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 unintentional) often affects clinical outcomes adversely. Examples of these behaviors include, but are not limited to, the following: 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 office policies relating to payment, treatment, and the operations of the practice—including disregard of CDC-recommended COVID-19 pandemic safety precautions.

Consider the following strategies for managing nonadherent and noncompliant patients.

Uncover and Address Compliance Barriers

A patient’s failure to engage in the planned treatment process may be related to health literacy, mental competency, language or cultural barriers, 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 barriers as soon as practicable. Ask patients to explain any issues preventing them from following your recommendations, and work to address any concerns.
  • 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?

(For more information about the Ask Me 3 communication tool, see our article “Rx for Patient Safety: Ask Me 3.”)

  • Establish written financial policies and procedures, and consider using payment plans to assist patients in meeting their financial responsibilities.
  • 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 informed care decisions. Meaningful exchanges of information with patients who understand and agree to a recommended plan lead to better adherence and, ultimately, to more favorable outcomes.

List the patient’s responsibilities as part of the written plan, and provide a copy to the patient. All written materials should be provided in a language that the patient can read.

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.

Request that patients respond to reminder calls and notifications regarding appointments, referrals, diagnostic tests, or medication refills.

Document Nonadherent or Noncompliant Behavior

Document with specificity nonadherent or noncompliant behavior, such as canceled or no-show appointments and failure to follow instructions. A well-documented record that reflects the patient’s responses demonstrates the provider’s attempts to develop a plan of care.

Document patient refusal. If, at some point, the physician-patient relationship is discontinued, documentation about patient refusal supports the physician’s efforts. (For more information on this topic, see our article “Informed Refusal.”)

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.

Continued nonadherent or noncompliant behavior—despite attempts to address the cause—impedes the ability to maintain a therapeutic physician-patient relationship and may require dismissing the patient from your practice. To learn about the steps to follow if dismissing 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.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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