Discharge Planning Advisor

Project examines why patients don’t take meds

New tool measures adherence intention’

A pilot project under way at Arnot Ogden Medical Center in Elmira, NY, is assessing how likely patients are to adhere to their prescribed medication regimen, with the ultimate goal of helping them to become more compliant, says Tina Davis, RN, MS, CNS, senior director of continuum of care.

The project is based on new guidelines issued in fall 2004 by the Case Management Society of America (CMSA), which the Little Rock, AR-based organization has described as "the first national evidence-based algorithm to assist case managers."

At Arnot Ogden, a student working toward a master’s degree in social work is interviewing patients to determine where they fall on a grid that illustrates two categories: medication knowledge and understanding the importance of therapy, and willingness to change behavior, Davis explains. "We have this tool to help identify: Is it a motivation deficit, and why? What are the issues, so we can have a set of interventions to help patients?

"Patients can have different levels of adherence based on their motivation and knowledge — so someone can have a high knowledge level and a low motivation level," she says, or any other combination of low and high.

A patient who is assessed as being "low" in both motivation and knowledge, Davis adds, will be in Quadrant 1 of the grid, which shows the adherence intention is low. Someone whose knowledge is low and motivation high, is in Quadrant 2, which shows the adherence intention is variable, while one whose knowledge is high and motivation is low is in Quadrant 3, she says, which shows the adherence intention is variable.

"If the person is in Quadrant 4, the knowledge is high and the motivation is high, which shows the adherence intention is high," Davis notes.

The assessment can be done surprisingly quickly, she points out. "We’ve found that it takes about 15 to 30 minutes, which is not a lot of time. If [the result] will be increased adherence to the medication regimen, it will be time well spent."

The pilot project began the first week of April 2005 and is to continue through August 2005, involving the patients on one nursing unit, Davis says. Those who have just had surgery or who are confused, are excluded, she adds. "Confused people won’t provide good data."

Davis says she is very excited at the potential — through use of the CMSA tool — for being able to "put our arms around" an issue with which clinicians have struggled for years.

One of the challenges, she points out, has been that — without the advantage of an evaluation tool — nurses and case managers may not have realized a particular patient would have a problem with medication compliance. "The person might look as if he or she would be adherent.

"Medications are one of the most difficult things to deal with for our patients," she adds. "I think it’s going to give us excellent information as nurses to intervene and improve adherence, to be able to identify the actual problems — what we need to help the patient with."

So far, Davis notes, patients interviewed at Arnot Ogden have fallen into all of the quadrants except Quadrant 3, the one that indicates a high level of knowledge with low motivation. "We’re waiting to see if that’s a pattern as we continue to evaluate patients."

In addition to the tools needed to evaluate patient adherence, the algorithm developed by CMSA includes guided interventions to help address patient adherence needs. Those suggested interventions, Davis says, include such strategies as patient reminder systems and referrals to home health agencies, which can provide staff to help patients with their medications.

One recommendation, she adds, is to educate patients on the consequences of not adhering to the medication regimen, and to use the "teach-back" method of asking the person to repeat the instructions he or she has been given.

"There can be specific interventions for specific quadrants," Davis notes. "We’re not trying to educate the person on everything. If they’ve scored in a particular quadrant, we know that’s where the potential problems are and the interventions to put into place based on the assessment of adherence intention."

The next step for Arnot Ogden, she says, is the meeting of an interdisciplinary team to determine, based on patient scores, the interventions that will be put in place, not only in the hospital, but after the person has been discharged and is back in the community.

That team, Davis adds, will include social workers, case managers, the senior director of nursing, a unit director, staff nurses, and the vice president of medical affairs.

Among other things, she says, the team will look at how to continue the program after the social work student leaves, and at creating a letter that will be sent to physicians as a communication tool to inform them of patients’ adherence intention. The idea, Davis adds, is that education efforts can continue in the physician’s office.

A potential strategy could be to use the hospital’s telephonic nursing program to assist patients who need help with medication adherence, she says. "The referral would come from the inpatient case manager, who would — based on the adherence score — refer the patient to the telephonic program, which would follow up with a designed intervention once the person is home," Davis notes.

The Case Management Adherence Guidelines, known as CMAG-1 because updates are planned on a regular basis, were developed when CMSA created the Council for Case Management Accountability to identify outcomes that should be measured in case management regardless of setting, explains Sherry Aliotta, RN, BSN, CCM, president of CMSA. "We did a bit of survey and research with our stakeholders — about 150 different organizations representing the health care field," she says.

