Discharge for Non-Compliance? The Shift to Patient Adherence

Ever wondered why patients miss their medication schedules despite clear instructions? Our enlightening conversation with Dr. Kate Jones reveals the critical shift from simply labeling patients as "non-compliant" to understanding the complexities behind "patient adherence." Discover how patient-centered care and shared decision-making can transform healthcare outcomes and why addressing social determinants of health (SDOH) is paramount for effective and realistic care plans.

Through a real-world case involving medication refills, we underscore the importance of thorough patient questioning. You'll hear how a nurse's persistence uncovered the true reasons behind missed refills and how practical solutions like pharmacy delivery services or mail-order options can prevent hospital readmissions. This segment highlights the value of taking extra time to identify and solve underlying issues, ultimately improving patient care.

Communication is the cornerstone of healthcare, and in our final segment, we discuss strategies to enhance patient interactions. Learn how using phrases like "tell me more" can foster a non-punitive, supportive environment and explore organizational techniques to encourage a culture of empathy and understanding. We also touch on the upcoming health equity standards from CHAP, emphasizing the need for continuous advancement in quality care. Join us for a thought-provoking episode that advocates for a more holistic and empathetic approach to healthcare.

Guide for Reducing Disparities in Readmissions
How Using the Term "Non-Compliant" Keeps Providers From Partnering With Patients

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Transcript

Jennifer Kennedy: 0:01

Greetings. I'm Jennifer Kennedy, the lead for Compliance and Quality at CHAP, and welcome to another special edition of CHAPcast. In this CHAP series, we are harnessing our board of directors' knowledge and experience to jump into insightful and meaningful discussions, and the essential goal of this series is to equip your organization with the insight and guidance needed to excel and push the boundaries of quality in a positive direction. So I hope you're going to enjoy this episode. Today we are talking about looking at discharge of non-compliant patients through the lens of social determinants of health, or SDOH. This is a really interesting concept to me and I guess I really hadn't thought about it before. I talked to our guest, kate, and it made me hearken back to my time at the bedside where I thought, you know, I guess I was thinking it was more of a one-way street. Remember, this is, you know, 30 years ago, where patient-centered care wasn't really developed and looked at in a meaningful way. It was here. We're coming out to see you, here we're developing a plan of care and you need to be compliant and if you're not, we're going to stop service with you. But we, I think, need to look at that whole concept of non-compliance in a different way with the discussion of health disparity and health equity being so prominent and upfront in the healthcare continuum as it is. Looking at discharge of noncompliant patients and linking it to SDOH is a really, really exciting concept when I think about it in my practice and my knowledge span. So, without further ado, I would like to introduce our guest today. Dr Kate Jones is a clinical professor emerita at the University of South Carolina and she joined the College of Nursing in January 2018 and directed the MSN Healthcare Leadership and the DNP Executive Healthcare Leadership Programs DNP Executive Healthcare Leadership Programs. Her area of clinical practice is home healthcare nursing, and she believes that health happens at home and values each person's participation in their healthcare decision-making. I share that completely, kate. Her areas of interest for scholarship are caring in nursing leadership practice and in the academic setting and the use of technology to support older adults in the community. She is presented at many local, national and international events focusing on the aspects of community-based care, and she has been a member of the CHAP Board of Directors since 2018. Welcome, kate, to CHAPcast. So glad to have you here.

Kate Jones: 3:52

Oh, Jennifer, thank you so much for inviting me and especially to talk about this topic. I think that it's a great follow-up to the discussion that you and Maricette had and kind of gets a little more in the details about those health inequities and social determinants of health and how we look at them really in the context of patient care.

Jennifer Kennedy: 4:13

I wholly believe you are right on the money with that, and you know I'm learning. I'm a student in the area of health disparity and health equity and I always learn something new when I speak with you, kate. So you know our discussion about a week ago talking about what we were going to frame in this chap cast was really an eyeener for me, and your framing or calling patient adherence versus noncompliance I think is brilliant. So I'd like to start there if we could.

