By Jeanie Davis

If a patient fears he or she will get robbed leaving the pharmacy, he or she is less likely to buy the medication. The patient may be homeless, or simply cannot afford the medication. He or she may struggle with literacy and reading the prescription information. The patient may be depressed, or may not believe the medication will help.

These all are realities for patients, especially those living in inner cities. The result is medication nonadherence, which can pose serious consequences for a patient’s health — and lead to billions of dollars in excess healthcare costs in the U.S. annually.

“I worked as a home care nurse early in my career, and that’s where you see it all,” says Lene’ Hudson, MSN, RN, CCM, CCDS, director of care management for Maricopa Integrated Health System in Phoenix. “In home care, you see their living conditions, their real problems,” she explains. “You learn about their finances, access to care, lack of transportation. They either don’t have a primary care provider, or the ability to pay, or they simply can’t get to a doctor for follow-up.”

Case managers and nurses have long known these factors to be barriers to healthcare, but public health researchers are digging deeper to understand these issues. Social determinants of health are the conditions in which people are born, grow, live, work, and age that shape health. Factors like socioeconomic status, education, neighborhood and physical environment, employment, social support networks, and access to healthcare all are important in this scenario.

Healthcare systems across the country are launching initiatives to help patients get past these social factors. At Valleywise Health System, case managers are guiding a broad program of efforts to address the multiple factors affecting a patients’ treatment.

For example, many more questions are asked at intake to help determine a patient’s needs. “You can never ask enough questions,” says Sondra King, MSN, ACM-RN, care coordinator at Valleywise. “The goal is to determine if they have risk factors that will impact their health at any point in their care.”

Social determinants are a little deeper than barriers to care, she explains. “They cover basics, but it also gets more personal — living arrangement, are you working, are you disabled, do you have a car? We ask about social support: Do you go to church? Attend social events regularly? Do you have family nearby, and do you talk to them regularly?”

The screening also addresses mental health by asking about how a patient has felt in the past two weeks to determine if there is hopelessness and depression.

“Medication adherence is directly related to social determinants of health because a patient’s ability to purchase medications and adhere to a medication regimen can be affected by a variety of social and economic factors,” explains King. “Education level affects the ability to understand difficult medication schedules while income and finances simply decide whether a patient will purchase medications or put food on the table.”

Transportation is a big issue for many people who do not have a primary care doctor or pharmacy nearby, King says. Many patients do not know Medicare has a transportation benefit. For others, community services like bus passes and vouchers are available. Valleywise is seeking grants for transportation initiatives, including Uber-style rides for patients, so they can get to a pharmacy or doctor safely.

Valleywise also provides 13 federally funded primacy care centers across the county for patients receiving their care at home for chronic conditions. “This is a unique structure within Maricopa County,” Hudson says. “We serve 68% Medicaid and 17-18% Medicare patients; the rest are uninsured or have commercial insurance.”

Food insecurity also is a problem, Hudson adds. “If they have a chronic disease, they may need four or five medications. Anyone on a limited budget will have difficulty paying for it all. They eat anything from a can; they don’t have money for better food.”

Valleywise has partnered with a local pantry to bring food to the hospital. The volunteer-led initiative serves inner city residents of all ages and gets a good turnout every time, she says. That popular program is now being expanded to one of the inner city family clinics.

Through a partnership with a major insurance company, Valleywise also is providing housing for homeless patients. Valleywise Health has purchased 40 apartments, and identified high-risk patients with “homeless” as their primary diagnosis.

The first group of 20 patients was placed in an intensive rehabilitation program for a year, explains Hudson. “This program has cut our costs of care across the board tremendously,” she reports. The second group of 20 patients is entering the program.

“Give people with chronic disease good food and housing, and their health will improve,” says Hudson.

Overcoming Medication Nonadherence

Studies have shown that patients with chronic conditions record adherence rates of 50-60%; typically, adherence declines after the first six months. Medication nonadherence is responsible for up to 70% of hospital admissions — costing up to $100 billion annually. An estimated 125,000 deaths per year in the United States have been attributed to medication nonadherence.1

To ensure patients take medications as prescribed, pharmacists advise healthcare providers to educate patients on three specific points: What is my main problem? What do I need to do? Why is it important for me to do this?

This simple dialogue helps ensure the patient’s understanding and compliance. Patients also should learn the consequences of not taking medication, like potentially fatal events such as heart attack or stroke. Follow up with a phone call to confirm the patient’s understanding.

Identifying community resources to help patients certainly is not new to hospital case managers, says Hudson. “People don’t know about these benefits, so we educate them.” But in setting up those benefits, it is important to dig deeper for all the problems a patient might be facing.

Depressed patients are at greater risk for medication nonadherence. Patients with diabetes may be overwhelmed by the cost of the medications. These patients benefit from open discussions of these issues so they can receive the help they need.

For those who lack prescription coverage, there are multiple plans, including Medicare Part D, Medicare Extra Help, Medicaid, the Together Rx Access Card, Partnership for Prescription Assistance, Coast2Coast Rx Card, and discount cards from some pharmacies and pharmaceutical companies. Generic programs offered by large chain pharmacies also are helpful. Some independent pharmacies offer price matching programs.

Also, physicians should be aware of the patient’s difficulties, as it will affect the patient’s success, adds King. “They should know if the patient has no support at home, especially a newly diagnosed diabetic patient. They’re going to enter this new diagnosis all alone, with no support, which can be very challenging. They may need to see the doctor in one month instead of three months to see how they’re progressing.”

She explains: “Navigating the healthcare system is a difficult task. When a person doesn’t feel well, and also has other factors to consider, such as food and shelter, it further impacts their health. To help patients heal, we must consider what social determinants they are facing, and how those things are impacting an individual’s life.”


  1. Wood B. Medication adherence: The real problem when treating chronic conditions. US Pharm 2012;37(Compliance suppl):3-6. Available at: