June 11, 2024 • 29 mins
Ever wondered why patients miss their medication schedules despite clear instructions? Our enlightening conversation with Dr. Kate Jones reveals the critical shift from simply labeling patients as "non-compliant" to understanding the complexities behind "patient adherence." Discover how patient-centered care and shared decision-making can transform healthcare outcomes and why addressing social determinants of health (SDOH) is paramount for effective and realistic care plans.
Through a real-world case involving medication refills, we underscore the importance of thorough patient questioning. You'll hear how a nurse's persistence uncovered the true reasons behind missed refills and how practical solutions like pharmacy delivery services or mail-order options can prevent hospital readmissions. This segment highlights the value of taking extra time to identify and solve underlying issues, ultimately improving patient care.
Communication is the cornerstone of healthcare, and in our final segment, we discuss strategies to enhance patient interactions. Learn how using phrases like "tell me more" can foster a non-punitive, supportive environment and explore organizational techniques to encourage a culture of empathy and understanding. We also touch on the upcoming health equity standards from CHAP, emphasizing the need for continuous advancement in quality care. Join us for a thought-provoking episode that advocates for a more holistic and empathetic approach to healthcare.
Guide for Reducing Disparities in Readmissions
How Using the Term "Non-Compliant" Keeps Providers From Partnering With Patients
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Jennifer Kennedy (00:01):
Greetings.
I'm Jennifer Kennedy, the leadfor Compliance and Quality at
CHAP, and welcome to anotherspecial edition of CHAPcast.
In this CHAP series, we areharnessing our board of
directors' knowledge andexperience to jump into
insightful and meaningfuldiscussions, and the essential
(00:23):
goal of this series is to equipyour organization with the
insight and guidance needed toexcel and push the boundaries of
quality in a positive direction.
So I hope you're going to enjoythis episode.
Today we are talking aboutlooking at discharge of
(00:44):
non-compliant patients throughthe lens of social determinants
of health, or SDOH.
This is a really interestingconcept to me and I guess I
really hadn't thought about itbefore.
I talked to our guest, kate,and it made me hearken back to
(01:04):
my time at the bedside where Ithought, you know, I guess I was
thinking it was more of aone-way street.
Remember, this is, you know, 30years ago, where
patient-centered care wasn'treally developed and looked at
(01:26):
in a meaningful way.
It was here.
We're coming out to see you,here we're developing a plan of
care and you need to becompliant and if you're not,
we're going to stop service withyou.
But we, I think, need to lookat that whole concept of
non-compliance in a differentway with the discussion of
(01:47):
health disparity and healthequity being so prominent and
upfront in the healthcarecontinuum as it is.
Looking at discharge ofnoncompliant patients and
linking it to SDOH is a really,really exciting concept when I
think about it in my practiceand my knowledge span.
(02:10):
So, without further ado, Iwould like to introduce our
(02:44):
guest today.
Dr Kate Jones is a clinicalprofessor emerita at the
University of South Carolina andshe joined the College of
Nursing in January 2018 anddirected the MSN Healthcare
Leadership and the DNP ExecutiveHealthcare Leadership Programs
(03:07):
DNP Executive HealthcareLeadership Programs.
Her area of clinical practiceis home healthcare nursing, and
she believes that health happensat home and values each
person's participation in theirhealthcare decision-making.
I share that completely, kate.
Her areas of interest forscholarship are caring in
nursing leadership practice andin the academic setting and the
(03:29):
use of technology to supportolder adults in the community.
She is presented at many local,national and international
events focusing on the aspectsof community-based care, and she
has been a member of the CHAPBoard of Directors since 2018.
Welcome, kate, to CHAPcast.
(03:50):
So glad to have you here.
Kate Jones (03:52):
Oh, Jennifer, thank you so much for inviting me and
especially to talk about thistopic.
I think that it's a greatfollow-up to the discussion that
you and Maricette had and kindof gets a little more in the
details about those healthinequities and social
determinants of health and howwe look at them really in the
context of patient care.
Jennifer Kennedy (04:13):
I wholly believe you are right on the
money with that, and you knowI'm learning.
I'm a student in the area ofhealth disparity and health
equity and I always learnsomething new when I speak with
you, kate.
So you know our discussionabout a week ago talking about
(04:34):
what we were going to frame inthis chap cast was really an
eyeener for me, and your framingor calling patient adherence
versus noncompliance I think isbrilliant.
So I'd like to start there ifwe could.
Kate Jones (04:53):
Sure.
So noncompliance is a term thatis commonly used when a patient
is not following their plan ofcare.
You hear it all the time.
You hear it at patient careconference, you hear it in
hospitals, home health.
You hear it in every clinicalsetting.
The emergency room is a verycommon place where you hear the
term noncompliance.
Jennifer Kennedy (05:14):
Right right.
Kate Jones (05:15):
But there are a lot of problems with the use of that
terminology if we really thinkabout it as clinicians.
First of all, it attaches anegative label to the patient
which is concerning.
It feels like and I dare say itis a paternalistic judgment.
You know, I told you to dosomething and you didn't do.
(05:38):
It Feels very paternalistic andnot very patient-centered.
I believe it puts the patientand the healthcare worker at
odds.
It doesn't feel like you'reworking as a team to improve the
patient's health status whenone of you has the ability to
tell the other what to do andthen, when the person doesn't do
(06:00):
it, you have the ability tolabel the person as
non-compliant.
Jennifer Kennedy (06:06):
It really, I was going to say it really
challenges that concept ofshared decision making.
You know, if you're not goingto engage in shared decision
making, then I don't think youcan say we provide
patient-centered care, Can you?
