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MODULE 11: PATIENT ADHERENCE & PERSISTENCY
Section 11.2: Patient Engagement Techniques and Behavioral Coaching
Mastering communication strategies like motivational interviewing, shared decision-making, and health literacy principles to empower patients and foster lasting behavioral change.
SECTION 11.2
Patient Engagement Techniques and Behavioral Coaching
From “Directive” to “Partner”: The Pharmacist’s Communication Masterclass.
11.2.1 The “Why”: Your Voice is Your Most Powerful Therapeutic Tool
In Section 11.1, we became barrier investigators. We created a framework—the 5 Pillars—to diagnose the complex “5-car pileup” of non-adherence. We learned to identify the clinical, financial, logistical, psychosocial, and behavioral reasons a patient might stop their therapy. Now, we move from diagnosis to treatment. And the “treatment” is not a drug; it’s a conversation.
As an experienced pharmacist, your entire career has been built on patient communication. You are an expert at providing clear, accurate, and direct counsel. You know how to explain what a drug is, how to take it, and what to watch out for. This skill is the foundation. However, the specialty pharmacy world requires a profound shift in the purpose of that communication. The old model was transactional and directive. The new model is relational and collaborative.
The traditional model of “patient education” assumes a simple, linear path:
(Old Way) 1. Patient has a knowledge deficit. → 2. Pharmacist provides information. → 3. Patient is now educated and becomes 100% adherent.
We know this is false. A patient who smokes knows, on an intellectual level, that smoking is bad. Giving them a pamphlet on lung cancer (more information) will not make them quit. A patient who is depressed and overwhelmed by their MS diagnosis knows they “should” take their injection, but they lack the motivation. Telling them “it’s important” (more information) will not solve the underlying problem.
This section is a masterclass on the new model. We are not just “educating”; we are engaging, coaching, and empowering. We will learn to stop being the “expert on the stage” who lectures and start being the “guide on the side” who partners. We will master three core skills:
- Health Literacy Principles: The foundation for ensuring our message is understood by everyone.
- Motivational Interviewing (MI): The technique for empowering patients to find their own motivation to change.
- Shared Decision-Making (SDM): The process for helping patients make a specific, informed choice that aligns with their values.
Mastering these skills will transform your practice. You will move from asking, “Are you taking your medication?” to asking, “What matters most to you in managing your health?” The first question gets a “yes/no” answer. The second one saves a life.
Pharmacist Analogy: The Drill Sergeant vs. The Personal Trainer
Think about the last time you tried to make a difficult change in your own life—eating healthier, exercising more, or learning a new skill. Now, imagine two different coaches.
The Drill Sergeant (The “Directive” Model)
You show up at the gym. The Drill Sergeant barks, “You’re overweight. You’re lazy. Your goal is to lose 30 pounds, and my goal is to make you do it. Drop and give me 50 push-ups. Don’t question me. Don’t complain. Just comply.”
The Result: You might do the push-ups that day out of fear or shame. But will you come back tomorrow? No. You’ll feel defeated, resentful, and disempowered. This is the “compliance” model. It’s paternalistic and focuses on the provider’s goals.
The Personal Trainer (The “Coaching” Model)
You walk into the gym, feeling nervous. The Personal Trainer smiles, shakes your hand, and says, “Welcome. I’m so glad you’re here. This is the hardest step, and you just took it. First, tell me about you. What are your goals? What are you hoping to achieve?”
You say, “I… I don’t know. I just want to have more energy to play with my kids.”
The trainer says, “That’s a fantastic goal. Playing with your kids is clearly so important to you. Let’s build a plan, together, that gets you there. What kind of activity do you like to do?”
The Result: You feel heard, respected, and empowered. The goal is yours, not theirs. When you struggle, the trainer doesn’t yell; they ask, “That’s okay, last week was tough? Tell me about it. What got in the way? Let’s problem-solve.” This is the “adherence” model. It’s collaborative and focuses on the patient’s values.
As pharmacists, we are all trained to be Drill Sergeants. “You must take this. Your A1c is high. You have to stop eating sugar.” This section is your certification as a Personal Trainer. We are here to listen, partner, and empower.
11.2.2 The Foundation: Mastering Health Literacy Principles
Before we can motivate or collaborate, we must first ensure we are understood. In Section 11.1, we introduced Health Literacy as a barrier. Here, we master the techniques to overcome it. Health literacy is not a patient’s intelligence; it’s their ability to find, understand, and use health information. The CDC estimates 9 out of 10 adults struggle with the complex information and systems in healthcare. Our communication must be designed for that 90%, not the 10%.
