Patient Compliance Techniques That Work

The cost of patient noncompliance - for both medical outcomes and the U.S. economy - has been well documented over the years. Patients who fail to take medication, skip out on appointments, or disregard lifestyle and dietary recommendations reportedly account for 10 percent to 25 percent of hospital and nursing home admissions per year, costing the U.S. health care system upwards of $100 billion annually. That doesn't include another $50 billion in indirect costs from lost patient earnings and workplace productivity. At the same time, complications that arise from not following a prescribed treatment regimen result in an estimated 125,000 deaths per year in patients with otherwise treatable conditions.

Despite the avalanche of statistical data on the topic, however, there remains a surprising lack of consensus on ways that physicians can increase compliance among their patient populations. Perhaps that's because there's no one-size-fits-all solution.

Indeed, the barriers to adherence are as varied as the patients themselves. Some fail to follow through because they fear medication side effects, don't believe that the treatment is working, or feel ill equipped to manage their own health. Others simply forget to fill their prescriptions and take the correct dose at the appropriate time. As researchers delve deeper into the predictive factors for noncompliance, however, a number of new tools and techniques are being developed that can help physicians tailor their treatment plans to individual patients. That, in turn, motivates patients to collaborate in their own care.

Patient motivation is the name of the game in the modern era of patient-centered care, says Anne-Marie Audet, vice president for health system quality and efficiency for The Commonwealth Fund in New York, a private foundation that promotes effective healthcare. "Our system is so much geared toward acute care, but we're moving toward investing in primary care and preventive care which means people will have to be even more engaged in their health," says Audet, noting those patients who fail to participate as medical decision makers could fall through the cracks. "Activating patients is something you can learn, but it's an acquired [skill]. Generally, I think we've failed [as an industry] to really establish the connection between what happens in the small amount of time that people spend in the healthcare system and in the 99 percent of the time they spend outside of it."

Patient surveys

While demographic factors - including age, sex, race, education, and socioeconomic status - appear not to influence adherence levels significantly, research suggests there are certain behaviors that play a role. For example, "many patients with a low level of activation have poor problem-solving skills," says Judith Hibbard, professor of health policy at the University of Oregon, who co-developed a self-assessment tool to categorize patients by how active they are likely to be in their own healthcare. "If the pharmacy is closed or [the patient's] copayment goes up, they're more likely to give up," she says. "Any barrier thrown in their path can throw them off, so knowing that is helpful in terms of making sure those patients get the help they need."

Hibbard's Patient Activation Measure, or PAM, uses 13 questions to assess patients' knowledge, skills, and confidence for managing their health. It produces a score of 0 to 100 and breaks out patients into four progressively higher activation levels. Each level is associated with distinct self-care behaviors and attitudes - the values, motivations, and emotional dispositions that drive those behaviors. The score is sent directly to the physician or healthcare provider.

"Physicians can use [the score] in medical homes as a way to personalize care, consistent with the patient's level of activation," says Hibbard, noting that staff could ask patients to fill out the survey in the waiting room before they're seen. "If they're low activated, they may feel overwhelmed and discouraged because they've had a lot of experience with failure in trying to manage their health. So the physician knows that instead of giving them a list of 17 things, they should start small. Give [patients] permission to focus on one thing first, so you build their confidence and set them up for success." The cost of the survey ranges from 30 cents to $1.60 per patient, per year, depending on how many patients are included in the provider's contract.

Another survey tool, available for free at howsyourhealth.org, gives patients the opportunity to score themselves on their emotional, physical, and economic status, along with their degree of social support and problem-solving skills. Physicians can customize the survey questions to better suit their practice and ask their patients to fill it out before their appointment using a unique code so the results get forwarded to them.