Kate Jones (06:21):
I don't think so, and so I actually think it's the
opposite of patient-centeredcare.
Jennifer Kennedy (06:26):
Right.
Kate Jones (06:26):
So if you read the literature, there's quite a bit
out there about the terminologyof noncompliance and the
alternative term, which isadherence.
Now I will say that in manyways maybe adherence is not that
much better, but addressingineffective adherence to a plan
(06:48):
of care, I do think comes acrossas less offensive than
noncompliance, and so that's agood.
First step is to shift yourmindset from is this patient
compliant with their plan ofcare to is this a plan of care
that a patient can effectivelyadhere to.
Jennifer Kennedy (07:10):
So patients are supposed to be working with
in our cases of community health, with your you know your
hospice team, with your homehealthcare team, to develop
reasonable interventions ontheir plan of care and goals
correct.
Kate Jones (07:29):
Exactly.
So you know, whatever term isused, let's say, for sake of
this discussion, we're going touse adherence.
Figuring out why a person ishaving difficulty adhering to a
plan of care is essential, andso, for just a second, I want to
think about the definitionyou've said a few times,
(07:50):
patient-centered care, which isat the core, should be at the
core of what we do, and so theCMS definition of
patient-centered care is healthservices delivered in a setting
and a manner that is responsiveto individuals, their goals,
values and preferences, in asystem that supports good
(08:11):
provider-patient communicationand empowers individuals
receiving care and providers tomake effective care plans
together.
So, with that definition, itreally should change our
thinking about use of the termnoncompliance.
Jennifer Kennedy (08:32):
I like that.
I like it a lot, and you didshare a document with me from
CMS that talked about SDOH andre-emissions and I was hoping
that we could spend a fewminutes talking about.
You know some of the thingsthat struck you from that
document.
Kate Jones (08:52):
Absolutely so.
Let's talk first about thisidea of social determinants of
health.
So we want patients to havegood outcomes right we do the
patient does.
That's a bottom line goal foreveryone, and there was an
(09:13):
article actually in the AmericanJournal of Preventive Medicine
that says medical care onlyaccounts for about 20% of health
outcomes.
The other 80% falls under theumbrella of social determinants
of health.
I was staggered by that becauseif you think about, you know,
the 80-20 rule, you might havethought it would have been the
opposite for health outcomes,right Right, but it's not so.
(09:39):
Let's talk about what fallsunder that umbrella.
So health-related behaviors,socioeconomic factors,
environmental factors, and thenunder that umbrella things like
housing instability, foodinsecurity, transportation
difficulty, exposure tointerpersonal violence, and then
(10:01):
there's health-related issuessuch as depression or other
mental health conditions andperson-related factors like
health literacy or culturalbeliefs or values.
So when you look at thatdocument that I hope we're going
to be able to share with ourlisteners as well, it's a great
resource from CMS that's a guidefor reducing disparities in
(10:26):
readmissions, and so the premiseis that these social
determinants of health that Ijust kind of outlined briefly
are the drivers of readmissionsin many cases, and we all know
the cost of readmissions to thehealth care system.
And no matter what setting wework in, we are concerned about
(10:49):
and trying to prevent anddecrease avoidable readmissions.
Jennifer Kennedy (10:55):
Yeah, it's a considerable cost to patients
too.
Right, they're on that churningtreadmill, depending on what
their disease is.
We know that many chronicdiseases, if we don't have a
good post-acute, you know, homehealth care or whatever it may
(11:15):
be will land the patient backinto the hospital.
Kate Jones (11:21):
So that's exactly right.
And so when you look at thebest practices around preventing
readmissions, many of them arethings like you know make sure
the patient fills theirprescriptions, make sure the
patient goes to their follow-upappointment.
Make sure the patient you knowsay they're a heart failure
patient.
Make sure they weigh themselvesdaily and keep track of their
(11:43):
weight.
When each of those things don'thappen, there's a reason for it
, and the reasons are usuallytied to either unmet social
needs or some aspect of socialdeterminants of health, rather
than a patient just sittingthere saying, well, I'm not
(12:05):
going to do any of those things.
Jennifer Kennedy (12:08):
Yeah, now I'm thinking back on my time, you
know, being a visiting pediatricnurse out in the District of
Columbia, and I'm thinking, ohman, obviously this is in the
late 80s, you didn't have all ofthis terminology and this
advanced focus.
But I thought going intosomebody's home and taking your
(12:31):
shoes off was enough if that wasthe request right, meeting them
on their turf.
But what I'm thinking is, youknow you can do all the
assessments you want in ahospital setting and ask them
the questions.
Hospital setting and ask themthe questions.
But once you get home, you getin that person's home and you
(12:51):
know you get whatever you get ona discharge summary.
You have to relook at thoseSDOH issues to really make sure
that you're understanding thepatient situation patient
(13:11):
situation, absolutely.
Kate Jones (13:12):
You know I always, I've worked in home health for
decades and I, while Iappreciate and value what our
colleagues in the acute caresetting do, these social
determinants of health are seenin the home setting.
That's where they're real.
You know you can do screeningin the hospital, you can ask
questions, but in the homesetting, that's where they're
real.
You know you can do screeningin the hospital, you can ask
questions, but in the homehealth setting you see what's
(13:33):
happening, you hear what'shappening, you can talk to the
patient in their environment andyou have so many more clues and
cues and ways to get to theroot of what's happening than
you do in the acute care setting.
So we have a real advantage andI would call it a real
(13:54):
opportunity to help our patients, to partner with our patients
in terms of following the planof care that they were given,
you know, on a paper that theybrought home from the hospital,
right?
