BUNCH OF CRAP
Joined: 20 Jul 2003
Posts: 1
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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