Page 919 - Cardiac Nursing

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Table 40-2 ■ STRATEGIES TO ENHANCE ADHERENCE ACROSS THE FOUR CATEGORIES OF FACTORS
AFFECTING ADHERENCE
Determinants Strategies
Patient related
Prior adherence behavior If history of nonadherence, monitor appointment keeping, reinforce importance of adherence to prescribed treatment/
intervention from initiation to maintenance phase, provide reminder of appointment (phone call, postcard, elec-
tronic mail), immediately follow-up on every missed appointment to prevent patient dropping out of system.
Self-efficacy, self-concept Instill in patients confidence they can achieve treatment goals; implement self-efficacy enhancing strategies: set
specific, short-term, attainable goals, provide opportunities for practice, provide credible models performing simi-
lar behaviors via use of videotapes or classes, verbally persuade patients they are capable of achieving treatment or
adherence goals, provide feedback on accomplished behavior changes.
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Presence of social support If applicable, include other support in education and counseling, assist patient to enlist support of others (e.g., have
an exercise “buddy”).
Knowledge and comprehension of Provide instructions in small amounts over time, follow up with printed materials, reinforce over time, and regularly
treatment regimen assess patient recall and understanding.
Skills to implement treatment Assess patient’s skill, use self-monitoring to reveal baseline habits; refer for training as needed, e.g., dietitian to learn
regimen how to make dietary changes. Ask patient to describe how to do something, e.g., how to take several medications
that may require specific time intervals between doses.
Low literacy level Provide explicit instructions in basic terms, keep instructions brief and use simple terms, ask patient to restate
instructions, assess patient’s recall and comprehension of new concepts. Use color coding to help identify concepts,
e.g., green for permissible foods, red for foods to avoid and yellow for ones to limit. Apply a similar rule for
reporting symptoms. Demonstrate as much of regimen as feasible.
Cognitive impairment Provide simple instructions with a copy in writing, teach patient how to use cues, set up reminder systems, use pill
organizers; include significant other in counseling sessions if possible. Keep instructions brief and simple.
Impaired vision or hearing Let patient know you are approaching and identify self, speak slowly and in a normal voice, face patient when
speaking; use visual aids with large print and pictures, provide video aids to reinforce materials. Enlist assistance of
person to assist patient with limitations, e.g., remove pills from bottle and place in pill organizer, use labels with
large print on medicine bottle.
Conscientiousness Commend for attention to details of following regimen and for adherent behavior.
Motivation Assess if ambivalence is present; if so, apply strategies guided by motivational interviewing. Provide frequent
reinforcement for positive behaviors as a means to maintain motivation.
Older age and living alone Involve available support system in educational and counseling sessions, arrange for home visit follow-up. When
possible, set up telephone follow-up plan.
Satisfaction with provider and Convey a nonjudgmental attitude when assessing adherence, maintain an open dialogue, develop treatment plan with
care received the patient’s input and assess satisfaction with treatment plan over time.
Health literacy Prepare the reading materials that match with patient’s literacy level, ask patient to restate instructions, assess patient’s
recall and comprehension of new concepts.
Ethnicity Ask the person about cultural or religious customs that have implications for treatment adherence. Develop a
regimen plan acknowledging cultural preferences; be sensitive to religious implications for dietary restrictions. De-
termine the extent that the person understands English and obtain assistance when indicated.
Regimen-related factors
Prescription size/duration, stability of Ask the patient about ability to have prescriptions refilled monthly vs. every 2 to 3 months, and the rules for copay;
regimen over time write prescription according to what best fits patient’s needs. Acknowledge the challenge of taking medication; pe-
riodically reinforce importance of maintenance of adherence, provide rewards, reduce visit frequency, consider
phone follow-up with longer intervals between visits.
Cost Prescribe less expensive or generic brand and seek sources for additional help.
Presence of side effects Assess for presence of side effects, discuss how they can be managed, if necessary modify treatment plan.
Presence of comorbidities leading to Be aware of the complexity that polypharmacy and multiple lifestyle changes add to a regimen, set priorities for what
polypharmacy needs to be addressed in treatment, introduce additional components as time and condition permit. Emphasize the
importance of not missing pills that are once daily.
Provider-related factors
Communication style and attitude of Actively listen and demonstrate sensitivity to patient’s feelings and situation, respect patient’s right to exercise choice,
provider use patient-centered counseling strategies and seek the patient’s input.
Continuity with health care providers Develop system to provide continuity in service where patient’s treatment goals, regimen components and progress
(lab values, weight) are recorded for easy review.
Provider’s teaching/counseling skills Use nontechnical language the patient can understand, ask patient questions to assess comprehension. Augment the
printed material with discussion of its content; determine if patient has read it. Follow-up and ask patient about
recall over time. Seek education/training in improving counseling skills.
System-related/process-oriented factors
Ease of arranging/receiving care Reduce the length of time patients need to wait to get an appointment, reduce waiting time in clinics. Facilitate low
turnover of staff, involve staff in patient related activities, have staff assist/reinforce adherence message.
Availability of reimbursement or Develop treatment regimen that fits within patient’s insurance plan and reinforce the importance of adherence.
amount of required copay for
services, drugs
Ability to follow and track patient’s Develop system for practice/clinic where patient’s treatment goal, regimen components and progress (lab values,
progress toward goal weight) are recorded for easy review. If possible, provide patient a copy. Create reminder system. Use telemedicine
strategies to follow patient between visits.
Supportive environment for Have prompts and reminders on patient record to remind provider and staff to follow up on adherence, e.g., have
adherence-enhancing strategies patient complete brief questionnaire to track patient’s progress or changes in lifestyle habits while waiting for ap-
pointment. Have educational materials available to give patients, video films for patients to watch in the waiting
room, e.g., how to prepare low fat meals, how to shop for healthy eating, how to exercise properly. Incorporate
nursing case management system into clinic.
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