Jennifer Kennedy (14:08):
Yeah, absolutely.
So.
Let's say I was just going tosay, you know, I think there is
a huger importance more thanever of pulling that piece
through from the acute to thenon-acute or post-acute, rather
of yeah, here's what we learnedon this assessment.
(14:30):
Great, I need all thatinformation and it often doesn't
make it to a discharge summary,right?
So you know, I think, in orderto, dare I say, better the
continuum of care for thatpatient, we need to work
together with the acute careproviders to do a better job in
(14:53):
getting as much information aspossible to arm we, the
clinicians, going out to do thatadmission and provide ongoing
care in the home setting forpatients.
Kate Jones (15:05):
That's absolutely true.
I agree with that.
I also think it gives home careclinicians home health care,
home care hospice a greaterdegree of responsibility for
addressing the issues that theysee.
So you know, what we identifyas non-compliance might be due
(15:26):
to any one of the factors thatwe've already talked about, and
if that's the case, I think it'sa responsibility to address it
and to work with the patient tofind a solution.
I also think, though, that wehave a responsibility to be
aware of the potential forimplicit bias when we label
(15:49):
patients as noncompliant.
So just from another study youknow, with my academic
background I don't want to giveyou any statistics that haven't
appeared in academic journals sothere's a study, a couple
studies actually that have shownthat Black patients are two and
a half times more likely tohave descriptors in their
(16:13):
medical record such asnon-compliant, difficult or
challenging.
Jennifer Kennedy (16:17):
Yeah, that's interesting, isn't it?
It really is, and really, youknow, it's not too difficult to
believe either what the outcomeof that study would be.
We have a lot of work to do, so, with that in mind, what can
organizations do?
Providers do?
Kate Jones (16:37):
So I have a couple thoughts about that, both at the
organizational level, but atthe individual clinician level
too.
So let's start with theindividual clinician level, if
that's okay.
Yeah, let's go.
So some suggestions forclinicians to use on home visits
.
So when you are in a patient'shome and you observe ineffective
(17:01):
adherence, you have aresponsibility, as we've said,
to do something about it andrecognize that the problem might
be due to unmet social needs.
So I'm going to talk about twotechniques that you can use, and
the first one is the five whys.
This is a technique that we useto get to the root cause of a
(17:22):
problem by asking why, until youhave an answer.
So, jennifer, I'm going to askyou to help me with this one.
You be the nurse and I'll bethe patient.
Okay, all right.
So you're the nurse, you'reseeing a patient who has had a
CHF exacerbation and during amed check on the home visit, you
(17:44):
notice that the patient'sprescription bottles for Corig
and Lasix are empty and theyshould have been filled three
days ago.
So what conversation are yougoing to have with the patient?
Jennifer Kennedy (17:56):
Kate, can you tell me why your medicines
weren't refilled?
Kate Jones (18:02):
My daughter was supposed to pick up my
prescriptions.
Jennifer Kennedy (18:06):
So do you know why she didn't pick them up?
Kate Jones (18:10):
Jennifer, no, I haven't talked to her since
Tuesday.
Jennifer Kennedy (18:15):
Why haven't you two had the chance to
connect and talk?
Kate Jones (18:20):
Well, when I talked to her earlier in the week, she
told me she was working doubleshifts this week and that she
would be busy.
Jennifer Kennedy (18:28):
So do you think that's why she hasn't been
able to pick up your medicationrefills?
Kate Jones (18:36):
Well, I suppose so.
Okay.
So thank you, Jennifer.
You're welcome For playing withme.
So, first of all, that onlytook four whys to get to what I
think we can work with as areason.
Jennifer Kennedy (18:56):
So let me ask you first, though, Jennifer, as
the nurse, how did you feelabout asking those questions?
I actually felt okay, I thinkyou know.
Again, I have to put myselfback in my old you know, nursing
sneakers, because I neverwalked in the hospital, worked
out in the community health, butI don't know if I would have
went down past maybe three Ys,you know, because I have a
(19:19):
caseload to see.
I've got, you know, six visitsto knock out in a day.
I don't know if I would havetaken the time to push down that
far.
Kate Jones (19:32):
Yeah, that's a really good point.
So this is a little bit ofhabit forming, where you don't
just say, oh okay, your daughterdidn't pick up your
prescriptions.
I put that in my note andthat's all there is to it.
Right, Think about yourresponsibility as a clinician to
make sure that there's aneffective plan of care that you
(19:53):
and the patient have agreed to.
So the solutions to the problemthat you uncovered in the
conversation really aren't thatchallenging.
It's an unmet need that can beaddressed.
So, off the top of my head,there's three things that I
think the nurse could talk tothe patient about.
(20:15):
First of all, can somebody elsein the family run and pick up
the prescriptions?
Maybe, that's a possibility,maybe it's not.
Second, does the pharmacydeliver?
Maybe that's the solution,maybe not.
Second, does the pharmacydeliver?
Maybe that's the solution,maybe not.
Third, the person couldconsider switching all their
meds to a mail-order pharmacy sothat they'll have everything
(20:36):
delivered regularly, and thatwould be one less thing for
their daughter to do.
So you know kind of taking thetime to problem solve this issue
.
Let's think back to ourdiscussion about readmissions.
Right May prevent a readmission, which is better for the
patient, better for the healthcare system.
(20:58):
You won't end up having to do areadmission oasis.
You know all those things.
So there's a lot of reasons whyto take that extra few minutes
to get to the root cause andthen to figure out to do some
problem solving which nurses aregreat at.
Jennifer Kennedy (21:15):
Yeah, and I don't see it taking that much
time.
