Adherence Management: An Introduction

Dr. Bob Wright

Dr. Robert (Bob) E. Wright, Major, USA, (ret.), PhD, MHA, MA, RN

An Interview with Dr. Bob Wright

The following is an interview with Dr. Robert E. Wright, founder of Behavioral Education and Research Services, Inc. (BEARS). In it, he describes the behavior-based health services clinician-driven process known as Adherence Management (AdM) Coaching®.

Q: Who is BEARS? 

BEARS is the registered fictitious name for Behavioral Education and Research Services, Inc. Needless to say, BEARS is easier to say than using the entire company name.

Q: Behavior is a large field.  Is there a specific area that BEARS focuses on?

BEARS focus is in two aspects related to patient care.  First, we created tools to help clinicians easily identify patients who are most likely “At-Risk” for choosing non-adherence to their medical plan of care.  Second, we teach clinicians (and direct support personnel) how to help their at-risk population create healthy, adherent habits.

Q: I have heard that non-adherence is a growing problem.  I have read that at least half of all my patients will not follow a plan of care.  Is this really true?

Yes, non-adherence is a big problem.  About the only thing that has really changed, since the days of Hippocrates, is the name.  Non-adherence was known as non-compliance for many years. Some physicians have even confessed that as much as 80-90% of their patients don’t do what they tell them to do.


Q: Wow! That sounds like a future discussion.  Tell me then, how do you identify at-risk patients? 

The bottom line about adherence can be found in two words: choice and consequences.  For more than 40 years, there has been a concentrated effort to identify factors influencing choice.  To create the BEARS Medical Adherence Assessment Scale (B-MAAS), our team dissected 35 years of behavioral research[1] and discovered 22 factors that are easily identified as potential risks for non-adherence.  We then created an assessment score that quickly identifies adherence as Green, Yellow, Orange and Red.

[1]E. Vermeire, MD; H. Hearnshaw, MD; P. Van Royen, MD; and J. Deneken, MD: Journal of Clinical Pharmacy and Therapeutics (2001) 26, 331-342.

Q: It has been well documented that at least 50% of all patients are non-adherent.  So, you believe the Green and Yellow are not at-risk while Orange and Red are? 

You’re close.  Patients in the Green category are likely to fall in the not-at-risk category.  The “At-Risk” target population will fall in the mid yellow to low red groups.  The high, red patient group will likely be well-monitored by family or an extended care facilities.  The young adults to middle aged population, with chronic or emerging medical issues, are often the most “At-Risk” population.  For the most part, they still think they are bullet-proof and nothing can harm them.

Q: So, once the patient is identified as “At-Risk” using the B-MAAS, what is the next step?

The B-MAAS can be easily completed in about 5 minutes by intake staff, pharmacy, or nursing, with little or no special training.  The next step is to identify any physical factors that might contribute to non-adherence.  This is another quick assessment tool, based on the military’s fitness for duty scale.  The B-PAAS is an acronym for BEARS Physical Ability Assessment Scale.  With some minor modifications regarding communication skills, this tool lists physical or cognitive factors that could contribute to non-adherence.  It is a 9 by 4 matrix that ranges from fully functional to significant difficulties.  Again, this tool can be used by any moderately trained personnel and can be completed in under 5 minutes.

Q: Does BEARS conduct these assessments or tell me how it works?

BEARS primary mission is to teach healthcare professionals, particularly nurses, pharmacists, social workers, Accountable Care Organizations (ACO), and patient educators/navigators, how to use these tools.  We train both end users and master trainers. 

The ideal situation is when a trained health professional becomes certified as an AdM Coach® or Adherence Management Coach®.  The AdM Coach, then, performs the assessments (B-MAAS and B-PAAS), usually upon admission or as part of an intake process into a primary or secondary care practice.  Then, the AdM Coach follows the patient’s progress through the plan of care.

Q: Your tools are the B-MAAS and B-PAAS for identifying at-risk patients.  Once they are identified, what’s the next step? 

Most patients don’t want to be non-adherent.  It’s not in their best interest.  It’s when they get home and discover the many problems associated with their plan of care is where non-adherence comes to life.  And, because traditional healthcare does not follow their patient beyond the hospital or practice doors, non-adherence abounds.

The primary reason patients don’t follow their plan of care is “choice.”  Choice is affected by what happens to a patient (“consequences”) when they follow or don’t follow their care plan.  Looking at these consequences and determining which ones are influencing adherence, takes some analysis and training to conduct. 

The Certified AdM Coach® conducts a “Consequence Analysis©.”   This is the most revealing part of the Adherence Management process. The focus is on the positive and negative consequences that the patient experiences when they follow their care plan and when they don’t.  The key to success is to look at the consequences from the patient’s perspective.

Q: Why are you focusing on the patient’s perspective?  If the diagnosis is correct and the plan of care is correct, isn’t that enough? 

If that were true, every patient would be adherent.  The main problem arises when care plans ask patients to change something in their lifestyle.  These plans have additional costs (consequences) that are usually not apparent when the plan is prescribed.  There may be side-effects or an impact on time.  Inconvenience, expense, and side-effects are the big three that lead to non-adherence. 

The Consequence Analysis© shows both the patient and the AdM Coach© both the positive and negative sides of each part of the plan of care.

That’s all the time we have for today.  Join us for more Q and A sessions with Dr. Bob Wright.  We’ll start where we ended today with a question about the differences between outcomes and consequences. 


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