“Americans always do the right thing…”

Sir Winston Churchill, a great warrior, and leader of the British people during World War II, offered this statement as an indirect jab at the American way of getting things done. He completed his thought with, “… when they have tried everything else.

As a nation, as a people, as a model for the free and not-so-free world, this statement reflects what our closest relatives and allies believe about who we are. We have historically done many things to achieve a goal. When we failed, we learned from it, adjusted, and moved ahead. That is clearly the story of our several hundred-year journey in health services. It is only when we persist in doing ineffective things that the system bogs down. Improving patient adherence to their plan of care represents such a condition.

I watched “Gangs of New York” last week starring Leonardo DiCaprio as an Irish street thug during 1863 draft riots of the American Civil War. While all men are modern in their own time, the 1860’s, even in the Big Apple, was a gritty time. Self-taught trade school physicians delivered health services such as they were. A standardized system of quality control, infection control, patient centered care, and patient empowerment were a century away. Infection control, patient centered care, physician credentialing and licensing had also been around for almost two millennia in ancient Persia. Some things cultures need to discover on their own. We find ourselves today nearing the end of the second decade of the 21st Century and I wonder what clinicians in the year 2163 will think of our “gritty time.”

Health services providers take a lot of process improvement from industry for several good reasons, it improves productivity, reduces costs and increases profit. Henry Ford stated, “We are charged with discovering the best way of doing everything.” In discovery, there has been and will continue to be a lot of mistakes and learning along the way. That is the nature of discovery and that is the history of mankind. Ultimately, we will, as Thomas Edison admonished his contemporaries, “There is a better way… find it.

Health Services is more than Process Improvement

There are two realities in health services delivery that Ford, Edison, Demming, Juran, and other proponents of process improvement programs, didn’t have to consider: 1. Parts on an assembly line don’t have a choice to be there and 2. Most (non-human) products are not self-destructive.

People who enter our health care “assembly lines” have a choice. Many will choose to ignore their symptoms until those symptoms become overwhelming and can’t be ignored. This is the “rescue population” and the health care system does a pretty good job of rescuing people from their self-injurious choices. Others might jump on the “assembly line” and then choose to jump off because of cost, inconvenience, or side effects. These patients are in the “primary non-adherence” category. Others will have new parts installed but return to the very habits that initially threatened the life of the old parts. Finally, there are many who will follow their plan of care, at least for a while. What all these groups have in common is the behavior of choice and the consequences that follow that behavior.

When they have tried Everything Else…

Patient non-adherence is hardly new. It has been the bane of existence since Adam and Eve were told to eat every fruit of the garden except one. To be sure, many of the medicines and treatments, from years long gone, were likely worse than the disease itself. In the grand scheme of life, most of us are "patients" in title only and only when we use the health services system. Other than during those brief moments, patients are people. People do the things they do because of the consequences of their behavior. Those consequences, from the person’s perspective, are ignored when clinicians offer the standard "patient education packets" to their patients.

In the last several decades, what have we focused on in “trying everything else” to improve adherence? Systems improvement comes to mind. Change the word from compliance to adherence and improvement will follow. Add adjectives to the word patient. There is patient centered care, patient enabling, patient entitlements, patient [fill in the blank]. Population health is another way to define a process to improve adherence. Finally, we have taken the term “patient” out of the equation as we seek the holy grail of adherence. Once we have tried “everything else…”, will we turn to behavior and adherence management to improve outcomes?

Weaning myself off…

A couple of weeks ago, I was traveling through North Carolina. I was having breakfast with my wife and could not help but overhear a conversation between a lady in her 50’s and her adult daughter. “My doctor says I have high blood pressure,” the lady said. Her daughter, clearly concerned about her mom responded, “Well Momma, what’s the doctor want you to do?” Without hesitation Momma responded, “I started on this blood pressure pill. I think I’ll take it until my blood pressure gets back to normal and then I’m going to wean myself off it.”

I wanted to have a conversation with her, but we had another 500 miles to drive that day. How many mommas and daddys are weaning themselves off a plan of care because the consequences of adherence today are negative, while the consequences of non-adherence are years away?

What non-behavior based techniques and processes, which have been used for the last 35 years without success, are going to suddenly become effective overnight and actually work this time at changing these patient behaviors, or are clinicians finally going to do the right thing? Stop focusing on non-behavior based processes. Identify your at-risk patients, figure out why they are at-risk, establish an Adherence Improvement Plan and work the plan with the patient and their families using positive reinforcement of the proper adherent behaviors until they become habits.

Adherence Management Coaching©… It’s the behavior based solution to true patient centered care!

Chief Adherence Officer (CAO): A new addition to the C-Suite?

Are you thinking about creating a Chief Adherence Officer position?

Everything there is to know about patient non-adherence and the billions of dollars lost in revenue, unnecessary admissions and readmissions has been written about, conferenced on, work-shopped with, debated over, discussed about and reviewed ad nauseum.  A recent conclusion is, “Strategic, corporate-wide, patient engagement initiatives to improve adherence will deliver scalable revenue growth and improve patient outcomes across brands and portfolios, with the added bonus of a positive public relations narrative.” [1]

If you are thinking about creating a Chief Adherence Officer position to deliver scalable revenue growth, which of a half-a-dozen health services professionals will your organization tap to be the “point-man” going where so many others have gone before? Who will be the first to achieve consistent results that have evaded each generation from Hippocrates to today? Which “patient engagement initiative” will be deployed and produce a significant dent in the $600 billion left annually on the table because millions of patients “choose” to be non-adherent? Choice is a behavior and behaviors are based on consequences. What’s in your Adherence Improvement Toolkit?

[1] Tom Kottler, Katrina Firlik, MD: Advocating for a chief adherence officer in pharma, http://medcitynews.com/2016/11/chief-adherence-officers-pharmas-future/?rf=1

There is a common denominator: Human Behavior!

Choice is a behavior and behaviors are based on consequences.

Behavior is the common denominator regardless of whether the patient is non-adherent with their medications, their diet, their lifestyle change, etc.  It matters not whether the CAO is a physician, nurse, pharmacist, or for that matter, a candlestick maker.  An effective CAO will need an applied behavior-based tool kit and an understanding of why people do the things they do.  What’s in your Adherence Improvement Toolkit?

For several decades, non-adherence has been addressed as a “patient education” issue.  “Teach them and they will learn.”  As they learn, they will become adherent.  Others have loudly stated, “Change their thinking, reduce their ambivalence, and they will stick to their plan.”  “Perhaps,” wondered others, “we should change the process?”

Countless hours, weeks, and months have been spent with people and their earned belts of many colors, teasing out changes in the process at various sigma levels.  “Improve the transitions and adherence will follow.”  Countless research programs into adherence improvement having quietly stated in their conclusions, “Results are promising but there are no statistically significant differences between the baseline and the intervention.”

The kiss of death for any research is the “no statistically significant difference” statement in the conclusion section. Yet every study completed on patient adherence over the last 35 years has included it. Having stated that, current researchers tweak a few words and another research effort is born.  We hopefully learn from our past and should reflect on the thoughts of Einstein and Edison respectively, “Doing the same things over again and expecting different results, is the definition of insanity” and “I have not failed. I’ve just found 10,000 ways that won’t work.”  For the purists reading this, you may argue that others should be credited with these quotes.  Mark Twain resolved the issue, “What a great thing Adam had.  When he said something, he knew it had never been said before.”

“Strategic, corporate-wide, patient engagement initiatives”

The Hospital Engagement Network (HEN) contracts (HEN and HEN 2.0) between 2013 and 2016 examined unplanned readmissions as a quality of care issue with a plan to reduce these events by 20%. After the 2013-15 HEN effort, readmissions had only been reduced by approximately 5%. HEN 2.0 was a year-long effort to follow-up on the recommendations of HEN. Even though results were “not statistically significant,” a third two-year HIIN (Hospital Improvement Innovation Network) was awarded in September 2016. The programs were essentially unchanged. However, the name was changed and improvement targets were lowered. The previous harm to patient goal of 40% was now reduced to 20% and unplanned readmissions was reduced from 20% to 12%. (Now I can’t be certain, but when you reduce the goals of a study but still only get a 5% change, doesn’t that change the significance numbers without actually changing anything? Food for thought!)

Patient engagement is a term everyone in health services is familiar with and yet it does not describe the two essential elements necessary to improve adherence. 1. Pinpoint the results necessary to achieve optimal health, and 2. Pinpoint the behaviors  necessary to achieve those results? The meaning of the word “engagement” rarely describes the behaviors necessary to achieve it. As Miller and Burgoon stated more than a half century ago, “the meanings of words are in people and not in the words themselves.” If health services providers cannot specifically state the behaviors necessary for improving patient engagement, how can a person with either an aggravating illness or life threatening condition come to appreciate whether they are “engaged” or not?

“Shouldn’t they want to be adherent?”

Regardless of culture, gender, belief systems or a combination of more than 170 variables, people behave and misbehave. The issue is, what may be considered “misbehaving” by a clinician, is considered “normal behavior” for patients. In fact, the plan of care or discharge plan is often filled with consequences that are “punishing” to patients. Countless episodes of care are abandoned because the disease is asymptomatic and/or the treatment itself, while likely very effective, is not producing results patients can perceive.

What tools will this new Chief Adherence Officer have in their toolkit that can:

  1. Identify patients who are at-risk,
  2. Identify physical and communicative barriers to adherence,
  3. Evaluate the plan of care for punishing elements,
  4. Establish an adherence improvement plan,
  5. Reinforce target behaviors, and
  6. Monitor and make adjustments quickly and easily when target behaviors or clinical results are not being achieved?

The short answer is: these tools are not available to them. Nor are they in the tool boxes of the teams of health services professionals they will lead or direct. How will they know in a month or two which patients are beginning their non-adherent slide for life? AdM Coaching© is the only way to know for sure!

There are more than 13,600 ways a person’s health can be at risk. We can treat these diseases with more than 6,000 medications and 4,000 procedures and protocols. The equation is terribly unbalanced as hundreds of millions of people, with an average eighth grade reading level are expected to understand and apply a plan of care developed by their clinicians.

Adherence Management (AdM) Coaches© can identify the at-risk population and, regardless of the disease or cultural background, answer these questions for patients: 1. Is this treatment good for me or not? 2. Will the results of this plan of care be immediate or some-time in the future? 3. Is the treatment plan “likely” or “unlikely” to be successful? And 4. Will I be aware of the consequences of following my plan of care or not? Clinicians will always respond, “The plan of care is good for their patient. The medications will be effective immediately on starting them. The plan of care, based on their experience is likely to be successful. Patients may not be aware the medication is working, but it is.” It matters not, when it comes to adherence, what clinicians believe. Adherence Management begins with understanding the consequences in the plan of care from a patient’s perspective.