You know if folks listening outthere are thinking, oh man,
that's this is going to add 15minutes, you know that I might
not be able to have today.
It may not take that long toget to sort of the crux of the
issue.
Plus, we're responsible, sotake the 15 minutes to make sure
(21:40):
that you know we have a plan ofcare that works both ways right
.
Kate Jones (21:46):
Exactly.
Now there is another techniquethat you can use, and this one
is very simple and it's makingthe habit of using the phrase
tell me more.
So again, you're seeing apatient, you're there on a
Friday, you're doing her medcheck and you notice, when you
look at the pre-filled med boxes, that she took her meds on
(22:09):
Monday, wednesday and so farshe's taken her Friday morning
meds, but the meds for Tuesdayand Thursday are still in the
box.
And you ask her why?
And she says I decided to justtake them every other day so you
could respond by, you know,scolding, by saying no, that's
(22:29):
not okay, you have to take yourmedicines every day.
Your response could be can youtell me more about that?
It's an open-ended questionthat hopefully helps you get to
the root cause.
So in this case, the patientsays well, they're so expensive,
I want my prescriptions to lastlonger and I figured that every
(22:50):
other day I would still begetting enough medicine.
Wow, you learned a lot just bysaying tell me more.
Jennifer Kennedy (22:58):
Yeah, that's a great tactic to use.
I like it.
Kate Jones (23:04):
So now you have an opportunity, instead of scolding
, to problem solve, right.
So here's some options for thisscenario.
You can use help introduce thepatient to good RX, or you know
some option like that Checkingto see if any of the meds that
the patient is on have patientassistance programs, you know,
(23:28):
seeing if there's genericequivalents, et cetera.
So you've done a great job offiguring out why it's happening.
Now let's figure out if there'sa problem-solving solution that
you can come up with that worksfor the patient.
And again, it's a conversationyou and the patient are having
together.
You know it's not you justsaying, okay, well then, this is
(23:49):
what we're going to do aboutthat.
Jennifer Kennedy (23:51):
Yeah, and I think you're right about it
being maybe a top skill, andperhaps the role playing within
the organization is somethingthat can be done to.
You know, whether it be thenurse or, you know, social
worker, what have you to getthem more comfortable with
(24:12):
digging down or getting to thosefive whys, as you mentioned?
Kate Jones (24:18):
Exactly.
You can role play just the sameway Jennifer and I did today.
Only you can maybe even usereal scenarios that come up.
So let's talk about, at theorganizational level, what can
you do?
So at patient care, conferences, idt, whatever.
I think there are a couple ofmajor changes you can make, and
(24:39):
I would say that the first oneis learning to stop using the
word noncompliance.
Just take it out of thevocabulary of the organization.
That might be hard becausewe've all been saying it for a
long time, right, but wheneverit's said, can somebody on the
team, anybody on the team, canjust say stop, and maybe you
(25:01):
even have a drawing of a stopsign that you can use and, you
know, make it that obvious.
Nope, that's not a word we use.
So let's talk about what'sgoing on.
So that may sound a little, Idon't know, challenging for some
people, but I think that it's.
I think it's a good way to holdeach other accountable.
Jennifer Kennedy (25:23):
Absolutely, and it's it's sometimes.
You know, having a visual alongwith the auditory learning is
another way to sort of solidifywhat is being taught or what is
being learned.
Kate Jones (25:36):
Exactly.
And then another thing I wouldsuggest is use that, tell me
more technique, but use it inpatient care conference.
So now if someone has said thatpatient's not compliant Oops,
I'm sorry, nope, I meant they'renot adhering to the plan of
care so then somebody maybe theclinical supervisor leading
(25:58):
patient care conference can saytell me more about why the
patient's having difficultyfollowing the plan of care.
I like that yeah the patient'shaving difficulty following the
plan of care.
Well, if the clinician hasalready taken the time to dig a
little, maybe they have ananswer, maybe they don't just
yet.
So then the next step isdetermining the root cause, and
(26:18):
if it's an unmet social need, orif it's depression or mental
illness or health literacy,whatever it may be, once you
figure that out, then you canproblem solve.
This is great.
Jennifer Kennedy (26:30):
This is going to make everyone, I think,
better healthcare professionals,by sort of flipping the tables
to a more positive approach than, as you mentioned earlier in
our chat.
You know, negative or punitive,rather.
Kate Jones (26:51):
Exactly.
I hope that that's what happensas a result.
I mean more people, the morepeople, I think, who really
clinicians who get this idea intheir head that, you know,
non-compliance is not a termthat we should be applying to
our patients.
I think, jennifer, we also aregoing to provide a link to
(27:15):
another article for ourlisteners.
That is from a nurse who wrotea really interesting article
called how Using the TermNoncompliant Keeps Providers
from Partnering with Patients,and it's got a lot of
interesting thoughts in it thatI think might be helpful as a
little bit of follow-up on thediscussion that you and I have
(27:35):
had today.
Jennifer Kennedy (27:36):
We'll definitely make that document
available as well as the CMSdocument, and we'll make sure
both of those are availablealong with the podcast Perfect.
Well, again, kate, I havelearned so much during our
exchange today.
Do you have any wise thoughtsfor departure here?
Kate Jones (27:57):
Well, I think the wisest thought I can emphasize
is check yourself when you usethe word noncompliant.
I hope that now you will thinkabout some alternatives as well
as some ways to do some problemsolving.
Jennifer Kennedy (28:12):
That's great, and thank you again for
partnering with us for thisspecial series of CHAPcast.
It's great to have you on, kate.
Kate Jones (28:21):
Absolutely.
