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The Provider-Patient Relationship
Adherence to medication regimens is critical to patient outcomes, yet of every 100 medicines prescribed in a clinic or office, 88% of the prescriptions are actually filled, 76% are started, and less than half – only 47% – are continued.1 While a variety of factors affect adherence, research shows that physician contact and provider continuity are important determinants of long-term medication persistence.2 For example, adherence is higher among patients who see the same healthcare provider each time they have a medical appointment, with this group’s adherence rate averaging 81%.3
While evidence confirms that providers play a vital role in adherence levels, several important barriers have limited healthcare professionals’ efforts to improve medication use among their patients. First, most physicians lack up-to-date information on their patients’ use of medication and may be unaware of which of their patients are at elevated risk of non-adherence. Second, given the many demands on their time, physicians and their office staff may lack the resources and capacity to fully manage non-adherence in their patient population. Finally, physicians may not have or know how to access practical tools or information that will help them foster medication adherence. Recent industry developments, however, are lessening these hurdles and encouraging providers and payers to elevate the role of medication adherence in their strategic plans:
The transition from a fee-for-service to a quality/outcomes-based payment structure means that financial reimbursement is tied to quality improvement metrics. Providers and payers recognize that they must approach Medicare Star Ratings, medication adherence and other care gaps in a much more deliberate, collaborative way in order to optimize reimbursement and stay competitive.
Web-based technologies are now available that allow providers to identify and target only those patients who need the most help and whose medication adherence will enhance the performance of a population. With access to near real-time, patient-specific information – along with tools to manage patient adherence – meaningful medication adherence programs are now a feasible proposition.
Transformations in the healthcare system, including Accountable Care Organizations and other innovative delivery models, are bringing a new focus on coordinated care in the community. This team-based approach to healthcare offers opportunities for multiple touchpoints to influence patients’ adherence to treatment plans.
Forward-thinking provider organizations are establishing the organizational models, workflow patterns, and policies and protocols to support their medication adherence programs. But they are also discovering approaches – from training care coordinators on motivational interviewing to enlisting an influential physician to champion the program internally – that are ensuring medication adherence success. Through its experience in working with provider and payer organizations that are realizing adherence improvements, RxAnte has gained insight on best practices and strategies on the front lines of these quality-focused efforts.
Reconciling the “Population Health” Focus and the “Individual Patient” Focus – A Multi-Disciplinary Approach to Medication Adherence
Medical practice consolidation and the integration of hospitals and physicians continue at a robust pace as provider organizations look for economies of scale and competitive advantage. Becoming part of a larger organization – whether through acquisition/merger with a healthcare system, payer organization or another physician group – can offer consolidated administrative services, expertise in negotiating risk-sharing agreements , and access to advanced software and process-management systems. Other physician practices are taking advantage of IPA (independent practice association) or MSO (management service organization) relationships to get varying levels of support and services.
As they participate in incentive programs and engage in more risk-based contracting, these larger, more sophisticated, healthcare organizations are in a position to focus on improving quality metrics and medication adherence among their patient populations.
Three primary functional areas within the provider enterprise are supporting these operations and must synchronize their activities:
The Administrative Accountability and Reporting area sets the pace for the medication adherence initiative, establishing policies and goals, creating patient education collateral, and distributing workflow to the care coordinators and other staff. Not only is this area driving the process, but it is also the one that tracks performance against goals and communicates these results to the organization as a whole.
The Population Health Teams and Care Coordinators support point-of-care activity and execute medication adherence policies and procedures set out at the administrative level. These staff members monitor the dashboards for each practice, conduct patient outreach for refill reminders, and intensify patient engagement for patients who are at urgent risk based on policy guidelines. They applaud and encourage patients’ efforts and determine if there are any barriers to medication adherence that need to be addressed. In addition to supporting patients in between provider visits, these care coordinators and nurse navigators are also alerting providers to opportunities, or “calls to action,” that can be addressed at the point-of-care.
As members of the population health team counsel and interact with patients, they are gathering patient-specific information that can strengthen the Patient-Provider Point-of-Care Activity. Physicians who are aware, for example, that a patient is not taking medication correctly or consistently can use the office visit as an opportunity to educate the patient on the importance of medication adherence. Other opportunities can be handled by the physician “in bulk,” such as converting a patient population from 30-day to 90-day refills.
Each of these operational groups brings its own unique perspectives to the process, with physicians engaged with the individual at the point of care and the care coordination team bringing in the population health component. By understanding these roles and integrating both the “population” focus and the “individual/patient” focus, the organization can start to put a framework in place to leverage these converging viewpoints.
