ISPP 2015

Career Opportunities in Pharmacy
Medication Adherence, Or not?



this conference will now be recorded all right so let's start again hi everyone hi Katie Kim Rhonda Tony um okay so we're talking today about medication adherence or not um just starting right from the beginning there is a difference in the language that is used compliance implies according to WHO it implies rule following it implies doing what you're told and I had said earlier that whether you're 15 or 50 nobody likes to be told what to do it's doing what you have to do again the question comes according to WHO the power differential between the case manager and the client we've talked about briefly in other areas using this kind of language about following rules that there's a consequence if you don't increases that power differential and puts people on the defensive and not just the client but the case manager as well and as a provider myself it within the hospital setting it was true for me as well and you can get yourself in a situation where all of a sudden you're going to toe to toe with someone and it's just it's gonna ruin the therapeutic relationship it's gonna put you at risk it'll put them at risk and it just kind of translates to less effective care and really lower positive result so so when we're talking about adherence we're talking about more of a choice am I gonna adhere to something am I gonna stay with it am I gonna remain with it am I gonna stick to it you know I just the word adhere means to fasten to or just stick to so it's also make a connection with if I adhere to the work ethic of the agency that I'm an employee of that means I develop some kind of belief in it or I connect with it whether it's the people or the philosophy or the duties of the job so keeping in mind the word adherence just listening to the word it's gonna bring less defensive Ness and lower that negative power differential rather than compliance and that's been my experience so you'll have to think about what your experience is directly been so it does imply choice and again that goes back to the bottom line of self-determination you know the client has the energy the well the right to refuse any services decisions but there are consequences to that there are outcomes are related to that so as long as they're informed and they do it then it's it's theirs and the problem comes when people are refusing to do something or non-compliant for lack of a better word and they're not informed properly because then they can't make an informed choice so it's going to be the responsibility of the provider to make sure that all the details of the situation including what the outcome could be whether you adhere to something or don't so that there's some understanding it just evens out the playing field and it makes it they are choice truly based on the information received we want to make informed decisions when we make disability there's not many missions that we make without knowing some facts and so it would be expected that the clients would have the same privilege to that so if we look at why people stay on medications these are the most common that came up in the inpatient setting and when I also worked in the probation and parole supervision program years ago so this this has been pretty steady for years and years one of the top things that people say why they stay on medications is because the schedule is easy and access as easy that's why I'm a huge believer in Bubble packs the meds are all set out there on one card they're dated aid and you don't have to worry about bottles you don't have to worry about you know check-in the dosage every time you still want to make sure the client know what the medications are by sight but the problems come to when the color of the pill changes or the shape of the pill changes and so that goes back to really providing that information and utilize your pharmacist and utilize the pharmacist that puts the bubble packs together they're a great resource to talk to you and to talk to the client yeah so your experience working at one a bagel mental health do you see that physicians try to get them on the minimum dosage like twice a day versus though I do in the day I do yep and that's the preferred not because what's been brought to their attention to is the cost on outpatient the cost on conditional release they've been a lot more educated on that as well as the accessibility in the medications there they will very readily say let's look at this rather than this because it's 56 dollars a pill you know so that's one piece of it the other piece of it is what's gonna make it easy for the case manager to teach how its dispensed how close is it gonna be to when they left and within 30 days of conditional release when I was there and that was just I left in October within 30 days we would put the patient on self meds and hopefully what is the final schedule so it would bring it down to two a day twice a day or you know at most three times a day very rarely four times a day um qid just isn't very common anymore so yeah does that answer your question okay so the other thing too is preferred form is going to increase the adherence to the medication some people prefer an injection despite popular belief because it's easy on outpatient in the Outagamie County dr. Patel I know is promotes injection first and foremost if it's available in an injectable form and by talking to the client about the benefits of injection the long-standing maintaining the level within the system things to watch for a lot of times they'll see the benefits of it and um it's becoming more popular it's also become more standard for people under civil commitment that they're gonna say yes you will take the injection and if they choose not to come for