John H. Wasson, a gerontologist and professor of medicine in community family medicine at Dartmouth Medical School, who helped develop the tool, notes howsyourhealth.org also allows patients to set up automated text messages to remind themselves to skip the bacon or take their pills. Physicians receive a summary report of how competent that patient is as a self-manager, and how well they feel their needs are being met in the exam room. Lastly, says Wasson, physicians can use the results to call out a group of patients over a specific period of time, say, the last six months, who reported low levels of competency. "You can send individual patients a reminder of something positive to boost their confidence, or send a blast e-mail to every patient with low confidence levels and tell them that you're holding a group visit or that there's a peer support session at the senior center," says Wasson.

Smart technology

Software solutions are springing up to help doctors create customized patient adherence programs, though some are available only through sponsoring health plans and hospitals. Providers using complyrx.com, for example, can enter data into their computer, select the patient template, and set up automated e-mails and text messages to their patients' cell phones on a daily or weekly basis. Authorized caregivers, family, and medical professionals in a patient's circle of care have remote access to daily compliance reports, advising them of the patient's up-to-the-minute compliance with the doctor's orders.

Engagement Communications, by TeleVox Software, meanwhile, enables two-way dialogue between patient and provider, and is being used in healthcare to create tailored communications via voice messaging, text messaging, e-mail, and Web portals. An OB/GYN clinic, for example, might send expectant mothers an e-mail reminder to take their prenatal vitamins or attend childcare classes at the local hospital, while those with chronic conditions (such as high blood pressure) could receive a series of text message reminders to renew their prescriptions. It can also alert your office if one of your Alzheimer's patients fails to confirm via phone or text that she has taken her medication, thus allowing for early intervention.

For its part, HealthHonors.com uses a Web- or Interactive Voice Response-based platform with customized incentives to motivate patients. Patients using the system can log on daily to confirm they're taking medications or following dietary recommendations, and receive educational materials while the system processes their information. When finished, they either receive points toward products that help them manage their condition, such as a blood pressure cuff or glucometer, or a notice that their participation drove contributions to a charity of their health plan's choosing. "They never know which incentives they'll get so it keeps it exciting and the program uses smart software so it learns over time what motivates that patient the most to help them develop sustainable behaviors," says Sean Teare, vice president of sales and marketing for HealthHonors.com.

Communicate well

Technology alone, however, is not enough. To compel their patients to action, physicians must also hone their communication skills. Tom Delbanco, professor of general medicine and primary care at Harvard Medical School and a practicing internist, says timing is everything. "The worst time in the world to educate a patient is when he or she is in the office," he says. "It is so tension filled that even if the patient feels well their recall for what goes on is abysmal." The best time to educate patients, he says, is before or after you see them, a job that can easily and cost effectively be done by a midlevel provider.

You can also aid recall tremendously by using the teach-back method. "If you say, 'Here are your medications. Do you understand?' most patients will say yes because they don't want to appear stupid," says Audet. "But it's more effective to ask them to teach you how to do it." For example, ask them to show you how to use their inhaler, or explain which medication they're supposed to use, how much of it, and when. "You're very much looking at whether the patient has internalized the information and it's not a one-time thing, but something you need to reinforce at every stage," she adds.

At the same time, practices should provide patients with pamphlets and other reading material that can be used to educate themselves about their medical condition on their own time, says Delbanco, noting it's equally important to direct patients toward reputable Web sites. And while it's never appropriate to talk down to your patients, don't forget that they haven't been to medical school. "We way overestimate the medical literacy of our patients," says Delbanco. "We use big words that they don't understand." Instead, use terminology that a teenager could understand, and pause to ask if there are any questions along the way.

Concrete evidence

Getting patients to make choices that improve their medical outcomes is essentially asking them to change their behavior. It's no easy task - especially among patients who are asymptomatic. "It's harder to impress upon patients who are emotionally neutral the urgency of their condition," says Hughes Melton, a family physician in Lebanon, Va., and the American Academy of Family Physicians' 2011 physician of the year. "You have to be more creative." Use every mode of communication available, he says, including verbal interaction, diagrams, and written reports that illustrate the gravity of their diagnosis. "Some patients are very sensitive to verbal cues, and others need to see it written out, so by using multiple ways of communicating with patients you're more likely to hit the sweet spot in the way that they learn and process," says Melton.

