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 make 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 behavioral areas that Adherence Management Coaches monitor and reinforce, everyday.)

medication adherence

In an age where providers are punished for unplanned, all-cause readmissions with financial withholds and quality report cards based on the behaviors of their patients, the reality becomes that up to 20% of all discharged patients will be non-adherent within the first 30 days. 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?  

PO = IdARP + POC + IdNC + DAIP + RTB + MFB

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 + Monitoring and Feedback

Anything less than this new formula will result in outcomes that will remain 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 role 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 reinforcers.  Each step must be reinforced and new habits formed.  Behaviors such as medication adherence will take more than a prescription (antecedent), a verbal or written plan of care (antecedent), repeating back instructions to technicians and nurses (antecedent), and the belief that all patients will exercise “common sense.” Behaviors go where reinforcers flow.  In order to help patients become more adherent, become an AdM Coach!

Nurses, nurse educators, providers, social workers, patient advocates, nurse navigators and any others on the home health and community health care team, need to understand the science of adherence management, if they are to apply the same level of support for the living (Adherence Management) as they provide loving care and compassion 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.

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