Helping Non-compliant Patients Overcome Barriers to Adherence

Non-compliant patients are among the stressors that can result in physician burnout.¹ The cause of noncompliance varies² from patient to patient, and often depends on the complexity of their situation and their ability to comply. Low patient activation, low health literacy, inability to pay for treatment, and behavioral health issues may all contribute to a patient’s failure to comply with treatment recommendations. Re-framing the issue–from dealing with challenging patients who willfully disregard medical advice to helping patients overcome barriers to adherence–may diminish the frustration associated with patient noncompliance that contributes to physician burnout.

Patient Activation Strategies to Improve Compliance

Patient activation refers to the patient’s motivation, knowledge, skills, and confidence to consistently maintain and improve their health and healthcare. It plays a major role in patient compliance. Consider the following strategies to assess and increase patient activation:

• Quantify patient motivation and ability to comply with treatment recommendations by using a measurement tool such as the Patient Activation Measure (PAM) or the Self-Efficacy for Managing Chronic Disease 6-item Scale.
• Educate patients about the role they play in disease management.
• Help patients identify their own concerns and challenges regarding treatment and self-care by using motivational interviewing techniques.
• Have staff meet with less activated patients prior to their appointment to help formulate questions for the clinician and after the appointment to discuss and review medications and other treatment recommendations.
• After obtaining the patient’s consent to do so, include family members in discussions and education.
• Propose treatment compliance improvements in small steps. Success is an important aspect of increasing activation level.

Health Literacy Strategies to Improve Compliance

If a patient cannot understand a physician’s instructions and recommendations, compliance with them is unlikely. Behavior may appear as willful noncompliance but may actually indicate that a patient is having difficulty comprehending what is expected of them. Consider the following strategies for assessing health literacy and increasing health information comprehension with a low health literacy patient:

• Learn to recognize low health literacy.
• Outline what is going to happen during the patient encounter.
  • Limit the information a patient receives in a given visit; for example, focus on three to five key points and repeat these points throughout the encounter.
• Use an active voice and avoid run-on sentences.
• Give specific directions and recommendations that focus on desired patient behavior.
  • When discussing self-care, demonstrate the skill, and then watch the patient perform the task to ensure comprehension.
  • Because patients understand and learn in different ways, supplement discussions with diagrams, models, pictures and demonstrations.
• Provide ample opportunities for patient to ask questions.
  • Ask Me 3 is National Patient Safety Foundation educational program intended to help patients better understand their health.
• Confirm comprehension by asking patients to repeat back instructions in their own words (aka teach-back method). The Always Use Teach-Back! Toolkit describes principles of plain language, teach-back, coaching, and system changes necessary to promote consistent use of teach-back and includes videos of clinicians using teach-back.
• Use plain language in patient documents and educational materials.

The AHRQ Health Literacy Universal Precautions Toolkit has additional useful tools to help practices increase their patients’ health literacy.

Medication Access Strategies to Improve Compliance

Patients may be noncompliant because they cannot afford the medications that you prescribe. Discussing drug cost in an empathetic and nonjudgmental way when prescribing the medication may reduce downstream frustration with patient noncompliance. Consider the following strategies:

• Learn how to recognize patients at risk, for example, patients with limited income, no insurance, high co-pays, or high deductibles; patients who have complained about the cost of medication; or patients who take multiple medications for chronic diseases.
• If you suspect or are informed that a medication will be financially prohibitive, help the patient obtain the medication at a lower cost.
  • Consider prescribing a generic version of a medication; or if no generic is available, a less-expensive brand name drug in the same medication family that would be equally effective; or, if the patient has a prescription drug plan, a “preferred” drug.
  • Be familiar with drug assistance programs.
  • Encourage the patient to comparison shop for the medications you prescribe by using medication price comparisons tools available on websites such as GoodRx, FamilyWize, and SingleCare.

References

1. Rosemarie Cannarella Lorenzetti, et al. “Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors.” American Family Physician, 2013 Mar 15; 87(6)419-425.

2. Dinah Wisenberg Brin. “Why Don’t Patients Follow Their Doctors’ Advice?” AAMC News, 1/16/2017.