Case Management Strategies for Assessing, Engaging PatientsIt’s no secret that many patients with chronic illness struggle to adhere to medical recommendations and treatment plans; the World Health Organization (WHO) has determined adherence to long-term therapy for chronic illnesses in developed countries is a meager 50 percent—and even lower in developing countries. What’s more, the WHO found, the impact of poor compliance is growing worldwide.
Poor compliance can lead to disease complications, avoidable exacerbations and frequent hospital admissions for patients, as well as increasing costs for health systems and the community. As families try to balance work and the responsibilities of being a caregiver, businesses lose highly productive and knowledgeable employees and patients face continued pain and suffering.
As a case manager, you play a central role in helping your patients or clients achieve better compliance and adherence to their care plans, which can lead to improved health, reduced hospitalizations, and stronger health systems.
Accurate Assessment Uncovers Barriers to Compliance
Patient compliance is influenced by several factors, each of which may present a barrier to the care manager and/or the patient. Case managers are in a unique position to help patients and the system break these barriers and solve problems that hinder compliance.
There is no single intervention, strategy or bundle of strategies that will be effective with all patients; interventions must be tailored to each person and each situation. That makes accurate assessment of both the situation and the factors that influence the patient’s ability to adhere to a healthcare plan a vital function of case management.
In Adherence to Long-Term Therapy: Evidence for Action, published in 2003, the WHO identified five categories influencing patient compliance with medical care plans:
- Social and economic factors
- Healthcare systems or teams
- Condition-related factors
- Therapy related to the disease
- Patient-related factors
To define this further, a separate team of researchers performed a literature search of the Medline database from 1970 to 2005, looking for research analyzing factors that impact patient compliance. The team found more than 2,000 studies, but only 102 that met their criteria for quality. From this review of the literature, they identified many factors contributing to therapeutic non-compliance.
This list of potential barriers included:
- Demographic factors such as age, ethnicity, gender, education, marriage status
- Psychosocial factors: beliefs, motivation, attitude
- Patient-prescriber relationship
- Health literacy
- Patient knowledge
- Physical difficulties
- Tobacco or alcohol intake
- History of compliance
- Treatment complexity
- Duration of treatment
- Medication side effects or taste
- Degree of behavioral change required
- Requirements for drug storage
- Lack of accessibility
- Long waiting time
- Difficulty getting prescriptions
- Unhappy clinic visits
- Inability to take time off work
- Cost and income
- Social support
- Disease symptoms
- Severity of the disease
Make Assessment an Ongoing Process
Because your client’s or patient’s illness and circumstances are not static, it’s important to continually revisit your assessment. In other words, while an initial assessment is a crucial first step to determine needs, ongoing assessments are necessary to determine if those needs have changed and to incorporate information patients may not have previously been willing to share.
As you work through an assessment process, focus your questions on the known barriers to compliance, ensuring you’ve covered each one likely to affect your patient. Don’t be surprised if another one or two show up later in your relationship—it’s likely your patient will talk about the most challenging obstacles first; the secondary and tertiary challenges may appear as you work through a care plan.
Patients who face social and economic factors may have trouble affording their medical treatments or medications. Some also struggle with homelessness or a lack of proficiency in the English language. However, it is not only the patient who may present a barrier to compliance; some healthcare providers may have poor communication skills or a poor bedside manner. A strong doctor-patient relationship is one key to improving compliance with healthcare plans.
In some instances, non-compliance may be tied to a specific health condition. In other words, if a patient no longer experiences symptoms of their condition they may stop taking their medication or if a patient suffers from behavioral or mental health issues, they may not understand how to engage in their health system and follow a care plan. It is not uncommon for patients who have high blood pressure or suffer from an infection to stop taking their medication once they begin to feel better.
Non-compliance may also be related to the specific regimen prescribed that disrupts the lifestyle of the patient—such as routine injections for diabetic patients or attending physical therapy following a stroke. In some instances, the patient may have no intention of addressing their health issues as they have a physical or psychological challenge preventing them from successfully following the doctor’s orders. If a patient is depressed and does not feel that treatment would help, it’s highly likely they won’t participate.
As you go through the assessment process with your patient, do so with an eye toward specific interventions that may work for your patients’ situation.
Keep Your Interventions S.I.M.P.L.E.
Although highly researched and addressed, the rates of non-compliance have not changed drastically in the last three decades. Case managers and healthcare providers play a unique role in improving patient behaviors, and research has shown that work can be enhanced using simple intervention categories remembered using the mnemonic, S.I.M.P.L.E.
Using original studies published in Medline from 1990 to 2002, researchers performed a qualitative synthesis and broke the studies into six broad categories based on the types of intervention used to address non-compliance. Complexity affects compliance, so the simpler the case manager can make an intervention, the higher the likelihood it may be completed. The following describes simple strategies and interventions for adaptation to your patient’s specific needs:
- Simplify the regimen. Simplifying the tasks your patient has to perform to manage their healthcare increases the potential they will be successful.
- Impart knowledge. Education is as important to compliance as location is to real estate. Provide your client or patient with written material about their illness, online or printed, that can be referenced later.
- Modify beliefs. Before you can modify your patients’ beliefs, it’s important to assess what they already know or believe to be true. Communication skills like motivational interviewing help you better assess needs and elicit information about what compels your client or patient to act.
- Patient/family communication. Use active listening skills and provide clear, direct messages to patients and families. When possible, communicate in writing so important information can be accessed later.
- Leave bias behind. Each of us have biases that impact the way we see the world. It’s important to identify those biases and understand how to work around them to achieve successful outcomes.
- Evaluate compliance. Revisit the care plan frequently to determine what is working and what needs to be changed. Valuable time is wasted when weeks pass before we realize the current plan of action has failed.
Effective Case Management Leads to Better Compliance
It’s important to remember compliance is a dynamic process requiring frequent follow-ups. If there is a discrepancy between a patient’s readiness to accept the healthcare plan and the provider’s attempt to initiate intervention, a failure in compliance is likely to follow. The end result is the patient suffers. Conversely, when case managers are successful in assessing and engaging patients, compliance improves, leading to better outcomes for the patient and the healthcare system.
Sabaté, E., & World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization.
Jin, J., Sklar, G. E., Min Sen Oh, V., & Chuen Li, S. (2008). Factors affecting therapeutic compliance: A review from the patient’s perspective. Therapeutics and clinical risk management, 4(1), 269-86.
Mathces, Tim, Jaschinski, T, Pieper, D. (2014) Adherence influencing factors—a systematic review of systematic reviews. Archives of Public Health
Atreja, A., Bellam, N., & Levy, S. R. (2005). Strategies to enhance patient adherence: making it simple. MedGenMed : Medscape general medicine, 7(1), 4.