There is no silver bullet answer to improving medication adherence and management in the outpatient setting. It requires a multi-faceted strategy that includes patient education, patient-clinician interaction, and patient engagement. Given the scarcity of time and clinical resources in many primary care clinics, improvement projects can easily become overwhelming in the face of high patient volumes and limited staff to implement them.
Rome was not built in a day. Moving patients to 100% adherence won’t happen in a day, either. Start with a few pragmatic steps and be consistent. Even if you don’t see immediate results. Success requires patient and staff behavior change, both of which take time.
Here are three areas to focus on, which I’ve chosen for their practical application and return on time invested.
1. Provide patients with fact sheets and tools
This sounds pedestrian, yet it’s something I don’t see done very well - if at all - in many primary care environments. Certainly pulling this information together takes time and effort on the part of clinicians and administrator. But the amount of time you’ll spend is minimal compared the educational and medication adherence improvement results you can achieve. And, you don’t have to start from nothing. There are loads of consumer-friendly information sheets available that can either be used or modified in your practice. Here are just a few examples:
- CardioSmart fact sheets, such as this one on Diuretics - CardioSmart is the patient education and empowerment initiative of the American College of Cardiology.org provides an array of easy to understand patient information tools.
- Agency for Healthcare Research and Quality’s How to Create a Pill Card for Your Patients.
- American Medical Association’s Medication Safety Checklist - which has excellent prompters for patients to have better conversations with their physicians.
- The Med List, developed by the Massachusetts Coalition for the Prevention of Medical Errors - includes prompters for prescribed and over-the-counter medications, as well as herbal, vitamin, or dietary supplements.
- AARP’s My Personal Medication Record - instructions and a downloadable form help patients keep track of their medications.
Use these materials as-is, or create customized tools that support your unique practice style. And direct staff to pull together a resource list of specific, medication related services in your area - such as statewide prescription assistance programs or safe places to dispose of expired medications.
After you’ve created the material, put a capable staff person in charge of making sure there are always enough copies for patients, and the information stays up to date. This person should also train existing and new employees about the importance of what the information is, why it’s important, and where they can find it if patients ask questions. It’s essential to have one person accountable for managing all of this. Without an owner, copies won’t get made and training won’t happen.
2. Get patients and families involved in the process
We know effective medication management leads to better adherence, and better adherence leads to better outcomes. But neither of these things will happen if clinicians are doing all the work. Patients and families must be involved in the process or, quite frankly, the chance of appropriate, long-term adherence will plummet.
When physicians and their clinical staff engage patients as collaborators in their own care, they feel empowered them to make better decisions for themselves. Medication management is no exception.
In conjunction with medication reconciliation, explain two or three key reasons that patients or family members should call the office when they have a concern about how a medicine makes them feel, or if they have questions about what they are taking. Reiterate this at every visit. Provide handouts such as AHRQ’s 20 Tips to Help Prevent Medical Errors. Put posters up. And as often as possible, don’t just hand patients fact sheets and other information - guide them through the material. This is why it’s so important to train the staff on the materials you provide. Everyone should be able to explain the basic use handouts and tools; not just physicians and nurses.
3. Fine-tune your patient conversations
Assessing adherence, like reconciling medications, requires a conversation. Given that a clinician’s time is limited during the patient encounter, it's essential to calibrate the conversation and focus on the right information.
Motivational Interviewing (MI) is a patient-centered, non-confrontational communications skill set that can effectively drive patient conversations about medication issues and adherence. Its four-step framework increases the potential for behavior change by stimulating a patient's own internal motivation for change.[1] In short, a clinician starts by talking openly about adherence issues in a non-judgmental environment, using empathy and listening techniques. Next, clinician and patient discuss the disconnects between the patient's goals and current behaviors, and the clinician refrains from arguing or advice giving. The clinician then collaborates with the patient to explore and resolve these discrepancies and guides them toward a readiness to change.
Another source for improving adherence conversations is the American Medical Association’s Steps Forward. The program distills adherence improvement education into eight steps, and provides material and guidance for physicians to implement them.
[1] Motivational Interviewing for Medication Adherence, Journal of the American Pharmacy Association, Jul-Aug 2015, Volume 55, Issue 4, Pages e354-e363, https://www.ncbi.nlm.nih.gov/pubmed/26161493
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