Thanks, Jennifer.
I enjoyed talking with youtoday.
Jennifer Kennedy (28:25):
And I, you and just another heads up.
You know we are talking aboutsocial determinants of health.
Heads up that CHAP is in theprocess of developing health
equity standards and they shouldbe coming later this year,
early next year.
So be on the lookout for those.
Be on the lookout for those and, with that, thanks to all of
(28:52):
you for taking time out of yourday to listen to our discussion
about changing or flipping thelanguage, or the tables, from
noncompliance to adherence.
It's been an exciting topic toexplore and, from me and the
entire CHOP staff, keep yourquality needle moving forward,
stay safe and well, and thanksfor all you do, thank you.
Greetings.
I'm Jennifer Kennedy, the leadfor Compliance and Quality at
CHAP, and welcome to anotherspecial edition of CHAPcast.
In this CHAP series, we areharnessing our board of
directors' knowledge andexperience to jump into
insightful and meaningfuldiscussions, and the essential
(00:23):
goal of this series is to equipyour organization with the
insight and guidance needed toexcel and push the boundaries of
quality in a positive direction.
So I hope you're going to enjoythis episode.
Today we are talking aboutlooking at discharge of
(00:44):
non-compliant patients throughthe lens of social determinants
of health, or SDOH.
This is a really interestingconcept to me and I guess I
really hadn't thought about itbefore.
I talked to our guest, kate,and it made me hearken back to
(01:04):
my time at the bedside where Ithought, you know, I guess I was
thinking it was more of aone-way street.
Remember, this is, you know, 30years ago, where
patient-centered care wasn'treally developed and looked at
(01:26):
in a meaningful way.
It was here.
We're coming out to see you,here we're developing a plan of
care and you need to becompliant and if you're not,
we're going to stop service withyou.
But we, I think, need to lookat that whole concept of
non-compliance in a differentway with the discussion of
(01:47):
health disparity and healthequity being so prominent and
upfront in the healthcarecontinuum as it is.
Looking at discharge ofnoncompliant patients and
linking it to SDOH is a really,really exciting concept when I
think about it in my practiceand my knowledge span.
(02:10):
So, without further ado, Iwould like to introduce our
(02:44):
guest today.
Dr Kate Jones is a clinicalprofessor emerita at the
University of South Carolina andshe joined the College of
Nursing in January 2018 anddirected the MSN Healthcare
Leadership and the DNP ExecutiveHealthcare Leadership Programs
(03:07):
DNP Executive HealthcareLeadership Programs.
Her area of clinical practiceis home healthcare nursing, and
she believes that health happensat home and values each
person's participation in theirhealthcare decision-making.
I share that completely, kate.
Her areas of interest forscholarship are caring in
nursing leadership practice andin the academic setting and the
(03:29):
use of technology to supportolder adults in the community.
She is presented at many local,national and international
events focusing on the aspectsof community-based care, and she
has been a member of the CHAPBoard of Directors since 2018.
Welcome, kate, to CHAPcast.
(03:50):
So glad to have you here.
Kate Jones (03:52):
Oh, Jennifer, thank you so much for inviting me and
especially to talk about thistopic.
I think that it's a greatfollow-up to the discussion that
you and Maricette had and kindof gets a little more in the
details about those healthinequities and social
determinants of health and howwe look at them really in the
context of patient care.
Jennifer Kennedy (04:13):
I wholly believe you are right on the
money with that, and you knowI'm learning.
I'm a student in the area ofhealth disparity and health
equity and I always learnsomething new when I speak with
you, kate.
So you know our discussionabout a week ago talking about
(04:34):
what we were going to frame inthis chap cast was really an
eyeener for me, and your framingor calling patient adherence
versus noncompliance I think isbrilliant.
So I'd like to start there ifwe could.
Kate Jones (04:53):
Sure.
So noncompliance is a term thatis commonly used when a patient
is not following their plan ofcare.
You hear it all the time.
You hear it at patient careconference, you hear it in
hospitals, home health.
You hear it in every clinicalsetting.
The emergency room is a verycommon place where you hear the
term noncompliance.
Jennifer Kennedy (05:14):
Right right.
Kate Jones (05:15):
But there are a lot of problems with the use of that
terminology if we really thinkabout it as clinicians.
First of all, it attaches anegative label to the patient
which is concerning.
It feels like and I dare say itis a paternalistic judgment.
You know, I told you to dosomething and you didn't do.
(05:38):
It Feels very paternalistic andnot very patient-centered.
I believe it puts the patientand the healthcare worker at
odds.
It doesn't feel like you'reworking as a team to improve the
patient's health status whenone of you has the ability to
tell the other what to do andthen, when the person doesn't do
(06:00):
it, you have the ability tolabel the person as
non-compliant.
Jennifer Kennedy (06:06):
It really, I was going to say it really
challenges that concept ofshared decision making.
You know, if you're not goingto engage in shared decision
making, then I don't think youcan say we provide
patient-centered care, Can you?
Kate Jones (06:21):
I don't think so, and so I actually think it's the
opposite of patient-centeredcare.
Jennifer Kennedy (06:26):
Right.
Kate Jones (06:26):
So if you read the literature, there's quite a bit
out there about the terminologyof noncompliance and the
alternative term, which isadherence.
Now I will say that in manyways maybe adherence is not that
much better, but addressingineffective adherence to a plan
(06:48):
of care, I do think comes acrossas less offensive than
noncompliance, and so that's agood.
First step is to shift yourmindset from is this patient
compliant with their plan ofcare to is this a plan of care
that a patient can effectivelyadhere to.