All other methods for improving adherence fail to recognize the gap between clinician’s perspective and the patient’s perspective. A basic law of behavior is, “behavior goes where reinforcement flows.” Where there is no reinforcement, adherence stops. Another reality of behavior is, people do not do things that are immediately harmful and perceived. Nor will they continue to do things that are helpful but not perceived. Hypertension is asymptomatic, vascular compromise from diabetes is asymptomatic, medications for hypertension are asymptomatic. In fact, many medications for the treatment of congestive heart failure, kidney disease, etc. produce no “aha!” moments to prove its effectiveness. A very common statement from non-adherent patients is, “I didn’t feel that it was working… so I quit taking it.” That’s extinction.

Chief Adherence Officer: A Prediction

Regardless of the basic profession of these potentially new C-suite candidates, I predict that without a clear understanding of the basic principles of Adherence Management Coaching©, it might only make a hiccup in the problems of non-adherence — both for readmissions and hospital acquired infections.

Teachback, Motivational Interviewing, and Medication Therapy Management are the primary mainstays of adherence improvement. Educational (Teachback) information is frequently forgotten before patients get home. Motivational Interviewing has patients reflect on their wrong-thinking and ambivalence until they desire improvement. Medication Therapy Management ensures medications are not conflicting or potentiating. MEMs caps and emails are used across the country and hailed as the “new-new” way to improve adherence. Behaviorally, each of these programs or items are referred to as antecedents. Antecedents are the devices or events that prompt or cue a behavior, but not necessarily get it to occur. Buzzers can remind a patient that it is time to take a pill, but those can be turned off or muted. MTM can prevent harm because of pill conflicts, but it does not improve the chance that patients will take the pill. Wrong-thinking may be corrected for a season and then patients go home, get on the internet, have conversations with friends and family and rapidly return to their life-long baseline of bad habits. Focusing on antecedents is the easiest course of action (from the clinician’s perspective) but the outcomes are predictable. The value of antecedents to change behavior is limited. If change is to be made with adherence, it is time to focus on consequences.

What’s in BEARS’ Toolkit?

The tools included in Adherence Management Coaching© 1. Identify at-risk patients, 2. Identify physical or communication factors that could contribute to non-adherence, 3. Identify specific requirements in the plan of care that are considered punishing to patients from their perspective, 4. An Adherence Improvement Plan, 5. Reinforcer Survey, and 6. Evaluation tool for finding where problems exist if patients are not making progress as expected.

“Habit is habit, and not to be flung out of the window by any man, but coaxed downstairs a step at a time.” Mark Twain.  Are your patients being “flung out of the window” with care plan in hand or are you coaxing them towards better habits… a step at a time?

Learn more about Adherence Management Coaching© and our “a step at a time” approach by visiting our website: www.adherence-management.com or call us at 321-439-5949.

What is Adherence Management: Q & A continued.

Dr. Bob Wright

Q: Dr. Wright, what is Adherence Management

It’s a way of getting patients to follow their care plan and enjoy doing it.

Q: Do you mean patients in a hospital or clinic? 

The correct answer is all patients wherever they happen to be at the time they interact with the healthcare system. At home, work, or wherever a provider requires a patient to do specific behaviors necessary to achieve a desired clinical outcome. This incorporates medications that are taken at various times and places throughout the day and night.  So of course, we are concerned with medication adherence. But care plans include other things such as diet restrictions, strength or physical exercises, monitoring behaviors such as taking BP or blood sugar readings, making future follow-up appointments, etc.  Adherence Management is helping clinicians (or their ACO transition care professionals) to get patients to follow their care plan with the use of Consequence Analysis and positive reinforcement.


Q: You mentioned patients enjoying doing what the doctor wants them to do. Why is it necessary for patients to like following their care plan?  

There are several methods to get a person to do what you want. However, unless the patient likes doing it, the patient-centered nature of the plan has lost something.  No one does anything for very long, unless he or she is positively rewarded for doing so. For example, if a provider threatens a non-adherent patient with being discharged from the practice, chances are he’ll do just enough to stay in the practice or not be truthful about his adherence. He might even go into a doctor shopping mode.  

Another problem with negative motivation (threatening), is that a patient who’s been bullied into doing something, will do just enough to get by. This explains why a lot of prescriptions get filled but are not taken (12.5%); or, patients start taking their medications but stop when symptoms subside or consequences are too negative (29.5%); or, prescriptions that never get filled in the first place (12%).


beating heart

Q: It’s important for patients to agree to do what the doctor wants them to do. But how do you get patients to continue their medication for months or even years?

Many clinicians strongly support the notion of common sense — the patient came to me for help, so it just makes sense that they will do what I tell them to do.  Others endorse patient education — if I teach them why they need to follow my treatment plan, they will do it.  And, another large contingent of clinicians have chosen motivational interviewing — if I can just motivate the patient to get over their ambivalence, they will do what I tell them to do.  Although, most clinicians can tell you why patients should take their medications as prescribed, nearly none of them can tell you why their patients choose to be non-adherent and usually become that way within the first two to three weeks or the first few months of starting a new treatment plan.   

Q: So, which is most effective?

While each of these methods have been around for decades, from a behavioral perspective, the correct answer is none of the above.  There are specific applied behavioral laws that clinicians need to know in order to explain patient behavior and non-adherence.

Over a hundred years ago, Edward Thorndike stated, ‘…Pleasing outcomes of a behavior are more likely to occur than outcomes that are unpleasant’.  His ideas started the concepts that positive consequences, that happen immediately after a behavior, will cause that behavior to continue to occur, while negative consequences are more likely to decrease that behavior from happening again.

When you think about taking medications, there is very little that is pleasing about swallowing pills or giving yourself a shot every day, whether for a short time or long-term.  The “pleasing outcome” consequence of this behavior is often not perceived by the patient or it may not happen for years into the future to reduced risk or prolong life. The negative aspects of pill-taking (such as swallowing, inconvenience, cost, side-effects, etc.) will cause a decrease in the behavior until the negative consequences cease or they are overcome with something that has an equal or greater positive impact.

Common sense approaches believe that a patient’s interest in self-preservation should be sufficient to ensure adherence.  Thousands of years of experience has shown that at least 50% of patients are not motivated enough to overcome something that has negative consequences or may have positive consequence but are decades into the future. 

Patient education and Teachback ensures that patients are exposed to information that clinicians believe to be important.  Decades of research on short-term memory and information retention, show that learning new information fades very rapidly if the information is not repeated and reinforced within 20 minutes, 4 hours and 24 hours, respectively.   Please keep in mind, patient education and Teachback are good tools for clinicians to keep in their toolkit, but these legacy approaches do not reinforce behaviors that are required hours, days, weeks, or months into the future nor do they focus on the creation of new adherence habits.

The most effective way to promote patient adherence is to analyze the negative consequence(s) that is causing non-adherence and develop a plan where behaviors can be measured and positively reinforced to build habits of adherence. This is Adherence Management (AdM Coaching™).


BEARS was founded in 2011, and is headquartered in Orlando, Florida, BEARS works globally with a diverse spectrum of clinicians. We help improve Patient Adherence worldwide by using positive, practical approaches grounded in the science of behavior and designed to ensure plan of care persistence. BEARS supports its clients in improving their MIPS adherence improvement strategy execution while fostering patient engagement and positive accountability at the patient-facing levels of their health services organization.  Please click here to become a Certified AdM Coach!

Adherence Management: More Questions and Answers

Dr. Bob Wright

An Interview with Dr. Bob Wright (continued)

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®.

We are back with Dr. Bob Wright in our Q and A sessions about Adherence Management.  We’ll start where we ended last time with a question about the differences between outcomes and consequences.

Q: You had mentioned in a previous conversation that there are four pairs or elements of consequences common to every behavior.  And, each type has two extremes.  Can you talk a little more about these elements?

Sure. We already discussed the first pair of elements in our previous session, positive vs. negative. This element is called the “Type” of consequence. This determines whether the behavior is strengthened and will occur again because the patient experienced something positive. Or, the behavior is weakened and will likely not occur again because the experience was negative. 

The other elements of all consequences are “Timing,” (the consequence is immediate or future); “Probability,” (the consequence is certain or uncertain to occur); and “Perception,” (the patient is aware or not aware that the consequence is happening.)

Q: Can you give me an example so our readers can quickly see what you are talking about? 

Let’s look at a 38-year-old, diabetic, male who was just discharged from the hospital for congestive heart failure, pulmonary hypertension and COPD.  His medication list may include albuterol as needed, baclofen 3 times a day, Lovenox injections twice a day, Lasix twice a day, Singulair and Coumadin at bedtime. 

From the physician’s perspective, this plan of care is positive and will lead to immediate and sustained improvement of the patient’s health and well-being. The physician is very aware of how effective this plan will be.  So, from the physician’s point of view, this plan is an all-around PICA consequence (positive, immediate, certain and aware.)

However, from the patient’s perspective, the medication schedule is very intrusive (NICA), the possibility of side-effects is very high (NFUA), and the cost of the medications could be several hundred dollars a month (NICA).  In addition, many of the medications work quietly in the background to prevent future symptoms, but the patient is not aware that they are working (PFUN).  These are mostly negative consequences in terms of convenience, cost and side effects; and, the only positive consequence is something that the patient is not aware of and is uncertain to happen sometime in the future. 

The Consequence Analysis© affords the patient and the AdM Coach the opportunity to evaluate these potential issues and determine ways to either avoid them (by modifying the plan of care) or pushing through these obstacles (with positive reinforcement.)

Q: Can you give me your thoughts on “Perceptions?”  Aware and not aware don’t sound like behaviors to me.

Thank you for pointing that out.  Our perception of a consequence lets us know that something happened or did not happen.  For example, when a patient uses a rescue inhaler, he or she experiences a positive, immediate, and certain outcome or consequence – they can breathe again.  That outcome is referred to as a “PIC.”  The fourth element, “Perception,” deals with whether the user is aware of the consequence or not.  In this case, immediate relief and the ability to breathe normally is very real to the patient.  This outcome is known as a “PICA.” 

Another example is burning your hand on a hot stove. It is negative, immediate, and certain, and you are aware of the pain (NICA). 

Sunburns, on the other hand, are negative, future, uncertain, and people are not aware that the burn is occurring at the time they are enjoying a day at the beach.  This consequence is known as “NFUN.” The sunburn may have negative effects (such as pain or skin cancer), but those effects are in sometime in the future; they may or may not happen; and, the person is not aware that the sunburn is happening, at the time of the behavior.

Many medications, particularly medications for chronic diseases, have consequences that are positive, future, certain but patients are not immediately aware of the benefit (PFCN.)   Consequences that are positive, immediate, certain, and perceived (PICA), will almost always lead to behavior habit development. However, when consequences are NICA or the patient is not aware of the consequence, behaviors will be put on extinction.