Barrier 1.1: The “Universal Precautions” Approach
This is the guiding philosophy of health literacy. In medicine, “Universal Precautions” means you treat all blood as potentially infectious, so you wear gloves with every patient. This protects you and the patient, and it removes any stigma or judgment.
The Universal Precautions Approach for Health Literacy means you assume all patients may have difficulty understanding health information. You therefore use clear, simple communication techniques with every single patient, every single time.
Why this works:
- It removes your need to “guess” who does or doesn’t understand. (You will guess wrong. A college professor can be just as confused by “coinsurance” as anyone else).
- It removes shame. The patient doesn’t feel “singled out” or “talked down to.”
- It is simply more efficient. Clear communication is just better communication.
Barrier 1.2: The Pharmacist’s Toolkit for Plain Language
We are trained to speak in precise, complex medical jargon. “This is a subcutaneous anti-TNF biologic indicated for your autoimmune spondyloarthropathy.” This is accurate, and it is also useless to a patient. Your first job is to become a “translator.”
Pharmacist Playbook: The Jargon-to-Plain-Language Translator
| Instead of this Medical Jargon… | Try this Plain Language… |
|---|---|
| “Your condition is autoimmune. Your antibodies are attacking your joints, causing inflammation.” | “Your body’s defense system is confused. It’s accidentally attacking your own joints, which causes the pain and swelling you feel.” |
| “This is a biologic anti-TNF monoclonal antibody. It works by inhibiting tumor necrosis factor.” | “This drug is a special protein. Think of it as a ‘fire extinguisher.’ Your body is making too much of a signal that causes pain. This drug finds that signal and ‘cools it down,’ stopping the pain.” |
| “Take this q12h, PRN for your exacerbation.” | “Take this twice a day. A good way to remember is once at breakfast and once at dinner. Use it when you feel a ‘flare-up’ or your symptoms get worse.” |
| “This drug has a black box warning for lymphoma and opportunistic infections.” | “This drug works by calming down your defense system. Because it’s calmer, you may have a higher chance of getting an infection, like a cold or the flu. We must watch for this. There is also a very, very rare risk of certain cancers, which we can talk about.” |
| “We need to check your hepatic function panel and your HFrEF.” | “We need to do a blood test to check on your liver health.” / “This is for your heart, which is a ‘weak pump’ and needs help.” |
Key Principles: Use simple, non-medical words. Use analogies (“fire extinguisher,” “defense system,” “weak pump”). Break complex ideas into 1-2 small chunks.
Barrier 1.3: The “Teach-Back” Method (A Deep Dive Tutorial)
We introduced this in 11.1. Now we master it as a core communication skill. Teach-Back is not a test of the patient’s knowledge. It is a test of how well you explained the concept. It’s “closing the loop” to ensure your message was received as intended.
Tutorial: The 5 Steps of the Teach-Back Loop
Case Study: You are counseling a patient on a new warfarin prescription after a PE diagnosis.
Step 1. Set the Stage (The “Blame-Free” Setup)
You first explain 1-2 critical concepts (not all 10).
Script: “Mr. Harris, we’ve gone over a lot of information about this new blood thinner, warfarin. This is a very important and tricky medicine, and I want to be sure I did a good job explaining everything clearly.”
(This is the most important part. You put the “blame” or “responsibility” on yourself. You are not saying, “Were you listening?” You are saying, “Was I being clear?”)
Step 2. Ask (Elicit the Teach-Back)
Do not ask a “yes/no” question like “Do you understand?” (They will always say yes). Ask an open-ended question that prompts them to explain.
Script: “Just to make sure I didn’t miss anything, can you tell me in your own words, what is the most important thing you need to watch out for while taking this?”
Step 3. Listen (Assess Understanding)
Listen carefully. Is the patient’s answer accurate? Is it complete? Are they confident or hesitant?
Patient’s response: “Well… you said I need to get my blood checked. And I shouldn’t… eat… vegetables?”
Your Assessment: The patient is hesitant. They got the “blood check” part right (partially) but completely misunderstood the Vitamin K counseling.
Step 4. Clarify (Re-Teach, Don’t Re-Lecture)
Do not say, “No, that’s wrong.” Acknowledge what they got right, and then re-teach the part they missed, using even simpler language.
Script: “You are exactly right that getting your blood checked is critical. That’s called your INR test. But let me be more clear about the food part, because I wasn’t very clear.
You can eat vegetables. In fact, you should! The most important thing is consistency. If you eat a salad twice a week, that is perfect. Just continue to eat a salad twice a week. The problem is not eating vegetables; it’s suddenly changing—like eating no salad for a month and then eating a huge one every day. The key is to keep your diet consistent.”
Step 5. Re-Check (Close the Loop)
Ask again, to make sure the re-teaching stuck.
