Health plans and systems are turning to primary care providers to follow up more actively with patients who fail to return for treatment. Often, the process requires an organization to identify members and patients, educate and train patients to be aware of their health care needs, and conform to patient privacy as an important factor of one’s compliance. The majority of managed care executives and physicians typically agree that educated patients are often happier and more compliant than their uneducated counterparts, with better chances for successful treatment outcomes. In that light, it would appear that the futures of direct-to-patient and nurse-to-patient communications are very promising. Moreover, patients are responding to the new flow of health information and communication patterns as they seek to become more involved in their own health care decisions.
In developing of the program of actions towards patient’s compliance it should be carefully defined by the nurse, who will make the healthcare decision, which consequently determined the efficacy of the program and medication itself. It is emphasized that a patient is a primary decision-maker. However, when the patient chooses not to follow the physician and nurse’s recommendation for treatment or preventive care, and the patient is covered by managed care, the managed care organization has to pay for the consequences of this behavior. The consequences can be trivial - for example, when a flu shot is recommended, refused, and a patient stays healthy. But on the other hand the outcome can be costly as well, such as when the same patient gets influenza complicated by pneumonia and requires a lengthy hospital stay, or when an asthmatic decides he no longer needs his daily prophylactic medication and an acute asthma attack requires a visit to the emergency room, hospitalization, and missed work days. These are costly consequences, indeed.
A review of approximately 80 disease and care-management programs indicates three distinct approaches for nurses to improving patient compliance with recommended care:
- Nurse actively participates in equipping the primary care provider with more resources and strategies to reach out to patients;
- Nurse pays closer attention to nurse-patient interaction;
- Nurse empowers patients to be more actively involved in decision making and monitoring of their care.
Various health programs are turning to nurses to follow up more closely and actively with patients who failed to return for treatment, or for prevention and screening. Thus, the program to improve mammography-screening rates exemplifies this approach. Moreover, in addition to sending reminder postcards quarterly to members who had not had a mammography screening in the previous 18 months, program developed a resource manual for the nurses, according to which nurses call noncompliant members to encourage them to undergo a mammography.
A common strategy to get patients to adhere more carefully to their treatment regimens, especially for chronic diseases, is to refer patients to specialized programs managed by nurses. For instance, the Cardiovascular Risk Factor Clinic at the Cincinnati VA Medical Center is an example of a nurse-managed clinic. It was developed in response to overextended primary care clinics where physicians did not have the time to address the lifestyle changes patients with coronary artery disease needed to make to reduce their cardiovascular risk factors, such as smoking and high cholesterol. Although the clinic is staffed by an interdisciplinary team of physicians, dietitians, pharmacists, social workers and psychologists, it is managed by nurses with clinical expertise in cardiology. Patients usually attend the clinic for four visits and continue to visit their usual primary care providers. At the clinic visits (after an individualized care plan is developed to meet the patient’s needs), a nurse counsels the patient individually to tailor the interventions to their needs. Moreover, Using a medication protocol developed at the clinic, a nurse manages a program for patients. The program begins with a 90-minute group teaching session in which the nurse reviews the signs and symptoms of the disease, triggers, use of medications in prevention and rescue. The pharmacist meets individually with each patient for 30 minutes to focus on patient adherence issues, including tools to monitor clinical symptoms and peak flow results, and guidance on using medications to self manage based on the monitoring results. Additional key to the success of the clinic is that the nurse emphasizes to the patient how important to understand the core of the problem, as well as to feel committed as a partner in the care plan and in managing the risk factors. Because in conditions where a disease cannot be understood readily by the patient, the treatment regimen also may be unfathomable.
A retrospective review of the clinic experience showed that patients were four times more likely to meet their risk factor goals if they participated in the four visits to the clinic over one year than patients managed traditionally.
Sending reminder postcards and educational materials by nurses to members to undergo screening and preventive care is becoming more common. Another approach is to teach patients to use more advanced technology to self-monitor key parameters related to their medical condition and transmit the information to a central location. Nurses follow up with patients whose condition seems to be deteriorating. The congestive heart failure program at Northwestern Healthcare uses this interactive approach. The program employs automated voice technology that is tracked by software. Patients are educated about the phone-in service and then call in daily using the automated technology with information about their weight and symptoms. Then software generates a report that identifies patients whose status has changed and who is in need of follow up. A nurse then phones the patients. By calling in daily, patients are made aware of the importance of paying attention to their symptoms and their weight. The educational component empowers them to be in charge of specific aspects of their care, and 85% to 90% of patients comply with daily self-reporting. The program also includes monthly feedback reports and graphs to the patients.
These examples demonstrate how health plans and nursing staff are actively intervening to help members get preventive care and patients to adhere to their treatment regimens and manage their conditions more effectively. This process requires nurses to carefully identify and follow members and patients in need, educate and train patients to be aware of their healthcare needs and monitor their health status, and follow up closely to maintain positive outcomes.