Confronting the Myth of the

“Non-Adherent” Patient:

How Overcoming Victim Blaming in Healthcare

Can Lead to Better Patient Outcomes

Kathleen Trujillo, LMSW

2

Introduction: A little about me…

Learning Objective 1: Understand the issues associated with the “non-compliant” label.

Learning Objective 2: Use specific assessment strategies to improve assessment.

Learning Objective 3: Understand how integrated healthcare teams can overcome victim-blaming in healthcare.

Learning Objective 4: Provide BETTER CARE for all patients.

At the conclusion

of this session, the

participant will be

able to:

3

LEARNING OBJECTIVES

4

Non-Compliance vs.

Non-Adherence

• Evolution of the terms over the years1

• Resulted from an intention to avoid value judgments of patients1

• Belief that term “non-adherence” = patient understanding and

participation in their own treatment process, while “non-

compliance” = patient submission to the will of medical

professionals.1

• Does the distinction matter?

The Myth of the “Non-adherent” Patient

How is non-adherence defined?

•Taking prescribed agents at doses & times recommended by providers2

•Different classifications2:

• Discontinuation, skipping, altering dosages.

• Forgetfulness, careless missing of doses.

What do medical professionals often mean when they use

the term?

Why is it problematic?

•Leads to healthcare “victim blaming.”

•Allows healthcare professionals and healthcare systems to avoid taking

responsibility for patient outcomes.

What Does “Non-Adherence”

Really Mean?3

Lack of Access to Care

Lack of Supports to Address Social

Challenges

Lack of Education & Understanding

Causes of “Non-Adherence”?

Causes of Non-Adherence3

Forgetfulness (32%) Cost Issues (23%)

Perceived Side Effects (27%) Don't feel it would help (19%)

According to Kaiser

Permanente study of

approximately 9,000

patients.

Note:

46% would fall under

the “better

education” category

Study says nothing

about social issues.

Why does non-

adherence matter?

Expensive

Shorter Lifespan

Quality of Life

The Expense of Healthcare

Healthcare Expense in General:4

•In 2010 the costs of U.S. healthcare exceeded $2.7T, 17.9% of GDP.

•By 2020, projections 20% of GDP.

•20%-30% of U.S. healthcare spending identified as wasteful.

Non-adherence = $100-$300 billion of avoidable healthcare costs.4

•Medical non-adherence account for 33%-69% of drug-related adverse

events that result in hospital admissions.5

Non-adherence to medical treatment is a major concern in chronic

disease management.6

•Almost half of all American adults---117 million people—suffer from

chronic disease.

•1 in 4 Americans has multiple chronic diseases.

Non-Adherence &

Patient Lifespan

• According to the CDC & DHS,

chronic diseases are responsible for

7 out of 10 deaths each year, and

treating people with chronic

diseases accounts for 86% of our

nation’s health care costs.7

• Individuals with mental health and

substance abuse disorders die

decades before the average

person—largely from untreated and

preventable chronic illnesses like

hypertension, diabetes, obesity, and

cardiovascular disease.8

Infographic: The University of Michigan, Center for Managing Chronic Disease.15

Non-Adherence &

Qualify of Life

• Cost is not only financial, it’s

emotional: chronic disease is

strongly correlated with

depression9. Addressing non-

adherence not only leads to

healthier patients, but HAPPIER

patients.

• Depressed patients are 76% more

likely to be non-adherent to

treatment than non-depressed

patients.1

Challenges to Addressing

Adherence

Challenges to Overcome:

• Not typically seen as a “social issue” akin to IV drug use, DV,

homelessness, etc. by medical professionals OR social workers.

• Social workers don’t widely receive formal training on basic

medical issues, meds, treatment regimens, side effects, etc.

• Disciplines remain in their “box”: Physicians and nurses aren’t

trained to understand social issues, social workers aren’t

trained to understand medical issues.10

Challenges to Addressing

Adherence

Physicians & nurses: understand

implications of non-adherence,

but don’t understand their role in

addressing it 11.

Role of Physicians and Nurses in

patient education & understanding of

their own medical treatment.

•Undermined by TIME pressures.

•Average physician spends 13-16 min

w/ patients.12

Evolution of

Healthcare14

Fee for Service

Focus:

Addressing Medical Acuity Per Visit.

- Little incentive to address overall health issues.

Quality Based Pmnts

Focus: High Quality Healthcare Delivery

- Measured by readmission statistics

Integrated Healthcare

Focus: Integration of healthcare disciplines

-Intended to provide more holistic care.

-Requires improved collaboration & understanding between disciplines.

Integrated Healthcare Model

Movement toward integrated healthcare models in major

healthcare systems

•Healthcare systems responding to changing fee-for-service model

quality-based reimbursement by encouraging inter-disciplinary models

in acute care settings.13

• Focus on readmissions due to penalties imposed by CMS/HRRP = over

$400 million for healthcare organizations in 2015 and 2016.13

•Behavioral health programs:

• Incorporating NP’s and pharmacy access.