Kate Jones: 4:53

Sure. So noncompliance is a term that is commonly used when a patient is not following their plan of care. You hear it all the time. You hear it at patient care conference, you hear it in hospitals, home health. You hear it in every clinical setting. The emergency room is a very common place where you hear the term noncompliance.

Jennifer Kennedy: 5:14

Right right.

Kate Jones: 5:15

But there are a lot of problems with the use of that terminology if we really think about it as clinicians. First of all, it attaches a negative label to the patient which is concerning. It feels like and I dare say it is a paternalistic judgment. You know, I told you to do something and you didn't do. It Feels very paternalistic and not very patient-centered. I believe it puts the patient and the healthcare worker at odds. It doesn't feel like you're working as a team to improve the patient's health status when one of you has the ability to tell the other what to do and then, when the person doesn't do it, you have the ability to label the person as non-compliant.

Jennifer Kennedy: 6:06

It really, I was going to say it really challenges that concept of shared decision making. You know, if you're not going to engage in shared decision making, then I don't think you can say we provide patient-centered care, Can you?

Kate Jones: 6:21

I don't think so, and so I actually think it's the opposite of patient-centered care.

Jennifer Kennedy: 6:26

Right.

Kate Jones: 6:26

So if you read the literature, there's quite a bit out there about the terminology of noncompliance and the alternative term, which is adherence. Now I will say that in many ways maybe adherence is not that much better, but addressing ineffective adherence to a plan of care, I do think comes across as less offensive than noncompliance, and so that's a good. First step is to shift your mindset from is this patient compliant with their plan of care to is this a plan of care that a patient can effectively adhere to.

Jennifer Kennedy: 7:10

So patients are supposed to be working with in our cases of community health, with your you know your hospice team, with your home healthcare team, to develop reasonable interventions on their plan of care and goals correct.

Kate Jones: 7:29

Exactly. So you know, whatever term is used, let's say, for sake of this discussion, we're going to use adherence. Figuring out why a person is having difficulty adhering to a plan of care is essential, and so, for just a second, I want to think about the definition you've said a few times, patient-centered care, which is at the core, should be at the core of what we do, and so the CMS definition of patient-centered care is health services delivered in a setting and a manner that is responsive to individuals, their goals, values and preferences, in a system that supports good provider-patient communication and empowers individuals receiving care and providers to make effective care plans together. So, with that definition, it really should change our thinking about use of the term noncompliance.

Jennifer Kennedy: 8:32

I like that. I like it a lot, and you did share a document with me from CMS that talked about SDOH and re-emissions and I was hoping that we could spend a few minutes talking about. You know some of the things that struck you from that document.

Kate Jones: 8:52

Absolutely so. Let's talk first about this idea of social determinants of health. So we want patients to have good outcomes right we do the patient does.

Kate Jones: 9:05

That's a bottom line goal for everyone, and there was an article actually in the American Journal of Preventive Medicine that says medical care only accounts for about 20% of health outcomes.

Kate Jones: 9:19

The other 80% falls under the umbrella of social determinants of health. I was staggered by that because if you think about, you know, the 80-20 rule, you might have thought it would have been the opposite for health outcomes, right Right, but it's not so. Let's talk about what falls under that umbrella. So health-related behaviors, socioeconomic factors, environmental factors, and then under that umbrella things like housing instability, food insecurity, transportation difficulty, exposure to interpersonal violence, and then there's health-related issues such as depression or other mental health conditions and person-related factors like health literacy or cultural beliefs or values. So when you look at that document that I hope we're going to be able to share with our listeners as well, it's a great resource from CMS that's a guide for reducing disparities in readmissions, and so the premise is that these social determinants of health that I just kind of outlined briefly are the drivers of readmissions in many cases, and we all know the cost of readmissions to the health care system. And no matter what setting we work in, we are concerned about and trying to prevent and decrease avoidable readmissions.

Jennifer Kennedy: 10:55

Yeah, it's a considerable cost to patients too. Right, they're on that churning treadmill, depending on what their disease is. We know that many chronic diseases, if we don't have a good post-acute, you know, home health care or whatever it may be will land the patient back into the hospital.

