BUNCH OF CRAP
Joined: 20 Jul 2003
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Posted: Sun Jul 20, 2003 8:41 am Post subject: The Intensive Intervention With The Non-Compliant Patient
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The Intensive Intervention With The Non-Compliant Patient Guide was developed by the ESRD Network of Texas, Inc., Medical Review Board, Executive Committee and Patient Advisory Committee as guide for renal professionals. <
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>Prior to the inclusion or incorporation of these or any other externally reproduced guidelines, the ESRD Network recommends that the governing body, and if applicable legal counsel, review the document for any legal implications.<
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>Published by the ESRD Network of Texas, Inc. under contract with the Centers for Medicare and Medicaid Services (CMS). The contents presented do not necessarily reflect CMS policy. Distributed October, 2002. <
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>This guide available at
http://www.esrdnetwork.org./ <
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>Non-Compliance Facts<
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>FACT: Almost 30% of all hospital admissions are directly attributable to medication non-compliance <
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>FACT: 125,000 people die each year from non-compliance, twice the number killed in automobile accidents <
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>FACT: Poor compliance with medication regimens costs society $150 billion per year <
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>FACT: Approximately 40% of people entering nursing homes do so because they are unable to self medicate in their own homes <
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>FACT: About one-half of the 1.8 billion prescriptions dispensed annually are not taken correctly, contributing to prolonged or additional illnesses <
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>FACT: At the present time, more than 7 million households have an unpaid "caregiver" who is providing daily assistance to a family member age 50 or older <
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>Sources: Archives of Internal Medicine, 1990, 150: 841-845; Archives of Internal Medicine, October, 1995; Biomedical Business International, January, 1988; Family Circle, 6/25/91. <
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>INTRODUCTION <
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>By Ramiro Valdez, PhD, Patient Services Coordinator<
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>"Non-compliance" is almost a way of life with some Americans. Many people with diabetes, for instance, do not monitor their insulin as they know they are supposed to. A lot of people do not take antibiotics for the full duration (usually ten days) as they have been instructed. Most Americans do not exercise or eat right even though they know they should. Being diagnosed with End Stage Renal Disease seldom changes this pervasive behavior. <
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>Most dialysis patients overload on fluids or "cheat" on their diet from time to time. While this can be a problem, in most cases the staff can see that the patients are making a sincere effort to follow the regimen. There are some patients, however, who flagrantly disregard the medical regimen and make it clear to the staff they have no intention of following it. For these few patients their non-compliance is not only risky, but it also makes it difficult for their doctors and renal staff to continue working with them.<
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>While the temptation may be to dismiss these patients, it is important to recall that their refusal to follow the regimen may be in and of itself a symptom. They may have psychological or emotional problems that will not allow them to develop insight. <
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>They may have psychosocial stressors unknown to the staff that prevents them from cooperating. Or they may have experienced a recent life change event that changed their desire to be healthy or their ability to cope. Finally, some of these patients may not have a good reason for refusing to attend all treatments; they just miss treatments. <
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>Whatever the reason for non-compliance, it is best to do everything possible to eliminate any deterrents to compliance and to enhance those factors that will encourage it. This will take some time and effort but can be extremely rewarding when the staff see a change in the patient's behavior. <
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>The following steps are suggested as a way to intervene with patients who repeatedly skip treatments without a reasonable explanation or who repeatedly sign off before their dialysis treatment is complete. These steps are not all - inclusive and if there is something else a staff member can envision, it should certainly be tried. Also, the order of these steps is dynamic; if staff find that doing one step prior to another is more effective, then it should be done this way. Finally, the steps are not absolute; if one particular step does not apply, feel free to skip it. <
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>THE GOAL OF THIS INTERVENTION EFFORT IS A CHANGE IN BEHAVIOR LEADING TO ADEQUATE DIALYSIS AND, THEREFORE, AN IMPROVEMENT IN THE PATIENT?S HEALTH. THIS IS NOT INTENDED AS A DISMISSAL PROCESS.<
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>The ESRD Network of Texas stands ready to consult with any staff member in working with non-compliant patients. Through our combined years of experience it may be that one of us has come up with a solution that your staff has not tried. Please call your Network at (972) 503-3215 and ask for the Patient Services Director, the Quality Management staff, or the Executive Director, and we will be glad to help. <
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>SUGGESTED STEPS IN AN INTENSIVE INTERVENTION<
>WITH NON-COMPLIANT DIALYSIS PATIENTS<
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>?Treatment Team Consensus: The treatment team should discuss the patient's behavior during either care plan review or a QI meeting and reach an agreement that the behavior is a problem and that an Intensive Intervention is needed. <
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>?Complete a focused psychosocial history, with the focus being an assessment of some possible causes of the present problem. <
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>a.Assess for peripheral contributing problems such as: <
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>i.Loss of income <
>ii.Transportation problems <
>iii.Marital discord <
>iv.Illness in the family <
>v.Conflicting family obligations (i.e., babysitting/care giving)<
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>b.If any psychosocial problems are found, address immediately. <
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>c.Evaluate for improvement (See Appendix A for evaluation procedures); if there is no improvement, proceed to another step. <
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>?Rule out significant life change events (LCE): <
