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


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!

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