Jennifer Kennedy (07:10):
So patients are supposed to be working with
in our cases of community health, with your you know your
hospice team, with your homehealthcare team, to develop
reasonable interventions ontheir plan of care and goals
correct.
Kate Jones (07:29):
Exactly.
So you know, whatever term isused, let's say, for sake of
this discussion, we're going touse adherence.
Figuring out why a person ishaving difficulty adhering to a
plan of care is essential, andso, for just a second, I want to
think about the definitionyou've said a few times,
(07:50):
patient-centered care, which isat the core, should be at the
core of what we do, and so theCMS definition of
patient-centered care is healthservices delivered in a setting
and a manner that is responsiveto individuals, their goals,
values and preferences, in asystem that supports good
(08:11):
provider-patient communicationand empowers individuals
receiving care and providers tomake effective care plans
together.
So, with that definition, itreally should change our
thinking about use of the termnoncompliance.
Jennifer Kennedy (08:32):
I like that.
I like it a lot, and you didshare a document with me from
CMS that talked about SDOH andre-emissions and I was hoping
that we could spend a fewminutes talking about.
You know some of the thingsthat struck you from that
document.
Kate Jones (08:52):
Absolutely so.
Let's talk first about thisidea of social determinants of
health.
So we want patients to havegood outcomes right we do the
patient does.
That's a bottom line goal foreveryone, and there was an
(09:13):
article actually in the AmericanJournal of Preventive Medicine
that says medical care onlyaccounts for about 20% of health
outcomes.
The other 80% falls under theumbrella of social determinants
of health.
I was staggered by that becauseif you think about, you know,
the 80-20 rule, you might havethought it would have been the
opposite for health outcomes,right Right, but it's not so.
(09:39):
Let's talk about what fallsunder that umbrella.
So health-related behaviors,socioeconomic factors,
environmental factors, and thenunder that umbrella things like
housing instability, foodinsecurity, transportation
difficulty, exposure tointerpersonal violence, and then
(10:01):
there's health-related issuessuch as depression or other
mental health conditions andperson-related factors like
health literacy or culturalbeliefs or values.
So when you look at thatdocument that I hope we're going
to be able to share with ourlisteners as well, it's a great
resource from CMS that's a guidefor reducing disparities in
(10:26):
readmissions, and so the premiseis that these social
determinants of health that Ijust kind of outlined briefly
are the drivers of readmissionsin many cases, and we all know
the cost of readmissions to thehealth care system.
And no matter what setting wework in, we are concerned about
(10:49):
and trying to prevent anddecrease avoidable readmissions.
Jennifer Kennedy (10:55):
Yeah, it's a considerable cost to patients
too.
Right, they're on that churningtreadmill, depending on what
their disease is.
We know that many chronicdiseases, if we don't have a
good post-acute, you know, homehealth care or whatever it may
(11:15):
be will land the patient backinto the hospital.
Kate Jones (11:21):
So that's exactly right.
And so when you look at thebest practices around preventing
readmissions, many of them arethings like you know make sure
the patient fills theirprescriptions, make sure the
patient goes to their follow-upappointment.
Make sure the patient you knowsay they're a heart failure
patient.
Make sure they weigh themselvesdaily and keep track of their
(11:43):
weight.
When each of those things don'thappen, there's a reason for it
, and the reasons are usuallytied to either unmet social
needs or some aspect of socialdeterminants of health, rather
than a patient just sittingthere saying, well, I'm not
(12:05):
going to do any of those things.
Jennifer Kennedy (12:08):
Yeah, now I'm thinking back on my time, you
know, being a visiting pediatricnurse out in the District of
Columbia, and I'm thinking, ohman, obviously this is in the
late 80s, you didn't have all ofthis terminology and this
advanced focus.
But I thought going intosomebody's home and taking your
(12:31):
shoes off was enough if that wasthe request right, meeting them
on their turf.
But what I'm thinking is, youknow you can do all the
assessments you want in ahospital setting and ask them
the questions.
Hospital setting and ask themthe questions.
But once you get home, you getin that person's home and you
(12:51):
know you get whatever you get ona discharge summary.
You have to relook at thoseSDOH issues to really make sure
that you're understanding thepatient situation patient
(13:11):
situation, absolutely.
Kate Jones (13:12):
You know I always, I've worked in home health for
decades and I, while Iappreciate and value what our
colleagues in the acute caresetting do, these social
determinants of health are seenin the home setting.
That's where they're real.
You know you can do screeningin the hospital, you can ask
questions, but in the homesetting, that's where they're
real.
You know you can do screeningin the hospital, you can ask
questions, but in the homehealth setting you see what's
(13:33):
happening, you hear what'shappening, you can talk to the
patient in their environment andyou have so many more clues and
cues and ways to get to theroot of what's happening than
you do in the acute care setting.
So we have a real advantage andI would call it a real
(13:54):
opportunity to help our patients, to partner with our patients
in terms of following the planof care that they were given,
you know, on a paper that theybrought home from the hospital,
right?
Jennifer Kennedy (14:08):
Yeah, absolutely.
So.
Let's say I was just going tosay, you know, I think there is
a huger importance more thanever of pulling that piece
through from the acute to thenon-acute or post-acute, rather
of yeah, here's what we learnedon this assessment.
(14:30):
Great, I need all thatinformation and it often doesn't
make it to a discharge summary,right?
So you know, I think, in orderto, dare I say, better the
continuum of care for thatpatient, we need to work
together with the acute careproviders to do a better job in
(14:53):
getting as much information aspossible to arm we, the
clinicians, going out to do thatadmission and provide ongoing
care in the home setting forpatients.