the injection that's where we go so financially accessible under the conditional release program I know a lot of financial for psych meds is not dumped on to the client but still you look at Medicare you look at Medicaid you look at benefits for medication benefits and that's gonna play a role because there's co-pays just like you and I have and some of these medications are 50 to 150 dollars per pill it's it's ridiculous and then you look at the labs for meds like clause rule that's an extra cost you know you look at the lithium levels that's an extra cost so think about these things as you're going along and talk to the pharmacist talk to the doctor about really with blood levels if the patient is doing well what's the minimum frequency that blood levels need to be done it you don't need to do overkill on those so just keep that in mind utilize the provider utilize the doctor the pharmacist use everyone you can what I did even though I worked in outpatient I utilize all patient resources like that especially pharmacy so the other the next thing too is the trust in the provider if I don't know my psychiatrist at all I am less likely to be confident in the medication decisions they're making for me and that's true for us as well helping to educate the client about the provider with the provider is really helpful you can say in my experience working with dr. Patel but until that client is sitting in the office with dr. Patel and dr. Patel says well in my experience that's gonna hold a lot more water um going to the appointments with the client especially initially and I would recommend everyone if it's possible time-wise I know that's hard is really important and not to create two-on-one because a lot of times what you can do is you can go in and start the conversation and if you don't need to be there the whole time just salmon restaurants in the lobby they're all wait for you I don't really know how that works with you guys so I don't want to go too far on that so so then advice of another that's a he that plays a huge part in why people say on medications advice of another could be from client to client advice from another could be from staff to client and we talked about disclosure by staff and often this is where a provider will talk to a patient about the benefits of medication in my experience it worked really well so I would think you'd want to stay on it and so you have to be careful about the disclosure there client to client keep an eye open for that because if I give lithium to person a and lithium in the same dose to person B they're gonna they may react very differently and person a doesn't know that there may be a sensitivity in person B so patients talking or clients talking to each other it can be helpful or it can really be harmful so try and monitor that and if a client comes across with ideas about a medication ask them where they got that information that's gonna be really important so understanding the purpose of the medication too often especially with new medications going o to coming out the purpose of the medication will be identified the very first time it's prescribed and it really won't be talked about again except how you're doing on the medication so that needs to be an ongoing part of the conversation because symptoms present differently like we all know there's different degrees of auditory hallucinations there's delusional stuff there's you know there's mood and thought schizoaffective disorder is a really good example if you give somebody Prolixin for schizoaffective do sorter and Prolixin for schizophrenia that may look different because of the need to add a mood stabilizer to augment the medication for dose so that's something to pay attention to enter and to have regular conversations with the client about what the medication is for it would be the same if we took a pill for diabetes and then all of a sudden switch for insulin you know I may think that they both work the exact same way in my body even though they're going after the same thing but it could be very different and I may forget so and then the purpose of the medication I mean that carries meaning in a lot of different ways and what I mean by that is sometimes it can reinforce people stigmatizing themselves so if I'm on an anti-psychotic a person will more readily identify themselves as psychotic when they're not doing well which points to schizophrenia which is one of the most stigma attached mental illnesses that you're going to find so when you're talking about medication with clients talk about what the purpose is and what the symptoms are rather than the labels you know they know hopefully what their diagnosis is but if you continue to refer to someone as schizophrenic bipolar they're gonna start to own that as a part of the identity and if you think about it for ourselves as well you know I'm asthmatic I'm diabetic I'm it puts us at a disadvantage because it automatically puts in the assumption that there's something wrong continuously so keep that in mind as well if the client has insight into the needs and benefits of the medication their investment in adhering to the medications is automatically gonna go up so it's not only helpful for us to point out the improvements and the benefits we see by to ask the client what they notice from their subjective experience do you notice that do you notice any things improved or do you notice anything is easier do you notice any less distressed do you notice but ask open-ended questions the yes or no I mean you have to be really careful with that because if I ask the client are you feeling better and they know that my goal is that they feel better even if they're not they might take yep yep I'm feeling better and so ask the open-ended questions ask how do you see