Are you thinking about creating a Chief Adherence Officer position?

Everything there is to know about patient non-adherence and the billions of dollars lost in revenue, unnecessary admissions and readmissions has been written about, conferenced on, work-shopped with, debated over, discussed about and reviewed ad nauseum.  A recent conclusion is, “Strategic, corporate-wide, patient engagement initiatives to improve adherence will deliver scalable revenue growth and improve patient outcomes across brands and portfolios, with the added bonus of a positive public relations narrative.” [1]

If you are thinking about creating a Chief Adherence Officer position to deliver scalable revenue growth, which of a half-a-dozen health services professionals will your organization tap to be the “point-man” going where so many others have gone before? Who will be the first to achieve consistent results that have evaded each generation from Hippocrates to today? Which “patient engagement initiative” will be deployed and produce a significant dent in the $600 billion left annually on the table because millions of patients “choose” to be non-adherent? Choice is a behavior and behaviors are based on consequences. What’s in your Adherence Improvement Toolkit?

[1] Tom Kottler, Katrina Firlik, MD: Advocating for a chief adherence officer in pharma, http://medcitynews.com/2016/11/chief-adherence-officers-pharmas-future/?rf=1

There is a common denominator: Human Behavior!

Choice is a behavior and behaviors are based on consequences. 

Behavior is the common denominator regardless of whether the patient is non-adherent with their medications, their diet, their lifestyle change, etc.  It matters not whether the CAO is a physician, nurse, pharmacist, or for that matter, a candlestick maker.  An effective CAO will need an applied behavior-based tool kit and an understanding of why people do the things they do.  What’s in your Adherence Improvement Toolkit?

For several decades, non-adherence has been addressed as a “patient education” issue.  “Teach them and they will learn.”  As they learn, they will become adherent.  Others have loudly stated, “Change their thinking, reduce their ambivalence, and they will stick to their plan.”  “Perhaps,” wondered others, “we should change the process?”

Countless hours, weeks, and months have been spent with people and their earned belts of many colors, teasing out changes in the process at various sigma levels.  “Improve the transitions and adherence will follow.”  Countless research programs into adherence improvement having quietly stated in their conclusions, “Results are promising but there are no statistically significant differences between the baseline and the intervention.” 

The kiss of death for any research is the “no statistically significant difference” statement in the conclusion section. Yet every study completed on patient adherence over the last 35 years has included it. Having stated that, current researchers tweak a few words and another research effort is born.  We hopefully learn from our past and should reflect on the thoughts of Einstein and Edison respectively, “Doing the same things over again and expecting different results, is the definition of insanity” and “I have not failed. I’ve just found 10,000 ways that won’t work.”  For the purists reading this, you may argue that others should be credited with these quotes.  Mark Twain resolved the issue, “What a great thing Adam had.  When he said something, he knew it had never been said before.”

“Strategic, corporate-wide, patient engagement initiatives”

The Hospital Engagement Network (HEN) contracts (HEN and HEN 2.0) between 2013 and 2016 examined unplanned readmissions as a quality of care issue with a plan to reduce these events by 20%. After the 2013-15 HEN effort, readmissions had only been reduced by approximately 5%. HEN 2.0 was a year-long effort to follow-up on the recommendations of HEN. Even though results were “not statistically significant,” a third two-year HIIN (Hospital Improvement Innovation Network) was awarded in September 2016. The programs were essentially unchanged. However, the name was changed and improvement targets were lowered. The previous harm to patient goal of 40% was now reduced to 20% and unplanned readmissions was reduced from 20% to 12%. (Now I can’t be certain, but when you reduce the goals of a study but still only get a 5% change, doesn’t that change the significance numbers without actually changing anything? Food for thought!)

Patient engagement is a term everyone in health services is familiar with and yet it does not describe the two essential elements necessary to improve adherence. 1. Pinpoint the results necessary to achieve optimal health, and 2. Pinpoint the behaviors  necessary to achieve those results? The meaning of the word “engagement” rarely describes the behaviors necessary to achieve it. As Miller and Burgoon stated more than a half century ago, “the meanings of words are in people and not in the words themselves.” If health services providers cannot specifically state the behaviors necessary for improving patient engagement, how can a person with either an aggravating illness or life threatening condition come to appreciate whether they are “engaged” or not?

“Shouldn't they want to be adherent?”

Regardless of culture, gender, belief systems or a combination of more than 170 variables, people behave and misbehave. The issue is, what may be considered “misbehaving” by a clinician, is considered “normal behavior” for patients. In fact, the plan of care or discharge plan is often filled with consequences that are “punishing” to patients. Countless episodes of care are abandoned because the disease is asymptomatic and/or the treatment itself, while likely very effective, is not producing results patients can perceive.

