New guidelines help case managers promote medication adherence 

CMSA tackles $100 billion-a-year problem

Nonadherence to medication therapies traditionally has been like the weather. Everybody talks about it but nobody does anything about it.

The Case Management Society of America (CMSA), based in Little Rock, AR, is changing all that with the development of Case Management Adherence Guidelines (CMAG-1) designed to guide case managers in helping their clients stick to their prescribed medication regimen. The guidelines can be downloaded, free of charge, at www.cmsa.org/CMAG.

"The problem of nonadherence has been studied for 40 years, but nobody has ever set out to develop guidelines to help people address it. We believe that we can establish case managers as leaders in improving patient adherence," says CMSA president, Sherry Aliotta, RN, BSN, CCM.

Nonadherence to medication is a problem of epidemic proportions that costs the health care system more than $100 billion a year and is responsible for 125,000 deaths from cardiac problems alone, adds Aliotta, president and CEO of Huntington Beach, CA-based S.A. Squared Inc., an independent consulting firm for the development and implementation of case management programs.

Aliotta cites statistics showing that 12% of patients don’t ever fill their prescriptions. Another 12% fill them but don’t take the medicine. Another 29% stop taking their medications before completing the course of therapy.

"Only about half of the patients in the U.S. take their medications as prescribed, which decreases both the quality of their lives and life spans and correspondingly increases health care costs," she says.

Other studies show that 10% of all hospital admissions and 23% to 40% of nursing home admissions are the result of nonadherence, Aliotta says.

"If you look at where our health care dollars are now being spent, the cost of nonadherence is very wasteful. If we could improve compliance, it would make a huge positive impact on the health care system," she says.

The problem of noncompliance is multifaceted and complex, and no single approach can be successful in improving adherence, Aliotta points out.

CMAG-1 addresses the problem by giving case managers guidelines to determine the patient’s particular level of readiness and gives strategies to increase adherence based on the patient’s knowledge and motivation. They include tools to assess patient adherence intention, looking at their readiness to change, their health care literacy and medication knowledge, their social support system, and any barriers to adherence and strategies to help the patient overcome the barrier.

Case managers can use the guidelines to identify patient motivation and knowledge deficiencies that may be barriers to adherence and techniques to help them overcome the barrier.

"Prevention through improved adherence can reduce the huge costs associated with relapses, emergency care, and other medical intervention and extended hospitalization. This becomes even more important as our population ages. The more case managers and medical professionals can do in the early stages, the better the results in improving outcomes while decreasing health care utilization," she says.

The CMAG-1 guidelines are part of CMSA’s initiatives to identify ways that case managers can demonstrate their value by tracking direct outcomes of case management.

Direct outcomes of case management include improving patient adherence, improving coordination of care, and improving patient involvement, empowerment, and education, she says.

"We looked at these three topics to determine if we could show that by directly impacting any one of these things, we could affect cost-effectiveness, quality, or health status. Adherence had the clearest link to the end outcome, and we could measure it directly from a case management standpoint," she says.

The guidelines were developed through CMSA’s Council for Case Management Accountability. They are designed to produce measures that demonstrate that case management produces better patient outcomes and reduces financial costs throughout the system.

The Council for Case Management Accountability searched the literature and found that nonadherence and its consequences are widely documented and that the impact of nonadherence was tremendous.

"There’s a huge negative impact. Being able to demonstrate that case managers can improve adherence is the best place to start," Aliotta says.

The guidelines were created over the past year in hopes of helping patients work with their health care providers to overcome the current epidemic of nonadherence.

The council determined that patient adherence is affected by two key factors: knowledge and motivation.

They identified tools that already have been developed to measure patient knowledge and motivation and stratify them into one of four adherence-intention quadrants.

A person in quadrant one has low knowledge and low motivation to change. A person in quadrant four has high knowledge and high motivation.

"The idea is for the case manager to use the tactics and interventions that are appropriate. If the person has low motivation, they can work on motivation. If the knowledge is low, they can work to increase the knowledge," she says.

CMAG-1 applies specifically to medication, but the guidelines may be adapted to any situation where patient adherence is necessary, such as exercise, weight reduction, and smoking cessation.

The guidelines contain four different tools, each of which has been independently validated. They are short and easily administered.

• REALM-R stands for Rapid Evaluation of Adult Literacy in Medicine-Revised and contains a list of health-related words that help determine the health literacy of patients.
• Readiness Ruler, developed by a group of family practitioners, asks the patient to rate readiness to address his or her problem on a scale of 1 to 10.
• A medication knowledge tool to determine what the patient knows about his or her medication and how to take it.
• The Duke-UNC Functional Social Support Questionnaire to measure the patient’s social support.

"Social support and readiness to learn affect motivation," Aliotta says.

The guidelines include instructions on motivational interviewing, which helps the case manager identify what the patient is thinking and feeling.

"One of the fallacies in health care is that we can persuade people to make behavioral changes because we think they should change. People change for their own reason. Motivational interviewing help us help the patient discover his own motivation," she says.

For instance, a patient with diabetes may not be inspired to take her medication because she might have a stroke, but she may be compelled to take it if she realizes that she could have to give up playing golf.

Starting in October, CMSA began offering members a half-day training on health care behavioral changes and using the guidelines. Case managers who participate in the training will be able to enroll themselves and their patients in a study on how effective the guidelines are in actual practice.

"We’re hoping to go to 30 cities by the end of the first quarter of next year and to train 50 CMSA members at each site," Aliotta says.

Those who go through the training will be able to use CMAG Tracker, a web-based tool that automatically scores and calculates patients’ likelihood to be compliant and displays interventions.

As an adjunct to the guidelines, CMSA plans to award the first annual Excellence in Adherence Management Award at its conference in Orlando in June. The winner will receive $1,500, plus a trophy and recognition at the conference.