Adherence management coaching

Adherence management coaching (AdM coaching) is an evidence-based applied behavioral approach for significantly improving patient adherence and reducing unplanned hospital readmissions. It is based on the research and work of Bob Wright, Aubrey Daniels and BF Skinner. AdM coaches identify patients at high risk for readmission as a direct result of not following their discharge plan. Once identified, AdM Coaches work with these patients (patient engagement) to identify consequences (consequence analysis) with their plan of care that might result in non-adherence. Together, with their provider, AdM Coaches establish a patient centered adherence improvement plan (AIP). The AIP is used to identify target behaviors, desired results (clinical outcomes) and reinforcers that support following their plan of care and developing adherent habits. Following hospital discharge, at-risk patients, and their families, are followed and coached by an AdM Coach for several months as the adherent replacement habits are developed and strengthened.

Home and work environments are filled with cues of a lifetime of habits. While meeting with at-risk patients and their families, AdM coaches identify these cues and work with the family to replace them and reinforce healthier habits. All new behaviors, if not reinforced, will return to the life-style habits that contributed to hospitalization in the first place. Adherence management provides a coaching toolkit to be used in conjunction with Teachback,^[1] motivational interviewing,^[2] pill counting, biochemical measurements, pharmacy data-base of usage and Directly Observed Treatment Short course (DOTS).^[3]

Worldwide, half of all patients choose to not follow their plan of care.^[4] Current programs, like the teach-back method, focus on teaching all patients, just prior to their discharge, the new information they need to follow to once they go home. Motivational Interviewing takes more nurse educator time as together, with the patient, they attempt to identify and overcome areas of ambivalence concerning their disease process and plan of care. Other programs focus on alerting devices and pill-minders to aid patients in remembering to take their medications on time. At best, these "cues" or antecedents have had a marginal impact on improving adherence.

The Centers for Medicare and Medicaid Services has extended provider responsibility and accountability well beyond the front doors of clinics and hospitals. CMS, in responding to a hospital question concerning levels of responsibility following discharge, responded writing, "Post discharge care is a joint responsibility."^[5]

Punitive programs have been established within the Affordable Care Act of 2010 as a "quality incentive" to create change. Hospitals with readmitted patients, above an allowable range and within 30 days of discharge, lose a 4% "Quality Withhold".^[6] A significant number of these readmissions, because of a lack of post-discharge transitional care coordination and patient engagement, will be the result of non-adherence to their discharge plan. Punishing hospitals for patient non-adherence may have some effect on hospital behavior, but little or no impact on improving patient adherence.

Contents

Terminology

1. Adherence – "Sticking" with the plan of care. Also referred to as "Compliance".
2. Adherence management- The application of an applied behavioral approach that focuses on improving adherence rather than just adding more antecedents. Adherence management (AdM) was coined by Robert (Bob) E. Wright^[7] in 2012 to describe a technology (i.e., science embedded in applications and methods) for improving both patient behavior and achieving desired clinical results throughout the clinical course. These two critical elements are known as adherence. The AdM Coaching approach is used most often following discharge from hospitals, and in physician practices, but applies wherever providers and patients interact—nursing homes, occupational/physical/speech therapy, home care, health settings (e.g., LTC/SNF) and family settings.
3. Antecedent – Any event that comes before a behavior and serves as a cue or reminder for a particular behavior.
4. Behavior – Anything a person says or does. Behaviors do not include thoughts, feelings, or beliefs.
5. Consequence – Any event that follows a behavior and increases or decreases the likelihood that the behavior will occur again.
6. Extinction – The reduction of a behavior due to lack of reinforcement
7. Extinction burst – A sudden increase in a behavior in the absence of reinforcement. It is quickly followed by extinction.
8. Negative reinforcement – Any behavior that decreases the likelihood of an undesired consequence (e.g., taking an aspirin to avoid or reduce the symptoms of a headache). Taking medications to avoid "punishment" by the provider is an instance of negative reinforcement.
9. Non-adherence- Not "sticking" with the plan of care.
10. Performance management – Improving outcomes, productivity and safety in the workplace using an applied behavioral approach.
11. Persistence – Staying with the plan of care, whether medications, exercise, dietary, smoking, etc. during the entire desired treatment period.
12. Punishment – Any consequence that reduces the occurrence of a behavior.
13. Reinforce – To strengthen a behavior by providing something the patient wants or needs when the behavior has been successfully completed.
14. Setting event – Any event or environment that sets the occasion for a behavior to occur (e.g., getting a speeding ticket while driving to work setting the occasion for being angry at work and leading to an inappropriate behavior).
15. Thinning – Reducing the amount of reinforcement over time. Initially the reinforcement schedule should be high and then over time reduced. Only under very rare circumstances should the reinforcement be stopped.