Kate Jones (15:05):
That's absolutely true.
I agree with that.
I also think it gives home careclinicians home health care,
home care hospice a greaterdegree of responsibility for
addressing the issues that theysee.
So you know, what we identifyas non-compliance might be due
(15:26):
to any one of the factors thatwe've already talked about, and
if that's the case, I think it'sa responsibility to address it
and to work with the patient tofind a solution.
I also think, though, that wehave a responsibility to be
aware of the potential forimplicit bias when we label
(15:49):
patients as noncompliant.
So just from another study youknow, with my academic
background I don't want to giveyou any statistics that haven't
appeared in academic journals sothere's a study, a couple
studies actually that have shownthat Black patients are two and
a half times more likely tohave descriptors in their
(16:13):
medical record such asnon-compliant, difficult or
challenging.
Jennifer Kennedy (16:17):
Yeah, that's interesting, isn't it?
It really is, and really, youknow, it's not too difficult to
believe either what the outcomeof that study would be.
We have a lot of work to do, so, with that in mind, what can
organizations do?
Providers do?
Kate Jones (16:37):
So I have a couple thoughts about that, both at the
organizational level, but atthe individual clinician level
too.
So let's start with theindividual clinician level, if
that's okay.
Yeah, let's go.
So some suggestions forclinicians to use on home visits
.
So when you are in a patient'shome and you observe ineffective
(17:01):
adherence, you have aresponsibility, as we've said,
to do something about it andrecognize that the problem might
be due to unmet social needs.
So I'm going to talk about twotechniques that you can use, and
the first one is the five whys.
This is a technique that we useto get to the root cause of a
(17:22):
problem by asking why, until youhave an answer.
So, jennifer, I'm going to askyou to help me with this one.
You be the nurse and I'll bethe patient.
Okay, all right.
So you're the nurse, you'reseeing a patient who has had a
CHF exacerbation and during amed check on the home visit, you
(17:44):
notice that the patient'sprescription bottles for Corig
and Lasix are empty and theyshould have been filled three
days ago.
So what conversation are yougoing to have with the patient?
Jennifer Kennedy (17:56):
Kate, can you tell me why your medicines
weren't refilled?
Kate Jones (18:02):
My daughter was supposed to pick up my
prescriptions.
Jennifer Kennedy (18:06):
So do you know why she didn't pick them up?
Kate Jones (18:10):
Jennifer, no, I haven't talked to her since
Tuesday.
Jennifer Kennedy (18:15):
Why haven't you two had the chance to
connect and talk?
Kate Jones (18:20):
Well, when I talked to her earlier in the week, she
told me she was working doubleshifts this week and that she
would be busy.
Jennifer Kennedy (18:28):
So do you think that's why she hasn't been
able to pick up your medicationrefills?
Kate Jones (18:36):
Well, I suppose so.
Okay.
So thank you, Jennifer.
You're welcome For playing withme.
So, first of all, that onlytook four whys to get to what I
think we can work with as areason.
Jennifer Kennedy (18:56):
So let me ask you first, though, Jennifer, as
the nurse, how did you feelabout asking those questions?
I actually felt okay, I thinkyou know.
Again, I have to put myselfback in my old you know, nursing
sneakers, because I neverwalked in the hospital, worked
out in the community health, butI don't know if I would have
went down past maybe three Ys,you know, because I have a
(19:19):
caseload to see.
I've got, you know, six visitsto knock out in a day.
I don't know if I would havetaken the time to push down that
far.
Kate Jones (19:32):
Yeah, that's a really good point.
So this is a little bit ofhabit forming, where you don't
just say, oh okay, your daughterdidn't pick up your
prescriptions.
I put that in my note andthat's all there is to it.
Right, Think about yourresponsibility as a clinician to
make sure that there's aneffective plan of care that you
(19:53):
and the patient have agreed to.
So the solutions to the problemthat you uncovered in the
conversation really aren't thatchallenging.
It's an unmet need that can beaddressed.
So, off the top of my head,there's three things that I
think the nurse could talk tothe patient about.
(20:15):
First of all, can somebody elsein the family run and pick up
the prescriptions?
Maybe, that's a possibility,maybe it's not.
Second, does the pharmacydeliver?
Maybe that's the solution,maybe not.
Second, does the pharmacydeliver?
Maybe that's the solution,maybe not.
Third, the person couldconsider switching all their
meds to a mail-order pharmacy sothat they'll have everything
(20:36):
delivered regularly, and thatwould be one less thing for
their daughter to do.
So you know kind of taking thetime to problem solve this issue
.
Let's think back to ourdiscussion about readmissions.
Right May prevent a readmission, which is better for the
patient, better for the healthcare system.
(20:58):
You won't end up having to do areadmission oasis.
You know all those things.
So there's a lot of reasons whyto take that extra few minutes
to get to the root cause andthen to figure out to do some
problem solving which nurses aregreat at.
Jennifer Kennedy (21:15):
Yeah, and I don't see it taking that much
time.
You know if folks listening outthere are thinking, oh man,
that's this is going to add 15minutes, you know that I might
not be able to have today.
It may not take that long toget to sort of the crux of the
issue.
Plus, we're responsible, sotake the 15 minutes to make sure
(21:40):
that you know we have a plan ofcare that works both ways right
.
Kate Jones (21:46):
Exactly.
Now there is another techniquethat you can use, and this one
is very simple and it's makingthe habit of using the phrase
tell me more.
So again, you're seeing apatient, you're there on a
Friday, you're doing her medcheck and you notice, when you
look at the pre-filled med boxes, that she took her meds on
(22:09):
Monday, wednesday and so farshe's taken her Friday morning
meds, but the meds for Tuesdayand Thursday are still in the
box.