Creating a Multi-Directional Workflow
Currently the marketplace is dominated by health organizations that take a distributive approach to medication adherence, with the administrative area communicating a basic policy and set of desires to the practice level; however, there are no specific goals, practices respond at will, and visibility of the initiative drops off quickly. For example, the administrative level may convey a desire to see as many patients as possible on a 90-day fill, but specific directives or measures of program success are absent. The workflow is in a single direction – from the administrators to the physicians – without any feedback loops to build consensus and share results.
As more consideration of policy is brought to the process, the administrative area may begin to be more direct with requests to the physician population, for instance sending out lists of patients to be targeted. This centralized passive workflow model still lacks enterprise-wide physician buy-in of the value of a medication adherence program. Again, the practices respond to these requests at various levels, and there is minimal accountability.
Often in these early stages, the tools supporting the process are lacking and reporting is paper-based, with long lag times between information generation and delivery. A physician who receives a list of non-adherent patients, only to find out that it is weeks or months old, will become discouraged by the out-of-date, non-actionable information and quickly reject the program. Similarly, if the list is too unwieldy and hasn’t been winnowed down to a targeted group of high-risk, high-value patients, physicians will lose interest because the assignment is just too cumbersome. Web-based tools are now available that can help structure the workflow in an effective, consistent way. RxAnte’s solution uses highly accurate predictive analytics to narrow outreach efforts to those patients who can influence population health measures.
As programs mature, adding dedicated staff and creating formal structures to truly support a medication adherence program, they can begin to adopt a centralized active workflow. The dynamic, multi-directional nature of this system gives physicians, administrators, population-health coordinators and patients the ability to influence and improve the process. These exceptional practices not only have well thought-out policies and established goals for medication adherence, they have the organizational infrastructure to support these efforts. Program attributes include dedicated staff to sustain patient outreach/monitoring, a physician champion(s) to promote the program enterprise wide, care coordination that is amortized over multiple practices, and clear-cut escalation points for patients that have medication barriers.
Best Practices from the Front Lines
In order to gain traction on their quality initiatives, healthcare organizations need to understand their leverage points. Every provider enterprise will have practices that have more opportunity to move the needle on population health metrics than other practices in the organization. By identifying those more influential physician groups, the organization can recruit these practices and establish them as models of the new concept. Results of these early efforts can be used to evaluate practice rollout potential and to assess staffing/resource needs, workflow requirements, and commitment levels. In addition, these initial trials can help identify a clinical champion to take a leadership role in the formal, enterprise-wide medication adherence program.
The Clinical Champion – Leveraging Peer-to-Peer Professionalism
Physician champions are critical to the program’s success. These are the individuals who will be able to communicate the value of implementing a medication adherence program to their peers and to garner support from the clinical side of the business. To be effective, though, the physician champion should also have strong influence with other stakeholders, including population health, care coordination, case management, and shared savings administrative staff. It is important to give this person a formal role or responsibility within the organization’s quality area, including medication adherence oversight.
Sharing the Vision across the Provider Organization
The deeply interactive clinical nature of medication adherence requires that physicians throughout the enterprise not only understand but truly embrace a systematic, population-based approach to improving adherence. The clinical champion is in the best position to orient other physicians to the medication adherence program, and early communication – including a formal letter of introduction – should:
- Outline the benefits to patients and the organization.
- Advise providers of the critical importance of the adherence initiative.
- Let them know how they will be able to help, and tell them that they will begin receiving periodic requests that are sensible and easy to understand/act upon.
- Let them know that their feedback is welcome and venues will be available for their suggestions for program improvement.
- Let them know that the patient relationship and their professional judgment will be respected above all.
Unless this recruitment to the vision is successful, physicians will focus on other initiatives that they think are of more value to their patients and practices.
Clear Calls to Action
Adopting a new process is easier when elements of the activity are similar to those already being performed. One of the best ways to gain early momentum for the medication adherence program is to start with engagements that fit current work patterns or habits. For instance, providers and other healthcare staff are accustomed to routine preventative measures such as colonoscopies, mammograms, and prostrate exams – one-and-done tasks to close care gaps. Short-run, high-yield campaigns that have that same “one-off” familiarity let providers participate in brief assignments that produce quick results. These actions can often be handled “in-bulk” and might include converting a group of patients from 30- to 90-day refills, reducing high-risk medications, or automating patient refills. Successes from these early efforts can build traction for the program.
Additional campaigns should be scheduled on a regular basis, with a frequency that keeps the overall initiative top of mind but does not overwhelm providers and support staff. Varying themes, whether it is a focus on a particular refill protocol, adherence barrier, or chronic condition, keeps the work fresh and on target. Healthcare software that can identify adherence improvement opportunities and the appropriate patient populations for outreach is vital to these efforts.