It may help, too, to show them scans, ultrasounds, and test result compared with their age-group norms. A 2006 study by LA Biomedical Research Institute at Harbor-UCLA Medical Center (LA BioMed) found that patients who were shown the buildup of plaque in their arteries after undergoing electron beam tomography (EBT) scans of their heart were far more likely to stay on statin therapy than those who did not see visual proof. Patients whose scans found the most plaque exceeded a 90 percent compliance rate after 3.6 years, according to the study.{C}

Melton says he also provides a written summary of each visit to patients before they leave. "I'll say, 'Here's where we talked about regarding changing your diet and increasing your blood pressure medication and here's where we need you to follow up on your labs," says Melton. "That way they walk out with something in their hand that's tangible."

Delbanco is taking that concept one step further. As one of the lead investigators of a study called OpenNotes, through Beth Israel Deaconess Medical Center in Boston, patients in his office are invited to log into a secure Web site and read the notes he writes about them following visits, e-mail correspondence, or phone conversations. "It's about transparency and trying to break down the walls between the patient and provider," says Delbanco. "We're trying to engage the patients and the notion is that it will help with recall and activation." Over time, Delbanco predicts patients and physicians will jointly sign the notes included in their medical record at the end of each visit.

Make it personal

Another way to motivate patients is to focus on their needs - emotional, not medical. "If a patient doesn't perceive a need to lose weight you have nowhere to go," says Melton. Rather than focusing on the number on the scale, he says, ask them to name some things they would love to do and can't because of their weight, or ask them what they'd like to be doing when they are 65 or 70. "If they tell you that they'd like to take walks with their grandson, say 'Let's talk about that, because with your trajectory that's not going to happen.' Or, 'Let's talk about what golf is going to be like for you in 15 or 20 years.' Now you have their attention," says Melton.

Wasson agrees that creativity goes a long way. One of his colleagues makes it a policy not to put her overweight patients on a scale during checkups. Invariably, they remind her when she walks out the door. "The doctor then says 'I know I didn't weigh you. Why? Do you think that's important?' So she turns it around to let them examine their own motivation, rather than making them defensive," says Wasson. "When they came in, they expected the same old lecture."

Likewise, Wasson gave the smokers in his practice $2 bills. "I tell those patients that when they quit smoking they should give it back to me and that'll make me happy," he says. "They scratch their heads and can't figure it out. But it works because it shifts the expected behavioral response so radically from where it usually is - which is always negative."

When it's financial

Given the economy, it's wise to remember that poor adherence among your patients may be due to financial concerns - especially for patients who have lost their job. You can help those patients stay on course by prescribing generic medications, and by prescribing a stronger dose of the medication, where possible, so patients can cut their pills in half. Consider, too, using older medications, which are often just as effective as the pricey new drug on the block. It's prudent, too, to find out how much your most commonly prescribed medications cost (you might be surprised) and familiarize yourself with pharmaceutical patient assistance programs that provide drugs at no or low cost to the uninsured. The nonprofit Web site needymeds.org keeps track of companies that offer free or low cost medications.

There's no question that poor patient compliance is a growing public threat, and the problem is difficult to solve. Doctors, however, can make significant strides by zeroing in on their patients' unique needs, using a combination of verbal and visual communication, and tailoring their treatment plans to address patients' self motivation. "Patients who are confident about managing their own health use fewer healthcare services and have better outcomes," says Audet. "We need to really try and engage them so when they leave the doctor's office they're prepared to take ownership of their health."{C}

In Summary

The cost of patient noncompliance has been well established, both for your patient outcomes and bottom line. But there are strategies that you can use to help your patients do better:

• Customize treatment plans to help patients manage their own care
• Use new software products to help create compliance programs
• Communicate both verbally and in print to drive your message home
• Tap into your patient's emotional needs

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 17 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.

This article originally appeared in the March 2011 issue of Physicians Practice.