Compliance

[michaelhansonRN]

Compliance in Healthcare

Sunday January 24, 2016

In Healthcare, the word compliance describes how well a patient adheres to prescribed Plan of Care. This includes taking medication appropriately, following dieting recommendations, performing treatments as ordered, and even using medical equipment as intended or ordered.

Compliance is one of the biggest challenges healthcare professionals face today in all areas of practice. From a personal standpoint, I don't see that patients are trying to be complicated or deliberately do the opposite of what they're asked, but more that they are settled in their lifestyle and just like most of us, change can be difficult. Compliance in Wound Care, just like other specialty practices is of utmost importance and can cost a person a limb or even his/her life if for whatever reason the prescribed plan of care cannot be followed.

One example of non-compliance might be a middle-aged female being seen in the clinic for bilateral leg edema and Venous Ulcers to both legs. This patient is about 550 pounds, living a sedentary lifestyle, and suffers from several comorbid conditions, such as Diabetes, Hypertension, Venous Insufficiency, Venous Hypertension, and Acquired Lymphedema. She has had ulcers on both legs for several months and instead of improving, they are getting worse.

At each visit, we assess the patient as a whole, realizing if dressing changes are being done properly, if appropriate infection control measures have been taken, if medications are being taken as prescribed, and etc. We also determine if Case Management needs are being met, such as having home care services in place, DME supplies in the home, and Wound Care supplies readily available. We often find that there are several reasons that patients become non-compliant with care.

A significant issue in healthcare is the patient's lack of knowledge. It is our responsibility as providers to ensure that the patient(s) understand what their problem is, what we are doing about it, and why we choose the treatment plan we chose. Often times, once these items are understood, patients make sense of the overall picture and are much more inclined to do what they are asked, rather than simply being sent home with a follow up appointment and an instruction sheet on how to change a dressing. We must consider that our patients are typically not knowledgeable in medical items and if they were, they may not have come to us for help.

Another concerning issue is the fact that insurance plans cover a given amount of supplies/equipment and once that number is exceeded, the patient is forced to purchase supplies on their own, which is often times not possible, causing the patient to keep the same dressings on, even when saturated with wound exudate, or to remove the dressing and rig up some cover dressing from paper towels or even toilet paper.

This particular patient had a Managed Medicaid and needed very aggressive care. This patient was compliant in the beginning days of treatment, but became frustrated and depressed when she saw no results and felt she was not getting what she needed from her insurance. Her ulcers drained constantly, saturating dressings, clothing, and even furniture. There was so much drainage that the dressings eventually fell off several times and they were covered with paper towels and chucks. Animal hair began getting in the ulcer beds due to lacking the appropriate dressings; and eventually the ulcers became infected. The patient needed to decrease the edema (swelling) in her legs, keep her ulcers covered, and keep away infection, while still being able to perform her Activity of Daily Living (ADLs) such as toileting, bathing, and etc.

We were able to get home care involved, the patient had a pneumatic compression pump (edema pump), offer some donated supplies (not nearly enough), and sit with the patient for about an hour simply explaining how each medical problems she suffers from is effecting her as a whole.

We attempted to order a hospital bed to allow appropriate leg elevation, but it was denied with the reason being that there were no upper body problems and that leg edema and circulatory issues were insufficient. We attempted to complete prior authorizations for additional wound supplies to treat the ulcers and repeat multi-layer compression, but were told she could have one ACE wrap, and a couple Coban each month. Realizing she had Medicaid, we already knew she was unable to purchase dressing supplies, totaling $50-60+ for each treatment, which at times were having to be done daily. Once the donated supplies were gone and all of the denied items were finalized, she became somewhat depressed and felt she had no reason to keep trying. She then stopped taking her diuretic (water pills) routinely and according to the home care nurse, began letting her ulcers seep all over the furniture and floor in her home.

A couple visits later the patient came in, still the same situation with uncontrolled edema and lacking dressing. This time the ulceration on her left posterior/lateral leg was black. This black was not an eschar that we could remove through a debridement; but instead was black from dying tissue. Again, we sat for a great deal of time explaining to this patient what had to be done to gain control of the edema and heal these ulcers. We went on to explain that failure to follow this plan of care could have life-altering effects. We explained that her tissue was now dying due to infection and such significant swelling. After seeing this black leg and hearing again that she may lose her leg or even die, she became concerned. She made some changes at home to allow her to save enough money to buy additional supplies for dressing changes, and she developed a way to keep her legs about eight inches above her heart the entire week, except when she had to go to the restroom.

After focusing in on the ultimate goal and making up her mind to do it, this patient spent just one week doing what she was asked (keeping legs elevated, taking prescribed diuretics, keeping compression wraps on, using the edema pumps as ordered, etc.) and she came back the following week with s significant decrease in swelling and her ulcers were about half the size of the week before. In addition, the black tissue was re-oxygenized by decreasing the edema and was nearly normal in color at her return. As soon as she learned that her edema was measured with fantastic results, and that her black leg was now nearly normal, she lit up” and became very excited. She was ecstatic to see such a dramatic improvement just in one week. She promised to continue with her treatment regimen and has agreed to diet to lose weight and be more proactive in her care.