Documenting Barriers to Adherence
As care coordinators build relationships with patients through outreach efforts, reasons for non-adherence will emerge. One RxAnte client noticed that patients frequently had issues getting prescriptions filled because of lack of transportation. This physician group partnered with a local pharmacy that provides a medication home delivery service. The success of this effort highlights that medication adherence programs take time to develop as staff members gain more experience, are trained on techniques to glean insights from patients, and respond with policies to improve compliance.
Common barriers to medication adherence include prescription costs, misunderstanding about the disease state, side effects, and transportation. By documenting all relevant barriers for a patient and then categorizing this information so that it can be used to detect trends, the provider group can develop strategies and tactics to address these issues. For instance, for a patient panel in which cost has been identified as a barrier to adherence, the medical practice might distribute materials that guide patients to financial resources.
Assertive Care Management
Medication adherence is one of the most difficult quality improvement measures to address, and providers and care coordinators may initially have some reservations about encroaching on patients’ personal lives outside of the point-of-care setting. One large physician practice that RxAnte worked with found that the care coordinators had not had much experience with outreach calls for medication adherence and were rather tentative in their approach to patients. Over time they have built strong relationships with their patients and become more confident in using the patient-specific information they have available through the RxEffect tool. Now they have a bolder approach to medication adherence outreach, holding their patients accountable for compliance.
Extend Practice Capabilities with Health Plan Resources
The tools and resources discussed in this paper are not exclusively for the use of physicians and their practice staff. While many physician practices are developing and training their own staff, they may also consider using health plan staff and resources to supplement and extend their outreach capabilities. For example, RxAnte worked with a health plan that identified several significant physician practices that could impact overall Star ratings. These particular provider groups did not have the benefit of dedicated resources for medication adherence outreach, so the payer created a program to place nurse care coordinators on-site at these practices. As with any outsourced personnel, these care coordinators had to gain the trust of the providers and their staff, but now they are a working part of the team, meeting face-to-face with patients in the office as well as conducting telephonic outreach between visits.
Conclusion
Medication adherence is difficult in any setting. In health systems and large provider enterprises, there are many challenges to fully engaging physicians in this important activity. First, medication adherence must compete with a multitude of formal initiatives all fighting for placement in the organization’s workflow. In addition, goals are generally established centrally and then distributed to the providers at the practice level, which can distort communication and diminish accountability. Next, patient engagement work is often parsed among various stakeholders, making the alignment of efforts complicated. Finally, patient engagement specific to medication adherence is typically staffed poorly or not at all.
The healthcare organization’s medication adherence strategy must focus on two primary areas. The first one is getting providers on board. Physicians and clinical staff must embrace the value of medication adherence – to the patient, the provider, the practice and the organization. And they must be shown that the program will not create extra work or require them to perform outreach at the point-of-care. Instead, it will conform to their current workflows and schedules. Physicians are supporting the team of care coordinators that will be acting on their behalf, with only certain cases being escalated back up to the physician.
Alongside these efforts to onboard physicians, the organization needs to establish a team of care coordinators and nurse navigators to engage patients in between their office visits. These types of outreach efforts may be new to staff members, and it will take time, practice, and encouragement to develop a well-organized, effective process. Taking inventory of adherence barriers, training care coordinators on behavior modification and other skill sets, and allocating workloads in an equitable manner are a few of the ways provider organizations are moving the needle on their outreach efforts.
For medication adherence to work, it has to elevate data on the individual patient to a population-level view, giving organizations a way to evaluate and prioritize cases. This requires access to the right data, decision support, incentives and engagement support. Healthcare technology companies such as RxAnte are supporting these efforts with predictive analytics and web-based technologies that are configurable within the practice’s workflow and target only those patients who need help the most and whose adherence will enhance the performance of a population. to perform outreach at the point-of-care. Instead, it will conform to their current workflows and schedules. Physicians are supporting the team of care coordinators that will be acting on their behalf, with only certain cases being escalated back up to the physician.
Alongside these efforts to onboard physicians, the organization needs to establish a team of care coordinators and nurse navigators to engage patients in between their office visits. These types of outreach efforts may be new to staff members, and it will take time, practice, and encouragement to develop a well-organized, effective process. Taking inventory of adherence barriers, training care coordinators on behavior modification and other skill sets, and allocating workloads in an equitable manner are a few of the ways provider organizations are moving the needle on their outreach efforts.
For medication adherence to work, it has to elevate data on the individual patient to a population-level view, giving organizations a way to evaluate and prioritize cases. This requires access to the right data, decision support, incentives and engagement support. Healthcare technology companies such as RxAnte are supporting these efforts with predictive analytics and web-based technologies that are configurable within the practice’s workflow and target only those patients who need help the most and whose adherence will enhance the performance of a population.
1 www.ihs.gov/…/WebBased/Seminars/Handout_Medication_Adherence.pdf
2 Brookhart 2007, Arch Intern Med
3 “Medication Adherence in America: A National Report Card”, National Community Pharmacists Association
