Nonadherent and Noncompliant Patients: Overcoming Barriers

Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company

Nonadherent or noncompliant patient conduct (whether intentional or inadvertent) can adversely affect clinical outcomes, undermine the practitioner-patient relationship, and disrupt the operation of the practice. Examples of these types of behaviors include failing to participate in the recommended treatment plan; missing or canceling follow-up appointments; discontinuing therapy or medication regimens prematurely; refusing to seek specialty referrals or obtain laboratory tests as ordered; and ignoring established policies relating to payment, treatment, safety precautions, or the routine functioning of the practice.

Consider the following strategies for managing nonadherent and noncompliant patients.

Identify and Address Compliance Barriers

A patient’s failure to engage in the planned treatment process, including keeping appointments, may be related to health literacy, mental competency, language or cultural barriers, lack of child/elder care, transportation, or financial restraints. Effective communication provides the critical link to discovering the cause of the behavior and assessing the patient’s comprehension of the treatment plan.

• Maintain an ongoing dialogue with the patient to identify potential adherence obstacles as soon as practicable. Ask patients to explain any issues preventing them from following your recommendations, and work in a respectful manner to address any concerns. (For more information, see our guide Effective Patient Communication: Strategies for Challenging Situations.)
• Use language services for your limited English proficiency (LEP) patients. (For more information see our article “Limited English Proficiency (LEP) Patients: Frequently Asked Questions.”)
• Determine the extent of the patient’s comprehension. Ask the patient directly or through an interpreter to repeat back what was said during the informed consent process, the treatment plan discussion, or any educational session with you or your staff.
• Use educational tools, such as the Institute for Healthcare Improvement’s Ask Me 3© approach. Ask Me 3 identifies three simple questions that all patients should be able to answer. Ask your patients to repeat back:

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

• Establish written financial policies and procedures, and evaluate the benefits of using payment plans to assist patients in meeting their monetary responsibilities. Consider including these requirements in your Conditions of Treatment document that the patient signs at the outset of the professional relationship.
• Aid compliance by referring patients to community resources, such as those providing appointment transportation, in-home care, meals, or smoking cessation support.

Promote Patient Engagement

Provide patients with the information they need to make educated decisions regarding their care. Meaningful exchanges of information with patients who understand and agree to a recommended plan generally lead to better adherence and, ultimately, to more favorable outcomes. Document informed consent carefully to avoid misunderstandings and potential conflict in the event of an adverse event. (To learn more about the informed consent process, read our article “Informed Consent: Substance and Signature.” Find sample documents on our Informed Consent Sample Forms page.)

List the patient’s responsibilities as part of the written plan of care, provide a copy to the patient, and place a copy in the patient’s record for later reference. Provide all written materials in a language that the patient can read and understand.

Emphasize to patients that they have responsibility for their own health. Encourage them to become involved by using interactive tools—such as links to websites, anatomical models, online educational materials—and written instructions with checklists or medication schedules. Motivate them to keep current on the status of their care by encouraging them to access the patient portal. (Learn about the 21st Century Cures Act by reading our article “12 Strategies for Success With Open Notes in Healthcare: The Cures Act.”)

Request that patients respond to reminder calls and notifications regarding appointments, referrals, diagnostic tests, or medication refills. The responses should be recorded in the patient record.

Document Nonadherent or Noncompliant Behavior

Document with specificity any nonadherent, noncompliant, or disruptive behavior, such as canceled or no-show appointments, failure to follow instructions, and inappropriate conduct toward staff or other visitors to the practice. A well-documented record that reflects the patient’s responses demonstrates the practitioner’s attempts to develop and implement a suitable plan of care that enhances the likelihood of a more favorable outcome.

Document patient refusal. If, at some point, the practitioner-patient relationship is discontinued, documentation about patient refusal supports the practitioner’s efforts. (For more information on this topic, see our article “Informed Refusal.”) Documentation that clearly demonstrates the patient’s lack of engagement decreases the risk of potential administrative actions by licensing boards, health plans, third-party payers, and even professional liability claims in the event of a complaint or unexpected consequence.

Manage Continued Nonadherent or Noncompliant Behavior

Discuss and document the patient’s understanding of the consequences of continued noncompliance. If you are not able to discuss the consequences with the patient in person, explain them in a letter. Describe the actions the patient needs to take, such as calling the office or obtaining a diagnostic study.

We provide three sample letters that you can adapt for situations involving patients who fail to make or keep appointments or those who neglect to follow through on ordered lab tests, diagnostic tests, or specialist referrals.

Continued nonadherent or noncompliant behavior—despite attempts to address the cause—impedes the ability to maintain a therapeutic practitioner-patient relationship, frequently impairs optimum clinical results, creates the potential for adverse outcomes, and may inevitably require dismissing the patient from your practice.

To learn about the steps to follow if discharging a patient under your care becomes necessary, see our article “Terminating Patient Relationships.” For assistance with this process, contact your patient safety risk manager at (800) 421-2368 or by email.