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%).
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!