Danielle Snyderman, MD Brooke Salzman, MD Geoffrey Mills, MD, PhD Lauren Hersh, MD Susan Parks, MD Department of Family and Community Medicine, Jefferson University, Philadelphia, Pa danielle.snyderman@jefferson.edu
The authors reported no potential conflict of interest relevant to this article.
Identify patients at risk for nonadherence . This includes those with complex regimens and/or uncontrolled disease states or symptoms.
Increase patient communication and counseling . Patient education, particularly on the importance of adherence, is one of the few solo interventions that can improve compliance. 31 Involving caregivers and using both verbal and written materials provides additional benefit. 31,32
Simplify dosing schedules . Simple, convenient medication regimens may im- prove adherence. For example, adjusting dosing from 3 times a day to once a day can increase adherence from 59% to 83%. 33 Aids such as pillboxes to organize medications may be of benefit. 29,32
Ensure consistent follow-up . Patients who miss appointments are more likely to be nonadherent. They may benefit from easy access, help with scheduling, and frequent visits. 32
Be mindful of patients’ out-of-pocket expenses . Reducing copayments improves adherence rates. 30
Minimize polypharmacy . Polypharmacy has been independently associated with nonadherence and increased risk for ADEs. 34
Identify patients who have limited health literacy . Limited health literacy may be linked to increased medication errors and nonadherence. 12,35 Patients with low health literacy may be unable to identify medications recorded in their medical record. TABLE W3 36-41 outlines strategies for identifying patients with low health literacy and improving communication with them.
CASE › By speaking with hospital staff before Mr. T is discharged, you are able to confirm that he has scheduled a follow-up visit with you for one week after discharge, and that a discharge summary will be available for him to bring to that visit. Mr. T brings his discharge summary with him to your office, and you reconcile his medication list. Because he is your last patient of the day, you have some time to sit with him and his wife to explore his goals of care.
Goal setting is an important element of postdischarge follow-up, particularly for elderly patients and those with progressive or end-stage diseases. Goal setting can improve patient care by linking care plans with desired outcomes and keeping diagnostic and therapeutic interventions relevant to the patient. 42 A patient who understands the purpose of a recommendation—especially when directly linked to a patient-derived goal—may be more likely to adhere to the plan of care.
Asking patients to articulate their goals of care using “Ask-Tell-Ask” framework described in TABLE W3 36-41 will allow you to deliver the prognosis, reinforce treatment options to achieve patient-specific goals, empower patients to assert their preferences, and develop a follow-up plan to see if treatment is successful.
Empowering patients
Consider using both verbal and written approaches when educating patients about self-care behaviors such as monitoring symptoms and adhering to dietary/behavior restrictions and medication instructions. One study showed that a brief one-on-one patient education session decreased readmissions in patients with heart failure, 43 although another study found that patient education alone yielded a nonsignificant decrease. 44
Providing caregivers with education and support is a critical and perhaps overlooked opportunity to reduce readmissions. 45 Involving key family members in discharge planning, preparation, follow-up, and ongoing management is essential in caring for patients with functional deficits and/or complex care needs. Educating caregivers can help them feel more prepared and effective in their roles.
