Finding solutions for noncompliance

Identifying root causes helps improve outcomes

Case managers often become frustrated by patients whose failure to comply with treatment plans lands them back in the hospital for potentially preventable complications. However, before judging patients too harshly, one nurse executive recommends looking for the root causes that lead to noncompliance.

"In 1994, the Medicaid program in Tennessee went to a managed care system called TennCare," says Stephanie Winfrey, MSN, RN, quality review manager for Regional Medical Center in Memphis. "Many of the problems experienced previously with Medicaid patients were exacerbated under TennCare. As external case managers began working with TennCare patients, the problems behind their noncompliance became more evident.

The lessons Winfrey learned as she and other staff searched for the reasons behind the high incidence of noncompliance in TennCare patients hold valuable lessons for case managers in any practice setting. Those lessons include:

1. Illiteracy.

"We find many patients are too embarrassed to admit that they cannot read the care instructions and health education materials given to them at discharge," she says. "There are ways that staff can assess literacy without embarrassing patients. For example, hand them a form upside down and see if they turn it around to read it properly."

2. Lack of education.

"Many patients have no basic understanding of their disease process. They don’t understand the impact of not taking their hypertension medication or managing their diabetes," Winfrey says. "They don’t see the need to take their asthma medication when they are feeling fine. Now, we contact patients in our high-utilization groups with additional information after discharge. We give them an opportunity to ask questions of a nurse or health educator and to attend classes on how to manage chronic disease."

3. Economic hardship.

"Patients are sometimes given five or more medications at discharge. Without assistance, they simply cannot afford to have all their prescriptions filled. Our pharmacy has established a medical assistance program through a number of pharmaceutical companies to get TennCare patients prescriptions at reduced cost."

4. Lack of transportation.

"Many of our TennCare patients have transportation problems. They don’t have access to a car, and the bus schedules aren’t convenient for keeping scheduled appointments," Winfrey says. "We set up an arrangement with local cab companies. Patients who have a real need to come into the clinic for an appointment can call a cab, and we reimburse the cost. Helping patients keep follow-up appointments really helps prevent subsequent readmissions.

5. Failure to understand managed care system.

"In the past, Medicaid patients presented themselves in the emergency department or clinic and received care," she says. "Under managed care, they must receive approval prior to treatment in many cases. We’re working to help patients understand that the system has changed, and there are levels of care that require authorization. We’re at risk financially when we fail to comply with authorization policies and procedures. Patients have to understand that."

6. Misdirection from physicians.

It’s not just patients but also physicians who must be educated about the managed care system, notes Winfrey. "Providers still tell patients that they should report to the emergency department if they don’t feel better. We’ve set up a telephone triage system for patients to call in for clinical direction from a registered nurse following established protocols and then receive help obtaining a clinic visit for the next day." In addition, providers have established after-hours urgent care clinics to help take some of the pressure off the hospital emergency department.

"The real solution to solving issues of noncompliance is to look at patterns of care and utilization," Winfrey explains. Most of the time, noncompliance has a psychosocial issue at the root, and finding the cause can lead to a solution, she notes.