Healthcare providers face many challenges when patients are nonadherent or difficult. These behaviors can compromise the provider- patient relationship, and patients might be at an increased risk of misdiagnosis and more likely to have negative outcomes.

One study, for example, showed that clinicians were 42 percent more likely to wrongly diagnose a complex medical issue and 6 percent more likely to wrongly diagnose a simple medical issue when dealing with difficult patients.¹

To mitigate the challenges that nonadherence presents, healthcare organizations should create a policy that specifically defines a patient’s rights and responsibilities, display it in the organization, and make it available to all patients. This policy will provide the basis on which to build effective provider-patient relationships.

The following strategies offer additional ways to proactively engage nonadherent and difficult patients and address potentially problematic behaviors.

1. Be aware of the difference between informed refusal of care and patient nonadherence to an agreed-upon treatment plan. A patient can refuse care even if the consequences might be dire.
   
2. During each patient encounter, emphasize the importance of following the agreed-on treatment regimen, even if symptoms subside. Explain the possible consequences of not following the prescribed treatment plan.
   
3. Provide nonadherent patients with education about their treatment plans both verbally and in writing — especially if a patient has serious health problems.
   
4. With patients’ permission, include family members, caretakers, and significant others in education about the importance of following treatment plans. These individuals might help reinforce the importance of adhering to treatment.
   
5. Consider that a patient-centered approach seeks to get patients more involved in their care. During patient encounters, ask open-ended, probing, and nonjudgmental questions to identify factors influencing nonadherence.
   
6. Try various communication techniques such as motivational interviewing to empower patients to set goals they believe are attainable. Understanding the patients’ stages of changing behavior and dealing with discouragement will support a mutually agreed on care plan.
   
7. Use a technique such as teach-back to ensure that patients fully understand the information and instructions provided. Patients from all racial, ethnic, socioeconomic, and educational backgrounds might have limited health literacy, which can contribute to nonadherence.
   
8. Consider patients’ lifestyles and medication costs when prescribing. A variety of situational, geographic, economic, and cultural issues can contribute to nonadherence.
   
9. If a patient has financial, physical, or emotional limitations that lead to nonadherence, determine whether any community services are available to help the patient overcome treatment barriers.
   
10. Consider using patient agreements that detail both provider and patient responsibilities relative to the treatment regimen. Both parties should sign the agreement.
    
11. If a patient is missing appointments, try to determine the reason (e.g., transportation, family care, or financial issues). After several missed appointments, consider sending the patient a letter stressing the importance of keeping the appointments and adhering to the treatment plan. Keep a copy of the letter in the patient’s health record.
    
12. Document missed or cancelled appointments by noting either “patient no- show” or “cancelled” in the patient’s health record. If possible, document the reason for a cancellation — e.g., “no transportation” or “child care issues.”
    
13. Do not delete original appointment entries; the appointment log might become a valuable tool if you have to demonstrate a patient’s continued nonadherence to appointments.
    
14. Document a description of all clinical nonadherence in the patient’s health record, as well any education provided to the patient, family, caregiver, and/or significant other regarding the possible consequences of not following the treatment regimen.
    
15. When documenting, use subjective statements from the patient or others and objective information obtained through patient encounters. Avoid disparaging remarks or editorializing when documenting information in the health record related to patients’ nonadherent behaviors.

Endnotes

¹Schmidt, H. G., et al. (2016, March). Do patients’ disruptive behaviours influence the accuracy of a doctor’s diagnosis? A randomised experiment. BMJ Quality & Safety. Retrieved from http://qualitysafety.bmj.com/content/early/2016/ 02/09/bmjqs-2015-004109 http://qualitysafety.bmj.com/content/early/2016/02/09/bmjqs-2015-004109

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