Q: So, what you are saying is many medications, taken for chronic illness, may be beneficial, but because, from the patient’s perspective, they are not aware of anything happening and what is happening may actually be causing negative consequences, they stop taking the medications

That’s correct.  All behaviors follow a set of well documented laws.  Any behavior that is not reinforced will eventually stop.  The negative consequences of chronic diseases are often many years into the future.  Also, the clinical positive outcomes of taking chronic medications may also be years away. Future and uncertain consequences are very hard to overcome without some sort of positive reinforcement.

Many times, the day-to-day aspects of pill-taking can often be punishing. And, that punishment happens immediately upon taking the pills.  Another law of behavior is that a punishing consequence will stop behavior.  Any time a consequence is negative, immediate, certain and aware (NICA), you can guarantee it will overwhelm a consequence that is positive, future, uncertain and not aware (PFUN).   

Thank you, Dr. Wright.  That’s all the time we have for today.  Join us next time for Q and A with Dr. Bob Wright.

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. 


Holding Patients Accountable™…

new car oil change
new car oil change

When you purchase a new car, you are told to have the oil changed every 3500 miles to keep the engine running smoothly. You are even given some incentives (antecedents) such as “First Oil Change Free,” or “Lifetime Oil Changes!”  However, it is still your responsibility to schedule, bring your car in, and have your car serviced.

How absurd would it be to penalize the dealership for your failure to get your oil change?

If we were to perform a consequence analysis on an oil change from the car owner’s perspective, we find some very interesting stuff…

First, there are four different behaviors:

No Oil Change Ever Buys Oil, but does not change Oil Gets First Oil Change, but no future Oil Changes Gets Regular Oil Changes as directed
There are many antecedents
that sets the stage
for or against
an oil change:
Behavior Alternatives: Consequences:
  • incentives
  • warranties
  • extended life of car
  • warning lights
  • owners manual
  • oil sticker
  • burning oil smell
  • engine knocking
  • cost of oil change
  • future cost of engine repairs
  • time
  • Regular Oil Changes
  • —————
  • Sporadic or No Oil Changes
  • Longer car life (PFCA)
  • Dependable Vehicle (PICA)
  • Increased Oil Cost (NICA)
  • Time to get Oil Change (NICA)
  • —————
  • Lose Vehicle (NFUA)
  • Time for engine repairs (NFUA)
  • Cost for new engine (NFUA)
  • No cost for Oil (when no oil change)(PICA)
  • No time (when no oil change)(PICA)

As shown in the table, there are several positive, immediate, certain, and aware of the consequences for NOT changing your oil on a regular basis and several negative, immediate, certain, and aware of consequences for changing your oil regularly. In the immediate, there is no cost of time or money by NOT getting the oil change. The possible negative consequences are all in the future and they are not certain to happen.

However, getting a regular oil change has negative, immediate, certain, and aware of consequences, including time and money, but the benefits are all in the future. What would prompt an owner to get regular oil changes?

From a responsibility and accountability standpoint, if the owner wants to maintain the car in good working condition for a long period of time, then regular oil changes are a necessity. It is the owners responsibility to perform the behavior. Should we penalize the mechanics, the dealerships, the manufacturers, or other car owners for the behavioral choice of this owner to NOT get an oil change? Absolutely not!

But, this is exactly what is happening in health services. The person most responsible for the outcome of their own health, is not held accountable for the behaviors necessary to achieve those outcomes. Furthermore, the providers, hospitals, and fellow tax payers are all penalized (using withholds or higher premiums), for the behavioral choices of patients who do not follow their plan of care.


BEARS AdM Coaches identify “At-Risk” non-adherent patients, help those patients identify the negative consequence in a plan of care and then, develops an Adherence Improvement Plan to positively reinforce the right choices that produce improved outcomes. Let us help you, help your patients make the right choice!

Joint Responsibility?

What is the duty of the provider after the diagnosis or discharge?

It all started, when…

According to the Centers for Medicare and Medicaid (CMS), transitional care is a joint responsibility.  However, “joint” was defined by CMS in a sentence, “Improving readmission rates is the joint responsibility of hospitals and clinicians.”  

A 2008 CMS contracted report[1] went on to add, “Measuring readmission will create incentives to invest in interventions to improve hospital care, better assess the readiness of patients for discharge and facilitate transitions to outpatient status.”   In a universe that strongly supports the notion of “patient centeredness,”  it appears the patient was left out of the equation and the focus of preventing unplanned readmissions fell squarely on hospitals and community based providers.

In Appendix 5 of this report to CMS, Krumholz, et. al. described 189 contributing conditions (CC) with potential complications to the index admission.  What is not discussed, or even mentioned, is the patient’s responsibility to follow their plan of care and specifically take medications as prescribed. The words “adherence” and/or “nonadherence” were nowhere to be found in this research article.  It appears the focus was to see where failure to treat, educate, and transition patients properly, contributed to unplanned readmissions.  The idea that patients contribute to their own readmission, through choosing to not follow their plan of care, was not even considered in this seminal research.

Many of the penalty elements in the 2010 Affordable Care Act and now, MACRA and MIPS, were based on this document.  However, the CMS system is hurling over itself at improving hospital and provider quality without considering the impact the patient’s behavior has on outcomes.

In a series called, “What MIPS can do for you?”, we will look at several of the Clinical Practice Improvement Activities (cp_IA) that CMS will be monitoring in both primary practice and hospital settings. Providers will see the over 200+ Quality Payments (QP), and 94+ Improvement Activities (cp_IA).

[1] Krumholz, H, et al, 2008, Hospital 30-Day Heart Failure Readmission Methodology, Harvard Medical School, Department of Health Policy. Download full text here: Baseline info on Readmissions: Krumholz


Common Sense + Plan Of Care + Patient Education = Outcomes divided by 1/2 the Patient Population

For thousands of years, up to the present time, we have depended upon the notion that providing patients with an appropriate plan of care and some basic instructions on how and why to follow that plan of care, is sufficient to change a lifetime of behaviors and habits.

The assumed net result is that patients who “could” get better “would” get better.  After all, it is only common sense that patients would follow the advice of their physicians or mid-level providers after seeking them out. Right?

Here’s the reality of common sense.  We all enjoy using the phrase. Not because it makes common sense, but because it readily tells others they are not as smart as we are unless they think, feel, believe and do as we do. 

Common sense only makes common sense to those who have things in common with the people advocating the use of common sense approaches. 

In fact, if “something” did have common sense, then everyone would do it.  The point that not everyone understands that “something” makes common sense, is a strong indicator that it lacks commonality. 

Aristotle pointed out that we all have senses in common.  Pain is a common event as are touch, smell, taste, hearing and seeing.  Regardless of gender, nation of origin, religious beliefs or any of ten dozen cultural beliefs, cold is cold, hot is hot and falling off high places is not healthy. 

So, if doing what the doctor tells the patient to do is NOT a matter of common sense, then what is it?  Unfortunately, more than 50% of all patients choose not to follow their plan of care (using the common definition then, they have no common sense) and the outcome is certainly not what the doctor ordered.

Perhaps, it is a lack of understanding about the disease on the part of the patient and things the patient can do (behaviors) to improve their health?  Patient education has long been the gold standard for ensuring patients learn about the myriad of things to rid themselves of a disease or move the inevitable a bit further down the road.

But, if the lack of doing is not understanding, then it must be ambivalence.  Motivational Interviewing can address the feelings of the patient to find out, why they feel they won’t follow the doctor’s plan of care.  “Contemplation” has certainly bolstered ambivalence through an abundance of websites and medical advice centers that almost always agree or maybe disagree with the provider’s recommendation.  Then, there are the non-traditional sites, which may completely disagree with the plan of care and even the diagnosis. Often the net result is what appears to be ambivalence.  Should I or shouldn’t I, do what my doctor recommends?  Ambivalence rarely is a function of thoughts, feelings, and beliefs, however. What is thought to be ambivalence, almost always reflects a punishing consequence that may be more than the patient is willing to endure.

The bottom line is: The old model of healthcare, CS+POC+PE equals an (O)utcome divided in half is no longer enough to fulfill our role as healthcare providers. 

CS + POC + PE = IO÷1/2: How Can We Improve the Outcome? Change the Formula to Include Adherence Management.

Behavior is What We Do! The need to define behavior may seem a little awkward, but most people use labels to describe behavior rather than defining the action steps of what behavior actually is.  Lazy, reluctant, ambivalent and so forth are merely labels often misrepresented to describe what a patient is doing when they fail to follow their plan of care. 

Without clear definitions of the behaviors, in terms of observable actions that we want our patients to do, we can’t begin to fix the problem. The most frequently cited “behaviors” related to non-adherence are “(I)nconvenience, (C)hoice, (E)xpenses, (I)llness, (F)orgetful, (S)ide effects, (A)ccepting and (D)istrust.”  ICE-IF-SAD.  But, even most of these well documented, non-adherence factors are not behaviors.

Forgetful is not a behavior!

“Choice” is the only behavior on this highly vetted list. Future choices are always determined by what happens before and after the desired behavior. 

“Inconvenience, Side effects and Expense are frequent “punishing consequences” of behavior.  What happens to a patient after they complete a behavior, which is one of the most reliable ways to determine if the behavior will occur again.

“Illness” is a pre-requisite or antecedent to seeking care.  Anything that comes before a behavior can influence whether the behavior actually occurs in the first place.  But what about the patient who may need care but lacks any symptoms (awareness)?  Do they choose not to seek care because nothing is pushing them to seek it out?  Once again, the lack of symptoms is an antecedent or a setting environment. 

Other patients may accept their illness as a divine act and they strongly believe nature will take the best course. Distrust is an increasing antecedent as more and more providers only see patients on an episodic basis. Anywhere along the episode of care, any number of detours can take place.  Distrust can also be a punishing consequence of providers taking a less-than-professional approach to care by using only punishers and penalties as a means to increase behavior. 

Forgetful is, more often than not, a reflection of choice.  Forgetful is not a behavior but a result of other consequences.  In other words, patients often tell their provider they simply forgot rather than say they don’t agree with the plan of care or the side effects are obnoxious or the cost of medications is more than they can afford.  For “chronically forgetful patients”, other than those with organic brain disease and disease related forgetting,  should be a signal to the provider to look further into the punishing aspects of their plan of care.

So Why Does Adherence Drop-off?

Looking at the McKesson chart, there is a common theme across many diagnoses. Pill-taking behavior decreases over time. This is just one observable, measurable, repeatable behaviors that Adherence Management Coaches monitor and reinforce, everyday.

medication adherence

In an age where providers are punished with withholds and quality report cards for the behavior of their patients, the reality that up to 20% of all discharged patients will be non-adherent within the first 30 days. In a reimbursement environment, where unplanned all-cause readmissions are punished with financial withholds, every discharge becomes a game of Russian roulette. 