Kate Jones: 11:21

So that's exactly right. And so when you look at the best practices around preventing readmissions, many of them are things like you know make sure the patient fills their prescriptions, make sure the patient goes to their follow-up appointment. Make sure the patient you know say they're a heart failure patient. Make sure they weigh themselves daily and keep track of their weight. When each of those things don't happen, there's a reason for it, and the reasons are usually tied to either unmet social needs or some aspect of social determinants of health, rather than a patient just sitting there saying, well, I'm not going to do any of those things.

Jennifer Kennedy: 12:08

Yeah, now I'm thinking back on my time, you know, being a visiting pediatric nurse out in the District of Columbia, and I'm thinking, oh man, obviously this is in the late 80s, you didn't have all of this terminology and this advanced focus. But I thought going into somebody's home and taking your shoes off was enough if that was the request right, meeting them on their turf. But what I'm thinking is, you know you can do all the assessments you want in a hospital setting and ask them the questions. Hospital setting and ask them the questions. But once you get home, you get in that person's home and you know you get whatever you get on a discharge summary. You have to relook at those SDOH issues to really make sure that you're understanding the patient situation patient situation, absolutely.

Kate Jones: 13:12

You know I always, I've worked in home health for decades and I, while I appreciate and value what our colleagues in the acute care setting do, these social determinants of health are seen in the home setting. That's where they're real. You know you can do screening in the hospital, you can ask questions, but in the home setting, that's where they're real. You know you can do screening in the hospital, you can ask questions, but in the home health setting you see what's happening, you hear what's happening, you can talk to the patient in their environment and you have so many more clues and cues and ways to get to the root of what's happening than you do in the acute care setting. So we have a real advantage and I would call it a real opportunity to help our patients, to partner with our patients in terms of following the plan of care that they were given, you know, on a paper that they brought home from the hospital, right?

Jennifer Kennedy: 14:08

Yeah, absolutely. So. Let's say I was just going to say, you know, I think there is a huger importance more than ever of pulling that piece through from the acute to the non-acute or post-acute, rather of yeah, here's what we learned on this assessment. Great, I need all that information and it often doesn't make it to a discharge summary, right? So you know, I think, in order to, dare I say, better the continuum of care for that patient, we need to work together with the acute care providers to do a better job in getting as much information as possible to arm we, the clinicians, going out to do that admission and provide ongoing care in the home setting for patients.

Kate Jones: 15:05

That's absolutely true. I agree with that. I also think it gives home care clinicians home health care, home care hospice a greater degree of responsibility for addressing the issues that they see. So you know, what we identify as non-compliance might be due to any one of the factors that we've already talked about, and if that's the case, I think it's a responsibility to address it and to work with the patient to find a solution. I also think, though, that we have a responsibility to be aware of the potential for implicit bias when we label patients as noncompliant. So just from another study you know, with my academic background I don't want to give you any statistics that haven't appeared in academic journals so there's a study, a couple studies actually that have shown that Black patients are two and a half times more likely to have descriptors in their medical record such as non-compliant, difficult or challenging.

Jennifer Kennedy: 16:17

Yeah, that's interesting, isn't it? It really is, and really, you know, it's not too difficult to believe either what the outcome of that study would be. We have a lot of work to do, so, with that in mind, what can organizations do? Providers do?

Kate Jones: 16:37

So I have a couple thoughts about that, both at the organizational level, but at the individual clinician level too. So let's start with the individual clinician level, if that's okay. Yeah, let's go. So some suggestions for clinicians to use on home visits. So when you are in a patient's home and you observe ineffective adherence, you have a responsibility, as we've said, to do something about it and recognize that the problem might be due to unmet social needs. So I'm going to talk about two techniques that you can use, and the first one is the five whys.

Kate Jones: 17:17

This is a technique that we use to get to the root cause of a problem by asking why, until you have an answer. So, jennifer, I'm going to ask you to help me with this one. You be the nurse and I'll be the patient. Okay, all right. So you're the nurse, you're seeing a patient who has had a CHF exacerbation and during a med check on the home visit, you notice that the patient's prescription bottles for Corig and Lasix are empty and they should have been filled three days ago. So what conversation are you going to have with the patient?