Script: “So, just to make sure I’m explaining this food part better now… what are your thoughts on how you’ll handle your salads or leafy greens next week?”
Patient’s response: “Oh! I see. So, I don’t have to stop eating them, I just have to be steady. If I usually have a salad on Monday and Thursday, I should just stick to that. And not, like, suddenly start a spinach diet.”
Pharmacist: “You’ve got it exactly right. That’s perfect.”
You have now closed the loop.
11.2.3 Masterclass: Motivational Interviewing (MI)
This is the heart of behavioral coaching. If health literacy is the foundation, MI is the engine. Motivational Interviewing is a “collaborative, goal-oriented style of communication with particular attention to the language of change.” It is designed to strengthen a person’s own motivation and commitment to a specific goal by eliciting and exploring their own reasons for change within an atmosphere of acceptance and compassion.
In simpler terms: MI is the art of helping people talk themselves into changing.
We are all hard-wired with a specific, unhelpful instinct: The “Righting Reflex.”
The “Righting Reflex”: The #1 Habit You Must Unlearn
The Righting Reflex is the natural, well-intentioned instinct of a helper (like a pharmacist) to want to “fix” a patient’s problem for them. We hear a problem, we provide the solution. The patient argues, we argue back. This is what all of us are trained to do. It is also the single fastest way to shut down a conversation and create resistance.
Anatomy of a Failed Conversation: The Righting Reflex in Action
Patient (ambivalent): “I know I’m supposed to take this insulin, but I just… I hate it. I’m not doing it.”
Pharmacist (using Righting Reflex): “But you have to take it. Your A1c is 10.4! If you don’t take your insulin, you could go blind or lose a foot!”
Patient (now defensive): “Look, it’s my body. I feel fine. My uncle went blind and he was on insulin, so it probably doesn’t even work. I’m not doing it.”
Pharmacist (arguing): “That’s not true! Insulin is proven to work. You are making a huge mistake. You must…”
Result: The conversation is over. The patient is angry and defensive. You have pushed them further away from change. By arguing for change, you forced the patient to argue against it. They have just spent five minutes vocally defending their non-adherence, strengthening their resolve to not change.
MI is the opposite of the Righting Reflex. It’s about resisting that urge to “fix” and instead, getting curious. Let’s rewind that same conversation, but this time, the pharmacist will use MI.
The Same Conversation, Powered by MI
Patient (ambivalent): “I know I’m supposed to take this insulin, but I just… I hate it. I’m not doing it.”
Pharmacist (resisting the Righting Reflex; using a reflection): “It sounds like you’re feeling really frustrated with this new plan. You just don’t like the idea of it at all.”
Patient (feels heard, less defensive): “Yeah. It’s… it’s just scary. And it’s a needle. And I’m going to have to do this forever. It just feels… hopeless.”
Pharmacist (using an open-ended question): “It feels hopeless. Thank you for saying that. What is it about it that bothers you the most?”
Patient: “The needle, for one. But also… I feel like this means I’ve failed. Like I’m at the end of the line. My uncle was on insulin, and he ended up going blind anyway.”
Pharmacist (using a double-sided reflection): “So on the one hand, you’re worried that taking insulin means you’ve ‘failed’ and that it might not even work… and on the other hand, you know your doctor (and I) are worried about your A1c of 10.4. That’s a really tough spot to be in.”
Patient (feeling understood): “Yeah. I mean… I don’t want to go blind. I want to be able to see my grandkids. I just… I’m scared of the needle.”
Pharmacist (noticing “Change Talk”): “Being there for your grandkids is really important to you. And it sounds like you’d be willing to do this if we could just get past that fear of the needle. [Summarizing]. Would it be okay if we just… looked at the pen? Not to use it, just to look at it? The needle is actually so small you can barely see it.”
Result: The patient is now engaged in a collaborative conversation. You have identified the real barrier (fear and a false belief about “failure”), and you are now problem-solving with them. This is Motivational Interviewing.
The “Spirit” of MI: Your Guiding Mindset (PACE)
Before you learn the techniques, you must adopt the mindset. The “Spirit of MI” is the ethos you bring to the conversation. It’s summarized by the acronym PACE.
| Acronym | Principle | What It Means for a Pharmacist |
|---|---|---|
| P | Partnership | You are not the expert “fixing” the passive patient. You are two experts (you are the expert on medicine; they are the expert on their life) working together. You are the “Personal Trainer,” not the “Drill Sergeant.” |
| A | Acceptance | This is about unconditional positive regard. You respect the patient’s autonomy to make their own choices, even if you disagree. You don’t judge them for their past failures. You accept them as they are. |
| C | Compassion | You are genuinely committed to the patient’s welfare and are acting in their best interest, not your own (e.g., not just to “improve your adherence scores”). |
| E | Evocation | This is the core idea. The motivation for change is not in you; it is already in the patient. Your job is to “evoke” it, or draw it out. You are not “installing” motivation; you are “uncovering” it. |
The Core Skills of MI: Your “OARS” Playbook
If PACE is the “spirit,” OARS are the practical skills you use to bring it to life. OARS is the “how-to” of MI. We will provide a tutorial for each.