Moreover, it is highly likely that CMS and third-party payers will extend the 30 day readmission requirements to 60 and then to 90 days.  By 90 days post-discharge, one in three patients who control diabetes, hypertension, or taking statins become non-adherent.  Russian roulette with one bullet and four empty chambers (20% readmission rate) may almost seem like a reasonable gamble. But, when compared with one bullet and two empty chambers, the risk is no longer acceptable.  Are providers willing to spin the cylinder hoping that the blank chamber always lands in front of the hammer?

The answer is painfully simple: People don’t perform behaviors with punishing consequences. People do perform behaviors that are reinforced.  Pill-taking is perhaps the least thrilling thing that any of us can do.  Pills cost money (punishing consequence), pills have side effects (punishing consequence), pills don’t appear to be working (distrust consequence), pills must be taken at varying intervals and fit into other activities of daily living (inconvenient punishing consequence).  

The AdM Solution

Assuming, as providers have done for decades, patients will do the right thing in terms of self-preservation, is exactly that, only an assumption.  There is very little evidence that Teachback and informational handouts are carried or remembered much beyond the doors of the clinic or hospital.  These findings are from numerous studies published in the AMA, CMS, HHS, Nursing journals, and more. Please, don’t take my word for it. Look It Up!  There is equally little evidence that overcoming “wrong-thinking” and ambivalence via motivational interviewing has been terribly effective over the past 35 years, especially within or much past the 30 day mark.  The fundamental realities are providers must:

  • First, identify at-risk patients.
  • Second, identify the consequences in the plan of care that are punishing to the patient and/or caregiver.
  • Third, implement an adherence improvement plan that focuses on changing the negative, punishing consequences into positive reinforcers and sufficiently reinforce the desired behaviors so they become habits.

Information packets or reading a plan of care to a patient as they are being discharged, may have been the standard for the past forty years.  But under provisions of the “Affordable Care Act” related to MACRA 2017 and MIPS, “Quality outcomes are going to take more work beyond hoping patients follow their plan of care.” 

Past performance is always the best indicator of future performance.  With that being a behavioral reality, are providers willing to place their bets on outcomes and reimbursements based on a 20th Century assumption that has been proven ineffective time and time again?  


The new formula for Positive Outcomes requires Identifying At-risk Patients + Plan Of Care + Identifying Negative Consequences in the Plan of Care + Developing an Adherence Improvement Plan + Reinforcing Target Behaviors

Anything less than this formula will result in outcomes that will be the same.  Common sense is removed because it does not exist. Patient education can still be used as part of the Adherence Improvement Plan, but it plays only a minor part in helping patients conquer the punishing consequences they need to overcome.

“Habit is habit, and not to be flung out the window by any man, but coaxed downstairs one step at a time.” Mark Twain provided a simple reality in the 19th Century.  Coaxing implies the necessity of positive reinforcement.  Each step must be reinforced and new habits, such as medication adherence, will take more than a prescription, a verbal or written plan of care, repeating back instructions to technicians and nurses and the belief that all patients will exercise “common sense.”

Nurses, nurse educators, social workers, patient advocates, nurse navigators and others on the home health and community health care team must understand the science of adherence management, if they are to apply the same level of support for the living (Adherence Management) as they do for the dying (hospice). 

Call us today! We are making our complete Adherence Management Training Program and Toolkit available to Early Adopters. Click Here for more details.

Forgetful… A Behavior or a Symptom?

Forgetful is not a Behavior!

Losing Control

“I kept trying to come up with new memory devices to improve her pill-taking, hoping that it was simple forgetfulness.”[1]  These were the thoughts of Dr. Michael Stein as he worried over the non-adherence of his HIV patient of three years, Beatriz.  One would think, that the patient education she received, regarding the results of not following her plan of care, (such as increased suffering and an early trip to the grave) might have improved Beatriz’s memory.  It did not.

[1] Stein, Michael, (2016) Losing Control, Harvard Business Review.

Simple forgetfulness is a function of choice, likely based on the consequences of following a care plan.  I am reminded of the inscription on the James Farley Post Office in New York City that reads, “Neither snow nor rain nor heat nor gloom of night stays these couriers from the swift completion of their appointed rounds.”  This inscription, which was not based on the US Postal Service, but rather the mounted couriers of Persia in 500 BC, showed that all things can be endured when the consequences of the behavior are positively reinforced. Is it possible to improve adherence so that patients let neither inconvenience, nor expense, nor illness, nor forgetfulness, nor side effects, nor distrust stay them from the appropriate implementation of their plan of care?

Nothing is forgotten more frequently than taking a pill or a handful of pills, day after day.  Every behavior has consequences.  Positively reinforced behaviors almost never end up in the pile of unfinished tasks at the end of the day?  To be sure, there are times when things are forgotten and then picked up at the next opportunity, as long as there is positive reinforcement. 

Care Plan Punishment

People avoid punishing consequences.  Whether they get something they don’t want (punishment) or avoid the loss of something (penalty) they already have and want, negative consequences are consequences that normal people avoid.  Patients, in particular, want to avoid negative consequences because their tolerance for negative consequences has been lowered by their illness. 

Few providers think of their care plans as punishing.  Punishment clearly violates the 2,400-year-old Hippocratic admonition to, “first, do no harm.”  From the provider’s perspective, care plans offer only positives.  By definition, harm refers to injury or damage, and is easily overlooked when the pharmacopoeia describes treatment as improving, reducing or stopping harm.  At the same time, all providers are aware that many medications have side effects.  Some medication therapies, once started, will be a lifelong commitment to a daily regimen of care.  Side effects, lifelong and daily regimens, from the patient’s perspective, are all punishing.   

Journals are full of articles listing the value of being “patient centered.” The 2010 National Healthcare Disparities Report stated there is a need, “To provide all patients with the best possible care, providers must be able to understand patients’ health care needs and preferences and communicate clearly with patients about their care.”

Today, it is not enough to know that your patients are non-adherent.  We need to know why they are non-adherent.  How can we possibly address this behavioral issue when we don’t know where the problem lies?  BEARS offers assessment and analysis tools that can be easily used with your  patients to assist you in looking at the “punishers” from the patient’s perspective. 

Beatriz: This is What You Need to Do… Show Me Where You Can’t or Won’t Do It!

Patient centeredness goes beyond just doing the right thing for your patient.  It goes beyond providing educational materials.  It includes identifying the things that your patients are likely and not likely to do.  Everything we ask our patients to do will have Positive and Negative consequences.  In addition, the consequences can be either Immediate or Future, Certain or Uncertain, and your patient may be either Aware or Not Aware of the Consequences.  Going through the care plan with the patient, using the BEARS Consequence Analysis, is the most practical and patient centered way to achieve adherence and persistence.  There is power in consequences.  Consequences that are Positive, Immediate, Certain and the patient is Aware of the event are highly likely to improve or continue adherence.  Conversely, Negative, Immediate, Certain and Aware of the consequences will stop adherence.  

Forgetfulness is a Symptom of Consequences.

Beatriz’s admission that she was missing pills was reasserted every three months.  “I forget.  I don’t keep them with me,” she said.  I warned her at every visit that forgetting to take her pills, two or three days a week, would get her in trouble…”  Dr. Stein wrote, “I needed her to be perfect with her pills.” 

The only way for providers to ensure adherence is to identify the consequences that are punishing to adherent behavior.  Consequences come in many forms. These can be divided into manageable categories.  ICE-IF-SAD is a good mnemonic to remember the key factors: Inconvenience, Choice, Expense, Illness, Forgetful, Side Effects, Accepting and Distrust. 

However, only Choice is the linchpin in this formula because choice is a function of convenience, expense, illness, side effects, acceptance and distrust.  The patient chooses to take or not take the medications because of the consequences.  Forgetful is a passive symptom of choice.  Perhaps your patient forgot to take his or her medicines because the cost was too great or the side effects too many.  Knowing why your patient chooses to forget or chooses to not fill the prescription is taking the correct step towards making your plan of care more “patient centered.” 

Forgetful is not a behavior.  Dr. Ogden Lindsley famously created the ‘dead man’ test saying that if a dead man can do something perfectly, it is not a behavior.  A dead man can be forgetful, but a dead man cannot make a choice!

Following the Plan of Care… It’s their Choice!

“No man ever does a duty for duty’s sake but only for the sake of the satisfaction he personally gets out of doing the duty…”  Mark Twain

Once patients make a health care decision, is the die really cast? Tens of thousands of articles and research papers, written over a millennia or two, describe the paradox created by people seeking the advice of healers. Half choose to ignore their plan of care. It is choice, that ultimate decision by the patient, that determines whether or not he or she will follow your carefully crafted plan of care. The numbers tell us that, if you see 32 patients today, 16 will make the decision to do their own thing.

We label patient behavior with dozens of adjectives to help us understand why anyone with half a brain would not do as we direct.  It is, after all, their health, their body and their medical condition.  To make matters worse, the primary third party payer is now “incentivizing” providers to give better quality care by withholding earned revenue for unplanned readmissions within 30 days of discharge. What if the patient chooses to not follow their plan of care?  The question today is, what is the responsibility of providers to influence patient choice regarding their plan of care?  In 2015 the Centers for Medicare and Medicaid clearly stated that care beyond the walls of clinics and hospitals is a “joint” responsibility. How is that to be divided?  In a patient centered world, the patient holds the majority.  When he or she votes no, is it fair to hold the provider responsible?

Physicians and non-physician providers have a moral and legal responsibility to offer the highest quality service they are capable of.  It is their duty to do so.  On the other hand, patients are under no such obligation.  Following their care plan is most often subjective and based on “… the satisfaction he [the patient] personally gets out of doing…” what is necessary to achieve better health.  What if the patient gets no perceived benefit out of doing?  Choice is based on what patients believe will happen when the care plan is followed.  In acute care, patients often do experience a rapid improvement in their health and have some level of personal satisfaction.  The consequences of their behavior are positive, immediate, certain and they are aware of what the treatment did for them.  Chronic illnesses offer a completely different scenario.  The consequences are typically positive but the benefits, although certain, are in the future and the patient is unaware of anything happening.  There is little, if any, “satisfaction he personally gets out of doing the duty.”

Most writers on the subject describe “behavior” as the major cause of non-adherence.  Then they list any number of adjectives to support that notion.  Lazy, forgetful, cost, side effects, and so forth tell us why people don’t do as they should.  To aid my memory, I use the mnemonic “ICE-IF-SAD” to ensure I don’t leave off any “behaviors”.  Inconvenience – Choice – Expense – Illness – Forgetful – Side effects – Accepting – Distrust.

