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.

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?  

PO = IdARP + POC + IdNC + DAIP + RTB

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.

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!