Noncompliant/Nonadherent Patient Management
Physicians are challenged and frustrated by patients who fail to adhere to and to follow a treatment regimen knowing that serious consequences may result in permanent injury and death. The reasons patients deviate from their care plan of keeping follow-up appointments, participating in ordered tests, and taking medications as prescribed may include:
- Denial, depression, dependence, and dementia
- Lack of agreement or understanding with the physician's assessment, recommendation, or instruction
- Lack an understanding of the seriousness of the illness/condition
- Language, cultural, or mental barrier which hinder a patient's ability to understand or follow the care plan
- Receiving conflicting advice from multiple caregivers with resulting confusion
- Cost of treatment, including lack of transportation, interfering with patient's ability to comply with the care plan
Noncompliance is often a communication breakdown or misunderstanding. Physicians need to appreciate the patient's understanding of their problems. Facilitating a face-to-face conversation with the patient allows the provider to develop effective strategies to manage and deal with the "noncompliance." Physicians must give clear explanations of health problems and recommended solutions to establish mutual cooperation.
Steps to Follow when Addressing Noncompliance:
- Use empathic listening skills to understand noncompliance from the patient's perspective
- Identify the patient's expectations and what will enhance compliance
- Ask the patient directly about compliance, and use visit history and prescription refill data to establish that noncompliance is present
- Review the patient’s understanding and agreement with diagnoses and treatment goals
- Ask the patient to describe their medical condition and recommendations in their own words
- Use health literacy tools (i.e. ask open ended questions and use Teach back)
- See MMIC Practice Tip: Health Literacy Delivering the Message Right Improves Patient Safety and Reduces Liability
- When disagreement is present, use "I" statements and conflict resolution tools to resolve discordance (i.e the 6 Es)
- See MMIC Practice Tip: Communication: Strategies for Effective Communication
- Reach out for additional support
- Case managers
- Therapists and outside agencies
- The patient's family and friends
Armed with additional information, tailor an approach to not only remove obstacles and encourage the patient's full participation in their care plan, but also include your patient's unique needs and expectations in the care plan.
- Ensure that your office has a tracking system to identify when test and referral reports are outstanding. When reports are absent:
- Contact the patient to determine whether or not the patient complied with the test
- See MMIC Practice Tip: Diagnostic Test Tracking Systems
Medical Record Documentation:
Thorough documentation is vital to protect against liability and to deal with a patient's non-compliance. Assure the medical record reflects:
- Each discussion of the recommended treatment plan with the patient
- The patient's refusal and/or failure to comply with tests, consults and office appointments. Document missed and canceled appointment information in the patient's medical record. Include all attempts to contact the patient.
- See MMIC Practice Tip: Appointments: Referral Not Completed, Missed (No Show) & Canceled Appointments
Discharging the Patient from your Practice:
Despite efforts made to build a partnership with a patient, on occasion a patient will continue to fail to comply with recommendations. When a patient may be harmed as a result of noncompliance the patient may be considered for discharge.
- Please refer to the MMIC Practice Tip: Termination of the Physician/Patient Relationship
The Permanente Journal, 2003 Fall: Understanding Noncompliant Behavior: Definitions and Causes
The Permanente Journal, 2010 Spring: Working with the Noncompliant Patient Medical Insurance Exchange of California: MIEC Loss Prevention Managing Your Practice, 2012: Noncompliant Patient Management
Medical Mutual Insurance Company of Maine's "Practice Tips" are offered as reference information only and are not intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a qualified attorney for any specific application to your practice.