the improvement what's improving what does it look like so if the and focus on the positive okis on the benefits as you see them I mean that's really important too many times client me saying I'm sleeping better but I have X Y Z okay so you know maybe night sweats or you have dry mouth you can deal with that but really balance that with your sleeping better so this is how that will help your thinking this is how it will help your mood this is how it'll stabilize possibly medical things because there's so many so many different effects just using that one example if a client wants to feel better they're gonna be more adherent to their medication if we want to feel better we're gonna adhere more strongly to medication I would encourage you to work with your clients to look at all options with the provider it doesn't always have to be like that was saying up health four times a day it doesn't always have to be for the rest of my life an injection or a liquid you know so if you can instill some kind of hope for change toward what they want and don't I mean one thing we really have to be careful of is it's fair to ask the client and give the client what we would want ourselves if I want proper care the client does too if I want the least restrictive means or the least invasive means of getting medication pill versus injection let's see how that can happen and if it can't let's be real real clear about it and why so on the other side of that there are clients that don't want to feel worse okay and that's different than wanting to feel better because sometimes where they are right now is okay because it's gonna take some more time so if I have some increased stability with regards to auditory hallucinations and my hallucinations are less but they're still present I don't want them to be more but the ultimate goal is that they're gonna be less yet so does that make sense so not wanting to feel worse doesn't have to be from the point of being fully stable and that's something to keep in mind because that's a motivator that's where the case manager and the provider can work with the client to say okay this is where you're at this is where you've come and this is where we're hopefully gonna go or this is what we're looking for for further improvement so back to the word compliance if a client feels like they have to take medications to avoid jail hold appeal hold restricted access to certain things or people whatever the case may be the defensive nurse is going to come in the challenging is going to come in or the apathy is going to come in and by apathy I mean well if I have to do all this and I'm not in control why do I care and then you're gonna have a whole nother host of problems because then investment goes down and you know investment can go down all the way across the board but it's gonna look different it's going to look more hopeless rather than an oppositional if that makes sense so keep that in mind to use the consequences of not taking medication as the primary conversation rather than the benefits of taking it there's going to be a game changer it's going to change the game if I'm told that if you don't take your medication you're going to jail versus I've seen when you take your medication that this and this and this go a lot better that feels different that conversation feels different is that does that make sense okay so marketing in news have a huge impact whether people know it or not on a client being willing to try and medication or not there's a reason why the commercial for lunesta has sheep and clowns and soft music and things like that and there's a reason why even new medications for bipolar disorder they don't show somebody in a manic state they sight all the benefits and so it's detached and it's kind of like going to the it's only you know I think of the lunesta commercial and I think kind of fairy tale you know the like the sheep are jumping over the moon and you know it's it's gonna work automatically there's benefits to these medications but that goes back to educating the client about the medication from the provider because the take on the drug company that's trying to solve the med is going to be different than the provider who prescribes it is going to be different from the case manager who supports it it's gonna be different from the client who believes in it does that make sense okay so if a client doesn't understand that lifestyle changes can support the success of a medication it's you're gonna be behind a little bit and the client is gonna be behind so for example excessive water drinking toward water intoxication and flushing meds that needs to be something that's put out there if you're on lithium and you have an excessive sodium or salt intake it's gonna make a difference because lucky was a salt if you're on an anti-psychotic and you have a dry mouth okay what's gonna work better water or orange juice just those kind of tips can help people think orange juice is gonna be much more effective because of right away you get more saliva but it you get more dry after that effect goes away soda diuretic so keeping these things in mind when with regards to other changes that can help support the medications being more comfortable is important so the other thing too is with exercise people will often say well I'm on lithium or depakote so I gained a lot of weight that is a true statement I mean waking is a side effect however movement and diet helps it be less and that's just the bottom line and I I hate the word exercise because it implies you know somebody's going to the gym and hoist and iron and you know all that kind of stuff if you use the word movement when I walk I move you know when I left I move when I cook I move when I you know so so that goes back to the language and