Focusing on patients boosts compliance

Change of perspective leads to better treatment

Managed care case managers must focus on patient compliance because it is the focus of almost every measure the National Committee for Quality Assurance (NCQA) in Washington, DC, uses to rate health maintenance organizations (HMOs).

"We have to place more focus on patient compliance because we’re being measured on it. Unfortunately, it’s the very issue we’re having the most difficulty with, especially in older populations," says Ellen Albierti, BSN, MS, CCM, manager of Medicare programs for MedPartners West in LaHabra, CA. "As case managers, compliance with treatment plans is a process we try to achieve with our interventions. Yet 50% of all older adult hospital admissions are due to noncompliance. It’s the bane of managed care."

The problem stems from poor communication and a failure to consider the patient’s perspective in treatment plans, Albierti says. "Most studies that look at compliance look at the perspective of the health care professional. Very few studies have looked at the other side of the coin, which is the competing worlds our patients live in. We look only at the clinical need for treatment, not the conflicts patients face between family demands and schedules, golf games, bingo nights. There are many outside influences that all work against what we hope to achieve with our patients."

Most providers and case managers view noncompliant patients as "bad seeds," when in reality, many treatment plans are too difficult to follow, Albierti says. "The average older American takes 101¼2 prescriptions each year. Some medications must be taken before meals. Some must be taken after meals. Some must be taken with food and some without food. Case managers must look at the whole picture and see if treatments are too difficult to follow," she adds.

"We often overestimate our patient’s level of understanding. We often incorrectly assume we have given our patients the necessary information," Albierti says. "And patients are too embarrassed to admit they are confused and ask their doctors questions about their medications. They think the doctor is too busy, and they don’t want to take up too much time."

Improving the odds

The bottom line is that patients comply with treatment plans when the plans make sense to them and appear to be effective, Albierti says. If case managers want to improve compliance, they have to focus on helping patients understand the plan and demonstrate how the plan could be effective, she says. Here are some strategies she suggests case managers use to boost compliance:

Understand by listening. "We are in such a hurry. This is especially true of physicians in managed care," Albierti says. "With patients booked every 10 minutes, doctors are making diagnoses and [providing] treatment as fast as they can. They don’t take enough time to factor in what issues patients use to make their decisions about compliance."

Counsel and communicate sensitivity. "This isn’t easy to do," she admits. "It involves attitude and body language. It’s especially hard for physicians. But case managers should encourage physicians to sit down in the exam room to talk to noncompliant patients rather than standing over them."

Encourage patients to ask more questions. "Physicians are sometimes threatened by patient questions, but we’ve got to ask questions. And, we have to admit that patients always listen to their physicians best." Try suggesting to the physician that if the physician shares more information with the patient, compliance might improve.

Provide both written and verbal information. "We must support written information with verbal information down the road," Albierti says. "There are studies which demonstrate a statistically significant improvement in compliance when written information is followed by verbal follow-up.

Maintain contact. "It’s really hard to consistently follow up on all patients, but many case management software packages have tickler files that help case managers monitor patients."

Schedule appointments and classes appropriately. Try to be sensitive to when older adults want to come, which tends to be between 10 a.m. and 1 p.m., Albierti says. "Don’t schedule health education classes, support groups, or appointments for older adults in late afternoon or evening."

Emphasize the benefits of compliance. "Don’t make your arguments too esoteric. Stick to really down-to-earth arguments that patients can relate to easily: ‘If you take your medication regularly, you will be able to finish 18 holes of golf.’ ‘If you comply with your treatment plan, you will be able to attend your granddaughter’s graduation.’"

Yet it’s also important to remember that you are speaking to an individual, she says. "Talk to a person, not a birth date."