ENGAGING THE PATIENT IN REHAB ADHERENCEWHAT MAKES YOUR PATIENT STICK WITH IT?

BY: ERNEST ROY PT, DPT

OUR OBJECTIVES TODAY

• Operationally define Adherence for purposes of clinician-patient

interactions.

• Describe what is known about rates of adherence among 4 different

patient problems seen in home care.

• Review concepts of Patient Activation.

• Learn at least 3 ways to use Motivational Interviewing with patients

to aid adherence.

• Explore Shared Decision Making to help patients stick with your care.

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WHAT IS ADHERENCE?

According to Webster’s, adherence can thought of as:

• “Steady, of faithful attachment”

The WHO defines adherence as:

• "the extent to which a person's behavior… corresponds

with agreed recommendations from a healthcare

provider”

QUOTABLE QUOTES

“Drugs don't work in patients who don't take them”

C. Everett Koop – Former United States Surgeon

General

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RATES OF ADHERENCE TO TREATMENT

• For pharmaceutical therapies,

research finds adherence rates for

chronic medications to average

around 50%.

• Adherence rates for medical advice

range from 20-80% rates depending

on the selected intervention.

Ref: Kim J, Combs K, Downs J, Tillman F. Medication adherence: The

elephant in the room. Medication Management. Published online Jan 19,

2018

Sharma B, Agrawal M. Factors affecting adherence to healthy lifestyle.

Int. J. Pure App. Biosci. 5 (4): 105-116 (2017)

WHAT ABOUT ADHERENCE TO HOME EXERCISE REGIMENS?

• Research by Morad and

colleagues reported on surveys

of 44 PT’s. They found reasons

for low patient adherence to HEP

included:

• Fatigue (65%)

• Forgot to do the HEP (81%)

• Lack of sufficient time (75%)

Ref: Mourad S et al. Patient’s adherence to prescribed home

exercises: Barriers and interventions. Genetics and Molecular

Research 17 2018 (1): gmr16039898

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FACTORS INFLUENCING ADHERENCE FOR SPECIFIC PATIENT POPULATIONS

• Dementia

• Total joint arthroplasty

• Cancer

• Low back pain

DEMENTIA PATIENTS AND ADHERENCE TO HOME EXERCISE REGIMENS

Findings based on the PrAISED study (Promoting Activity, Independence and

Stability in Early Dementia). Findings of the study revealed:

• 5 subjects exceeded adherence expectations, 7 met expectations, 8 did not

meet expected adherence levels.

• There were 6 overall factors identified as being related to patient

adherence.

Ref: Jennie E. HancoxID, Veronika van der Wardt, Kristian Pollock3, Vicky Booth, Kavita Vedhara, Rowan H. Harwood. Factors influencing adherence to home-based strength and

balance exercises among older adults with mild cognitive impairment and early dementia: Promoting Activity, Independence and Stability in Early Dementia (PrAISED). PLOS ONE

| https://doi.org/10.1371/journal.pone.0217387 May 23, 2019

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FACTORS THAT IMPROVED ADHERENCE

• Routine, but with flexibility built in.

• Practical and emotional support-from both care givers AND

clinicians.

• Memory supports, including pictures and simplified progression

strategies.

• Prior history on sport/exercise participation.

• Having a sense of purpose for the exercises.

• Belief in the program and experience of benefiting.

TOTAL JOINT ARTHROPLASTY PATIENTS

Results based on a 2016 study of 8 TJA patients and 5 PT’s. Central

themes included:

1. Consistency or lack in health care delivery

2. Ability of PT’s to tailor exercise to fit patient needs and abilities

3. Expectations

4. Barriers to rehab

5. Incongruence of definition of successful outcome

Ref: Magklara E, Burton cC, Morrison V. Adherence to exercise after joint replacement surgery: patients’ and health professionals’ perceptions. The European Health Psychologist

2016. Vol 18 (Supp) 1070.

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THE USE OF TELEPHONE FOLLOW UP FOR ADHERENCE S/P TKA

A study of 202 TKA patients post op from the People’s

Republic of China with 1 year follow up found significant

differences in favor of the intervention group for:

• Mean # of days and total time spent doing the HEP

• AROM @ 6 and 12 months post op

• Functional ability in everyday activities.

Ref: Mochuan Chen, Pihong Li, Feiou Lin. Influence of structured telephone follow-up on patient compliance with rehabilitation after total knee arthroplasty.