And you ask her why?
And she says I decided to justtake them every other day so you
could respond by, you know,scolding, by saying no, that's
(22:29):
not okay, you have to take yourmedicines every day.
Your response could be can youtell me more about that?
It's an open-ended questionthat hopefully helps you get to
the root cause.
So in this case, the patientsays well, they're so expensive,
I want my prescriptions to lastlonger and I figured that every
(22:50):
other day I would still begetting enough medicine.
Wow, you learned a lot just bysaying tell me more.
Jennifer Kennedy (22:58):
Yeah, that's a great tactic to use.
I like it.
Kate Jones (23:04):
So now you have an opportunity, instead of scolding
, to problem solve, right.
So here's some options for thisscenario.
You can use help introduce thepatient to good RX, or you know
some option like that Checkingto see if any of the meds that
the patient is on have patientassistance programs, you know,
(23:28):
seeing if there's genericequivalents, et cetera.
So you've done a great job offiguring out why it's happening.
Now let's figure out if there'sa problem-solving solution that
you can come up with that worksfor the patient.
And again, it's a conversationyou and the patient are having
together.
You know it's not you justsaying, okay, well then, this is
(23:49):
what we're going to do aboutthat.
Jennifer Kennedy (23:51):
Yeah, and I think you're right about it
being maybe a top skill, andperhaps the role playing within
the organization is somethingthat can be done to.
You know, whether it be thenurse or, you know, social
worker, what have you to getthem more comfortable with
(24:12):
digging down or getting to thosefive whys, as you mentioned?
Kate Jones (24:18):
Exactly.
You can role play just the sameway Jennifer and I did today.
Only you can maybe even usereal scenarios that come up.
So let's talk about, at theorganizational level, what can
you do?
So at patient care, conferences, idt, whatever.
I think there are a couple ofmajor changes you can make, and
(24:39):
I would say that the first oneis learning to stop using the
word noncompliance.
Just take it out of thevocabulary of the organization.
That might be hard becausewe've all been saying it for a
long time, right, but wheneverit's said, can somebody on the
team, anybody on the team, canjust say stop, and maybe you
(25:01):
even have a drawing of a stopsign that you can use and, you
know, make it that obvious.
Nope, that's not a word we use.
So let's talk about what'sgoing on.
So that may sound a little, Idon't know, challenging for some
people, but I think that it's.
I think it's a good way to holdeach other accountable.
Jennifer Kennedy (25:23):
Absolutely, and it's it's sometimes.
You know, having a visual alongwith the auditory learning is
another way to sort of solidifywhat is being taught or what is
being learned.
Kate Jones (25:36):
Exactly.
And then another thing I wouldsuggest is use that, tell me
more technique, but use it inpatient care conference.
So now if someone has said thatpatient's not compliant Oops,
I'm sorry, nope, I meant they'renot adhering to the plan of
care so then somebody maybe theclinical supervisor leading
(25:58):
patient care conference can saytell me more about why the
patient's having difficultyfollowing the plan of care.
I like that yeah the patient'shaving difficulty following the
plan of care.
Well, if the clinician hasalready taken the time to dig a
little, maybe they have ananswer, maybe they don't just
yet.
So then the next step isdetermining the root cause, and
(26:18):
if it's an unmet social need, orif it's depression or mental
illness or health literacy,whatever it may be, once you
figure that out, then you canproblem solve.
This is great.
Jennifer Kennedy (26:30):
This is going to make everyone, I think,
better healthcare professionals,by sort of flipping the tables
to a more positive approach than, as you mentioned earlier in
our chat.
You know, negative or punitive,rather.
Kate Jones (26:51):
Exactly.
I hope that that's what happensas a result.
I mean more people, the morepeople, I think, who really
clinicians who get this idea intheir head that, you know,
non-compliance is not a termthat we should be applying to
our patients.
I think, jennifer, we also aregoing to provide a link to
(27:15):
another article for ourlisteners.
That is from a nurse who wrotea really interesting article
called how Using the TermNoncompliant Keeps Providers
from Partnering with Patients,and it's got a lot of
interesting thoughts in it thatI think might be helpful as a
little bit of follow-up on thediscussion that you and I have
(27:35):
had today.
Jennifer Kennedy (27:36):
We'll definitely make that document
available as well as the CMSdocument, and we'll make sure
both of those are availablealong with the podcast Perfect.
Well, again, kate, I havelearned so much during our
exchange today.
Do you have any wise thoughtsfor departure here?
Kate Jones (27:57):
Well, I think the wisest thought I can emphasize
is check yourself when you usethe word noncompliant.
I hope that now you will thinkabout some alternatives as well
as some ways to do some problemsolving.
Jennifer Kennedy (28:12):
That's great, and thank you again for
partnering with us for thisspecial series of CHAPcast.
It's great to have you on, kate.
Kate Jones (28:21):
Absolutely.
Thanks, Jennifer.
I enjoyed talking with youtoday.
Jennifer Kennedy (28:25):
And I, you and just another heads up.
You know we are talking aboutsocial determinants of health.
Heads up that CHAP is in theprocess of developing health
equity standards and they shouldbe coming later this year,
early next year.
So be on the lookout for those.
Be on the lookout for those and, with that, thanks to all of
(28:52):
you for taking time out of yourday to listen to our discussion
about changing or flipping thelanguage, or the tables, from
noncompliance to adherence.
It's been an exciting topic toexplore and, from me and the
entire CHOP staff, keep yourquality needle moving forward,
stay safe and well, and thanksfor all you do, thank you.
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