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New CM adherence guidelines expected soon
Medication reconciliation is priority
Discharge planners soon will have revised guidelines to assist them with case management adherence.
The Case Management Society of America (CMSA) soon is expected to release a third version of its Case Management Adherence Guidelines, says Susan A. Rogers, RN-BC, BSN, CCM, president of Rogers Professional Guidance in Overland Park, KS. Rogers has contributed to the guidelines, particularly on the issue of diabetes care.
The second version, published in June 2006, focuses on health literacy, mediation knowledge, motivation, social support, factors that influence adherence, motivational interviewing, and hospital discharge planning and adherence counseling to ensure a successful discharge.1
Medication reconciliation is a major part of treatment adherence, Rogers notes.
Discharge planners and others who provide medication reconciliation are crucial to transition of care coordination, Rogers says.
"They assess what medications are at a patient's home, what the patient knows about these medications, when the patient plans to have prescriptions refilled, or when the doctor will prescribe them again," Rogers explains.
Discharge planners and case managers take into account a patient's lifestyle support, health literacy, and adherence motivation, she adds.
"That is a huge thing in today's world," Rogers says. "Up to half of the 1.8 billion prescriptions made each year aren't taken appropriately."
Barriers include lack of transportation, side effects, and forgetfulness.
"These guidelines were developed with all of these in mind," Rogers says. "We case managers and discharge planners have always looked at cost effectiveness and what are the outcomes of our interventions."
Discharge planners educate and coordinate care, but have never really spent a great deal of time promoting adherence and encouraging patients to participate in their own care, Rogers notes.
The adherence guidelines are intended to be used as a resource guide and tool kit.
For example, in the chapter discussing discharge planning, there is a model for a successful discharge plan for successful transition to outpatient care.
The tool lists tasks performed, such as "Patient understands transition plan for care in post discharge setting." And it has columns for assessment, date, reviewer, and notes.
Other tools in the guidelines include patient assessment forms, adherence improvement tools, and a readiness ruler.
"The readiness ruler is an assessment for motivation," Rogers says.
The readiness ruler is a simple drawing of a ruler with a transition of colors from bright red to bright green. Patients are asked to describe how ready they are to make a change. Those who are not at all ready would select the bright red or zero at the far left of the ruler. Those who already are making a change would select bright green or 10 at the far right. Others will fall in between.
It's important for discharge planners to use all of the tools in their arsenals, including health literacy tools, to determine what additional support and education patients might need to ensure treatment adherence.
CMs need to understand patient literacy
"You need to know if a patient understands what they're taking and whether they have health literacy issues where they may not understand what you're telling them," Rogers says.
Also, discharge planners need to know whether patients have someone at home who can help them, she adds.
"If they don't have help, then you need to use motivational interviewing and psychosocial assessment and questioning to determine whether they want to take their drugs and why adherence might be a challenge," Rogers says.
The CMSA guidelines also provide information about comorbidities, such as clinical depression, that sometimes impact adherence.
For instance, patients who are being treated for depression need to be educated about how their antidepressant medication sometimes takes some time to work and they might not experience an immediate relief from the blues, Rogers says.
"You tell the patient, 'You have to continue to take the medication so that you will feel better,'" Rogers says. "And you have to make sure the patient is safe during the transition of care, noting who will be watching out for the patient after discharge."
Safety is the bottom line for discharge planning.
"We have to keep our patients safe no matter what," Rogers says. "If we release them with a whole bunch of drugs, then we need to make sure they're safe when they get home and they're safe from harming themselves or being a threat to others."
Each disease state has a slightly different assessment, and patients are at various levels of educational knowledge and adherence ability.
Diabetic patients, for example, have a variety of adherence issues, including exercise, food, blood glucose monitoring, and medication, Rogers says.
"We need to know what their motivation is for adhering to their treatment and when it's an appropriate time to provide discharge education," she adds.
Sometimes, patients with complex medical needs, like diabetics, will not be able to handle adherence post-discharge without help. So discharge planners might need to pass the baton to the next person, whether this is a post-acute health care professional, minister, family physician, community pharmacist, caregiver, or someone else, Rogers says.
"It's very important to not discharge the patient and be done with it," she adds. "Part of the discharge planning process is to communicate with the next step and whoever that is."
A full transition to care is very important, Rogers says.
Some patients might need one visit from a home health nurse to reinforce the teaching, she adds.
1. Case management adherence guidelines. Version 2.0. Case Management Society of America. June 2006. Available online at http://www.cmsa.org/portals/0/pdf/CMAG2.pdf.
For more information, contact:
Susan A. Rogers, RN-BC, BSN, CCM, president, Rogers Professional Guidance, Overland Park, KS. Email: firstname.lastname@example.org