Help patients, caregivers achieve compliance

By Elizabeth E. Hogue, Esq., Burtonsville, MD

Compliance by patients and/or primary caregivers with patients' plans of care is another of the "never-ending stories" for home health agencies. What can practitioners do to assist patients and/or primary caregivers to achieve compliance?

Documentation of noncompliance

Providers first should carefully document instances of noncompliance as follows:

    1) Staff must document every instance of noncompliance by both patients and/or their primary caregivers regardless of the risks associated with the noncompliant behavior.
    2) Documentation must be very specific. It is not sufficient to document as follows: "Patient (or primary caregiver) noncompliant." Providers, for example, may document the failure to change the diapers of a bed-bound patient who is incontinent of both bowel and bladder as follows: RN found patient with urine and feces in diaper. RN removed diaper, cleaned patient, and placed clean diaper on patient. RN marked the right tab of the clean diaper with a red X. When the RN visited the following day, the patient was again lying in urine and feces. When the RN removed the diaper, she observed a red X on the right tab of the diaper the patient was wearing when she arrived.
    3) Staff must then counsel with patients and/or primary caregivers regarding each instance of noncompliance and document that they have done so.
    4) Staff must provide additional education, if there appears to be a need for it, and document that they have done so.
    5) Successful return demonstrations, if appropriate, must be obtained and documented.

The number of times practitioners are willing to repeat this "protocol" depends on the risk of injury/damage to patients associated with the noncompliance and/or the likelihood that noncompliance will adversely effect quality of care. If patients are likely to be injured or damaged or quality of care may suffer, providers should not tolerate additional instances of noncompliance after taking the above steps.

In some instances, the noncompliance may be so serious that immediate termination is warranted. When noncompliance is serious enough to warrant discontinuation of services, providers may wish to take additional action to protect patients, which may include reports to adult and/or child protective services, as indicated in applicable state statutes.

On the other hand, chronic noncompliance may be acceptable, if it involves very little risk, if any, of poor outcomes or injury to patients.

Additional strategies to achieve compliance

If the actions described above do not result in adherence to plans of care, providers may wish to use the additional strategies described below. These strategies are described in more detail in an article by Mihail Cocosila and Norm Archer in Informatics in Primary Care titled "A Framework for Mobile Healthcare Answers to Chronically Ill Outpatient Non-Adherence" (2005; 13:145-152):

1) Monitoring.

Monitoring may be implemented with regard to patients' behaviors, their conditions or the specific therapies included in plans of care. Staff may, for example, regularly monitor the number of diapers used for incontinent patients with wounds.

The possible benefits of monitoring include:

  • Diminishing forgetfulness, stress, and anxieties.
  • Improving motivation, knowledge, and skill in managing the treatment and disease in general.

2) Reminding.

Reminding also may be related to patients' behaviors, their conditions, or the specific therapies included in plans of care. Practitioners may, for example, establish systems to periodically remind patients and primary patients about repositioning.

Possible benefits of reminding include:

  • Reducing forgetfulness and treatment stress and anxieties.
  • Controlling aggravating factors.
  • Increasing optimistic attitude, self-confidence, and motivation.

3) Consulting.

Consulting also may be related to patients' behaviors, conditions or specific therapies. In addition, it also may be related to the health care team and/or system-related. The health care team may, for example, decide to consult with wound care specialists or representatives of manufacturers of wound care products regarding which products may assist with wound healing.

Possible benefits of consulting include:

  • Reducing the effects of stress and anxieties.
  • Diminishing consequences of insufficient knowledge or skills.
  • Improving self-confidence and optimistic attitude.

4) Supporting.

Supporting patients may be related to both their behaviors and social and economic interventions. Wound care patients may, for example, need assistance to achieve compliance with a nutritious diet because they lack the resources to obtain appropriate types or amounts of food.

Possible benefits of supporting include:

  • Diminishing the feeling of isolation.
  • Providing encouragement.
  • Improving self-confidence.
  • Informing.

Like supporting patients and primary caregivers, this strategy can have important benefits in terms of patients' behaviors and social and economic interventions. Practitioners may, for example, be successful at helping patients and/or primary caregivers by making them aware of needed resources, such as respite care, so that primary caregivers have more energy and commitment to compliance.

Possible benefits of informing include:

  • Improving knowledge of patients and/or primary caregivers.
  • Fighting anxieties, misunderstandings, and negative beliefs of patients and primary caregivers.

5) Educating.

Additional teaching may assist patients and primary caregivers to achieve adherence. If so, staff should provide it and document that they have done so. Practitioners also should use return demonstrations and documentation to help educate patients and primary caregivers.

Possible benefits of educating include:

  • Improving adherence following persistent and personalized application of the other interventions described above.

As the Centers for Medicare & Medicaid Services implement pay for performance (P4P) for home health agencies, practitioners are more likely to experience reductions in revenues when noncompliance interferes with their ability to provide quality care. Now is the time to practice good risk management and to prepare for P4P by addressing issues of noncompliance by patients and their primary caregivers.