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.
Farawyn
12,646 Posts
Or, don't use the Quote feature...