"Those groups, which included the American Medical Association, the American Hospital Association, and the Joint Commission for the Accreditation of Healthcare Organizations, came up with three things as being the most important outcomes to measure — adherence, coordination of care, and patient empowerment and involvement," Aliotta continues.

At the behest of CMSA, nurses researched the literature on these concepts "to see if we could have any impact on them," she says, "and with adherence, we saw the strongest link. We could measure, we could predict, we could impact, and there was a cost benefit. So we could improve quality of care, cost of care, and patient health status."

Working with a grant from Pfizer, the international pharmaceutical company, Aliotta says, the CMSA researchers identified tools that could help predict the likelihood of adherence — "adherence intention" — to whatever course of treatment was prescribed.

The CMSA model was based on a white paper by the World Health Organization, which outlined "the key factors to be in place to make lasting behavior change," she continues.

"We identified tools that would address each area — education, behavior skills, and motivation — and packaged them into what is now known as CMAG-1," Aliotta explains.

The organization will be working in the fall of 2005 on CMAG-2, she notes, "which will be enhanced with what we’ve learned from the application of guidelines and newly identified tools and will be more in-depth in certain focuses."

The tool is free and available for download to anyone who is interested. During the first two months after it was introduced in October 2004, there were 22,000 hits on the web site where the information is offered, she says.

Shortly afterward, CMSA began offering half-day training sessions on the guidelines exclusively to its membership, Aliotta says. "We did 39 workshops around the country that were very well attended and received good feedback."

These classes, she adds, eventually will be available to nonmembers.

Another benefit that at present is limited to CMSA members is the CMAG Tracker, a web site created to support the new tool that is both an on-line version of the guidelines and a place where data can be recorded and aggregated to look at results, Aliotta explains. "It is a database of assessments and interventions that have been done," she adds.

"It is only through actually documenting results that we will have usable outcomes," Aliotta points out, "so it is important for as many CMSA members as possible to investigate this and if possible participate in research. One person said the situation reminded her of the story of the Little Red Hen — everyone wants a piece of bread, but no one wants to do the work. I encourage people to participate."

Future plans include train-the-trainer sessions, whereby those who have been trained as users can sign up to learn how to be trainers, she explains.

Meanwhile, the organization has a research project under way to evaluate the impact of the CMAG-1 that is open to any case manager who wants to participate, Aliotta says, adding that she and CMSA president-elect Susan Rodgers are co-principal investigators for the project.

A three-legged stool’

Elaborating on the content of the guidelines, Aliotta says that if one thinks of adherence as a three-legged stool, those legs are:

  • Education/knowledge.

This would include such information as the benefits of any therapy that is prescribed and why it’s important to take a certain medication at the same time each day, or to take it with food, she notes. "If you don’t understand why [instructions] are important, it’s less likely you will carry them out."

  • Motivation.

This has to do with discovering if a patient has ambivalence about taking his or her medication, and if so, the reason behind it, Aliotta says. "Mine might be thinking it will make me feel bad, and yours might be that it cost $300 a day."

  • Behavioral skills.

An example here would be placing the medication where you can see it and remember to take it, she notes.

A technique called "motivational interviewing" is a key skill to master for those using the CMSA algorithm, Aliotta says. Motivational interviewing is described on the CMSA web site as a directive, patient-centered method that requires an atmosphere of collaboration between case manager and patient to identify mutually agreeable goals.

In this model, the case manager spends less time giving advice and more time asking questions and providing information requested by the patient.

"It’s different than the typical biomedical interaction that people are used to having, but necessary to help [patients] discover their own internal motivation to change," Aliotta notes.

Davis points out that medication administration, particularly how patients will continue their medication regimens at home, is one of the hot topics of the Joint Commission and that the tool may help address that issue. "If we understand how to affect nonadherence with specific interventions, we may succeed in preventing a number of medication errors," she adds.

"By evaluating all patients and taking a proactive approach, we can address these problems up front, instead of waiting for the patient to come back and finding out after the second or third admission that [medication adherence] is the issue," Davis says. "We’re looking forward to being able to roll this out, and possibly give feedback to CMSA about how it works in the field."

[For more information, contact:

  • Tina Davis, RN, MS, CNS, Senior Director, Continuum of Care, Arnot Ogden Medical Center, Elmira, NY. E-mail: tdavis@aomc.org.
  • Case Management Society of America, Little Rock, AR. Phone: (501) 225-2229. Web site: www.cmsa.org.]