Identifying at-risk patients

Since 2003 the World Health Organization has reported that 50% of all patients are not adherent to their provider's plan of care. Identifying hospitalized patients who are at risk for non-adherence is essential prior to discharge. There are a number of behavior based factors that can be used to determine levels of risk.^[8] These factors have been quantified over the past thirty years and provide a good indicator of the need for possible intervention. Once patients have been identified, then related physical, intellectual, and communicative factors need to be evaluated. A Medical Adherence Assessment Scale can be used to identify at-risk patients (Who). An easily used tool for assessing social, physical, communication and intellectual capabilities is also essential for identifying "what" factors may also contribute to non-adherence.

Consequences in the discharge plan

Everything patients are asked to do to improve their health or slow down a progressive disease has a cost. Discharge plans and the various patient care plans are carefully considered by providers and are designed to provide patients with the standard of care to meet their acute or chronic healthcare needs. Each of the written requirements represents a potential stumbling block from the patient's perspective and these need to be considered. Teachback was developed and deployed to ensure that patients can repeat back information on their plan. Motivational Interviewing represents the domain of identifying and overcoming ambivalence and does a good job of getting patients to make a decision. Consequences in the plan of care, that are discovered in the immediate post-discharge period, however, are quite frequently the reason for non-adherence. Prudent practice identifies these prior to discharge and appropriate clinical modifications are reviewed with the provider and patient.

Adherence improvement plan

The adherence improvement plan (AIP) is the roadmap to developing habits that are consistent with the patient's health care improvement goals. Clinical improvement requires that the patient, significant others and their AdM coach know the results the provider is looking for within the plan of care. Once the results (e.g., normal blood pressure, A1C levels within normal limits, movement towards target weight, etc.) are identified, it is appropriate to review the behaviors (e.g., ingest medications as prescribed, exercise 10 minutes per day, etc.) necessary to achieve the results. Is the target behavior in the patient's repertoire? How are these behaviors reinforced? Are the consequences of the adherent behaviors punishing to the patient (e.g., high cost medications, side effects, disruptive medication routine)? How will the punishing consequences be modified and the adherent behaviors reinforced? A basic law of behavior is that, "behavior goes where reinforcement flows."^[9] The AIP offers an opportunity for a patient centered approach to developing and reinforcing adherent behaviors.

Reinforcing behavior

The late Ivar Lovaas documented the effects of his applied behavioral techniques with autistic children. Regrettably, even though he was making progress, his funding ran out and the children were returned to their previous environments. All of the behavioral improvements, without continued reinforcement returned to baseline and Doctor Lovaas concluded, when it comes to a lack of reinforcement, "... all behavior returns to baseline". Clearly this is a pretty pessimistic outlook for expending a great deal of effort if all is for naught when reinforcement is concluded.

In 2012, Grace Lomax^[10] completed a study in the United Kingdom regarding patient non-compliance/adherence/concordance/etc. "What would happen," the authors wondered, "If we provided high levels of training and reinforcement to patients on chronic medications?" The results were astonishing. The control group responded with typically dismal non-adherence levels. The experimental group showed high levels of adherence for several months. When the reinforcement stopped it did not take terribly long for the behaviors to return to baseline. Lomax clearly demonstrated the value of reinforcement on patient behavior. Equally important, she demonstrated the well-known behavioral concept of extinction and extinction bursts. Adherence actually continued to improve after the reinforcement ended. Then when the patients realized there would be no continued reinforcement, they began to return to baseline. While her most significant finding was that adherence improved through increased communication and reinforcement, when these elements were discontinued after 6 months, adherence started returning to pretreatment levels.

Performance management guru Aubrey Daniels stated: "Where reinforcement goes, behavior flows."^[11] Daniels also concluded, during three decades of applied research, that baselines can be improved and new habits developed and maintained for years. Reinforcement needs to continue through self-reinforcement and support by family members. Providers can also offer an intermittent level of reinforcement when follow-up appointments are made.

A related reason for failure to maintain adherence is the use of negative reinforcement by the primary provider for managing most non-adherent behaviors. "You need to take your medicine, or you will die, have a stroke, get your leg amputated, etc." "Do-it-or-else" adherence methods will get the patient to be somewhat adherent when they are in the company of the threat. If the patient's behavior baseline is non-adherence, improved adherence will not be achieved. The key to developing new habits or replacing old habits is found in reinforcing the targeted behaviors frequently at first and then thinning the schedule.

Training and certification

Adherence management coaching is an adjunctive tool designed to identify, shape, reinforce and modify patient behavior following discharge. Understanding the science of behavior and using these skills are well within the scope of practice for the health services transition team and allows a single voice and plan to develop and reinforce desired adherent behavior to the point of becoming a new habit. AdM coaching is a precise use of this science and should be taught/trained by well-qualified, clinically licensed (e.g., nurses, OT, PT, speech therapists, pharmacists, social workers) or behavioral experts to ensure the highest quality outcome as patients go through the transitional care period.

