Non-adherent patients? Check your communication skills

It may be that they just don’t understand

If your patients aren’t following their treatment plan and end up in the hospital or emergency department or fail to keep their chronic disease under control, resulting in complications, don’t automatically blame the patient. Instead, look to yourself to see what you could do to help them understand, says BK Kizziar, RN, CCM, owner of BK and Associates, a case management consulting firm based in Southlake, TX.

“Patients do not freely decide to cause harm to themselves, to deliberately cause deterioration in the quality or quantity of their lives, or as care providers, in the lives of their loved ones. In my opinion, the issue of non-adherence is more a matter of health literacy than anything else,” adds Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy and Associates, a case management consulting firm based in Huntington, NY.

The healthcare system can be frustrating and anxiety-producing for everyone, even if a person has a lot of knowledge and skills, adds Sandy Roland, senior communications coordinator for Passport Health Plan, a Medicaid HMO with headquarters in Louisville, KY. “When someone is struggling with literacy, the healthcare environment can be very overwhelming, and that’s why we work so hard to make a difference,” she says.

Healthcare professionals often take for granted that people know more about their illness than they really do, Kizziar says. “We are expecting our patients to be adherent and change their behavior when they don’t always understand what they are supposed to do or the reason to follow the treatment plan,” she says.

“Low-income patients and people for whom English is a second language tend to have greater healthcare literacy challenges than the general population. However, people may be extremely well educated in other areas, but when it comes to health information, they have trouble understanding,” says Lucy Ricketts, director of marketing for Passport Health Plan with headquarters in Louisville, KY.

The National Patient Safety Foundation estimates that the health of 90 million people in the United States may be at risk because of difficulties in understanding and acting on health information and that 66% of adults over age 60 have inadequate or marginal literary skills.

“Case managers as an individual, as a member of a team, and organization can make a difference in developing ways to help people understand and navigate the healthcare system. This is regardless of the setting in which they work,” says Helen Osborne, MEd, OTR/L, president of Health Literacy Consulting, a Natick, MA-based firm.

In addition to being aware of health literacy yourself and applying what you have learned when you communicate with patients, use your knowledge to raise awareness about health literacy among others in your organization, Osborne says. She recommends that case managers review the white paper “Ten Attributes of Health Literate Healthcare Organizations by members of the Institute of Medicine Roundtable on Health Literacy” and apply the attributes to their everyday activities.1

Keep in mind that not everybody has the same level of knowledge, so don’t assume anything when you work with patients, Roland says.

Remember that the ability to comprehend instructions depends on many things, Kizziar adds. Older adults may have problems understanding because of cognitive issues or the decline of physical functions, such as vision and hearing.

Stress can play a role in a patient’s ability to process information and understand his or her treatment plan, Mullahy adds. “Even those of us who are healthcare professionals respond quite differently when we or a member of our family becomes the patient,” she adds.

“All of us in the healthcare field want patients to take more responsibility for their own health, and as case managers we can provide information and make sure they understand it so they can do so,” Kizziar says.

Case managers often feel they don’t have time to spend with patients and make sure they understand their medication regimen and treatment plan, Kizziar points out.

“The case management job has gotten so complex and multi-faceted that there is a tendency to get in a hurry. But it’s crucial to make sure patients understand, and find out why patients are not adherent,” she says.

She advises case managers to slow down and spend time with patients. “Typically, in the hospital, the case manager is the most consistent face the patient sees,” she says. The same is true of case managers who work for payer organizations and have a telephonic relationship with members.

Make sure patients are given information in a way they can understand and incorporate it into their lives, she says. Keep in mind that behavior often is influenced by culture and financial status, she points out. For instance, you can’t expect someone with a low income level who has eaten unhealthily all his or her life to switch to more expensive fresh vegetables and fruit.

When they give patients instructions, case managers should look for cues to determine if the person they are working with can understand. Body language can be a tip-off that people don’t understand when you’re talking face to face, Roland says. If you are talking on the telephone, silence after a question is an indicator that the person is confused about what you are telling them, Roland says. She suggests repeating the information, maybe using simpler language, or offering to read the material to them.

In addition to clearly explaining to patients what they should be doing, include information on why it’s important to do so, Kizziar adds. “Too often, case managers give patients instructions, but the patients don’t understand the rationale behind what we are telling them to do. We can’t expect patients to be adherent if they don’t understand the reason for their treatment plan or changing their behavior,” she says.

For instance, if you are going over a patient’s medication regimen, explain what will happen if they take it at the wrong time or take certain medications at the same time, she says. Say something like: “Remember if you take the red pill and the blue pill at the same time, it will make your heart flutter,” or “Since you’re usually at home in the morning, take your water pill when you get up so the pill will be used up in the afternoon and you can go shopping without worrying about where there is a bathroom.”

At the same time, if patients make an informed decision not to be adherent, leave that behavior alone and concentrate on something else, Kizziar says. For instance, if someone tells you they aren’t willing to stop smoking, don’t harp on that. “If you keep after people to do something they aren’t willing to do, you’ll alienate them,” she says.


1. Institute of Medicine Roundtable on Health Literacy. Ten Attributes of Health Literate Healthcare Organizations.