As noted above, this patient was in a peculiar situation with multiple obstacles to overcome. The circumstances are not always this unfortunate, but they certainly do occur in a less-than-desirable frequency. It took an entire team of healthcare professionals (Wound Center overseeing and treating the edema and ulcers as well as providing on-going education, the Primary Care Physician to prescribe diuretics and oversee weight, Endocrinologist to adjust diabetic medications and oversite of Diabetes, Home Health Agency to provide Skilled Nursing Services and Case Management, and multiple others who became involved in simply listening to her voice concerns or vent” for a while) a couple of months, working together for the same goal to get this patient moving in the right direction. It can be frustrating when the patient doesn't seem to care about him/herself or when it seems it is a constant fight with insurances, or even that you are literally losing money by investing so much time, energy, and focus into offering appropriate care to a patient when he/she doesn't seem to care and when you're unable to get even close to what the patient needs in supplies.

It is important to be proactive and diligent in ensuring that our patients are compliant with care. When we learn that they are not, then it is our responsibility to determine why. Once we determine why, we must intervene and do our best to turn the situation around. We CANNOT give up on our patients and we cannot drop the ball or be lazy when it comes to meeting their needs. We are sometimes their only advocate and their only means of support, so we need to treat them the way we hope someone treats our parent or grandparent someday. Additionally, patients MUST gain an understanding of their disease or problem. They must understand what it is, what treatment options are, and be involved in deciding what plan of care works best for them. If they agree to a plan of care or assist in developing a treatment regimen, they are empowered and will be more apt to engage in doing what is expected.

[nutella, MSN, RN]

You make good points and touch several challenging situations.

Personally, I do not use the word "compliant" , I use the word "adherence" because the word compliance has a negative connotation and often is also understood as "the patient not trying enough".

When a patient does not adhere to a tx plan it is important to get a multifactorial assessment to find out if there is anything that could help.

Literacy level, financial needs,mood and lifestyle can play a role - sometimes patient plainly just do not want to follow a recommendation. In home care I often found that depressive mood played a role as well.

While I think it is always worth looking into the situation there are some situation we can not change no matter what and we can only continue to treat those patients with dignity and practice to be non -judgmental (even though that may be hard at times).

When I worked in acute dialysis there were plenty of patients who would skip dialysis tx in their chronic unit and come to the ER in the middle of the night or on a Sunday with chest pain, shortness of breath or heart rhythm problems due to inability to adhere to the very strict regimen of fluid restriction, diet, and dialysis tx. Yes, I tried my best to educate and find out why somebody would not get their tx or skip but often there was no solution to the dilemma. Instead of giving those patients are hard time I would get them out of the ER asap or dialyze them in the critical care area and ensure them that I was doing my best to help.

Anyhow, it is good that you have compassion.

[VivaLasViejas, ASN, RN]

Excellent post. Welcome to Allnurses!

[Farawyn]

Seriously refreshing, OP. Thanks!

[michaelhansonRN]

Hey there. Thank you for your response. I have never thought about using "adhere" rather than comply, but can certainly see your point of view.

I was talking with someone just this evening about the challenges in the home care setting. Most nursing specialties focus on care provided in controlled settings where there are other staff and plenty of supplies/equipment. Additionally, there are typically several patients to care for simultaneously, whereas in the home care setting, the nurse is the primary care provider at most times. He/she is the one who builds that trusting relationship with patients and their families and has more interaction than the physicians, making it imperative that he/she be "on their game" and able to control unstable situations and deal with all aspects of care, including physical, mental, and even emotional. I am new to this site and am yet to learn to maneuver it, but I would love to read some things that you have written if you can provide instructions or a link :) Again, thank you for your response and I look forward to learning from you.

[michaelhansonRN]

Thank you very much. I have heard of the site for a while, but didn't really take the time to explore it. It's a pleasure meeting you :)

[michaelhansonRN]

Thank you for reading :)

[Farawyn]

OP, if you want to respond directly to a poster, please use the Quote feature on the bottom right of your message box, thanks!

[dishes, BSN, RN]

When it comes to healthcare teaching, I stopped using the terms non-compliance and non-adherance, instead I use the terms shared decision making and full informed consent. My goal when I teach, is not to have the patient comply with the recommended treatment plan, but to have the patient and family demonstrate or verbalize their understanding of the risks and benefits of their healthcare choices.

During my base nursing education, I was taught what to teach, but not taught how to teach patients and families. Now I focus on how to teach in a style that a patient can best learn from, whether it is visual, auditory, tactile or reflective. (I have found a large number of people are visual learners and often use diagrams while teaching). I try to get the patient to teach back the information to me, so that I can be assured that they truly do understand and are making informed decisions.

Some resources that I have found helpful are No Time To Teach by Fran London and Health Professional as Educator by Susan Bastable et al

[michaelhansonRN]

Very nice. Thank you for your input!

[nutella, MSN, RN]

Like always - the devil is in the detail!

Home care is only for home bound patients (unless it is home hospice, in which case home bound does not matter). In addition, home care nurses have a certain productivity, means that they have only a certain time per visit. For patients with complex issues and perhaps family and social financial problems a team approach is really best but sometimes difficult to realize.

Plus there is still the primary care provider who directs care and sometimes they are not very responsive.

It all comes down to the fact that in our society we face a a lot of challenges in general and money is tight in health care.

[michaelhansonRN]

I can certainly relate to difficulty reaching PCPs for info. I'm sure it's much more involved on your end. I think HH is a special area of practice and definitely not everyone! Thank you for your response.