Follow these simple tips to improve patient adherence
Follow these simple tips to improve patient adherence
These days, home care patients have a lot to learn
Shorter hospital stays have resulted in patients being sent to home care with a lot of instructions and less time in which to learn them.
This means home care nurses have their jobs cut out for them.
"We need to educate patients more than once: before surgery, afterward, and when they are sent home," says Sharon Henry, RN, BA, product line director of CV Respiratory Care and CV Nursing Services of Mercy and Unity Hospitals in Minneapolis. The integrated delivery system is part of Allina Hospitals and Clinics and includes a home care agency.
Patients often do not follow instructions about managing their disease or care because they fail to understand what is required of them or lack enough assistance to carry out the plans, Henry says. "Typically, people are not compliant because they don’t have the social support system to help them."
Home care agencies can help them find appropriate social support and help improve their education. "Education is much more of a continuum of care issue," Henry notes. Therapists should give patients only the information they need at certain points in their therapy, he adds, and wait until their therapy progresses before providing more complex information.
Henry also suggests nurses bring all patient education down to the third-grade level and not assume that everyone will read.
She offers these strategies for improving patient adherence and education:
• Provide case management.
This is particularly important for patients who are more vulnerable to not adhering to a plan of care, including patients with congestive heart failure (CHF), Henry says.
CHF patients tend to be older and less willing to learn technology that could aid them in managing their disease, so education and case management are especially important, she adds.
A case manager might follow the patient from the hospital or emergency department into home care. "These case managers keep patients in a compliance mode and provide an intense program in the beginning," she says.
The idea is for clinicians to repeat the exercises and medication explanations that the patient first heard in the hospital. "Repeat the information on diet and what to buy in the grocery store and what to avoid. Repeat it over and over," Henry adds.
What works best is for the patient to meet with a nurse case manager who asks direct questions, such as these:
— Do you have enough money to buy your medications?
— Do you have a support system or family to take care of you?
— Do you understand what you need to buy at the grocery store?
— Do you have someone who can take you to the grocery store or go there for you?
— Do you understand about the sodium content of fruits?
— Are you eating tuna or other foods with sodium?
— Do you know of some community agencies that can help you?
• Help patients remove obstacles. Henry advises nurses to always listen closely to what patients are saying — both their indirect and direct messages — because these will have some clues about why the patient is not adhering to a particular direction.
For example, a patient with CHF might feel that he is going to die pretty soon anyway, so why bother to follow all of these instructions. The nurse, who perceives that the patient is depressed and feeling as though all of the efforts are futile, can address this by talking about how the patient will feel better right here and now by following those instructions.
• Convince patients that they’ll feel better if they comply. "Patients want to feel better, and you can say, If you do these things I’ve outlined for you, you’ll have a better quality of life; and while you’re living, you’ll feel better and feel like doing more, like taking a walk around the block,’" Henry explains.
Home care staff can help patients get in touch with social service and community agencies that could provide them with help with medications, activities of daily living, and other problems.
Home care agencies can also solve simple medication problems by having preprinted physician orders that will permit nurses to change or increase medications as needed. These orders give them some latitude and often are used for CHF and chronic obstructive pulmonary disease populations, Henry explains.
Transportation might also be an obstacle for patients, and again a home care agency might be able to find local resources to help with that.
• Give patients cues to help with medication adherence. "Typically, nurses are good at teaching patients how to lay out their medications," Henry says.
Strategies include giving the patient pill boxes with divisions for each day.
Also, home care nurses should reinforce the physician’s instructions about the medication, as well as modifying the education to fit the patient’s lifestyle. For example, a patient who is concerned about money might decide to take only half of the pills that the physician prescribed for each day. It’s the nurses’ job to explain how a CHF patient, for example, must take all of the pills in order to keep the fluid out of the ankles, and taking only half of them will not help.
Nurses need to explain how the physician prescribed the medications according to the patient’s specific needs, and maybe some pills must be taken in the morning with breakfast and others at night before bed.
For example, home care nurses might learn that a CHF patient puts off taking the evening diuretic because the patient wants to play bridge with friends and is embarrassed by having to continually get up to go to the bathroom.
"The nurse will need to talk about the consequences of how the patient will have fluid in her lungs and ankles after the bridge game, and if there is an exacerbation of the disease, then the patient might have to go to the hospital," Henry says.
"Once they have an intense learning experience with their nurses, they can manage their disease much better than they have before because they understand what the issues are and are working through these," she adds.
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