Solve oral medication management problems

Unintentional noncompliance easier to address

(Editor's note: This is the second of a two-part series that identifies the obstacles home health staff members face when helping patients improve their oral medication management. Last month, we highlighted some major challenges staff members face along with strategies that can be used to overcome them.)

A range of factors affects a patient's ability to manage oral medications: cognitive ability, number of medications, and understanding why and how to take medications. To help patients better manage their medications, it is important to identify the reasons they don't and address those in the simplest manner possible.

"There are several reasons for noncompliance and some reasons are unintentional and others are intentional," says Diana Hildebrand, RN, BS, CPHQ, project coordinator at TMF Health Quality Institute in Austin, TX. The main unintentional reason is lack of education, leading to misunderstanding the reason for the medication and how to take it, she says.

As a home health nurse, not only do you need to continuously educate patients about medication, but when you evaluate patient education techniques don't forget that illiteracy may be a problem that patients won't readily admit, Hildebrand points out. "Even if the person can read at some level, he or she may not be able to comprehend medical information easily."

When talking with the patient and the patient's family at the first visit, ask questions about daily routines, such as brushing teeth and meal times, Hildebrand says. "Their answers to these questions will tell you how organized they are and how well they stick to a schedule," she points out, adding that this information will help you tailor your education and will provide tips on managing medications.

Because helping the patient understand the proper timing and dose of each medication, a medication calendar or schedule posted in an easy-to-find location is important. Write the name of the medication exactly as it appears on the label so there is no confusion, Hildebrand suggests. If the patient is not able to read, paste one of the pills to the calendar, she says.

"Even if the patient can't read, he or she can match the pills in the bottle to the pill on the calendar." If you do paste pills to the calendar, be sure to check the prescriptions regularly to make sure that the pharmacy has not changed brands of the medication, as this may mean a change in the color, size, or shape of the pill, she warns.

You also can add a label to the bottle to identify the medication's purpose, suggests Hildebrand. "Water pills or heart pills are easier to understand and a label with larger print is easier to read," she says.

Ask patient to demonstrate understanding

"Our nurses don't just ask the patient to show us where the medications are; we also ask them to open the bottle, take out a pill, and tell us why they take it and how often," says Lisa Sprinkel, RN, BA, MSN, executive director of home health and hospice for Carilion Home Care Services in Roanoke, VA. "This gives us a chance to evaluate their manual dexterity and ability to open the medication, and it gives us a chance to see how well they can read and understand the labels." If the patient is unsure about a medication, the nurse can immediately explain the reason for taking it, she adds.

Not all patients remember to ask for bottles with traditional caps as opposed to child safety caps, so be sure to tell patients that they can ask for traditional caps for all of their medications, Sprinkel suggests.

Another option to explore with pharmacists is the use of blister packs, suggests Hildebrand. "Some pharmacists will package individual doses for the day in a blister pack from which the patient can easily pop the pill," she says. Not only is it easier to open but if all of the medications that are to be taken at one time are together in the pack, the patient won't forget anything, she adds.

If there is a physical reason that the patient cannot open the medication, ask for a therapy consult, suggests Hildebrand. "There are a number of assistive aids that can be used to help patients open bottles," she explains.

Financial concerns also might cause a patient not to fill the prescription when needed, says Hildebrand. "If finances are a challenge for the patient, ask a social worker to visit to find out what assistance is needed," she recommends.

There are instances in which patients choose not to follow instructions about medications, says Hildebrand. "Intentional noncompliance is usually the result of a patient's opinions, beliefs, and values, as opposed to physical, mental, or financial reasons," she explains. "A patient might believe that suffering is a part of life because this is part of the patient's cultural background."

Other patients might be afraid of becoming addicted to the medication, Hildebrand points out. While there are medications that can be addictive, proper education about the use of the medication might alleviate some of these patients' concerns, she says.

"You can also offer alternatives, such as ointments, muscle rubs, or heat, as one way to reduce pain or soreness and reduce the need for pain medications," says Hildebrand. These alternatives might also be more acceptable for patients who don't want to use multiple medications due to their beliefs, she adds.

While there are many reasons for a patient's mismanagement of oral medications, the key to improving the situation is to first identify the real cause of the mismanagement, says Hildebrand. "It is impossible to find the best solution if you don't start by finding the cause of the problem."