If “behavior is what a person does, not what he thinks, feels or believes,” choice is the only behavior on this list.  The rest of the words represent why patients don’t follow their plan of care.  Inconvenience, expense, and side effects are consequences that “punish” the patient for following their care plan.  Paraphrasing Twain, “No patient ever takes a pill or diets or exercises for the doctor’s sake, but only for the satisfaction (reinforcement) he personally gets out of following the plan.”  Paraphrasing Jerry Maguire (1996), “Show me the [reinforcers]!”

Where reinforcement flows, behavior goes.  When new habits are not reinforced, old reinforcing habits fill the gap.  When new habits are “punished” with costs, inconvenient schedules, and side effects, they have no chance to become the new normal.  The patient who is “forgetful”, in the absence of organic brain disease, has made a choice.  Telling you “I forgot” or “I keep leaving my medication at home” is saying that he or she is getting no satisfaction personally out of doing their duty to themselves.

Behaviors are always surrounded by antecedents or things that get the behavior started (prescriptions, diagnoses) and consequences.  Consequences are what happens following a behavior that either increases or decreases the likelihood that it will continue in the future.  Illness, Acceptance, and Distrust are not behaviors but rather antecedents.  Without the illness there is no need for treatment.  If, because of one’s deeply held beliefs, the course of the disease is the will of God, there may be no “call to action” or a resignation to let nature take its course.  Acceptance is an antecedent.  Distrust of the provider or health services system may have developed based on previous misadventures, real or perceived.  Distrust is then a consequence of previous experiences that becomes the antecedent for non-adherence with future illnesses. Ambivalence is a consequence and the mixed feelings are a result of previous direct or indirect experiences.  Ambivalence will always find its roots in inconvenience, expenses, side effects, acceptance and/or distrust.

For the 50% choosing to ignore or loosely follow your plan of care, adherence is never a roll of the dice.  It is most likely a set of consequences that either punished or failed to reinforce previous episodes of care.  Patient choices are more powerfully reinforced by the 8,759 hours they spend with family and friends than the 15 minutes they spend with you once every three months. Be thankful they sleep for 2,920 of those hours or non-adherence might be higher.  A provider’s understanding the science of behavior may not influence all of the non-adherent patients in your practice, but it will give you a better understanding to the question, “Why would anyone in their right mind not follow my plan of care?”  If you know that, you can begin to design and implement an Adherence Improvement Plan. Click to find out how!

BEARS In A Nutshell…

PROBLEM: Patient Non-Adherence / Hospital Readmissions

1 in 4 hospital patients will be discharged and get readmitted within 30 days of discharge.

This is costing taxpayers and insurance companies an estimated $41 billion per year.

We know from a variety of studies, completed over the last 25 years, that at least 50% of patients DO NOT DO WHAT THEIR DOCTOR TELLS THEM TO DO AFTER BEING DISCHARGED FROM THE HOSPITAL!

The Center for Medicare and Medicaid (CMS) thought the problem was SO BIG that it started penalizing HOSPITALS by as much as 4% this year, when hospital readmission rates are higher than the norm. Funny thing is, they are punishing the doctors for the behavior of the patient.

SOLUTION: So, what can we do about it?

Over the past five years, BEARS Therapy has developed evidence-based tools and training necessary to assist hospitals and care providers to positively reinforce their patients to be more adherent to their care plan and thereby reducing the amount of patients who are readmitted to the hospital.

First, our training teaches Adherence Management techniques to nurses, hospital staff, home health providers, and Occupational & Physical Therapists on how to shape behavior. Our tools, then, identify patients who are at HIGH RISK for non-adherence based on 22 characteristics that would affect their behavior.  Then, we look at the negative consequences of each discharge plan as it affects the patient (FROM THEIR PERSPECTIVE) to see where changes could be made or where positive reinforcement needs to be applied to mitigate any negatives THAT CANNOT BE CHANGED.

In addition, we provide these AdM Coaches (AS WE LIKE TO CALL THEM) an APP to give to their patients that will positively reinforce the new behaviors until they become habits. This APP will provide FEEDBACK to both the patient and the provider as to their progress to determine where adjustments need to be made.

The providers are also given a portal in order to manage these patients over the next 30 days (or more). The portal allows consistency and shared responsibility for the patient’s successful outcomes across all providers (hospital transition team, home health care, Primary Care Providers, pharmacies, OT/PT, etc.)


Our business model is simple: Hospitals, Health Groups, or Individuals pay a subscription which allows them access to a specific number of Adherence Management (AdM) coach training packages.  We provide access and integration into existing EHR systems of the tools to assess who is a HIGH RISK patient and training to develop an Adherence Improvement Plan.  We provide access to a portal to manage the patient’s progress and outcomes.  And, we provide an APP that will provide feedback and positive reinforcement to the patient to increase adherence and reduce the likelihood of readmission.


3251 Progress Drive
Orlando FL, US
Phone: 1 321-439-5949


Improving Patient Adherence

Improving Patient Adherence: Changing the Conversation!

Are we asking the right questions about hospital readmissions? Are care providers and ACOs performing the correct behaviors that will promote a positive change in their patients?

Included in this paper is a comparative analysis of tools and change packages currently in use in hospitals around the country to address patient adherence in order to reduce patient readmissions.  These tools include the LACE, Top Ten Checklist, Project BOOST 8P Screening Tool and the Transitional Care Model.

Adherence Management (AdM) is a behavior change package, intended for hospitals participating in the Hospital Engagement Network (HEN) 2.0 project led by the Centers for Medicare & Medicaid Services (CMS) and the Partnership for Patients (PFP), to be adopted as a tool to supplement the above by reducing unscheduled readmissions and improving care transitions.

Punishing providers for the patient’s decisions NOT to follow the plan of care may have a slight impact on readmissions because it forces providers to change behaviors rather than the patient, and the consequences of these provider behavior changes will most likely hover well below the expected 20% reduction.  If a sustained impact is to be developed, then the conversation needs to change

Reducing readmissions begins with changing the behavior of the patient and sustained behavior change requires the use of positive reinforcement.   As much as we would like to believe that education programs provide patients with the information they need to be successful, the results tell us quite the opposite.   

The content of this paper includes:

  • Part 1: Improving Outcomes Post Discharge
    • Table 1. Provides a quick overview of four programs currently in use for recognizing “at-risk” patients and transitioning them to some higher level of care at discharge.
    • Table 2. Offers three Primary Drivers essential in developing a post-discharge plan that can increase adherence to the plan of care.
    • Table 3. Provides an introduction to the Adherence Management or AdM Coaching process which begins at admission.
    • Table 4. A review of the AIMs, Primary, Secondary Drivers and Interventions that have been identified and shared throughout the Hospital Engagement Network. The greyed areas shows where AdM Coaching augments, replaces, or adds a specific intervention to achieve the desired drivers.
    • A detailed analysis of each of the primary drivers with interventions, tasks and measures.
  • Part 2: Looking at Human Behavior for Causative Factors
    • Behavior Basics: Bringing Out the Best in Patients
    • The Consequences of Behavior
  • Part 3: Who Owns the Behavior Change Area and What are You Going to Do About it?
  • Part 4: Consequence Management and the Adherence Improvement Plan
    • PDSA of The Consequence Analysis
  • Part 5: Measurement
    • Feedback
    • Reinforcement
  • Part 6: Conclusion and Next Steps
    • Change the Way You Work with Patients
    • No Formal Psychological Training
    • Improving the Likelihood for Success
  • Part 7: Appendices
    • I: AdM Process Map
    • III: Modified LACE Tool
    • IV: Transitional Care Model (TCM):
    • V: B-MAAS
    • VI: Project Boost
    • VII: B-PAAS
    • VIII: Consequence Analysis
    • IX: Adherence Improvement Plan
    • XI: The General Patient Care Team
  • Part 8: Graphics
  • Part 9: References


Click Here to order this White Paper


Hospital Readmissions: Processes, Outcomes and Buy-in

Series 1 Paper 3

What do weight-loss plans and process-improvement programs such as Six Sigma and “lean manufacturing” have in common? They typically start off well, generating excitement and great progress, but all too often fail to have a lasting impact as participants gradually lose motivation and fall back into old habits.[1]

Whether your facility is implementing Six Sigma to improve a patient service process or you are trying to reduce unplanned readmissions,  the common theme is human behavior?  Understanding the science behind why people do the things they do isn’t necessary, unless you want to make some lasting changes in their behavior.   Based on the sheer numbers of readmissions due to non-adherence, lasting change is not a bad idea.

[1] http://www.wsj.com/articles/SB10001424052748703298004574457471313938130

Behavior is the process of outcomes.

Outcomes are, “the way things turn out.”  There is always a consequence when a behavior occurs.  For most of our patients, the outcomes are out of sight and thus out of mind until the patient comes in for his or her annual or quarterly check up.  How much of an impact can you make on a person when you see them once or twice a year?  Perhaps, if they have a monthly visit, you may have a greater impact simply because you can reinforce your message more frequently. 

Outcomes are always based on the behavior of people.  As much as we might hope that we can “fix and forget” the patients we serve, the reality is people are created in a complex array of conditions.  So, vast amounts of resources and time have been spent looking at all of the complex factors that effect patient outcomes.

Read More…


Click to Download White Paper


Patient Adherence is not about “Process Improvement!”

Quality Management and other process improvement programs typically show early progress… and then things return to the way they were.

What do weight-loss plans, unplanned readmission reduction programs and medication adherence-improvement programs have in common?

They typically start off well, generating excitement, but all too often fail to have a lasting impact as patients receive less and less reinforcement and return to their old habits that provide years of positive reinforcement.

Quality Management and other process improvement programs typically show early progress… and then things return to the way they were.

What do weight-loss plans, unplanned readmission reduction programs and medication adherence-improvement programs have in common?

They typically start off well, generating excitement, but all too often fail to have a lasting impact as patients receive less and less reinforcement and return to their old habits that provide years of positive reinforcement.

Many health services providers have embraced Teachback, a patient education program which aims to teach patients the things they need to do to improve their clinical outcomes. But many of those agencies have come away less than happy. Recent studies, for example, suggest that nearly 50% of all patient education initiatives fail to yield the desired results.  The Hospital Engagement Network (HEN 1.0) targeted a 20% reduction in readmissions over the two years of that program.  They fell short of their goal by at least 15%.

Behavioral Education and Research Services, Inc. (BEARS) has studied patient adherence programs over the past five-year period to gain insight into how and why so many of them fail.

We found that when confronted with the increasing pressures of nursing shortages, increases in the number of patients in the system, the addition of new tasks over the already overworked nursing staff, and the myriad of over reasons, that over time, these programs react in much the same way as any behavior does when it is not achieving the desired results.  The cries for doing something becomes louder and longer.  There are calls for having all nurses trained and certified in Teachback, even though the data is less than convincing as to the efficacy once the patient has left the hospital.

A closer look at the characteristics of patient education and adherence improvement programs offers lessons for health services and clinical executives seeking to avoid unplanned readmissions within 30-days post discharge.