Jennifer Kennedy: 17:56

Kate, can you tell me why your medicines weren't refilled?

Kate Jones: 18:02

My daughter was supposed to pick up my prescriptions.

Jennifer Kennedy: 18:06

So do you know why she didn't pick them up?

Kate Jones: 18:10

Jennifer, no, I haven't talked to her since Tuesday.

Jennifer Kennedy: 18:15

Why haven't you two had the chance to connect and talk?

Kate Jones: 18:20

Well, when I talked to her earlier in the week, she told me she was working double shifts this week and that she would be busy.

Jennifer Kennedy: 18:28

So do you think that's why she hasn't been able to pick up your medication refills?

Kate Jones: 18:36

Well, I suppose so. Okay. So thank you, Jennifer. You're welcome For playing with me. So, first of all, that only took four whys to get to what I think we can work with as a reason.

Jennifer Kennedy: 18:56

So let me ask you first, though, Jennifer, as the nurse, how did you feel about asking those questions? I actually felt okay, I think you know. Again, I have to put myself back in my old you know, nursing sneakers, because I never walked in the hospital, worked out in the community health, but I don't know if I would have went down past maybe three Ys, you know, because I have a caseload to see. I've got, you know, six visits to knock out in a day. I don't know if I would have taken the time to push down that far.

Kate Jones: 19:32

Yeah, that's a really good point. So this is a little bit of habit forming, where you don't just say, oh okay, your daughter didn't pick up your prescriptions. I put that in my note and that's all there is to it. Right, Think about your responsibility as a clinician to make sure that there's an effective plan of care that you and the patient have agreed to. So the solutions to the problem that you uncovered in the conversation really aren't that challenging. It's an unmet need that can be addressed. So, off the top of my head, there's three things that I think the nurse could talk to the patient about. First of all, can somebody else in the family run and pick up the prescriptions?

Kate Jones: 20:20

Maybe, that's a possibility, maybe it's not. Second, does the pharmacy deliver? Maybe that's the solution, maybe not. Second, does the pharmacy deliver? Maybe that's the solution, maybe not. Third, the person could consider switching all their meds to a mail-order pharmacy so that they'll have everything delivered regularly, and that would be one less thing for their daughter to do. So you know kind of taking the time to problem solve this issue. Let's think back to our discussion about readmissions. Right May prevent a readmission, which is better for the patient, better for the health care system. You won't end up having to do a readmission oasis. You know all those things. So there's a lot of reasons why to take that extra few minutes to get to the root cause and then to figure out to do some problem solving which nurses are great at.

Jennifer Kennedy: 21:15

Yeah, and I don't see it taking that much time. You know if folks listening out there are thinking, oh man, that's this is going to add 15 minutes, you know that I might not be able to have today. It may not take that long to get to sort of the crux of the issue. Plus, we're responsible, so take the 15 minutes to make sure that you know we have a plan of care that works both ways right.

Kate Jones: 21:46

Exactly. Now there is another technique that you can use, and this one is very simple and it's making the habit of using the phrase tell me more. So again, you're seeing a patient, you're there on a Friday, you're doing her med check and you notice, when you look at the pre-filled med boxes, that she took her meds on Monday, wednesday and so far she's taken her Friday morning meds, but the meds for Tuesday and Thursday are still in the box. And you ask her why? And she says I decided to just take them every other day so you could respond by, you know, scolding, by saying no, that's not okay, you have to take your medicines every day. Your response could be can you tell me more about that? It's an open-ended question that hopefully helps you get to the root cause. So in this case, the patient says well, they're so expensive, I want my prescriptions to last longer and I figured that every other day I would still be getting enough medicine. Wow, you learned a lot just by saying tell me more.

Jennifer Kennedy: 22:58

Yeah, that's a great tactic to use. I like it.