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>a.An LCE is an event that will result in changes in coping or adapting skills for several weeks to several months. Some LCEs are: <
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>i.Death in the family <
>ii.Divorce <
>iii.Problems with the police or going to court <
>iv.Change in housing <
>v.Hospitalization/new illness <
>vi.Loss of primary caregiver <
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> For a more extensive list of LCEs see Appendix B <
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>b. If any LCEs are identified, help the patient either through a referral for assistance outside the clinic or through staff assistance. <
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>c.Evaluate for improvement; if there is none, proceed to another step. <
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>?Eliminate (whenever possible) the discomforts of dialysis. <
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>a.Patients often "hate" to come to dialysis or else cut the treatment short because they are so uncomfortable during the treatment; check for: <
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>i. Restless Legs Syndrome<
>ii. Pain <
>iii. Being too cold <
>iii. Patient/staff friction <
>iv. Need to eat (especially for people with diabetes) <
>v. Need to smoke <
>vii. Restroom use <
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>b. Address each of these "discomforts" on a case-by-case basis. <
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>c. Evaluate for improvement; if there is none, proceed to another step.<
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>? Convene a meeting with the patient and the treatment team to discuss the harm of skipping/shortening treatments. Invite the family if the patient agrees. Wait two or three weeks. If there is still no improvement, proceed to another step.<
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>? Have the social worker or another staff member develop a "therapeutic alliance" with the patient, where the two work together to achieve adherence to the regimen. <
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>a. Meet with patient weekly or every time s/he comes. <
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>i.
Repeat time and again the benefits of dialysis in simple terms. (For a review of Patient Education Techniques, see Appendix C).<
>ii. Attempt various techniques in patient education. <
>iii. Be certain patient understands consequences of non-compliance. <
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> b. Evaluate for improvement; if there is none, proceed to another step.<
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>? Mobilize the patient mentor program in your clinic and have a fellow patient meet with the patient to discuss adherence to the regimen.<
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>a. Before setting up the meeting, ask the mentor if s/he is willing to do this and ask the non-compliant patient is s/he is willing to talk to the mentor. If either refuses, do not do this.<
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>b. If both agree, facilitate the meeting and offer support and resources to the mentor as usual. <
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>? With the patient?s permission, include the patient?s family:<
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>a. If the patient has no immediate family, include any significant other that is listed in the current psychosocial assessment.<
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>b. The family can be made aware of the seriousness of the patient?s inadequate dialysis treatments.<
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>c. If the patient does not approve of the family or friends being involved, proceed to another step.<
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>? Enter into a BEHAVIOR CONTRACT with the patient. <
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>a. For instructions on writing a contract refer to Nephrology News & Issues, April 2002 (or call the Network for a copy). <
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>b. Assign a staff member to help patient achieve the goal; any staff member can serve in this role. Ideally it would be the doctor, nurse, or social worker, but it can be the dietitian, PCT, or any other staff member. <
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>c. Monitor over 30, 60, or 90 days. <
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>d. Evaluate for improvement; if there is none, proceed to another step. <
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>? Have the nurse or social worker write the patient an informal letter of voicing concern that this behavior is self-destructive and could have long-term effects; wait two or three weeks. If there is still no improvement, proceed to another step. (See Appendix D for an example of such a letter.) <
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>[This will need to be done verbally with patients who cannot read; patients with limited English-reading skills should receive the letter in their own language if possible or have it translated into their own language.]<
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>a. With the patient?s written permission, send a copy of the letter to the patient?s family.<
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>b. If the patient will not give permission, do not inform the family about this letter.<
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>c. Wait two or three weeks. If there is no improvement, proceed to another step.<
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>? Review the problem with the entire treatment team in QI or care plan meeting and write a formal letter of warning from the medical director or attending physician (see Appendix D for an example letter); at this time write in bold, capital letters a warning stating that <
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>?Continuation Of This Behavior Could Result In Your Being Placed On Another Shift, And/Or We May Wait Until You Are Actually In The Clinic Before We Set Up Your Machine. This Could Mean As Much As A Half Hour Wait On Your Part And Possibly A Shortened Treatment Since You Will Be Taken Off Dialysis When The Shift Is Over.?<
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>[For patients who cannot read, this warning will need to be given verbally. Patients with limited English-reading skills will need to have the letter written in their native language or have it translated for them.] NOTE: Be sure to take extenuating circumstances (such as transportation) into account. Ask the patient in this letter to meet with the doctor or any member of the treatment team to discuss the problem. Wait another two or three weeks. <
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>a. With the patient?s permission, include the patient?s family in this discussion. <
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>b. If the patient?s family cannot be included in the discussion, with the patient?s permission, inform them of the contents of the letter.<
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>? Discuss the problem a third time in QI or care plan meeting and determine if the problematic behavior is totally unacceptable to the staff or disrupts the orderly functioning of the clinic. <