The discussion that follows is based on what happens at any hospital that has implemented numerous quality improvement projects.  On review they often find, less than two years later, that many have failed to generate lasting improvement.


  1. In the last two years, since the implementation of HEN 1.0 and the Partnership for Patients Program, has your organization achieved lasting gains from readmission reduction and adherence-improvement programs such as Teachback or Motivational Interviewing?
  2. Do you pay attention to your patients once they have been discharged?
  3. Are you involved enough with patient adherence and readmission prevention plan to judge for yourself whether your program is worth continuing?
  4. Have you tied patient education and adherence coaching performance appraisals to 30-day readmission reductions?
  5. Do you plan on having an Adherence Management professional or other applied behavioral improvement experts on your patient education and coaching staff for the long-term?
  6. Are you providing continued reinforcement and ongoing behavior-based follow-up for your community based providers and your patients?

If you answered no to any of these questions, you should understand how and why many patient readmission reduction programs will fail.

Patient Education and Teachback Phase

When a staff nurse starts his or her shift, they stretch to accommodate the increasing workload pressure. In much the same way, the nurses involved in patient education generally find themselves stretching and willing to tackle all necessary tasks in the early hours of their shift.  Admissions, medications, treatments, patient rounding, and an endless list consumes large chunks of time.  Then comes the discharge order and a myriad of tasks that have to be seamlessly shuffled into the “to do” card deck.  Discharge planning and Teachback begins when the transportation tech shows up with the wheelchair at 2:30 as the nurse is preparing for shift change.  A harried review of the discharge plan is provided and placed in the “Patient Belongings” bag along with the disposable emesis basin, water pitcher, and wash basin.  Whether the change of shift report is dictated or given verbally, it is presented and concluded with, “Mr. X was discharged.”

Too often, after the patient educator or nursing staff expert moves on to the next patient and top management turns it focus to another group of quality management programs, implementation patient education starts to wobble. Understanding where the stress and strains are offers managers an opportunity to avoid them.

C-Suite Support – The Common Themes

In the health services arena, a patient education quality improvement project typically began with the formation of a team consisting of members from various departments. A patient educator or other quality improvement expert is assigned to the team to guide and train them. At this stage, teams are excited to learn and apply what they were being taught.  The educator may be exposed to some cognitive behavior texts or workshops to improve their Motivational Interviewing knowledge.  Keep in mind, the goal is to change patient behavior post discharge.  Reducing ambivalence has not been shown to have a long-term measureable effect.

Team members collect data on their current patient population and, with the help of the patient education expert, identify the changes they most needed to make to achieve their stated goal—say, a reduction in unplanned readmissions or hospital acquired illnesses or injuries. The experts develop a “to do” list that included action items, responsibilities and deadlines and ensure needed resources are available.

Because top executives are paying close attention to the project at this stage, nurse managers made clear to staff nurses that the initiative for reducing unplanned readmissions was their top priority. For example, Teachback might become more important than rounding on assigned patients in a timely manner.

While time nurses spent in direct patient care slipped initially when the team transitioned to the new way of working, it improved when the nursing staff grew accustomed to the new process. When the team reached its goal—say it increased Teachback training by a certain percentage—the improvement project was declared a success.

The nursing director who was spearheading the hospital’s patient education initiatives shared the teams’ achievements with others in the hospital. Nursing team members were given rewards such as gift certificates to restaurants, and their pictures appeared in the hospital newsletter. The Chief Nursing Officer reported on the team’s success to the hospital’s other vice presidents and to its top executives.

Yielding Phase – A Crystal Ball Look

Unfortunately, the story doesn’t end there.

If staff nurses continue to be stretched, there will come a point when the nursing care yields as it struggles to support the increase in patient teaching demands. Though still intact, the nurse becomes disillusioned—stretched out, for example—as the demands between old requirements are continued or even increased and new ones added.

Similarly, in the middle stage of a quality improvement project—when the readmissions reduction expert moves on to another project and top management turns it focus to another group of cost saving or quality improvement programs—implementation starts to wobble, and nursing teams may find themselves struggling to maintain the gains they achieved early on. With increased demands on the patient education and transitional care team, the patient loses their objective advocate in the discharge process and readmissions return to their previous high rates.

Some transitional care team members will start spending too much time on their preferred quality improvement project, which will certainly affect their ability to meet other quality management objectives and other daily responsibilities.

When reporting on the status of their patient readmission reduction projects, teams may try to make themselves look better by highlighting what they hoped to accomplish in the future, instead of what they were accomplishing now. Some team members may become discouraged and start to doubt the benefits of the readmission reduction strategies.

The Quality Improvement Director, whose salary and bonus depends on the success of the hospital’s readmission reduction initiatives, will highlight projects that show great progress and ignore those that don’t. As a result, hospital executives will be unaware that some patient education/readmission reduction improvement teams are slowly starting to crack under the pressure. While transitional care teams at this stage continue to look for the flaws in their current working environments, they will get bogged down trying to perform any additional duties.

Failing Stage – What Might Happen

We have all seen stress tests on television where materials are stretched.  Over time, as stress is increased material begins to narrow, creating an area that becomes smaller and smaller until it is unable to sustain any more pressure. At that point, it breaks.

Similarly, when deploying a readmission reduction program with minimally behaviorally trained staff, team members become stretched thin of resources and find themselves unable or unwilling to learn the new tasks of modifying patient behavior. At this stage the reduction levels are not achieved and the effort is abandoned.

Team members become increasingly discouraged by their failure to achieve numbers developed by an outside source. They eventually stop caring about the readmission improvement project, partly because it wasn’t tied to their performance reviews nor was it positively reinforced and gains were not celebrated. As morale sags, no one steps forward to assume leadership of the readmission reduction improvement project. The team loses interest in looking for ways to improve their current work environment.

Hospitals may even allow newly formed “Try Me, This Might Work” quality improvement teams to poach people and resources from older, more established patient education and readmissions reduction/transitional care teams.  However, the only improvements made under these quality improvement efforts were those related to reducing patient harm—and even then, only the bare minimum was done because the efforts were focused on the processes and not on the individual patient or staff behavior.

Team members will steadily return to their old ways of working, and the group’s performance will return to its previous levels before the project began.  Past performance is always the best indicator of future performance.

As quality improvement projects fail, teams will report their achievements incorrectly, giving a false sense of success. Because assistant directors of nursing communicate only about projects that are showing excellent results, it will take several months for the CNO to become aware of the widespread failures and reluctantly inform the hospital’s top executives.

There is a Better Way!

Lessons Learned

Four lessons from our research stand out.

First, senior executives need to directly participate in Adherence Management/Patient Education/Readmission Reduction/Transitional Care projects, not just “support” them with the occasional wink and nod. Because it is in their best interest, directors in charge of quality improvement projects must observe firsthand the successes and failures of readmission reduction programs through objective data and feedback, rather than relying on someone else’s (CMS) after-the-facts interpretation.  Senior executives can make more accurate assessments as to the programs that are worth continuing. It is also, extremely counter-productive to penalize the provider, for the “Sins of the Patient.” The penalty “quality withholds” by CMS for high readmission rates do nothing to change the behavior of the patients who are being readmitted. It simply changes the behavior of the top management to find a better way to solve the problem.

Second, an Adherence Management (AdM) Coach is needed who can administer the Consequence Analysis™ to evaluate, from the patient’s perspective, the positive and negative consequences of the transition care/discharge plan, and who can developed the Adherence Improvement Plan™ that allows the transition team to prioritize the behavior based tasks that most affect the patient’s performance. Without the AdM Coach™ to manage and maintain the transition process (including the positive reinforcement and feedback from the patient’s behavior), some transition team members might begin pushing other agendas that benefit themselves and their departments rather than the patient. This makes it harder for the patient care team to agree on new directions and goals.

Also, the extended involvement of a trained Adherence Management (AdM) Master Coach is required if patient education and transitional care teams are to remain motivated, continue learning and maintain improvements in patient outcomes with the reduction of readmission rates. If the cost of assigning an Adherence Management Master Coach to each team on a full-time basis is prohibitive, one Master Coach should be assigned to several Adherence Management (AdM) coaches with basic training. Later, nurse managers could receive advanced training to take over the role of the Master Coach.

Third, performance appraisals of C-Suite down to the floor level providers need to be tied to successful implementation of readmission reduction and transitional care outcomes. Studies point out that positive reinforcers, even in small amounts, can motivate team members to embrace new and better work practices. Without such incentives, employees often regress to their old previously reinforced ways of working, once the initial enthusiasm for Adherence Improvement/Readmission Reduction/Transitional Care Management dies down.

Fourth, Improvement Teams should have no more than six to nine members who are trained as Adherence Management (AdM) Master Trainers per hospital. The timeline for training and launching an Adherence Management/Readmissions Reduction project should be no longer than four to six weeks. The bigger the team, the greater the chance team members will have competing interests and the harder it will be to agree on the aims and goals of the adherence mission. Adherence Management Master Coaches can move through a department, unit, or nursing division to teach nurses, nurse educators, pharmacy, and other members of the transition care team in the use of the Consequence Analysis™, Reinforcement Survey™, and Adherence Improvement Plan™.

Looking for the Unplanned Readmission Reduction Miracle

Understanding why most of our patients should follow their plan of care, for them, is not an “AHA!” moment.  Patients do not suddenly “see the light” following a Teachback session.  They just want to go home and resume their lives.  A fifteen to thirty minute Teachback session will almost never change the two or three or four decades of the patient’s self-injurious behaviors (e.g., smoking, over eating, etc.) which ARE positively reinforcing to them every time they light up or take a bite.

Following HEN 1.0, there was an almost universal cry from all of the HEN Partners and hospitals to require all nurses to “Be Certified in Teachback…  Every patient should have Teachback before discharge.”

I don’t disagree with this sentiment.  Universal Teachback alone, however, even if every nurse in America is certified, will not achieve the targeted 20% reduction in all-cause 30-day readmissions.  Behavior change, for both professionals and patients, takes training and time.  Providing Adherence Management Coach Certification will instruct direct-care professionals how to recognize “at-risk” patients, how to evaluate the negative consequences in the discharge plan of care, from the patient’s perspective, and how to develop and implement an Adherence Improvement Plan.  However, as with most hospital based patient education programs, if the Adherence Improvement Plan stops at the front door of the hospital, there may be some improvement in adherence, but as Dr. Ivar Lovass pointed out a half-century ago, “All behavior returns to baseline.”  New habit such as taking medications as prescribed, maintaining a salt restricted diet, exercise, etc., requires positive reinforcement as long as you want the new habit to continue.