it really we constantly communicate with our clients and so the language is going to be important from day one to the end and it's a different way of it's a different way of talking because we're not used to them and so that means being very mindful and intentional to hearing what's coming out of our mouths too often we're in a hurry we talk fast and if somebody says what did you say you're like oh I don't remember um so that happens at home that happens in our personal life that happens in our work life so it's I mean it's bound to be a pattern that we've been stealing in different practices so so let's look at why people stopped taking medication or don't follow the prescription was written one of the top ones the opposite II the other is that it takes too much effort I have to put the meds together out of numerous bottles by myself I have to use a pill splitter and I have to split my meds think about three steps skincare okay am i more likely to wash my face every day or wash my face use toner use lotion and then go on my way okay if I have my medication set up in a bubble pack I don't have to do anything if bubble pack is not possible because sometimes there's a cost to the client then assist the client in doing their pill boxes or have the pharmacist do it or have the you know the nurse do it have the Community Support Program person do it and do all the splitting if there's pill splitting right away and get them in there because that is just as much work as put in the turnaround so the other thing too that we refer to a little bit is that medication reinforces that an illness is present and that is that's hard I mean that's emotionally hard it tells me something's wrong with me just the word ill if you think of illness ill-will you know it means negative negative impact on health negative impact on intention is ill-will so keep that in mind so expense of course is a factor for anyone if I have to take a pill four times a day and so on a 30-day supply I'm getting 120 pills that's going to cost more than if I'm taking the pill twice a day and for a month's supply I have 60 pills so that's another reason to work with the provider and the most efficient med schedule possible not just for bees but for you know most effective dosing and absorption in the body because those all play a part so people stop taking medication again because they have the advice of another if a client says I took lithium and oh my god I gained 80 pounds I'm less likely to say well I want to take lithium because I heard it really helps with mood or I took Prolixin by injection and I got a really bad sore on my arm I got a hard bump on my arm I'm much less likely to think that the injection site is going to be pretty easy or if a client says I didn't realize that the injection site needs to change because of the effects of the needle on the skin and thus you know the subcutaneous area that's another factor so when you think about medications in addition to thinking about the side effects think and think about the method of administration if somebody has choking swallowing risk you're not gonna put them on pills four times a day you're gonna maybe supervise them when they take them if it's only available in pill form or you're gonna really look to talk to them about an injectable form if it's available so you have to pay attention to the medical the medical indications of their condition physically and mentally so so the other thing too is the obstinance the I'm not going to take it because you told me I have to that goes back to the language compliance versus adherence if I can say clearly that that person knows the outcome of taking it or not taking it as far as the program goes as far as supervision goes as far as past response goes that's going to be a game changer so the another thing too is that people are often embarrassed that they have to take medication and so if we can reduce that exploit the exposure to that in any way it would really be helpful and that means that if a person is in a group home maybe not having the open discussion about their medications when there's three other clients in the room that's going to make a difference the other thing too is that in talking about the medications you have to take your medications for you know when you get mad or let's take your medications so you don't get irritable or so that you don't I mean that that counts to it if if people don't take an antipsychotic often there's gonna be a resurgence of symptoms but in front of other people and even to the patient or the client to prevent the defensive miss if I say to them you know well I've seen that you feel better when you take your medication if I'm in front of three other clients that's going to have a lot different impact than last time you didn't take your medications you you blew it you blew up at me because you got so mad or so irritable that's gonna that's gonna sound different I would just really encourage confidentiality though that's just as much as possible that really is a lot of mine oh and I know it's not always easy alright so not understanding what the illness or the condition is especially with more newly diagnosed clients it goes right from day one being informed of why you're taking medication if I say I'm prescribing you as an anti-psychotic and I'm a provider or psychiatrist or a nurse practitioner you better hope that person knows what psychosis is specific to them because the psychosis can look different from person to person and I think we've all seen that so being informed again that's what that goes back to and being informed not only about the illness itself what is schizophrenia but how do I exhibit those symptoms what are my symptoms that support the diagnosis of schizophrenia because it's gonna look