Medication adherence assessments in community pharmacy

Medication adherence assessments give community pharmacists a structured way to understand whether a person’s medicines are being taken as intended and whether the regimen remains workable. The conversation can reveal missed doses, intentional changes, affordability barriers, side effects, or practical difficulties that are easy to miss when a script is simply handed over. Its purpose is to improve treatment and safety, not to judge the patient.

An effective assessment combines the patient’s account with medicines reconciliation, dispensing information, and observation of the medicines themselves. It also considers whether prescribers, pharmacists, carers, and community services share the same plan. In Australia, this matters wherever Pharmaceutical Benefits Scheme prescriptions, Medicare subsidised medicines, over-the-counter products, supplements, and medicines supplied in residential care meet at one counter.

The following process suits routine consultations, medication reviews, and post-discharge support. It uses open questions, practical screening tools, and clear follow-up. Adapt it to language, culture, cognition, disability, and the time available, while avoiding assumptions about who is responsible for adherence.

Prepare for a patient-centred conversation

Begin with consent and a clear purpose. Move to a private area when sensitive information or complex decisions are involved, and arrange an interpreter or communication support rather than relying on family members to interpret clinical details. Explain that the pharmacist is checking safety and ease of use, not auditing compliance. If the person declines the discussion, document the brief exchange and offer an appropriate time to continue.

Ask what the medicines look like within the person’s daily routine rather than immediately asking whether they are “taking them properly.” Useful prompts include: “Can you tell me how you take each medicine?”, “Which dose is hardest to remember?”, and “What happens when you miss one?” Open questions reveal the reason behind a missed dose and help distinguish forgetting from a deliberate decision. Asking about the previous week can produce a more realistic account than relying on general impressions.

Listen for differences between the prescribed regimen and the routine described. A medicine may be taken at a different time, moved to another day, doubled after a missed dose, or stopped because the person feels better. Avoid interrupting when details emerge that challenge the dispensing record. Teach-back is useful for checking understanding: the person should be able to explain which medicine is taken when, why it is needed, and what to do if a dose is missed. The pharmacist can then correct gaps without taking control away from the patient.

Build a reliable picture of medicine-taking

Reconcile what is prescribed, dispensed, stored, and actually used. Include regular medicines, as-needed products, over-the-counter drugs, vitamins, supplements, and recently discontinued preparations. Ask about hospital discharge changes, residential aged care schedules, and medicines belonging to another practitioner. Check labels, repeat records, dose administration aids, and the person’s current medication list, including My Health Record information where clinically appropriate and authorised.

Dispensing history provides valuable patterns. Refill dates may indicate irregular collection, an early refill, or a supply large enough to suggest a different routine. Compare these findings with what the patient reports and investigate possible explanations such as holidays, changed dosage instructions, hospital stays, or difficulty reaching the pharmacy. Collection does not prove ingestion, just as a missed collection does not prove non-adherence. Discrepancies should open a conversation rather than become evidence against the patient.

A validated adherence measure can add structure. Depending on the setting, a pharmacist may use the Morisky Medication Adherence Scale, ASK-12, or a suitable PROMIS adherence measure while following the tool’s instructions and interpretive guidance. Combine the result with medication reconciliation and the patient’s account. Where consent permits, a carer, nurse, or aged care worker may provide useful information. Observation of blister packs, dose administration aids, opened packages, or a medication calendar can strengthen the assessment, but no single source gives a complete picture.

Identify barriers and choose practical interventions

Classify barriers before selecting an intervention. Intentional and unintentional non-adherence can occur together, so treat the distinction as a starting point rather than a fixed label. Intentional changes may reflect disbelief in treatment, fear of side effects, cost concerns, or a decision to prioritise other needs. Unintentional barriers often involve forgetfulness, complicated instructions, swallowing difficulties, poor dexterity, memory impairment, disrupted routines, or difficulty obtaining medicines. Ask open, non-judgemental questions about what makes each medicine harder to use.