We have to rethink the post-discharge period and what US lawmakers and the Center for Medicare and Medicaid meant when they wrote, “Improving readmission rates is the joint responsibility of hospitals and other clinicians…”  Changing patient behavior is the responsibility of health services professionals.  The most appropriate tool for doing that is a clear understanding of why people do the things they do and how to shape, reinforce and change behavior.  We do that through Adherence Management (AdM™) Coaches.

For more information on Adherence Management (AdM) Coach training programs, visit our website at www.bearstherapy.com or call 1-888-955-5591.

Communicating, Coordinating, and Collaborating

Series 1 Paper 2

In 2014, it was projected that some of Medicare’s Pioneer ACOs would transition from a shared savings/shared loss model to a completely “population-based payment.”[1]

This means they would bear the full brunt of the cost of an unnecessary readmission, not just a percentage. [2]

Each of the 22 systems shown in this graphic want to ultimately do two things: 1) Provide a correct diagnosis and 2) Offer an appropriate plan of care for the patient to follow.  Historically, we have been pretty good at accomplishing these two tasks.  On the other hand, adherence or patients reaching up and taking our advice, has at best, been a 50/50 proposition.  As time passes post diagnosis, the persistence rate often drops below 30%.  Correlation is not causation, but it is curious that there is a higher incidence of unscheduled readmissions for non-adherent patients than adherent patients.

A significant part of today’s literature focuses on describing how coordinating, collaborating, and communicating within and between our organizations and practices can improve outcomes related to hospital readmissions. There is also the increasing reality that providers are held financially accountable for the outcomes of their patients, even after they have been discharged.  Sufficient evidence exists in the CMS literature to support the reality that providers will be held jointly accountable for patient outcomes.  In the world of Respondeat Superior, that means ultimately the providers will be 100% accountable.  Coordinating, collaborating, and communicating with patients will take on an altogether different meaning as time passes.

In this paper, we explore why the missing part of the Coordinating, Collaborating, and Communicating argument is Consequences.


[1] Center for Medicare and Medicaid Innovation, “Pioneer Accountable Care Organization Model: General Fact Sheet,” Centers for Medicare and Medicaid Services, updated September 12, 2012, page 4, Baltimore.  http://innovations.cms.gov/Files/fact-sheet/Pioneer-ACO-General-Fact-Sheet.pdf

[2] Jordan Rau, “Medicare to penalize 2,217 hospitals for excess readmissions,” Kaiser Health News, August 13, 2012. http://www.kaiserhealthnews.org/Stories/2012/August/13/medicare-hospitals-readmissions-penalties.aspx



ACOs and Transitional Care

Series 1 Paper 1

“The researchers concluded that, although hospitals are being penalized for excessive readmission rates, the strategies that an individual hospital can implement to improve transitional care remain largely undefined.” This study was supported by AHRQ (Contract No. 290-07-10062). [1]

The most commonly used interventions included patient engagement, ranging from general patient education to more specific instruction on symptom management, and medication counseling. Other interventions included postdischarge outreach to patients by telephone and/or home visit. One of the strategies used by some hospitals, the Care Transitions Intervention, has been successfully implemented and evaluated in multiple patient populations and health care systems. A similar intervention, Project RED (Re-Engineered Discharge), has been implemented in a safety net system. Although these strategies are relatively intensive and probably require considerable resources, information on the cost of transitional care strategies was lacking.

As an Accountable Care Organization (ACO) and Transitional Care Team, we all see our roles as important. However, if the only approach to patient adherence you are using is Teachback, you won’t get very far.  If you are using Transitional Care in addition to Teachback, you won’t get far enough.  Long term habit change requires a clear understanding and the application of applied behavior science.  Adherence Management Coaching is an evidence-based tool for augmenting what you are doing and improving patient behavior.

This is the first in a series of White Papers looking at an applied behavioral approach to reducing readmissions by improving patient adherence.  Unlike traditional chess, adherence management is a readmissions reduction strategy in which the pieces are not competing to beat the other players on the board.  The competition is non-adherence and the complex nature of today’s health services system.  The competition is morbidity, mortality and financial unhealth to the providers.  Health care and patient adherence is more like the multi-dimensional chess board, introduced in Star Trek back in the 1980s, where the aspects of the playing field is the competition.

To Read More…

Click Button Below to Download this White Paper.

[1]  “Hospital-initiated transitional care interventions as a patient safety strategy,” by Stephanie Rennke, M.D., Oanh K. Nguyen, M.D., Marwa H. Shoeb, M.D., and others in the March 5, 2013, Annals of Internal Medicine 158(5) Part 2, pp. 433-440.



The Cost of Bad Medicine

We are currently in a time that third party payers and government agencies are looking for ways to reduce the cost of health services. One way to do that is to attack providers and state that “a lack of quality care is the cause for increased costs.”  There was great fanfare in 1995 when “To Err is Human” was published. Pundits pointed to the fact that somewhere between 48,000 and 95,000 people unnecessarily die each year in health services organizations due to provider negligence. So, Congress and the President acted.In response to this crisis, the Agency for Healthcare Research and Quality (AHRQ) developed and fielded TeamSTEPPS and has since created hundreds, if not thousands, of TeamSTEPPS Master Trainers.  Health services professionals recognized a problem and addressed it. Right?

The Cost of Non-Adherence

On the other side of the equation, however, are the people we serve. Thousands of articles and reports on patient non-compliance are available for all to read, but very little progress has been made because patient still do not follow their provider’s plan of care. Numerous new programs have been described in dozens of journals as barely making a dent in increasing compliance and yet there has not been the same focus coming out of the government.  Still, significantly more people are dying from not following their provider’s plan of care.Thousands of articles have been written stating that the word “compliance” appeared to be too harsh and patients were “non-compliant” because they were left out of the decision making process. “Adherence” they cried was a kinder, gentler term and so the word was changed. Clearly, and not to my surprise, the new and improved label has made no difference in the long term improvement of patient “compliance.”

Pinpoint the Problem First

I am reminded of the chicken farmer whose chickens had become ill. Without hesitating, he went to the local guru and made his case. The guru responded asking, “What are you feeding your chickens?” The farmer replied “cracked corn” and the guru recommended adding white wheat and barley. The farmer, satisfied with the recommendation went home and changed the food. Before long his chickens continued to become ill and more died. He returned to the guru and once again stated that his chickens were dying. “How do you give them water?” asked the guru. “I used galvanized troughs,” replied the farmer. Quickly the guru stated, “Copper. You must use copper troughs,” Once again the farmer returned to his farm and changed out the troughs to copper. After several more days more chickens had become ill and even more were dying. Completely beside himself, the farmer rushed back to the guru. “Oh guru, I have done what you asked and even more of my chickens are sick and dying.” “How do you have them living?” The guru asked. “In coops,” responded the farmer. “That is the problem. You need more his coops.” After a few more days, he noticed that all of his chickens had died. Completely frustrated he returned to guru. “All of my chickens have died,” he cried to the guru. “That is too bad,” responded the guru. “I had so many more solutions for you.”

Change the Name and You will See a Difference

Non-compliance has been around from the earliest days of medical practice. “Adherence, change the name to adherence and things will get better” the gurus cried out. They have not changed, we said. “Concordance, change the label to concordance and patient’s will follow their plan of care…” but they have not. “Empower them. Give patients autonomy in their decisions and adherence will improve.” Non-compliance and non-adherence, along with their British cousin ‘non-concordance,’ still hovers at 50%. Perhaps it is time that we step away from theories designed to improve the quality of processes and move towards the science of behavior to change behavior.

Empower the Patient and You Will See a Difference

Thousands of journal articles and programs focus on “Empowering the Patient.”  It is a term that has gathered momentum as a way of having the patient participate in their care decisions. Empowerment is defined as “…to enable or give authority to someone.” It has further been described in the following paragraph.

“The empowerment approach involves facilitating and supporting patients to reflect on their experience of living with diabetes. Self-reflection occurring in a relationship for laying the foundation for self-directed positive change in behavior, emotions, and/or attitudes. Such reflection often leads to their enhanced awareness and understanding of the consequences of their self-management decisions.”[i]

Pick the word or words that describe the behaviors that you want your patient to accomplish as a result of empowering him or her. I highlighted a number of words in the definition that may seem to reflect behavior. None of them do. The cognitive components are not without meaning or merit. The real question is what did you empower your patient to do?

You cannot give that which is not yours to give

You can only reinforce the behaviors necessary to achieve better health. People seek health care services based on the consequences of their particular medical problem. No providers empowered the person to make that decision. An illness reached a point that something needed to be done. Self-empowerment was in the person’s decision to seek care in the first place. Once that decision was made, we can identify and reinforce the behaviors necessary to develop new habits in support of the plan of care. None of the underlined words under empowerment is a behavior. Desired behaviors must be identified. Reinforcers that increase the likelihood of target behaviors must also be identified and used frequently. Reinforcers change behavior, not empowerment.

All of My Patients Are Adherent

For providers who may see 32 patient visits a day, it is highly likely that 16 or less of them will follow your plan of care. For the “worried-well,” that may not be much of a problem. For your more challenging “at-risk” patients, the best plan of care will still reflect on your practice’s lack of P for P, if it is not followed by the patient. You might see these patients for a total of 4 hours this year of the 8,760 hours we each have. After they leave your office, they will spend 1,960 hours with their friends at work. They’ll spend hours on the internet looking at their disease and recommended treatments and 3,836 hours with family and friends. Your time with them represents 0.0005% of their year. That is not a lot of empowerment time.In our next discussion, we will look at an evidence based way to identify your at-risk patients for behavioral intervention.

[i] Daniels, A. Bringing Out the Best in People, McGraw-Hill, New York, 2000.

Take this and call me in a week or two…

People, regardless of the era in which they live, have the well recognized behavior of not following their provider’s plan of care. Hippocrates warned his student, “Keep watch also on the faults of the patients, which often make them lie about the taking of things prescribed.”Whether the “faults of the patient” are described as non-compliance, non-adherence, or non-concordance is not important, although hundreds of papers and articles have been written concerning the virtue of using “adherence” over “compliance.” Labels are not behaviors and nothing is accomplished, relative to patient care, by debating which label best describes the problem. People are not following the plan of care and the end result is a significant increase in readmissions, morbidity and mortality.To date, no better definition of behavior has arisen more than the poet Emily Dickinson. She wrote, at least a century ahead of B.F. Skinner, that “Behavior is what a man does [or says]. It is not what he thinks, believes, or feels.” As you continue through this blog, it is important to keep this simple definition in mind. Other methods for combating non-adherence focus on feelings, beliefs, attitudes, ambivalence, and a number of internal or cognitive events.

Why Are Patients Non-Compliant?

I can understand why people in ancient Greece may have been reluctant to take some of the compounded medications of that era. Keep in mind, that every generation was “modern” in their time. In our modern time, major pharmaceutical agencies have pointed to “behavior” (see title chart above) as the most common cause for noncompliance. Take a closer look at each of the major categories described in this research (see chart below) by AstraZeneca and Frost and Sullivan. You will see that “behavior” represents only one of the eight categories described (or in my observation – mislabeled) as “behavior.”