different that that comes up a lot between schizophrenia and schizoaffective disorder and it comes up a lot between bipolar one and bipolar two because the word bipolar is loaded the word schizophrenia is loaded but they look different bipolar one looks different than bipolar two bipolar one is most strongly manic bipolar two is most strongly depressed that's going to present very differently so keep that in mind so denial of the need for medication as the intervention you're gonna get people who are in denial everybody goes through that depending on the condition somebody new to the illness as well new to the diagnosis it's gonna be stronger often or if somebody has been stable for a long time the denial of I need to stay on this that's where that comes in sometimes where well I've been doing really good I don't need to take my medication it's actually a very firmly planted rational belief to the person I'd been good for this long so I don't need the medication and I'm fixed that's not unreasonable that is not an unreasonable thought and too often we'll jump on that as providers and say don't you realize that if you don't take this that's gonna go back to what it was well that doesn't carry a lot of weight if I'm feeling really stable so that goes back to talking to the client about what has your been your experience when you're on medication when you're not on medication and have that conversation something else to remember too is I've seen it most with antipsychotics rather than mood stabilizers but it applies to both each time a person gets stable on medication goes off of medication and then the vacation is reinstituted it can take longer to stabilize and that's the way the system works too often that's when complete med changes or washes are necessary or considerations so that is another factor in the benefits of stayin adherent to the medication is that it does it can very well take the body longer to stabilize and over time as persons as people are on medication over time there may be a chance that they will not stabilize again on that medication so it's going to be necessary to look at a different one so I think that it's important at least a couple times a year to stay informed from the provider about are there some new options that our medications are coming out all the time and the side effect profiles are going down the side effect profiles are changing but the the most common side effects the profile is going down so you need to be as form as informed as the client and that's something to keep in mind they're coming out all the time and we see that we see that especially when we get new nurse practitioners or sometimes even new psychiatrist like oh god he's really good meds so they take somebody who's been extremely stable and they put him on the new ones them on the new ones and then we go back to where we were before usually at time to time I bet you do every time they get a new provider yeah and it's generational it really is it's generational when I left Winnebago there were three patients that were still on Thorazine which is unheard of but they have been stable for years and so we're gonna use Thorazine which is about a dollar thirty a pill you know but if it works it works and so generationally with providers you're gonna see that a lot yep and so that can really be so knowing the history of the client and having documented history in the client with the medications is huge is huge so the the other thing too is that looking at not just the medication as the intervention but things like exercise somebody's gonna probably not be as inherent on their medication if you push that other piece you gotta balance them you know you got to save the medication and the movement work together not if your medication isn't working malaria movin you know things like that so you need to balance the benefits to make them a little more palatable and some people aren't gonna do it though we don't do it all the time you know you join the gym twelve months later you betting through the door and so just think about that and if you talk to yourself the same way I mean it can really help us to you know it's put your you know kind of putting the rubber to the road and it's not always easy and it's not always possible and we're all human and I know that and I know I am too and so there isn't a pie in the sky don't get me wrong but these are things that really do work I think that some of our clients have the impression that getting up off the chair and just going to the bathroom is considered exercise mm-hmm and you know what its movement it is movement so if you can use that especially if somebody has mobility issues well I see you walk this far let's try just low further you can actually use that as a tool and so but I know what you mean you know it can be it can go to the other extreme all I do exercise I move around the house all day you know so let's just work with that you know and really the word movement has less negative connotation than the word exercise so but they also need to hear the fact that the weight gain doesn't have to be as significant as that as people say it is because it really doesn't I related people love children through constantly moving body needs to it does that's I mean that's how our body regenerates that's how it heals that's how if we sit still the healing process is gonna be slower just genetically and physiologically so so yeah use that use that so lack of understanding and education about the medication very commonly is it reason why somebody won't take it or if say I'm working with the client and I'm misinformed about a medication and I say well it it really helps with acts and then all of a sudden it doesn't then here we go you told me it would help the indications for the