Other adherence improvement programs

The scientific principles associated with human behavior have been well documented for more than a century.^[12] The positive consequences related to taking a behavioral approach are limited only by the ability of the provider/pharmacist to work with their patient population to change their behavior. For the most part the health services industry has placed a great deal of stock in the use of "cognitive" responses such as "motivational interviewing".^[13] Cognitive programs are a product of the 1980s and are considered the gold standard for dealing with non-adherent patients. Teach-back is used by nurse educators to ensure their patients have some understanding of information related to their health. For more than 30 years "Performance Management" has developed an evidence based body of literature and applied research that demonstrates that reinforcing targeted behaviors leads to better habits and better outcomes. Adherence management coaching is the clinical application of performance management with an end goal of improving patient behavior.

AdM coaching is an adjunctive component of the various medication therapy management (MTM) programs that have been implemented over the past several decades. AdM coaching is a tool that can be used to support the technologies and patient education programs in a manner that is significantly more likely to result in behavior change. Having a clear understanding of why a particular patient is not adherent offers the provider and pharmacist the opportunity to change the patient's behavior.

Maslow's hammer

The noted psychologist Abraham Maslow coined the term "Maslow's hammer" in stating, "I suppose it is tempting, if the only tool you have is a hammer (pill bottle, prescription, information leaflet, etc.) to treat everything as if it were a nail."^[14] The problem, patient behavior, will never be resolved when everyone is focusing on their part of the process. Prescriptions, time schedules, instructions, education, training, the diagnosis, and recommendations are all antecedents (events or things that may lead to behavior).

• Pill makers provide pills that can be effective with a single dose thus simplifying the pill taking routine.
• Pill bottler's change the shape and color of the bottles believing that if the bottle is brighter or has a certain colored band it will improve adherence.
• Pill packagers take volumes of information and condense it into single pages, 12 font, so that it can be easily read.
• Pill retailers reduce cost, remove co-pays, or even make the medications free.
• Pharmacists correctly fill the prescriptions and ensure they are available to ask if there are any questions.
• Physicians within the 2–3 minutes allotted for follow-up in the average 15 minute appointments ask if the patient has any questions and completely answers in a foreign language in the allotted time.

It is the consequences where we have consistently lost the battle. The goal of AdM coaching is providing a reliable set of tools that can be used by nurses, case management nurses, therapists (occupational, physical, and speech), patient advocates, family members, pharmacists, and mid-level providers to assure continuity (coordination, communication, collaboration and celebration) as patients transition between and within their home and treatment facilities.

The 18th-century poet, Emily Dickinson (1830–1886), provided the simplest definition of behavior far exceeding the efforts of behavioral scientist who today equate behavior to the functions of organisms in a given environment. "Behavior is what a man says or does. It is not what he feels, thinks, or believes."> Miss Dickinson did not diminish the importance of cognitive behavioral therapy nor advance the importance of physical behavior over cognitive. In fact, cognitive behavior did not exist for almost a century after her death.^[15] Neither has an advantage over the other and as the lyrics on Love and Marriage go, "you can’t have one without the other."^[16] Behaviorists logically argue, "Change the behavior and the feeling will follow."^[17] "The bottom line message is useful... The shortest, most reliable way to change how you're feeling is to change what you are doing."^[18] The equally radical cognitive professions argue that getting people to understand their feelings and manage their ambivalence will result in improved behavior. "Basically, thoughts affect behavior and actions. Change the thoughts and the rest will follow." Each argues to the exclusion of the other. When it comes to behavior change there is also strength when the cognitive is deployed with the behavioral. Exclusive and independent use of either profession will always result in sub-optimal outcomes.

Teachback

Nurse educators provide all patients with "Teach back" and are confident they have advanced the patient's knowledge. The literature supports that 85% of the information is forgotten before the patient gets out the front door of the hospital.

MEMS and other devices

Pill organizers and reminders, visual aids, and other such devices are antecedents or cues to do a behavior such as take a pill or exercise. Antecedents can be used effectively to get behaviors started. Stop signs at intersections are pretty effective consequences in terms of taking the foot off the accelerator and moving it to the brake pedal. As with many antecedents, they don’t apply in all situations. If they did, then every passenger in a car would reflexively move their right foot from the imaginary gas pedal to the equally imaginary brake pedal. Consequences are necessary to create new habits and replace existing behaviors that may be harmful to patients. "Behavior can be modified, that is increased, initiated, or extinguished, by systematic manipulation of its consequences."^[19] AdM Coaches focus on identifying the consequences that are "punishing" to the patient and replacing them with consequences that are more likely to reinforce and strengthen the target behavior. AdM Coaches, patients and family members need to understand the limited effects of MEMS and other devices. They can be easily defeated by turning the buzzers off, putting pill bottles in locations that can be ignored, etc.