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>a. If the answer to the above is "no", consider changing the patient's dialysis time to another shift.<
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>i. Inform the patient of the team's decision to change times and that s/he will have to wait to have his/her machine set up before each and every treatment. <
>vi. Do not set up the dialysis machine for the patient until s/he walks in the door (the patient will have to wait).<
>vii. If the patient shows up late for a treatment and your clinic closes or another shift is scheduled before his/her treatment is complete, stop his/her dialysis at the end of the shift. It was the patient?s choice to shorten the treatment.<
>viii. Continue the therapeutic alliance efforts, as described above, and document the efforts. <
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>b. If the answer to the above is "yes," change the patient's dialysis time as instructed<
> above, contact the ESRD Network and ask for assistance in continued intervention<
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>APPENDIX A<
>EVALUATION OF PROGRESS<
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>Evaluating the progress of the Intensive Intervention involves both a qualitative and a quantitative measurement. Both need to be considered equally. The qualitative measurement involves the observation by the staff, especially the patient?s ?ally? if there is one, as to the effort the patient is making. One patient may be cooperative, make an effort, and show a desire to change, but has a hard time achieving the goals. Another may be cavalier about the plan, ignore efforts to help and disregard the suggestions of the staff. Still a third may defy the plan entirely and even blame the staff for not doing their jobs as the reason s/he does not come to dialysis. A crucial factor is to evaluate whether the patient is working with or against the staff. Some patients actually could change if they wanted while others just do not want to make the effort. Certainly the patient who shows an attitude of cooperation and willingness to work with the staff should be given every opportunity to do so. On the other hand, the patient who is able but unwilling to change should be moved quickly through the steps of the plan.<
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>The quantitative measurement involves tallying the number of hours of dialysis the patient receives in the present month and comparing this total to the number of hours in the previous month. If the patient has made some gain, remember that even one hour more than the previous month represents progress!<
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>If the patient has made a small progress, one to four hours more than last month, continue on the same step with the same plan. Give the patient lots of praise and positive reinforcement. Brag to fellow staff members about how well the patient is doing. Have the doctor mention it on rounds. Mention to the patient that any change in behavior which is going to last a long time is going to be slow. Continue with the same intervention and encourage the patient to continue with the small but meaningful progress.<
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>If the progress is substantial ( four hours more than the previous month, but still short of the prescribed time), stay on the same step but try another intervention. Review the types of patient education techniques (Appendix C) and try a technique other than the one you have been using. The present technique has most likely reaped all the benefits it is going to because it led to a substantial progress. Another technique should be attempted within the same step.<
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>If the patient has become compliant, continue on the same intervention technique, but meet less often with the patient and at different times. Do not meet weekly, as before, but meet at various intervals. Further, if you always met with the patient on a Wednesday, try a Monday or a Friday instead. Change the approach you are taking, but keep the intervention technique the same for at least another month. If the patient continues doing this well after a second month, you can discontinue the Intensive
Intervention. The stages of readiness can be assessed and utilized in evaluating progress. (Appendix F)<
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>When both the qualitative and the quantitative measurements are made with the patient, the patient who is trying but not succeeding can still feel that s/he has gained some ground. This gain is in the area of social reinforcement with the staff recognizing that the patient made a good effort.<
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> APPENDIX B<
>A LIST OF LIFE CHANGE EVENTS<
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>This list of Life Change Events (LCEs) has been taken from the Holmes and Rahe Social Readjustment Rating Scale. It includes typical LCEs that most people in our society may experience at one time or another in their lives. Most dialysis patients experience some LCEs when they first start dialysis. The initial psychosocial assessment addresses these and helps the patient adjust to life on dialysis. Thus, this list is intended for those patients who are past their initial adjustment. The patient who is non-compliant from the start requires intensive patient education and help with adjusting to dialysis, not an assessment for Life Change Events.<
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>Although the LCEs are common, they can still affect our lives in various ways. LCEs may result in an inability to handle daily problems with our usual coping skills. Routines frequently become disrupted and things that were previously important may take a back seat. Doing routine chores, such as making arrangements for a ride, become almost insurmountable. This is due to the extreme stress of some of these events. The stress of any one of these events may continue from a few days to a few weeks. Because our usual coping skills do not work for a short time, other daily stressors, which would usually not disrupt our daily lives, may now do so. It is anticipated that within a few days to a few weeks the stress of the LCE will wear off or the patient will achieve a new level of functioning that will allow him/her to cope once again with daily problems. It usually takes about six weeks for scar tissue to form, both in our bodies and in our emotions! If the stress and inability to cope with the LCE continues longer than a few weeks a referral for psychological help is indicated.<
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>The Holmes and Rahe Social Readjustment Rating Scale can be administered and scored by a professional to determine the level of stress a patient may experience. Most dialysis patients experience some of these events, such as ?business readjustment? or ?change in financial state,? at the onset of dialysis. This list does not include a scoring sheet, as it is not intended as a psychological test, but merely a review of some of the events that could affect the daily coping skills of our patients and could result in non-compliance. The LCEs are listed in order of severity. Most dialysis patients experience some of these events at the onset of dialysis.<
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