Open-Ended Questions
Questions that don’t have a “yes/no” answer. They invite the patient to tell a story.
Affirmations
Statements that recognize the patient’s strengths, efforts, and good intentions.
Reflective Listening
The most important skill. Stating back to the patient what you think you heard them say.
Summaries
A special type of reflection that pulls together multiple ideas to transition the conversation.
OARS Tutorial 1: Open-Ended Questions
These are the “key” that unlocks the conversation. They are questions that cannot be answered with a single word. They prompt the patient to reflect and elaborate. This is the opposite of the rapid-fire “yes/no” checklist you might use in a community pharmacy DUR.
Pharmacist Playbook: “Closed” vs. “Open” Questions
| Closed-Ended (Avoid This) | Open-Ended (Use This) |
|---|---|
| “Are you taking your Humira every two weeks?” | “How has it been going with your Humira since we last spoke?” |
| “Do you have any questions?” | “What questions do you have for me today?” |
| “Did you have any side effects?” | “What have you noticed, if anything, after you take your injection?” |
| “Are you willing to try this?” | “How do you feel about trying this new approach?” |
| “Is your diet good?” | “Tell me a bit about what you typically eat in a day.” |
The Rule: If your question starts with “Are you,” “Do you,” “Did you,” or “Is,” it’s probably a closed question. Start your questions with “How…,” “What…,” or “Tell me about…“
OARS Tutorial 2: Affirmations
Affirmations are not praise. Praise (“Good job!”) is about your judgment. An affirmation is about noticing and reflecting the patient’s own strengths and efforts. This is critical for building self-efficacy—the patient’s belief that they can change. Patients who are “stuck” often feel like failures. Affirmations help them see themselves as capable.
Pharmacist Playbook: The Affirmation Generator
Listen for: Any sign of effort, any statement of values, any past success.
| When the Patient Says… | Instead of Praise (“Good job!”)… | Try an Affirmation (Noticing their strength) |
|---|---|---|
| “I only missed one dose this week, instead of three.” | “Good job, that’s much better.” | “You really worked hard this week to remember your medication. That shows a lot of commitment.” |
| “I’m just so worried about this. I’ve been reading everything I can…” | “That’s good.” | “You’re a very resourceful person who wants to be fully informed about your health. You’re a strong advocate for yourself.“ |
| “I don’t know… I tried to quit smoking once, but I failed.” | “Well, you need to try again.” | “You’re a person who doesn’t give up. The fact you tried before shows this is important to you, and you have experience we can learn from.” |
| “I guess I could try to walk for 10 minutes.” | “Great. Do that.” | “You’re willing to try a new approach, even if you’re not 100% sure. That’s a big step.“ |
OARS Tutorial 3: Reflective Listening
This is the most important and powerful skill in MI. It is the engine of empathy. A reflective listening statement is not a question. It is a statement that reflects back to the patient what you think you heard them say or mean. It’s a “guess” at their meaning. This does two things:
1. It proves you are actually listening, which builds trust.
2. It helps the patient hear their own thoughts, which helps them process their ambivalence.
There are different levels of reflection, from simple to complex.
Pharmacist Playbook: The Levels of Reflection
Patient says: “I’m supposed to use this inhaler twice a day, but I just… I only use it when I feel short of breath. It’s expensive and I don’t think it’s doing anything.”
Level 1: Simple Reflection (Repeating or Rephrasing)
You repeat a key word or phrase. This is safe and shows you’re paying attention.
Script: “So you’re only using it when you feel short of breath.” or “You’re not convinced it’s doing anything for you.”
Level 2: Complex Reflection (Paraphrasing or Reflecting Meaning)
You make a “guess” at the unspoken meaning or feeling. This is more powerful.
Script: “It sounds like you’re not convinced the benefit of this inhaler is worth the cost and the hassle.” or “You’re wondering if this ‘preventer’ inhaler is really necessary, especially since you don’t feel an immediate effect.”
Level 3: Amplified Reflection (Overstating)
You amplify what the patient said (without sarcasm) to encourage them to elaborate or correct you. This is a great way to “roll with resistance.”
Script: “So, as far as you can tell, this inhaler is completely useless.”