Medication therapy management (MTM)

Medication therapy management consists of five core components: a medication therapy review (MTR), personal medication record (PMR), medication-related action plan (MAP), intervention and/or referral, and documentation and follow-up. The MTR provides a systematic process for collecting patient and medication-related information during the pharmacist-patient encounter. The MTR identifies and prioritizes medication-related problems. Pharmacists develop a PMR for use by the patient during the MTM encounter. The medication record includes all prescription and nonprescription products and requires updating as necessary. Pharmacists assess and identify medication-related problems and develops a patient-specific MAP. The MAP is a list of self-management actions necessary to achieve the patient's specific health goals. The patient and pharmacist use the MAP to record actions and track progress towards health goals. During the MTM session, the pharmacist identifies medication-related problem(s) and determines appropriate intervention(s) for resolution. Often, the pharmacist collaborates with other health care professionals to resolve the identified problem(s). Following the patient encounter and/or intervention, the pharmacist must document his/her encounter and determine appropriate patient follow-up.^[20]

Adherence improvement processes have been described in countless journals and the bar has not significantly moved over the last century. Millions of man hours, patient and provider, have been spent training and documenting the fact that the patient was made aware of the need to take his or her medication. Data points have been measured and analyzed from every possible angle without much change. Until the consequences of carefully considered discharge plans are reviewed from the patient's perspective, non-adherence will continue to represent a significant factor in premature deaths, hospitalizations and unplanned readmissions.

Adherence management coaching

People do the things they do because of what happens to them when they do it. If the behavior leads to a positive consequence that behavior will likely increase. On the other hand, if the consequences are punishing, the behavior will likely decrease. In medicine, there are specific positive outcomes in following the provider's plan of care. The problem is that these positive outcomes may be weeks, months or even years into the future. In many instances the positive consequences can occur quickly but they are below the level that people can perceive them. Awareness of the consequences of doing any behavior is an essential element for behavior change. Whether the consequences of treatment are good or bad, not being aware that anything has resulted from the treatment is essentially the same as extinction.

Many authors describe antecedents and consequences as "behavior" when in reality these are not behaviors at all. While there are many "behaviors" that result in non-adherence, Frost and Sullivan, as well as AstraZeneca identified eight "behaviors" that account for the majority of cases of non-adherence. To help remember them, you can use the mnemonic "ICE-IF-SAD". I is INCONVENIENCE (13%); C is CHOICE (18.5%); E = EXPENSE (18.5%); I – ILLNESS (2%); F = FORGETFUL (15%); S is SIDE EFFECTS (17%); A – ACCEPTING (15%) (; D = DISTRUST (2%). While each of these has been described as a "behavior", only CHOICE is a behavior. The rest are either antecedents (inconvenience, illness, accepting, and distrust) or consequences (expense and side effects). Forgetfulness (15% of cases), while listed as a common reason for non-adherence, tends to be a catchall phrase indicating there is a consequence that is not supporting the development of a new habit. Unless there is an organic reason related to forgetfulness, it is highly likely that a combination of the consequences is contributing to the non-adherence. AdM coaches can determine the contributing factors related to "forgetfulness" and determine ways to work around this "behavior".

Most adherence improvement programs are designed to guide, teach and assist patients and their families as they prepare for discharge and the return to their home environments. The AdM coaching difference includes identifying, shaping, reinforcing and replacing old habits with new habits that can lead to healthier lifestyles during the transition period.

Impact

Annually, more than four billion prescriptions are written.^[21] At least 12% of patients do not fill them. In addition, another 12% of the prescriptions are written and filled by the pharmacies but are never taken by the patient. 29% of the prescriptions are filled and started but the patient chooses to not complete the acute or chronic course of therapy.^[22]

Unfilled prescriptions have a direct impact on the pharmaceutical industry with lost revenue in the tens of millions of dollars. More important is the reality that each prescription represents an ignored treatment plan and increased risks for morbidity and admissions or readmissions to hospital. Filled but not taken prescriptions are third party or primary payer expenditures for medications that are purchased but not ingested. This category represents both a primary waste of money and a similar risk for increased morbidity and hospitalization/readmissions. Category three, incomplete treatment plans have the same risks for hospitalizations and readmissions. In addition, with communicable diseases, there is the very real risk that pathogens will become resistant to the treatment.

As with any health care services program, adherence management coaching cannot guarantee a finite number of patients with improved adherence, savings in hospitalization/readmissions costs, increases in pharmaceutical sales or reductions in patient morbidity. What it does provide is a tool that can be used to increase the likelihood that patients will become more adherent through developing new or better habits.

See also

• Medication therapy management
• Organizational behavior management
• Therapeutic behavior management

References