., Kripalani, S. & DuRapau, V.J. (2012). Improving Medication Management Among At-Risk Older Adults. Journal of Gerontological Nursing, 38(6), 24–34.

  1. Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Limited health literacy adversely affects health and health care utilization and contributes to health disparities.

  2. Older adults with limited health literacy and who have chronic diseases require complex medication and disease management of comorbidities.

  3. Nearly half of Medicare recipients read at less than a sixth-grade level, which is a determinant in understanding health instructions (e.g., dosing schedules) and can lead to medication errors.

  4. PictureRx cards along with educational instruction using the teach-back method significantly improved medication-related self-efficacy and adherence among community-dwelling older adults.

Authors

Dr. Martin is Assistant Professor of Nursing, Department of Nursing and Allied Health, Our Lady of Holy Cross College, New Orleans, Louisiana, Dr. DuRapau is Professor Emeritus, Department of Mathematics, Xavier University of Louisiana, New Orleans, Louisiana, and Dr. Kripalani is Chief of Hospital Medicine and Associate Director of the Effective Health Communication Program, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee.

Drs. Martin and DuRapau disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Dr. Kripalani is a consultant to and holds equity in PictureRx, LLC. The terms of this agreement were reviewed and approved by Vanderbilt University in accordance with its conflict of interest policies.

Address correspondence to Delinda Martin, DNP, RN, Assistant Professor of Nursing, Department of Nursing and Allied Health, Our Lady of Holy Cross College, 4123 Woodland Drive, New Orleans, LA 70131-7399; e-mail: demartin@olhcc.edu

Received: October 11, 2011
Accepted: January 27, 2012
Posted Online: May 18, 2012

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