ICE IF SAD is a mnemonic I created to help me remember the most common reasons people are non-compliant. While the above researchers suggested that these factors are “behaviors,” the reality is,  most of the reasons people do not follow the plan of care are related to events before (antecedents) or consequences following a medication taking behavior. Can you pick the one label that is a behavior?

One of the really inconvenient aspects of our language is that we use labels to frequently describe behavior. Patients are described as “non-compliant.” Keep in mind that not doing something is not a behavior. People are “forgetful” and forgetful is not a behavior. Describe what a person does when they are “forgetful.”  According to this study, 16% of the patient population don’t take their medications because “they forgot.” Describe the behaviors associated with “being forgetful”. Dr. Ogden Lindsley developed the dead man’s test (as we discussed in a previous blog) as a way to demonstrate whether an event was a behavior or not. “If a dead man can do ‘it’ perfectly… it is not a behavior.” A “dead man” has forgotten everything. Forgetting is therefore not a behavior.

Everything Related to Behavior is either an Antecedent or a Consequence

All behavior, things we say or do, are surrounded by cues or antecedents (things that come before the behavior) or consequences (things that follow the behavior thatincrease or decrease the behavior). In the next blog I’ll get into the ABC’s of behavior in more detail. The desired behavior in medication adherence is taking the right medication, at the right time, by the right person, via the right route, in the right dose. From our patient’s perspective, if the consequences of taking medication is punishing, you can count on non-compliance. In the coming blog “Following the ABCs of Behavior” we’ll review the consequences of behaviors with a tool that will help you look at your recommendations from the patient’s point of view.

Inconvenience, expense, and side effects are punishing consequences that can be easily managed by providers if they are aware that their patient is having some difficulty with them. Then there is accepting and distrust. Motivational Interviewing practitioners would most likely blend them together under the title “AMBIVALENCE.” The question is, “Is ambivalence an antecedent or a consequence to non-adherence?” For the answer, check back in the next blog.

If the goal of patient education is behavior change (e.g., taking medication as prescribed) then we need to focus on behavior. Motivational interviewing (MI) has animportant role to play in addressing ambivalence and addressing feelings and thoughts. When the interviewing is done patients are discharged back to theenvironment and reinforcers that got them admitted in the first place. The real question is “With who and how are you going to reinforce the new behaviors?” Thomas Edison once said, “There’s a better (BeTr) way… find it.”

Behavioral Education and Research Services, Inc. (BEARS) focuses on improving patient outcomes by training nurses and other health services professionals in Adherence Management (AdM) Coaching.

All Behavior Returns to Baseline If Not Reinforced!

In the next several weeks, I’ll be posting short articles related to improving patient behavior and following their provider’s plan of care.

Over the past half century, starting with Dr. Ivar Lovass and his study of children on the autism spectrum, researchers have been aware that behaviors will always return to baseline when they are not reinforced. A well done United Kingdom pharmacy study showed that the behavior of patients who were highly reinforced returned to their baseline once their reinforcement programs were withdrawn. In fact, the behaviors began to approach the same levels as patients who had received no training or reinforcement. Motivational Interviewing has shown similar results. These findings strongly support that schedules of reinforcement must be continued on “at-risk” patients even after 8 to 12 months of treatment.


The Lovass Loop is shown in Figure A. In 1965, Lovass worked with children on the autism spectrum. When his funding ran out, these children were all returned to their previous facilities. While he made excellent progress, you can see that all of them returned to baseline.

The UK Pharmaceutical study in 2012 (Figure B), presented patients with different opportunities to learn. The red lined group receive the greatest amount of training and reinforcement. After more than eight months, the enhanced reinforcement was removed and they began to return to baseline.

Figure C was a study done in Australia with business workers. No intentional reinforcers were used in the Masero-Lee study. This was simply a study of workplace behavior and productivity. There are two points of interest, however:

1. New employees were highly motivated early in their employment and then their productivity started a long decline to match other employee’s baselines. (Conclusion: when behavior is not reinforced, it moves to the mean.)

2. Equally important, as shown in the graph, is that the next three decreases in performance demonstrated that punishment or the threat of punishment returned below average behavior to baseline. This improvement was not long lived and it gravitated to the mean until punishment was again threatened.

Threats to “punish patients” (e.g., take your medicine or else) will prove just as ineffective. Dr. Aubrey Daniels suggests that we, “Change the baseline!” The only way to effectively do that is through the power of positive reinforcement. At a minimum, we need to provide some level of intermittent reinforcement, even when our patients have been on medication for an extended period of time.

The question is who is going to do that work? A second question is, “Which of my patients are the most at risk of non-adherence?” In our next post we will continue the journey into Adherence Management (AdM) Coaching… A Better Approach to Improving Patient Adherence when the Motivational Interview is over.

I’m never going to be just a nurse

Quite uncharacteristically, Miss Colorado, Kelley Johnson walked to her mark on the stage of the Miss America Pageant the evening of September 13th and the audience fell silent. There was no musical fanfare, no dancing shoes or instruments in her hands. A quick look around the stage revealed no Steinway grand piano waiting for fingers with a thousand hours of practice to rattle the keys. The only music to be heard had already passed through the tubing of the white stethoscope hanging around her neck. The rhythmic “lub-dup, lub-dup” of countless hearts. Her outfit was far from the one-of-a-kind evening gown, but was the daily evening wear of the 3.2 million nurses who pull on scrubs of every hue and shade. With no hesitation, she walked to her spot, paused briefly, reflected on her first words, and started.“Every nurse has a patient that reminds them why they became a nurse in the first place.” That was the one and only time in her almost two minute monologue that she used the word “patient.” As Miss Johnson was reaching the end of her reflection, “you are a person … first.” There is nothing magical about the term patient. It is a label and little more. Each was a person before they entered our clinical world and each is a person when they leave. We may heal their bodies, save their lives, and return to them the precious gift of time. We also need to change some of their habits or the efforts may be somewhat in vain.She spoke about Joe and her words fell on millions of ears around the world. Several times she repeated the phrase, “I am just a nurse.” Speaking for Joe, Kelley went on, “Although you say it all the time, you are not just a nurse, you are my nurse and you have changed my life because you have cared about me.”

“Can’t do versus won’t do”

Each year 125,000 hearts in the US cease to beat because people failed to follow their plan of care after discharge. Each will have died from any number of common diseases and disorders, but the death certificate will never state “non-adherence” as the cause of death. When questioned as to why they failed to follow their provider’s plan of care, there will be as many excuses or reasons as there are stars in the night sky. Who cares about the Joe’s, when they go home? Who does the follow-up after discharge that will maintain the fixes that were started in the hospital by a million Kelley Johnsons?The patient-centered world of nursing wraps around the patient during the average 4.8 day hospital stay. We have 115 hours with the person assigned to us to learn about his or her disease, complete the ever important nursing assessment, review and implement the doctor’s orders, and hustle them off to this test or that therapy.If the environment is quiet at night, we lose 38 hours as the patients sleep. We now have 77 hours to learn more about Joe and to begin to see what new skills and habits are required to change his life. Who makes the decision with the patient and their family whether the patient can’t do or won’t do the necessary behaviors to sustain a recovery effort? “Can’t do” is a training issue. “Won’t do” is a motivational issue. Both require behavior based interventions.

Nothing so needs reforming as other People’s habits – Mark Twain

Habits are stubborn things and replacing “old bad” with “new better” is well within the professional domain of nurses. Far too often, patient education is relegated to the last few hours on the final day of discharge. The tools of Teachback and Motivational Interviewing are pulled out by staff nurses and patient educators and while well-intended, the information is pretty much forgotten by the time the patient becomes a person and that means when they depart through the front door of the hospital. People trust the information provided by their nurse, but it becomes a sideshow to the main event of being discharged. In many instances, patient education is a book or pamphlet that is hastily reviewed as the transportation tech is standing in the door with a wheelchair. People return to the environment that contributed to their illness.The average face time with a primary care physician during an appointment is 8 to 10 minutes. It has been reported that the average time to smoke a cigarette is 7 minutes. A pack-a-day smoker will spend 140 minutes a day getting reinforced from their habit and less than 30 minutes a year with their physician getting negative reinforcement (e.g., “if you don’t quit smoking you are going to die).

Home is where the habit is

The familiar habits and reinforcers surround their very being and the 2 hours of patient education are overcome by 1,960 hours of counter teaching and reinforcement by colleagues at work. Add to that an additional 3,880 annual hours of time with family and friends and internet based second opinions. My father was a very young 2nd lieutenant at the conclusion of World War II. In fact, he was commissioned in the Quartermaster Corps at the age of 19. Barely a man and needing to look more mature, he took up smoking. I cannot remember a time in the 50s, 60s, and 70s that he did not have a cigarette in his hand. His nails were clubbed and yellowed from years of smoking. We all knew the cues for him to light up. A cup of coffee in the morning and a newspaper; a beer in the afternoon or early evening; walking outside; walking inside; sitting at his easel with a paintbrush or palate knife in one hand. The list was endless and the reinforcers; time with friends, time outside, time reflecting on his art, the nicotine fix, the local watering hole, and dozens of other reinforcers far too numerous to list. Dad was non-adherent to his plan of care and there was no one to advocate for a lifestyle change or someone to be “just a nurse” for his behavior change. In 1992, Dad died of emphysema at the age of 65.

Plan of Care Adherence – Another Challenge for Nurses

When it comes to trust, there is no other profession that tops nursing, according to a January 2015 Gallup poll. Since 1999, when nurses were first added to the survey, they have consistently held the top spot for honesty and ethical standards. In 2001, firefighters moved to the top spot but it took an act of war to make that shift.Medication non-adherence is the 4th leading cause of death in the US each year overall and is the leading cause of death if it is characterized as “accidental death.” If the health services industry is serious about changing “patient” behavior, then now is the time to be serious about teaching nurses how to be better educators through understanding and practicing the science of behavior. Adherence Management (AdM (pronounced ‘Adam’)) Coaching provides nurses, pharmacists, and therapists with a practical set of tools that will allow them to work individually and together as a combined services team to improve medication and plan of care adherence. Home health nurses and nurse advocates spend a great deal of time with their patients. AdM Coaching skills also provide these health services professionals with a much needed tool kit to determine the functions of behavior, identify reinforcers, evaluate and understand the consequences of behavior from the patient’s perspective, and establish a viable nursing care plan.

You will never be ‘just a nurse’

There is probably not a nurse in practice today who has not said, “I am just a nurse.” You can be an AdM Nurse and you can help save many of the 125,000 people who die each year because “you cared about” the thousands of Joes and Josephine’s who come into your world every day. AdM Nursing requires more time with patients, former patients and their families.