Patient Prefer Adherence. 2016; 10: 257–264.Published online 2016 Mar 3. doi: 10.2147/PPA.S102156

ADHERENCE TO EXERCISE REGIMENS IN BREAST CANCER

A Dutch trial of combined supervised and home based exercise

aimed at preventing lymphedema found:

• Lowest adherence rates were in women who were obese (BMI

> 30 points), and who had low overall strength levels @

baseline.

• Authors recommend identifying such patients early on for more

consistent intervention, as these patients are at higher risk of

low adherence.Ref:Lund LW, Ammitzbøll G, Hansen DG, Andersen EAW, Dalton SO. Adherence to a long-term progressive resistance training program, combining supervised and home-based

exercise for breast cancer patients during adjuvant treatment. Acta Oncol. 2019 May;58(5):650-657. doi: 10.1080/0284186X.2018.1560497. Epub 2019 Jan 30

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DOES THE NUMBER OF EXERCISES IN A HEP IMPACT ADHERENCE?

Anecdotally, patients appear to report lower adherence rates

for complex, lengthy HEP’s

• An older study from 1998 in Physical Therapy compared

quality of performance for approx. 1 week between HEP’s of

2, 5, or 8 exercises.

• Review of exercise technique found that subjects assigned 2

exercises performed them more correctly vs those assigned 5

or 8 exercises.Ref: Henry KD, Rosemond C, Eckert L, Effect of Number of Home Exercises on Compliance and Performance in Adults Over 65 Years of Age. Physical Therapy . Volume 78 .

Number 3 . March 1998, 271-277

LOW BACK PAIN AND EXERCISE ADHERENCE

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FIRST, LET’S RUN THE NUMBERS

When people think of home health patients, they do not always

think about chronic low back pain. However, data finds:

• An estimated 20% of adults adults 65 y/o or older report

suffering chronic low back pain.

• Those patients covered by Medicare or Medicaid had higher

odds ratios of reporting chronic low back pain

Ref: Shmagel A, Foley R, Hassan I. Epidemiology of Chronic Low Back Pain in US Adults: Data From the 2009–2010 National Health and Nutrition Examination Survey. Arthritis

Care & Research. Vol. 68, No. 11, November 2016, pp 1688–1694. DOI 10.1002/acr.22890

FACTORS RELATING TO PROGRAM ADHERENCE IN STUDY OF 29 CLBPSUBJECTS

• Having > four exercises in the training program was considered

excessive.

• Many patients would stop an exercise if it caused pain, or was

perceived as not relieving pain.

• Having clear cut instructions.

• Routines perceived as boring or redundant showed lower adherence .

• Ref: Palazzo c , et al. Barriers to home-based exercise program adherence with chronic low back pain: Patient expectations regarding new technologies.

Annals of Physical and Rehabilitation Medicine 59 (2016) 107–113

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WHAT CAN CLINICIANS DO TO IMPROVE ADHERENCE FOR THEIR LOW BACK PAIN PATIENTS?

The study made a number of recommendations including:

• Consider ways to provide video feedback of the

program to reinforce correct technique.

• Individualize advice/counselling to the patient.

• Individualize goals and objects to fit patient preferences.

TEST YOUR KNOWLEDGE!

WHICH OF THE FOLLOWING DID NOT IMPROVE ADHERENCE TO HEP’S FOR DEMENTIA PATIENTS?

1. Loudly repeat exercise

instructions at least 3 times

per exercise

2. Include pictures of the

exercises

3. Provide emotional support.

SURVEY SAYS>>>

• It’s #1-this is NOT a

recommended technique to

improve HEP adherence for

patients dx with dementia.

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CASE STUDY

86 y/o man, had refused PT consults on prior home care admissions.

Hats off to one of my RN’s, who persuaded the patient to at least

speak with me.

• Turned out his reluctance was related to a “bad experience I had

with PT at rehab. They wouldn’t listen to me and I got hurt”

• I asked him to talk about his goals (he did have some!). Obtained

his permission to teach a basic HEP. He agreed to try it.

• Met his wife 2 months after he was D/C, she reported he was still

adherent

A FEW WORDS ABOUT PATIENT ACTIVATION

Defined as ‘an individual’s knowledge, skill, and confidence

for managing their health and health care.”

Ref: Hibbard JH, Mahoney ER, Stockard J, Tusler M (2005). ‘Development

and testing of a short form of the Patient Activation Measure’. Health Services Research, vol 40, no 6, part 1, pp 1918–30.

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OFTEN REFERENCED AS A SET OF SIX PATIENT CHARACTERISTICS

• Ability to self manage illness

• Ability to engage in health related activity

• Ability to be involved in Dx and Rx choices

• Able to collaborate with providers

• Able to select providers based on outcomes/quality

• Able to navigate the health care system.

