5 Ways to Improve Medication Adherence in Chronic Care Patients

What is keeping patients from using their meds?

There is a litany of reasons why patients don’t take their medications: the patient forgets about the medication, she can’t afford the medications, she has a mental barrier or stigma associated with the med, or she is fearful of an adverse side effect.

Regardless of the reason, providers need to begin medication adherence improvement efforts by uncovering these roadblocks.

“People don’t wake up in the morning and think ‘I’m not going to follow what my doctor told me to do today,’” asserted Lisa Roome-Rago, Director of Enterprise Outpatient Care Management at Advocate Health Care, in a previous interview. “It’s a matter of figuring out what’s actually going on and then trying to create a plan around that and minimize as many barriers as you can.”

Providers cannot simply tell patients to take their medications or give arbitrary instructions. This will not eradicate patient barriers. Instead, providers need to use their communication skills to probe patients about what keeps them from taking their medications and then develop strategies to overcome these challenges.

Set up reminders, organizational systems

Medication management poses a significant threat to all chronic illness patients. Patients lead hectic lives and remembering to take a medication often falls by the wayside.

Health IT presents numerous opportunities for helping patients to remember and manage their medications. Chronic care self-management apps can, among other things, send reminders to patients to take their daily pills.

One April 2016 study showed that these apps drive better medication adherence, with 80 percent of study participants responding to text message reminders.

However, this strategy isn’t always effective for older, nonwhite patients of lower socioeconomic status. This is likely because of late technology adoption, lower health literacy, and more hopelessness with their conditions. After identifying these reasons, smartphone apps can be adapted to certain patient populations.

Providers can also encourage patients to develop a consistent medication management routine without using technology.

Does the patient take her medication with breakfast? She should follow that pattern and keep her pills where she goes every morning while preparing her meal.

Sticky notes are helpful for patients who prefer visual reminders and medication synchronization is beneficial for patients managing multiple medications.

Strategies as simple as using pill boxes can also improve medication adherence and management. At Cincinnati Children’s Hospital, David Hooper, MD, MS, Medical Director of Kidney Transplantation, has tapped a Bluetooth pill box that helps hold patients accountable.

The pill box sends doctors a remote monitoring message each time the patient opens the pill box, providing doctors with the information necessary to detect adherence issues.

Of course, this tool is not useful for all patients. Some might perceive the pill box as a “Big Brother” surveillance effort and be resistant to the idea. It is important for providers to work with patients to determine how a medication management strategy will adhere to patient preferences.

Identify cost-cutting strategies

High drug costs are plaguing the entire healthcare industry. A recent report from Consumer Reports Best Buy Drugs showed that 25 percent of patients are paying more for their medications than ever before, and 14 percent can’t fill prescriptions due to high costs.

Medication subsidies may help improve medication adherence. A 2017 study showed that patients who received Medicare Part D subsidies were more likely to take their medications than those without the subsidies. Sixty-nine percent of black patients, 70 percent of Hispanic patients, and 61 percent of white patients receiving the subsidy achieved full medication adherence by study’s end.

These results were likely because subsidized medications are cheaper, coming in at around $10. Those without subsidies faced costs over $100.

Policy should be such that all eligible patients are accounted for in the subsidy program, the researchers said.

“The substantially higher persistence and adherence among women of all three race or ethnicity groups enrolled onto the Medicare D Low-Income Subsidy should lead to further efforts to ensure all eligible women are enrolled,” the team noted.

Additionally, clinicians or care managers should help patients find ways to reduce copayments, according to Advocate’s Roome-Rago.

“If a care manager can reduce a copayment of $500 to $20, that is a huge win for a patient and it really helps with that value proposition and allows the manager to do something that is meaningful for that patient,” Roome-Rago said.

Providers need to take careful consideration when uncovering cost barriers, said David Weinstock, MD, a primary care provider at Grove Medical Associates. Using strong interpersonal skills will help doctors discover cost challenges for patients who are embarrassed to discuss money matters.

“Patients don’t always like to admit that they’re having trouble with payments,” explained David Weinstock, MD, a primary care provider at Grove Medical Associates. “The way to overcome these barriers is by working with the patients. I usually ask them more than if they’re taking their pills. I try to get a little more information from patients like if they’re taking pills, how they’re getting them, where they’re getting them.”

If he discovers a cost barrier, Weinstock works with the patient to find the most cost-accommodating pharmacies for patients or helps the patient prioritize her medications.

Address mental barriers and stigma

Many patients also face their own mental barriers or fears of stigma that keep them from taking their pills.

Some pediatric providers have found that adolescent patients are resistant to taking their medications in front of their peers, many of whom don’t have to manage a chronic illness.

Other studies have indicated that patients’ preconceived notions about medication can keep them from following their regimens. Researchers recently surveyed 343 patients and found that over half had poor medication adherence.

Fifty-two percent of patients reported negative beliefs associated with taking a medication. Those patients were about half as likely to take their medications as those with positive or neutral beliefs.

“The most commonly reported negative belief about medicines was fear of dependence, but this did not have the greatest association with adherence,” the research team wrote. “Though reported less frequently, if patients did not feel that their doctor understood them or if they were taking alternative medications, they were less likely to take medicines as prescribed.”

Mental barriers were about equally as prevalent as external barriers, such as cost or side effects. However, mental barriers were significantly more pervasive.

These findings pose a considerable challenge to providers because they must employ strong interpersonal skills to help a patient overcome a preconceived notion. Instead of leveraging external solutions, they must change a patient’s mind, which can be difficult.

Providers can work to overcome mental barriers and stigma with patients by using motivational interviewing and coaching.

Direct symptom, side effect management

Sometimes barriers to medication adherence are as simple as not liking the medication. Some adults may be averse to side effects that can be managed, and many pediatric patients struggle with meds that don’t taste good or are too big.

“I was in with a patient the other day and she identified that it’s hard to swallow pills on her assessment,” said Hooper, the kidney specialist from Cincinnati Children’s. “We talked about that and went to her pill box and she showed me one very large pill. With some sleuth work, we realized that we could prescribe two small capsules instead of one large capsule for her, so we could overcome that variable.”

This strategy was helpful because Hooper did this with the patient by his side. Developing this strategy read more like a conversation, which put the patient in the driver’s seat. If the patient had thought Hooper was an enforcer of taking medication, it may not have been successful.

Hooper has also worked to develop more palatable pill coatings to assist young patients who don’t like the taste of their medications.

Although these problems are more prevalent in children, adult providers should also be aware of issues, specifically those surrounding pill size. Warning patients are asking about their preferences will be helpful.

Ultimately, approaches to overcoming medication adherence barriers must be patient-centered. Most medication challenges are unique to the individual patient preferences. As such, providers need to use unique strategies to help patients.

Clinicians should start by identifying the patient’s challenge, and then work to overcome it. This will ideally result in better medication adherence and stronger overall patient wellness.