medication the side effects of the medication you have to know them before you start talking about them and that is where the provider and the education from the provider written material if a person responds to that kind of thing use it use the medication sheets you know and there's acceptable ones and there's not acceptable ones you know WebMD is the most reliable website if you want to show somebody a website for medical and psychiatric conditions it's the go-to it really is the go-to for education as far as websites go websites are of course are not the number one preferred people are but then again I'm going to point to the pharmacist because I I don't think I've ever come across a pharmacist outside of like these ridiculously busy pharmacies like Walmart's and things like that that won't take time to talk to somebody and the psych Tech's they can be really helpful as well if you have specific questions while the medication itself asks for I found salt what the pharmacist you're supposed to be offered one every time you pick up a medication you're supposed to be offered to consult with a pharmacist and so know that there you're not supposed to get a medication whether it's new or a refill and be able to walk out without having the option to talk to them some of those prescription sheets that they get their medications it'll list you know what it's used for and then clients will be reading that and all the sudden you'll hear well I don't have Parkinson's right I don't have this why am I taking this medication dose well that's a great teaching opportunity to go through that sheet with the provider or with the case manager and highlight what applies to me and use a highlighter because there are tons of indications for medications also so use that as an educational tool highlighters are beautiful things and so so those can really be used as tools but you have to indicate what so I have two couple to me I'm not taking that medication I don't have this I don't have that mm-hmm so what if the if you go with them to get the medication one of the medication sheet starts with you rather than being another client right away I mean no but I mean just thinking about that yeah if you if you go with the client to pick up the medication and there's a big sheet staple to the bag why don't we take that off and then make it time to sit down with them you know relatively quickly after the medications I received not my response usually is that while medications have multiple uses for difference and they do I said but ultimately I said if you have questions about this medication you should talk to your case manager mm-hmm yeah but a lot of clients are going to need a prompting and all yeah a system what to do they have that answer right here right now well that and many just won't ask because if I don't take my meds I go to jail or if I don't take my meds you know I'm not gonna get this or that privilege if I don't get that if I don't take my meds I'm not going to be able to warm to the community on the outing you know so think about that those all play a part they all play so embarrassment denial a condition we talked a little bit about that so that understanding the purpose of the medication again there's that chunk of stuff that the education is absolutely necessary what is the medication was it look like what could it look like when it changes pill color you know it that needs to be a discussion what is the medication for specifically to you what are the side effects that you should watch for but that don't happen all the time you know a lot of times if I suggest side effects somebody's going to think automatically they have them so you can discuss you know the most common or you can discuss the ones that you really need to look forward with lamotrigine you really need to look for a rash and the rash is gonna appear within the first couple days and it can be lethal and so those are the kind of things that the provider needs to talk about that the pharmacists needs to talk about that's a beautiful opportunity for a consult at the pharmacy because I don't want to be the one to say if you get a rash this and this and this could happen who are you a doctor so and that's the kind of thing that should be provided and that's what those consults are for and lamotrigine sticks out the the biggest because that rash it happens fast and half and severe and I mean if it's caught it's good but it can it can progress very rapidly and just some really bad results so so back to the news and marketing that's also a reason people will not take medication and some of it can have to do with the actors in the commercials okay if there's a if there's a housewife on the commercial that's flitting around the house and taking care of the kids or doing the dishes or putting a nice meal on the table that's not my life that's not my life is that going to give it to me no and so there has to be some kind of identification with how the medication is presented for me to buy into it okay if the other thing too is one another example to think about is if a medication is said to be for bipolar disorder and I have schizoaffective disorder which it can be real helpful with you better talk about what the indications are for me specifically because if they think it's for a bipolar disorder and they have schizoaffective without being informed they're gonna say that's not the medication they need to take does that make sense and so it goes back to education but I cannot educate a client until I am fully educated and if you don't know the answer don't make one up that's huge not only you're gonna put the client at risk you're gonna put your relationship at risk you're gonna act outside of your scope of practice and that's none of that works none of that works