(This often prompts the patient to soften their stance: “Well, I wouldn’t say useless… I guess my breathing is a little better than it was last month… but…”) ← They just produced their first piece of Change Talk!
Level 4: Double-Sided Reflection (The Ambivalence-Killer)
This is the #1 tool for ambivalent patients. You listen for both sides of their argument (the “Sustain Talk” and the “Change Talk”) and reflect them back in one sentence. This holds up a “mirror” to their ambivalence.
Script: “So, on the one hand, you hate the hassle and the cost, and you’re not even sure this expensive inhaler is working… and on the other hand, you’re looking for a way to get your breathing under better control.”
This perfectly captures their “stuck” feeling and invites them to explore it further.
OARS Tutorial 4: Summaries
Summaries are just “super-reflections.” They are a way to pull together all the threads of the conversation, show the patient you’ve been listening the whole time, and strategically transition to the next topic. They are often used to “collect” all the Change Talk the patient has offered.
A summary has three parts:
1. An announcement (“Let me see if I’ve got this all straight…”)
2. The summary itself (linking together their feelings, ambivalence, and any Change Talk).
3. An invitation to continue (“…Is that about right? What else?”)
Pharmacist Playbook: The “Change Talk” Summary Script
Script: “Okay, Mr. Johnson, let me just pause and make sure I’m following you. [Announcement]
…You came in today feeling really frustrated with your diabetes. You’re tired of taking so many pills, and you’re especially worried about the side effects of this new GLP-1 you were prescribed. You’ve heard some scary things online, and it’s making you want to just… stop everything. [Summary – Sustain Talk & Feelings]
…At the same time, you told me that your energy is really low, and you’re really worried about your father, who had a lot of complications. You said you want to be able to hike with your son, and you’re worried your current path isn’t going to get you there. [Summary – Change Talk & Values]
…Is that a fair summary of what’s on your mind?” [Invitation]
(The patient feels incredibly understood. Now you can transition.)
“Where should we go from here?”
MI Masterclass: Key Strategies & Tools
OARS are your tools. Now, here are the “blueprints” for how to use them.
1. The Importance/Confidence Ruler
This is a fast, powerful way to assess motivation and ambivalence. You use a 1-10 scale for two different questions.
Step 1: Ask about Importance.
Script: “On a scale of 0 to 10, where 0 is ‘not at all important’ and 10 is ‘the most important thing in my life,’ how important is it for you right now to [make the change, e.g., ‘get your A1c under control’]?”
Patient: “Oh, it’s important. I’d say it’s an 8.”
Step 2: Ask “Why not lower?” (This is the magic question)
Pharmacist: “Okay, an 8. That’s a high number. Can I ask, why did you say 8 and not a 4 or 5?”
Patient: “Well, like I said, I don’t want to end up like my dad. I want to be healthy. I need to be here for my kids.”
(The patient has just given you their “Change Talk.” Your job is to reflect it: “Being a healthy, present father is your top priority.”)
Step 3: Ask about Confidence.
Script: “Okay, so the importance is an 8. Now, a different question. On a scale of 0 to 10, where 0 is ‘not at all confident’ and 10 is ‘100% sure I can do it,’ how confident are you that you could [make the change, e.g., ‘start this new injection’]?”
Patient: “Oof. That’s different. My confidence is… maybe a 3.”
Step 4: Ask “What would it take…?”
(You have just diagnosed the problem! It’s not a lack of desire; it’s a lack of self-efficacy.)
Pharmacist: “Okay, a 3. That’s a very honest answer, thank you. What would it take to get you from a 3 to a 4 or 5?”
Patient: “Well, a 3 because I’m just scared of the needle. I don’t even know how to use the pen. If someone could just… show me… I’d probably feel like a 5.”
Pharmacist: “I can do that. We can do that right now. [Opens training pen].”
This technique, in 60 seconds, allowed you to bypass the “importance” argument (which the patient already agreed with) and pinpoint the real barrier: a lack of confidence and a need for training.
2. Rolling with Resistance
Resistance (e.g., “No,” “You don’t understand,” “This is stupid”) is not a “bad patient.” Resistance is a signal. It’s a signal that you are using the wrong strategy. You are probably using the Righting Reflex. The patient is resisting you, not the change. Your job is to stop pushing and “roll with it,” like a judo master using your opponent’s momentum.
| Patient’s Resistance | Your “Righting Reflex” (Bad) | “Rolling with Resistance” (Good) |
|---|---|---|
| “You’re just like my doctor, you don’t get it. This drug is a poison.” | “It is not a poison! It’s an FDA-approved drug. You’re wrong.” | (Amplified Reflection) “It sounds like from your perspective, this drug is 100% harmful.” |
| “I don’t have time for this. Just give me my pills.” | “This is important, you need to listen to me!” | (Reflecting Autonomy) “You’re clearly on a tight schedule and this is a bad time. You are in control here. Would it be better if I called you tomorrow at 5?” |
| “This is pointless. Nothing is going to work.” | “You have to be more positive. This will work if you just try.” | (Reflecting Feeling) “You’re feeling really defeated right now, like you’ve tried everything and you’re just stuck.” |
In all “Good” examples, you are not arguing. You are reflecting and validating their feeling, which de-escalates the tension and allows the conversation to continue.
