Improving adherence has been a gradual process in our practice. Like most practices, we ask patients to bring all of their medications to every office visit so we can reconcile them. When we first started a program to keep patients out of the emergency department and reduce readmissions, we felt pretty smug about adding phone medication reconciliation with each patient within 48 hours of discharge. Our nurses' phone conversations with patients went something like this: “I see your furosemide was changed in the hospital from 20 mg a day to 40 mg a day. How's that going?”
Eventually we learned to ask patients “Are you taking the medications you were prescribed?” and, even better, “Do you have the medications you were prescribed?”
The problem is that patients lie about taking their medications for a variety of reasons – they do not care whether they get better, they feel fine, or they don't want their doctor to be disappointed in them. Instituting the Morisky Medication Adherence Scale3 helped, but we eventually came up with a broader set of questions:
1. Do you have all of the medications you were prescribed? (Probe for barriers such as cost or confusion.)
2. Do you understand why you are taking them?
3. Do you ever forget to take your medications? (Discuss phone alarms, putting pills by the coffeemaker, etc.)
4. Do any of your medications make you sick?
5. If you feel worse, do you stop taking them?
6. If you feel better, do you stop taking them?
7. If you have asthma, do you have a spacer? Do you carry a rescue inhaler (at work, in the car, at school, etc.)?
A nurse or medical assistant asks these questions, along with questions about health confidence, prior to the patient being seen by the provider. We record the answers in our electric health record so we can track adherence over time.
Here are some of the lessons we have learned:
1. Be aware of the tendency to use medical jargon. Instead of saying, “This will treat your hypertension,” say, “Let's try this for your high blood pressure.”
2. Don't judge. Instead of saying, “Why aren't you taking your metformin?” say, “I'm curious to know what happens when you take your metformin.”
3. Be aware of costs. Most patients are hesitant to say they can't afford a medication, so ask the patient to get back to you if the copayment or cost is too high.
4. Look for underlying conditions. For example, patients who are depressed rarely take their medications, so consider treating the depression first.
5. Be clear about the benefit of the medicine. For example, you might say, “If you take your diabetes medicines and control your blood sugar, you may not need to have your eyeglass prescription changed as often.”
6. Move your patients' prescriptions to mail order if possible. Going to the pharmacy is often an obstacle.
Medication adherence is key to improving patients' confidence to manage their illness, improving clinical outcomes, and lowering utilization. Asking the right questions has made a real difference in our practice.