really acceptable what's in our and on my forehead no way they can find out from a yeah put it through the person that's responsible for it yeah yeah so get them to a person that can handle think they can answer yeah absolutely so if the clients not educated just a final point it's unfair and unrealistic to expect them to be fully engaged with medication something's gonna come up something is going to come up and so if if the education is thorough right from the beginning that's gonna reduce the chance of that happening and it's got to be continuous if I hear amount of medication and then the dose changes something about that is gonna change in the education but if that's not provided and then all of a sudden there's another don't change and I missed what could happen here it's going to invalidate the experience so the education needs to be continuous and it needs to build on itself and that's huge and that's how we build our education we build one thing on from another and that's how we expand our fund of knowledge that's how that works so the right to choose what we do and do not do for ourselves whether the choices we make are in our best interest or not or not the choice is ours and the choice is going to be the clients and you know there are Guardians that make decisions but you know what whether I have a guardian or not I've got something that I can control I can keep my mouth closed I can spit out my meds I can you know there's always going to be an element of choice somewhere even how I react to the fact that I'm told I have to take a medication I'm going to choose that reaction so self-determination if somebody is non-compliant as a case manager it has nothing to do with me but if I don't provide education that's gonna support adherence to that medication that's my dad if I'm not going to involve the provider to provide the education or someone in a supporting role that has the information that's my bad I'm missing that step so you can't do it all for the client they need to do things for themselves don't get me wrong but be the advocate that can really help in the success and isn't that a role that we have is to be an advocate I hope I hope but again I can't make her break it correctly you know I can't do it for him I also think though there are people out there who have schizophrenia and they don't understand why they're taking the medication just yet I like the fact that they've been on it for a long time in the brain stable so I can think of an example that we currently have a very host guy with a very violent history I'm positive for like six years that's what's or maybe even longer than that that what kept him stable for the longest time comes to burying within a very short period of time is the lulz from now we're starting to hold the classroom which is making everybody more than a little bit nervous here's the medication that's captain's day right so then he decides that he's not only going to now that he's got that medication held maybe he doesn't have to take his other medications either you know there's a court order he's got to take the medications so we've had the conversation with them part of you need you you're doing well when you're taking medication they need to continue to do this because that's how you do well okay so we have those conversations because what are the alternatives here if you don't take exactly the reason that you're at very most is because you're taking and one of the reasons and one of the conditions is you can stay because you're taking the medication yep and the court order needs to be a part of that conversation well yeah composition and you can do the motivational interviewing we found with this particular gentleman because he's also developmental disability going on so they're thinking about doing a guardianship we had one staff person will actually turn it yes you need to take your medication and like a child he's okay okay yep there's no very concrete that's concrete you can't do that yep you can't have the long conversation okay yeah absolutely that's a great point because cognitive level is gonna determine response yet to education yeah yeah you know you do better when you take your medication okay likelihood taking medication is gonna go up is that yeah absolutely that's a great point that's a great point so as far as you know any questions if you guys have any questions feel free to you know you can type in we can chat that way I only have one other comment I'd like to make and I'd like to go back to what you said previously about people going to those psychiatric appointments okay I was at a conference with dr. Mayes and he talked about the role of the providers with the client and I also had the opportunity to be in the doctor's appointment with one of our clients from very host to three weeks ago in Oaxaca County and it was a beautiful work of art those psychiatrists are so trained and what they do is they zero and that client and they want the conversation to be between them and the course they do and they don't want the staff person being there first and foremost it was a it was just a wonderful display for my client she said everything I would have wanted to say in five minutes he zeroed in and exactly then he turned to me and said anything you wanna have to know what you see is what you get it was perfect it's all good to say and then is taken the ad because he wrote yes that is taken there because he role and sometimes saying less was more yeah yeah absolutely was that dr. kurtzweil my channel no oh okay cuz he's a big one for the client fully yeah so okay so if anybody else has any questions feel free to type in and if not thanks for being a part of this today and we'll see you next time

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