Kate Jones: 23:04

So now you have an opportunity, instead of scolding, to problem solve, right. So here's some options for this scenario. You can use help introduce the patient to good RX, or you know some option like that Checking to see if any of the meds that the patient is on have patient assistance programs, you know, seeing if there's generic equivalents, et cetera. So you've done a great job of figuring out why it's happening. Now let's figure out if there's a problem-solving solution that you can come up with that works for the patient. And again, it's a conversation you and the patient are having together. You know it's not you just saying, okay, well then, this is what we're going to do about that.

Jennifer Kennedy: 23:51

Yeah, and I think you're right about it being maybe a top skill, and perhaps the role playing within the organization is something that can be done to. You know, whether it be the nurse or, you know, social worker, what have you to get them more comfortable with digging down or getting to those five whys, as you mentioned?

Kate Jones: 24:18

Exactly. You can role play just the same way Jennifer and I did today. Only you can maybe even use real scenarios that come up. So let's talk about, at the organizational level, what can you do? So at patient care, conferences, idt, whatever. I think there are a couple of major changes you can make, and I would say that the first one is learning to stop using the word noncompliance. Just take it out of the vocabulary of the organization. That might be hard because we've all been saying it for a long time, right, but whenever it's said, can somebody on the team, anybody on the team, can just say stop, and maybe you even have a drawing of a stop sign that you can use and, you know, make it that obvious. Nope, that's not a word we use. So let's talk about what's going on. So that may sound a little, I don't know, challenging for some people, but I think that it's. I think it's a good way to hold each other accountable.

Jennifer Kennedy: 25:23

Absolutely, and it's it's sometimes. You know, having a visual along with the auditory learning is another way to sort of solidify what is being taught or what is being learned.

Kate Jones: 25:36

Exactly. And then another thing I would suggest is use that, tell me more technique, but use it in patient care conference. So now if someone has said that patient's not compliant Oops, I'm sorry, nope, I meant they're not adhering to the plan of care so then somebody maybe the clinical supervisor leading patient care conference can say tell me more about why the patient's having difficulty following the plan of care.

Kate Jones: 26:05

I like that yeah the patient's having difficulty following the plan of care. Well, if the clinician has already taken the time to dig a little, maybe they have an answer, maybe they don't just yet. So then the next step is determining the root cause, and if it's an unmet social need, or if it's depression or mental illness or health literacy, whatever it may be, once you figure that out, then you can problem solve. This is great.

Jennifer Kennedy: 26:30

This is going to make everyone, I think, better healthcare professionals, by sort of flipping the tables to a more positive approach than, as you mentioned earlier in our chat. You know, negative or punitive, rather.

Kate Jones: 26:51

Exactly. I hope that that's what happens as a result. I mean more people, the more people, I think, who really clinicians who get this idea in their head that, you know, non-compliance is not a term that we should be applying to our patients. I think, jennifer, we also are going to provide a link to another article for our listeners. That is from a nurse who wrote a really interesting article called how Using the Term Noncompliant Keeps Providers from Partnering with Patients, and it's got a lot of interesting thoughts in it that I think might be helpful as a little bit of follow-up on the discussion that you and I have had today.

Jennifer Kennedy: 27:36

We'll definitely make that document available as well as the CMS document, and we'll make sure both of those are available along with the podcast Perfect. Well, again, kate, I have learned so much during our exchange today. Do you have any wise thoughts for departure here?

Kate Jones: 27:57

Well, I think the wisest thought I can emphasize is check yourself when you use the word noncompliant. I hope that now you will think about some alternatives as well as some ways to do some problem solving.

Jennifer Kennedy: 28:12

That's great, and thank you again for partnering with us for this special series of CHAPcast. It's great to have you on, kate.

Kate Jones: 28:21

Absolutely. Thanks, Jennifer. I enjoyed talking with you today.

Jennifer Kennedy: 28:25

And I, you and just another heads up. You know we are talking about social determinants of health. Heads up that CHAP is in the process of developing health equity standards and they should be coming later this year, early next year. So be on the lookout for those. Be on the lookout for those and, with that, thanks to all of you for taking time out of your day to listen to our discussion about changing or flipping the language, or the tables, from noncompliance to adherence. It's been an exciting topic to explore and, from me and the entire CHOP staff, keep your quality needle moving forward, stay safe and well, and thanks for all you do, thank you.