11.2.4 Masterclass: Shared Decision-Making (SDM)
If MI is the tool you use to help an ambivalent patient find their motivation for change, Shared Decision-Making (SDM) is the process you use when a patient is at a “fork in the road” and needs to make a specific, informed treatment choice.
SDM is the pinnacle of patient-centered care. It is a process where the “two experts” (the pharmacist with clinical expertise and the patient with life expertise) work together to make a health decision that is based both on the best clinical evidence and the patient’s personal values and preferences.
MI vs. SDM: The Right Tool for the Right Job
This is a common point of confusion. They are related but distinct.
| Motivational Interviewing (MI) | Shared Decision-Making (SDM) | |
|---|---|---|
| Primary Goal | To elicit and strengthen a patient’s internal motivation for change. | To make a specific, informed choice between two or more reasonable options. |
| When to Use It | Patient is ambivalent, unmotivated, resistant, or needs to make a behavioral change (e.g., “I don’t know if I want to start this drug.”). | Patient is motivated but at a “choice point” (e.g., “Should I choose Drug A or Drug B?” “Should I choose the pill or the injection?”). |
| The Pharmacist’s Role | Guide. You are “evoking.” You listen more than you talk. | Partner & Educator. You are “informing.” You provide unbiased data on options, then help the patient filter that data through their values. |
| Analogy | The Therapist helping a client discover if they want to quit their job. | The Career Counselor helping a client choose between two different job offers. |
Key Insight: You often use MI first to get the patient to the “starting line,” and then you use SDM to help them choose their “lane.”
The SHARE Approach: A 5-Step Tutorial for SDM
The AHRQ (Agency for Healthcare Research and Quality) developed the SHARE approach as a simple, memorable process for implementing SDM in a real-world clinical setting. Your job as a specialty pharmacist is to be the “decision coach” who facilitates this process.
The 5-Step SHARE Approach
S
Seek your patient’s participation.
Explicitly invite the patient into the decision. This signals a shift from the “directive” model.
Script: “Dr. Smith has prescribed [Drug A], but your insurance also covers [Drug B], which works in a similar way. This is a preference-sensitive decision, which means there is no single ‘right’ answer. My job is to help you figure out which one is the best fit for you and your lifestyle. Would you be open to exploring those two options with me?”
H
Help your patient explore and compare options.
This is your “educator” role. You must provide objective, unbiased information about the risks, benefits, and logistics of each choice. The “Option Talk” table is your best tool here.
Script: “Great. Let’s make a quick comparison. I’ve found a table is the easiest way to do this…” (See playbook below).
A
Assess your patient’s values and preferences.
This is the most important step. You pivot from facts to feelings. The “best” choice is the one that aligns with what matters most to the patient.
Script: “So, that’s the data. Now, let’s talk about you. Looking at this… what stands out to you? Are you the kind of person who prefers the convenience of a pill, even if it means potential GI side effects? Or are you more comfortable with an injection every two weeks if it means you don’t have to think about it every day?”
R
Reach a decision with your patient.
The patient makes the final call. You can offer a recommendation, but it’s their choice. They are now an “active” participant.
Script (Patient): “You know… I have a really sensitive stomach. The GI side effects of the pill scare me. I think… I think I’d rather do the injection. I’m nervous, but it seems like a better fit.”
Script (Pharmacist): “That sounds like a very reasoned choice. You prioritized your GI health and are willing to take on the injection. That’s a great decision. We will start the [Drug B] and I will set you up for an injection training.”
E
Evaluate your patient’s decision.
Set a follow-up plan. A decision is not “final”; it’s a test. You will circle back to see if it’s working for them.
Script: “Okay, so we’ll move forward with the injection. Here’s what I’m going to do: I’m going to call you in two weeks, after your first dose, just to see how it went. This isn’t a permanent decision. If you hate it, we can always circle back and re-evaluate. How does that sound?”
SDM Playbook: The “Option Talk” Table
This is your primary tool for Step H (Help explore options). You are creating a “Decision Aid” for the patient, live.
