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!