What tools will this new Chief Adherence Officer have in their toolkit that can:

  1. Identify patients who are at-risk,
  2. Identify physical and communicative barriers to adherence,
  3. Evaluate the plan of care for punishing elements,
  4. Establish an adherence improvement plan,
  5. Reinforce target behaviors, and
  6. Monitor and make adjustments quickly and easily when target behaviors or clinical results are not being achieved?

The short answer is: these tools are not available to them. Nor are they in the tool boxes of the teams of health services professionals they will lead or direct. How will they know in a month or two which patients are beginning their non-adherent slide for life? AdM Coaching© is the only way to know for sure!

There are more than 13,600 ways a person’s health can be at risk. We can treat these diseases with more than 6,000 medications and 4,000 procedures and protocols. The equation is terribly unbalanced as hundreds of millions of people, with an average eighth grade reading level are expected to understand and apply a plan of care developed by their clinicians.

Adherence Management (AdM) Coaches© can identify the at-risk population and, regardless of the disease or cultural background, answer these questions for patients: 1. Is this treatment good for me or not? 2. Will the results of this plan of care be immediate or some-time in the future? 3. Is the treatment plan “likely” or “unlikely” to be successful? And 4. Will I be aware of the consequences of following my plan of care or not? Clinicians will always respond, “The plan of care is good for their patient. The medications will be effective immediately on starting them. The plan of care, based on their experience is likely to be successful. Patients may not be aware the medication is working, but it is.” It matters not, when it comes to adherence, what clinicians believe. Adherence Management begins with understanding the consequences in the plan of care from a patient’s perspective.

All other methods for improving adherence fail to recognize the gap between clinician’s perspective and the patient's perspective. A basic law of behavior is, “behavior goes where reinforcement flows.” Where there is no reinforcement, adherence stops. Another reality of behavior is, people do not do things that are immediately harmful and perceived. Nor will they continue to do things that are helpful but not perceived. Hypertension is asymptomatic, vascular compromise from diabetes is asymptomatic, medications for hypertension are asymptomatic. In fact, many medications for the treatment of congestive heart failure, kidney disease, etc. produce no “aha!” moments to prove its effectiveness. A very common statement from non-adherent patients is, “I didn’t feel that it was working… so I quit taking it.” That’s extinction.

Chief Adherence Officer: A Prediction

Regardless of the basic profession of these potentially new C-suite candidates, I predict that without a clear understanding of the basic principles of Adherence Management Coaching©, it might only make a hiccup in the problems of non-adherence -- both for readmissions and hospital acquired infections.

Teachback, Motivational Interviewing, and Medication Therapy Management are the primary mainstays of adherence improvement. Educational (Teachback) information is frequently forgotten before patients get home. Motivational Interviewing has patients reflect on their wrong-thinking and ambivalence until they desire improvement. Medication Therapy Management ensures medications are not conflicting or potentiating. MEMs caps and emails are used across the country and hailed as the “new-new” way to improve adherence. Behaviorally, each of these programs or items are referred to as antecedents. Antecedents are the devices or events that prompt or cue a behavior, but not necessarily get it to occur. Buzzers can remind a patient that it is time to take a pill, but those can be turned off or muted. MTM can prevent harm because of pill conflicts, but it does not improve the chance that patients will take the pill. Wrong-thinking may be corrected for a season and then patients go home, get on the internet, have conversations with friends and family and rapidly return to their life-long baseline of bad habits. Focusing on antecedents is the easiest course of action (from the clinician's perspective) but the outcomes are predictable. The value of antecedents to change behavior is limited. If change is to be made with adherence, it is time to focus on consequences.

What’s in BEARS’ Toolkit?

The tools included in Adherence Management Coaching© 1. Identify at-risk patients, 2. Identify physical or communication factors that could contribute to non-adherence, 3. Identify specific requirements in the plan of care that are considered punishing to patients from their perspective, 4. An Adherence Improvement Plan, 5. Reinforcer Survey, and 6. Evaluation tool for finding where problems exist if patients are not making progress as expected.

“Habit is habit, and not to be flung out of the window by any man, but coaxed downstairs a step at a time.” Mark Twain.  Are your patients being “flung out of the window” with care plan in hand or are you coaxing them towards better habits… a step at a time?

Learn more about Adherence Management Coaching© and our “a step at a time” approach by visiting our website: www.adherence-management.com or call us at 321-439-5949.

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