Case Study: A patient with Psoriatic Arthritis, new to therapy. The two formulary options are Otezla (oral) and Humira (injection).
Pharmacist “Option Talk” Script
“Let’s compare these two options head-to-head. They are both excellent drugs.”
| Feature | Option 1: Otezla (apremilast) | Option 2: Humira (adalimumab) |
|---|---|---|
| How you take it | It’s a pill. You start with a “titration pack” for 2 weeks, and then it’s one pill, twice a day, every day. | It’s an injection. It comes in an “auto-injector pen” (like an EpiPen). You give it to yourself once every two weeks. |
| How it works | It’s a “small molecule” that works inside the cell to calm down inflammation. | It’s a “biologic” that works outside the cell. It’s the “fire extinguisher” we talked about that finds and blocks the pain signal (TNF). |
| Common Side Effects | In the first month, many people get GI upset (nausea, diarrhea) and headaches. This usually goes away. | The main thing is a “site reaction,” like a red, itchy spot where you inject. The main risk is a higher chance of getting infections, since it calms your defense system. |
| Lab Monitoring | Just a baseline blood test. No regular monitoring needed. | You need a blood test for TB before you start, and then your doctor will probably check your blood 1-2 times a year. |
| Main “Pro” | It’s a pill (no needles) and it doesn’t “suppress” your immune system in the same way. | Many consider it to be “stronger” and it’s only once every 2 weeks, so you don’t have to think about it every day. |
| Main “Con” | Twice-a-day dosing, and you have to get through the first month of GI side effects. | It’s an injection, and you have to be careful about infections. |
Now, pivot to Step A (Assess Values): “Okay, so that’s the snapshot. Looking at these two, what’s your first gut reaction? What matters more to you: avoiding a needle, or avoiding daily GI side effects?”
11.2.5 Putting It All Together: The High-Impact Adherence Call
You have now mastered the three pillars of behavioral coaching. You know how to ensure understanding (Health Literacy), how to explore ambivalence (MI), and how to make a choice (SDM). Now, let’s see how they all weave together in a single, high-impact specialty pharmacy call.
The scenario is a 30-day follow-up call. This is not the first counseling session. This is the call where you find out if the patient is actually persistent.
Patient: “Sarah,” a 34-year-old with newly diagnosed Relapsing-Remitting Multiple Sclerosis (MS).
Drug: Copaxone (glatiramer acetate), a daily subcutaneous injection.
Barrier (from 11.1): Asymptomatic disease, needle phobia, side effects (ISRs), and psychosocial (overwhelmed). This is a 5-car pileup.
Case Study: The 10-Minute Adherence Coaching Call
Pharmacist: “Hi Sarah, this is [Your Name], your specialty pharmacist from [Pharmacy Name], just calling for our scheduled one-month check-in. I’ve set aside about 10 minutes for us. Is now still a good time?”
[Technique: Sets agenda, respects patient’s time.]
Patient: “Oh… hi. Yeah, I guess. I’m… I’m not doing great.”
Pharmacist: “I’m sorry to hear that. You sound pretty discouraged. Tell me more about what’s been going on since you started the Copaxone.”
[Technique: Reflects feeling (“discouraged”) + Open-Ended Question.]
Patient: “I… I stopped taking it. I took it for about two weeks, and I just… I can’t. The shots hurt, I have these awful red welts all over my stomach, and I feel fine. I don’t even feel sick! Why am I putting myself through this? I think I’m just going to… not. I haven’t told Dr. Smith.”
Pharmacist (Resists Righting Reflex): (Deep breath. Do not say “You must take it!” or “You have to tell your doctor!”).
Pharmacist (Good): “Thank you so much for being honest with me, Sarah. That took a lot of courage. It sounds like this has been a miserable experience. You’re putting yourself through painful, daily shots that are leaving welts, all for a disease you can’t even feel. It makes perfect sense why you would stop.”
[Technique: Strong Affirmation (“courage”) + Complex Reflection (validating her choice).]
Patient (feels validated, not judged): “Exactly! My partner thinks I’m crazy for stopping, but they’re not the one stabbing themselves. I just… I feel so overwhelmed by all of it.”
Pharmacist: “You’re feeling overwhelmed by the diagnosis, and this daily, painful shot is just a constant, physical reminder of a disease you’d rather not think about.”
[Technique: Reflecting Meaning.]
Patient: “Yes! That’s it exactly.”
Pharmacist: “This is a really tough spot to be in. On the one hand, these injections are painful and a huge hassle, and you’re not seeing any benefit… [Double-Sided Reflection, side 1] …and on the other hand, I remember you telling me when we first spoke that your biggest goal was to be able to keep hiking and ‘be yourself’ for as long as possible, and you were worried about a future relapse. [Double-Sided Reflection, side 2 – her own ‘Change Talk’]. I’m wondering where that leaves you now.”
