DPs can address patients' adherence barriers

Understanding and behavioral are big ones

One key to discharge planning is understanding what might prevent your patient from following medication and other instructions.

Once you have an idea of what the patient's adherence barriers are, you can find solutions.

A substantial reason why continuity of care fails is that once patients are discharged, they're on their own with taking the medications they're given and following their discharge instructions, says Alan J. Christensen, PhD, a professor in the departments of psychology and internal medicine at the Carver College of Medicine of Iowa City, IA. Christensen also is a senior scientist with the Veterans Administration Iowa City Health Care System.

Christensen describes the following potential barriers to discharge adherence:

• Psychological: "Does the patient understand the instructions?" Christensen says.

Patients' mental status and cognitive capacity should be assessed to make certain the patients are capable of following a complicated set of medication instructions, Christensen says.

"There are related issues like the division of attention during this stressful time period," Christensen notes. "I've never been in a hospital as a patient, but I know things are happening fast and furious, and a patient's attention is divided."

Patients already have extra cognitive demands, so it makes it difficult for them to concentrate when a discharge planner asks them to think about medication instructions, he adds.

"It's not only the demented patients who have trouble," Christensen says. "Most of us would have less than perfect memory, processing, and attention in that situation."

• Behavioral barriers: Cognitive barriers relate to understanding the instructions, and behavioral barriers relate to acting on what's taught, Christensen says.

Just because a patient understands what the discharge planner says doesn't mean the patient will follow instructions, he adds.

The reason why is that it's difficult to remember to take one's medications at certain times of the day, Christensen explains.

"This overlaps with the cognitive, but we address it separately," he says. "We address the cognitive barriers by simplifying the instructions, and we address the behavioral barriers by giving people pill boxes and memory aides to use."

Discharge planners can provide patients with behavioral cues that will remind them of how and when to take their medications.

For instance, a discharge planner can show a patient how the medication is taken by having the patient demonstrate taking the pills, Christensen suggests.

"And we often talk about linking medication administration with other daily tasks that are habitual, such as brushing your teeth," he adds. "So you tell a patient to take his medication when he brushes his teeth in the morning and when he eats dinner at night, instead of saying he should take the pills in the morning and at night."

• Social barriers: For some patients, such as HIV-infected patients and diabetics, there might be a social stigma attached with taking medication or giving themselves injections, Christensen says.

"For younger, active patients there is a stigma associated with medication-taking, particularly if it involves having to give yourself an injection before a meal if you're a diabetic," he says.

There also are patients who don't like to take their medications during certain social situations or when other people are around, Christensen adds.

Another social barrier includes transportation problems, such as not having a way to go to the pharmacy and pick up the prescriptions, he says.

For these patients, the solution might be to have them use a mail-order pharmacy.

"But if they can't use a computer and are not that good on the telephone, then it might be an issue," Christensen says.

So part of the discharge planner's job is educating them about what options there are in terms of ordering prescriptions by mail and how to refill their prescriptions over the telephone or computer, he adds.

* Financial barriers: For some patients, the solution to financial barriers is to change their medication to generic forms, he says.

Other patients might need additional help, such as assistance from a hospital program that provides an initial supply of medications, Christensen says.

"But that depends more on the patient's long-term chronic regimen," he adds. "Because sending someone home with a seven-day sample of pills to get them started is not related to adherence over the long run."