Motivate your patients to follow their treatment plan
Empower them to take charge of their own health
There's no doubt that chronically ill patients who have the best outcomes are those who adhere to their treatment plan and receive care that follows evidence-based clinical guidelines.
But case managers and other providers in all settings constantly struggle with how to motivate patients to follow their treatment plan.
"Everybody understands that people need to improve their adherence, but the person with absolute control over adherence is the individual patient. He or she can choose to go on a diet or take a pill or exercise or not," says Connie Commander, RN, CCM, ABDA, CPUR, owner and president of Commander's Premier Consulting Corp., and national president of the Case Management Society of America (CMSA).
The biggest challenge for Hudson Health Plan is getting members to take ownership of their own health care, says Margaret Leonard, MS, RN, FPN, CM, vice president of clinical services for the plan, which provides free or low-cost insurance for residents of New York's Hudson Valley.
"Many of our members don't feel empowered. They don't think it's up to them and expect an instant fix if they go to the doctor and get a prescription," she says.
Diet, exercise, and lifestyle changes usually don't happen unless there is someone to motivate the client to make the changes, Commander points out.
"Support is essential for the individual attempting a health behavior change," she adds.
In fact, in addition to ignoring the rest of their treatment plan, a significant number of individuals don't even get their prescription filled, she adds.
"About 12% of those patients who are given a prescription don't even get the prescription filled. Then about another 12% don't take it or don't take it the way they should. Then another 29% don't continue to take the medicine as directed. In the end, only about 47% of patients with chronic conditions take their medications like they are supposed to and continue taking it as directed," Commander says.
In addition, many people who are taking medicine for a chronic condition miss a day here and there because they forget, she adds.
The problem is compounded by the fact that many people are not motivated to make the lifestyle changes needed to keep their chronic condition from exacerbating.
For instance, members need to understand that diet does affect their diabetes and that it's something they can control, Leonard points out.
"With our population, we struggle with cultural barriers to good health care. For instance, Hispanic women feel that if they serve a healthy menu to the family, they're depriving the man in the household of his favorite foods. They don't know how to read the labels," she says.
The health plan has had success in educating the public by holding educational meetings in the community and bringing in a nutritionist to educate participants on the importance of a healthy diet, how to read the labels on food, how to shop for healthy food, and how diet can affect diabetes.
The plan offers incentives, usually a gift card from a department store or a food store, and transportation if necessary for people who attend the meetings.
"If we want to control health care dollars, we need to keep the majority of the population either disease-free or at least cut down on the number and severity of exacerbations, and that means that patients need to adhere with their treatment plans. Case managers are in an excellent position to help them do it," Commander says.
In an effort to guide case managers as they work with their clients, CMSA has developed the Case Management Adherence Guidelines (CMAG), a free on-line tool that case managers can use to evaluate their patients' knowledge and adherence, then use that information to educate the patients and motivate them to follow their treatment plan. CMSA is offering free seminars on using the guidelines at locations throughout the country.
"This data we collect using these guideline give us a perfect opportunity over the next years to demonstrate that managing an individual effectively will improve outcomes and will improve readmission rates, decrease complications and also help us demonstrate case management performance," Commander explains.
Hudson Health Plan is conducting a pilot project using the CMAG, along with a series of other studies to determine the best way to achieve the best outcomes in chronically ill patients.
The project began in May, and it's too soon for definitive outcomes, but the case managers who have used CMAG have found it helpful, according to Leonard.
"The guidelines have a way of posing questions that are not threatening. They're things we thought we knew how to do, but the questions are posed in a way that is helping us gain patient trust and get buy-in a little quicker," she says.
At the end of the conversation, the case manager and the patient have created a joint plan of care the patient has agreed to follow.
"The care plan is based on what they think they can do and not what we would like them to do," she says.
Hudson Health Plan is planning another study using CMAG, targeting members with diabetes who have comorbidities of coronary artery disease, and it plans to measure the outcomes to determine if hospitalizations and emergency department visits have decreased.
Hudson Health Plan uses a combination of member outreach and rewards and provider incentives and pay-for-performance to improve the outcomes among its members with chronic diseases.
The health plan is part of a statewide collaborative formed to improve care for people with asthma. Working with Columbia University, Hudson Health Plan is trying to determine which of four different approaches will be the most effective in keeping members' asthma under control by increasing adherence to the New York State Asthma Guidelines around the used of controller medications. Primary care providers have been randomized to one of four groups.
Members with asthma who are served by the first group of providers receive the usual and customary care and will serve as the control group. Members with asthma treated by physicians in the second group will receive only case management outreach.
The third group's physicians receive education from the health plan and reports on individual patients with suggestions on actions they should take. For instance, the report may alert the physician that a patient is not on controller medication but has filled his or her prescription for emergency medication several times.
Members in the fourth group of providers receive case management, and their physicians receive education and actionable reports from the health plan.
"In order for members to get the care they're supposed to get, case management outreach and provider education must work hand-in-hand," she says.
Incentives such as small gift cards seem to work best to motivate Hudson's Medicaid population, Leonard says.
For instance, the health plan developed a women's health incentive and offers a coupon for a manicure and pedicure for members who get a mammogram between Oct. 1 and Dec. 31.
The health plan sends members a mailing reminding them to get a mammogram, and offering the incentive. It also sends providers lists of members who have not had a mammogram, Pap smear or chlamydia screening.
The number of mammograms has significantly increased over the last two years, Leonard said.
"We don't know whether it's due to the incentives or a multitude of factors," she says.
The health plan's outreach program, which provides coaching and motivation on quitting for members who smoke, has resulted in 5% to 6% of smokers enrolling in a smoking cessation program and staying with it, compared with a 3% average success rate for smoking cessation in other similar health plans, Leonard says.
Commander offers other tips for helping patients comply with their treatment plan:
• Pace yourself when you work with patients. Don't give them an overload of information.
"Case managers should pace themselves when they work with patients. If they get that deer-in-the-headlights look, it's time to stop and consider a new way of explaining the situation," she says.
There's more of a challenge to telephonic case management because the case manager can't see if the patient still is engaged, Commander adds.
• Look for subtle clues that the person isn't interested today and follow up in a mutually agreed time frame, then remeasure and see if something has changed that might make him or her more adherent, she says.
"Someone might say no today but change their minds tomorrow. If you don't follow up, you might miss an opportunity," Commander says.
• Make sure that patients understands the treatment plan and what you are telling them. Explain it in plain, easy-to-understand language.
"If people have learning issues or communication issues, it impacts on adherence. Multiple diagnoses make it more difficult. One of the biggest mistakes case managers can make is to look at someone like the CEO of an organization and know how intelligent they are, and assume that you can give them medically technical information about their disease, using medical terminology and that they'll understand," Commander says.
There's no doubt that chronically ill patients who have the best outcomes are those who adhere to their treatment plan and receive care that follows evidence-based clinical guidelines.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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