Patient (processing her ambivalence): “…I am worried about that. I guess… I just wish it wasn’t this. I wish there was another way. The side effects are just… they’re awful.”
Pharmacist: “The side effects are the main barrier. It sounds like you’re still committed to your goal—staying healthy for the long run—but this particular path is just not working for you. [Summary]. You know, you are not the first person to have this exact problem with the injection sites. Would it be okay if I shared a few tips that have worked for other patients?”
[Technique: Affirmation + Asking Permission (key step!).]
Patient: “Sure… I guess.”
Pharmacist: “Okay, first, about the welts. This is the most common complaint. I want to be sure I explained the injection technique clearly. Just to check, can you tell me what you’ve been doing?”
[Technique: Health Literacy “Teach-Back,” blaming self.]
Patient: “Well, I take it out of the fridge, I swab my stomach, and I inject it. It stings like crazy.”
Pharmacist: “Okay, that’s a great start. I have two tips that might make a huge difference.
1. Are you letting the pen warm up for 30 minutes at room temp? Injecting cold medicine is what causes most of that stinging.
2. Are you using a cold pack on the site before you inject, and a warm compress after? That can really help with the welts.
…I should have mentioned that on our first call, that’s my fault.”
[Technique: Plain Language, practical tips, taking responsibility.]
Patient: “Oh. No, I was just… taking it straight from the fridge. I didn’t know you could use a cold pack.”
Pharmacist: “That right there could be the game-changer. But Sarah, even with those tips, a daily shot is still a huge burden. This brings us to a ‘fork in the road.’ You’re not happy with the daily shot, and that’s 100% valid. There are other options. Would you be open to hearing what they are, just so you know all your choices?”
[Technique: Pivoting from MI to Shared Decision-Making (SDM).]
Patient: “There are? Dr. Smith just… gave me this one.”
Pharmacist: “Yes. This is a great drug, but there are also pills and other injections you take less often. For example, there’s an oral pill (Tecfidera) you take twice a day, or another injection (Avonex) you only take once a week. They all have different pros and cons, just like the Copaxone. [SDM – Step H: Helping explore options.]
Pharmacist: “Looking at those choices—a daily shot with the tips we just talked about, a twice-daily pill that has some GI side effects, or a once-a-week shot that can cause flu-like symptoms… what matters most to you? Is it avoiding a shot altogether? Or is it having to think about it less often?”
[Technique: SDM – Step A: Assessing values.]
Patient: “I… I had no idea there were pills. I think… I’d much rather try a pill. Even with GI side effects. I just… I hate the needles.”
Pharmacist: “That is a perfectly reasonable choice. You’re prioritizing a needle-free option. [SDM – Step R: Reaching a decision.]. Here’s what I propose: I’m going to call Dr. Smith right now. I’ll explain that you’re having a really tough time with the daily injections and the site reactions, and that you’d like to discuss trying an oral therapy like Tecfidera. I will handle the new prescription and the new insurance authorization. Then, I’ll call you back and we’ll do a ‘Teach-Back’ on that new medicine, including the plan for managing the GI side effects. How does that sound?”
[Technique: Closing the loop, creating a concrete action plan.]
Patient (sounds relieved): “That… that would be amazing. Thank you. I feel… so much better.”
Pharmacist: “You did the hard work today, Sarah. You were honest about what wasn’t working. You’re a strong advocate for yourself, and my job is just to be your partner in this. I’ll call you back as soon as I hear from the doctor.”
[Technique: Final Affirmation + Summary of Partnership.]
11.2.6 Conclusion: Your Voice is Your Most Powerful Tool
As this masterclass has shown, your role as a Certified Advanced Specialty Pharmacist (CASP) is as much “behavioral coach” as it is “medication expert.” You have seen how a single, 10-minute conversation can transform a patient from “non-compliant and non-persistent” to “empowered and engaged.”
You have learned to unlearn your “Righting Reflex.” You have mastered the foundational skills of Health Literacy to ensure you are always understood. You have a complete toolkit in Motivational Interviewing (OARS) to “evoke” a patient’s own reasons for change. And you have a clear, 5-step process in Shared Decision-Making (SHARE) to act as a true partner in their care.
These skills are not automatic. They are a practice. You will make mistakes. You will catch yourself using the Righting Reflex and have to pause and pivot. This is the work. By mastering this “Personal Trainer” mindset, you are not just dispensing a specialty drug; you are ensuring it actually has a chance to work. In the next section, we will learn how to apply these skills over the long term, by designing effective follow-up protocols and measuring our success.