• Social services providers are beginning to understand that addressing

medical issues must be addressed with mental health issues.8

IHC Success…

Depends on Better…

•Collaboration & Understanding

• Between disciplines working together to address

medical and social issues.

• Gaining better understanding of each other’s

diagnostic terms, treatment, and prognosis.

• To fully participate in an interdisciplinary team we

must understand each other’s language.

•Advocacy

• Must encourage all professionals in medical settings to

see non-adherence as a social issue.

• Must stand against healthcare “victim blaming”

•Patient Assessment: Today’s Primary

Focus

Assessment…

Must:

• Be open-ended

• Take both medical AND social

acuity into consideration.

• Addresses the 3 main barriers:

• Patient understanding/education

on disease management.

• Access to medical treatment &

prescribed regimen

• Social Challenges

Assessment Math

Diagnosis + Social Issues – Mitigating Factors = Sociomedical Acuity

Sociomedical Acuity: The combination of medical factors and social

factors which determine a patient’s overall risk

(low/moderate/high).

•Risk for readmission

•Risk for “non-adherence”

•Risk of long-term illness, significant harm, and/or

death.

•Higher sociomedical acuity = higher need for integrated services

Group Assessment

Activity:Patient Poker

Playing The Hand You’re Dealt

•Review case scenarios & apply the “Assessment Math” sequence to determine risks

vs. mitigating factors.

•Assign a level of sociomedical acuity (low/moderate/high).

•Identify services and/or plan of action for your patient.

Today’s Takeaways

How we can do better….

•Better initial assessment.

• Consideration of sociomedical acuity.

• Avoiding victim blaming & the “non-adherent” label

•Better discharge & community planning

• Increased advocacy for patients.

•Better financial outcomes for healthcare entities.

Above all: Better CARE for patients.

QUESTIONS?

Contact:

Kathleen Trujillo, LMSW

ktrujillo@css.edu

(602) 710-0553

References (Slide 1 of 2)

1) Kleinsinger, F. (2010). Working with the noncompliant patient. The Permanent Journal, 14, 54-60.

2) Iihara, N., Nishio, T., Okura, M., Anzai, H., Kagawa, M., Houchi, H., and Kirino, Y. (2014). Comparing

patient dissatisfaction and rational judgment in intentional medical non-adherence versus

unintentional non-adherence. Journal of Clinical Pharmacy and Therapeutics, 39, 45-52.

3) Oyekan, E., Nimalasuriya, A., Martin, J., Scott, R., Dudl, R.J., and Greek, K. (2009). The B-SMART

Appropriate Medication-Use Process: A Guide for Clinicians to Help Patients. The Permanente

Journal, 13, 62-69.

4) Luga, A. & McGuire (2014). Adherence and health care costs. Risk Management Healthcare Policy, 7, 35-

44.

5) Blaschke, T. & Osterberg, L. (2005) Adherence to Medication. The New England Journal of Medicine, 353,

487-97.

6) Rafii, F., Fatemi, N.S., Danielson, E., Johansson, C.M., & Mondanloo, M. (2014). Iranian Journal of Nursing

and Midwifery Research. 19, 159-167.

7) The Centers for Disease Control and Prevention (2010). Multiple chronic conditions: A strategic

framework. Retrieved from:

https://www.hhs.gov/sites/default/files/ash/initiatives/mcc/mcc_framework.pdf

References (Slide 2/2)

8) U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. (2010) Can we live longer? Integrated Healthcare’s Promise. Retrieved from: http://www.integration.samhsa.gov/about-us/what-is-integrated-care

9) Lorden, L. (2003). National Fibromyalgia & Chronic Pain Association. Chronic illness and happiness: Finding meaning in everyday life. Retrieved from: http://www.fmcpaware.org/fundraising/181-positive-attitude/951-chronic-illness-and-happiness-finding-meaning-in-everyday-life.html

10) Basu, G. & McCormick, D. (2017). Future doctors should be trained to promote social change. STAT. Retrieved from: https://www.statnews.com/2017/02/09/doctors-training-social-change/

11) Emsley, R., Alptekin, K., Azorin, J.M., Canas, F., Dubois, V., Gorwood, P., …Schreiner, A. (2015). Nurses’ perceptions of medication adherence in schizophrenia: results of the ADHES cross-sectional questionnaire survey. Therapeutic Advances in Psychopharmacology, 5, 339-350.

12) Medscape (2017). Medscape Physician Compensation Report. Retrieved from: http://www.medscape.com/features/slideshow/compensation/2016/public/overview?src=wnl_physrep_160401_mscpedit&uac=232148CZ&impID=1045700&faf=1

13) Centers for Medicare & Medicaid Services (2015). What’s the CMS Quality Strategy? Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/CMS-Quality-Strategy.html

14) Centers for Medicare & Medicaid Services (2016). Readmissions reduction program (HRRP). Retrieved from: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html

15) The University of Michigan, Center for Managing Chronic Disease. Retrieved from: https://cmcd.sph.umich.edu/

NOTE: Any photos without citation obtained without charge from: www.pixabay.com