Financial and social circumstances require particular attention. A PBS medicine may still have a co-payment that strains a low-income household, and a person may be using a non-PBS brand because of prescriber instructions or pharmacy availability. Work shifts, commuting, housing instability, depression, substance use, and caring responsibilities can also affect adherence. In metropolitan Melbourne and Sydney, time outside work and pharmacy may make rigid dosing times difficult; in regional and remote areas, travel and limited nearby services can create different barriers. For Aboriginal and Torres Strait Islander patients, culturally safe care may involve Aboriginal health workers, local health services, and communication methods that respect preferred language and decision-making.

Match the intervention to the identified barrier. For forgetting, consider a dose administration aid, calendar, phone reminder, or linking a dose to an established routine. Ask the prescriber or pharmacist to review synchronised repeat medicines, dosing frequency, and conflicting instructions. Some people benefit from simplified directions, while others need an appropriate container, larger labels, or easier-opening packaging. Address affordability through generic alternatives, PBS options, and prescriber review without promising a change that is not clinically suitable. Following a knee replacement, mobility, pain management, and daily activity can alter the dosing routine; information on post-operative knee rehabilitation can help identify practical changes that should be discussed with the clinical team.

Distinguish adherence problems from clinical deterioration or an unsuitable regimen. Severe side effects, signs of toxicity, accidental duplication, overdose risk, or inability to manage essential medicines require prompt assessment and appropriate escalation. Acute symptoms need urgent medical review rather than an adherence label. Document what was found, the patient’s explanation, advice provided, agreements made, and any referral. A medicine that remains inaccessible or poorly tolerated is unlikely to become more adherent through repeated reminders alone.

Coordinate care beyond the dispensary

Involve the appropriate health professionals when the barriers extend beyond the patient’s memory or organisation. Community pharmacists can refer eligible people for a Commonwealth-funded Home Medicines Review, while general practitioners may also initiate reviews for complex regimens, polypharmacy, or transitions in care. Pharmacists working with residential aged care services can contribute to medication management reviews. A clear referral should state the suspected barrier, current medicines, relevant observations, and the specific question for the other clinician.

After hospital discharge, confirm the final medication list rather than relying on an interim supply or an old community record. Compare the discharge summary with the medicines now at home, identify cancelled or altered preparations, and ensure the patient understands any new directions. The value of hospital-to-home pharmacist care is especially clear when several clinicians are involved: one person should coordinate the handover, supply an accessible regimen, and confirm that the patient or carer can manage it.

Share information securely and seek consent before involving carers or external services. Useful communication includes a concise medicines list, the adherence barrier, advice already provided, and any unresolved issue. Community pharmacies can also work with nurses, physiotherapists, diabetes educators, mental health services, alcohol and other drug services, and Aboriginal health services. Record each contact and avoid creating parallel plans. The patient should leave the consultation knowing which person will do what, by when, and how progress will be reviewed.

Make adherence assessment routine

Use a repeatable workflow that reflects the consultation rather than adding an unstructured task at the end. A practical sequence is to prepare, explore the patient’s routine, identify barriers, agree on actions, and arrange follow-up. Standardise a brief screen for high-risk situations, such as multiple medicines, recent hospital discharge, a changed regimen, recurrent late refills, or a concern raised by a carer. Make sure privacy, consent, interpreter access, and cultural safety are part of the workflow rather than optional extras.

Document both the clinical issue and the response. Record the patient’s own explanation, objective findings, medication discrepancies, education provided, referrals, responsible clinicians, and agreed review dates. Shared pharmacy systems can flag unresolved barriers and remind the team when a patient is due for review. Documentation should allow another pharmacist to continue the conversation without repeating sensitive questions or restarting the assessment from the beginning.

Agree on follow-up that is specific enough to be useful. This might involve contacting the patient after one to two weeks to check whether a dose administration aid is working, arranging a pharmacist review within a month, or asking the general practitioner to review a complex regimen. Seek permission before using phone, text, email, or other contact methods. Audit completed assessments, identified barriers, referrals, follow-up completion, and patient-reported improvements; case reviews can also help the team refine its questions and referral pathways. Begin by selecting one screening prompt, one referral pathway, and one follow-up standard for the pharmacy team, then make every adherence conversation a safe, practical step toward better medicines use.