Ref: Greene J, Hibbard J. Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes.

J Gen Intern Med 2011 27(5):520–6 DOI: 10.1007/s11606-011-1931-2

HOW IS PATIENT ACTIVATION ASSESSED?

One method is with the PAM (Patient activation Measure).

• This is a 13 item scale measuring responses to statements

about skills, beliefs, and confidence in managing one’s

health.

• Scores range from 0-100, with 4 broad categories of

classification

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WHAT CAN YOU DO TO HELP IMPROVE YOUR PATIENT’S LEVEL OF ACTIVATION?

Studies suggest simple things that we can all do with our patients

to help foster activation:

• Help them plan concrete goals, starting with smaller,

attainable goals for folks you feel are lower on the activation

scale.

• Teach patients ways to monitor their progress or their overall

condition. Remember to use teach back/show back, to make

sure your patient can effectively use the information you

provide

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THE THERAPEUTIC ALLIANCE-AN ESSENTIAL ELEMENT

Defined as “the working relationship or positive social connection between the

patient and the therapist and established between therapist and client through

collaboration, communication, therapist empathy, and mutual respect.”

Ref: Joyce AS, Ogrodniczuk JS, Piper WE, McCallum M. The alliance as mediator of expectancy effects

in short-term individual therapy. J Consult Clin Psychol. 2003;71:672–79. doi: 10.1037/0022-006X.71.4.672

PHYSICAL THERAPY-SPECIFIC RESEARCH

Studies identify 4 essential elements for the Therapeutic Alliance :

1. Present

2. Receptive

3. Genuine

4. Committed

Ref: Miciak et al. The necessary conditions of engagement for the therapeutic relationship in physiotherapy: an interpretive description study. Archives of

Physiotherapy (2018) 8:3 https://doi.org/10.1186/s40945-018-0044-1

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BEING PRESENT

“…. reflects physiotherapists’ and patients’ intentions

and abilities to be in-the-moment or embodied

in time and space.”

BEING RECEPTIVE

This characteristic requires 2 ingredients:

1. Open Attitude

2. Focused Receptivity

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BEING GENUINE

Comprised of three elements:

1. The ability to be yourself

2. Honesty

3. Investing in the personal

COMMITTED

Committedness in this context refers to the therapists view

of their role and duty to be “all in” for the well being and

health of their patients.

Comprised of the 2 sub elements of :

1. Committed to Understanding

2. Committed to Action

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SELF DISCLOSURE

SELF-DISCLOSURE: BENEFITS AND RISKS

Defined as “a planned intervention with the goal of enhancing

the clinician-patient relationship”

• Clinicians must be aware of the power imbalance in the

relationship they have with the patient.

• Done correctly, it can be effective at “to enhancing therapeutic

relationships, reducing power inequities between the client and

professional, normalizing the client’s experience

Ref: Steuber P, Pollard C. Building a Therapeutic Relationship: How Much is Too Much Self-Disclosure? International Journal of Caring Sciences. May-August

2018 Volume 11 | Issue 2| 651-656

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CASE STUDY-USE OF SELF DISCLOSURE

This therapist has frequently found connection with certain

patients thru a ring I

wear on my right hand.

• The ring belonged to my father. It’s his Marine Corps ring. For

some reason, many older patients notice it and ask about it.

• The stories around the ring and my father’s service stories have

helped me connect to several hard to reach patients,

especially veterans.

FACTORS AROUND PATIENT MOTIVATION

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THE IMPACT OF LOW MOTIVATION ON PATIENT ADHERENCE

Why are some patients seemingly unmotivated to

participate or adhere to your treatment program?

Theories about this include:

• Amotivation: based on self determination theory. The person is unable to provide clear-

cut reasons to explain their inaction.

• The pre-contemplative patient, based on Prochaska’s transtheoretical model.

Ref: Hardcastle S , et al. Motivating the unmotivated: how can health behavior be changed in those unwilling to change? Frontiers in

Psychology. 6 June 2015 doi: 10.3389 /fpsyg. 2015.00835

MI: A TECHNIQUE TO ADDRESS THE AMOTIVATED PATIENT

Motivational Interviewing: “Motivational interviewing is a

directive, client-centered counseling style for eliciting

behavior change by helping clients to explore and resolve

ambivalence. “

Ref: Miller WR, Rollnick S. Ten things that motivational interviewing is not.Behav Cogn Psychother. 2009 Mar;37(2):129-40. doi:

10.1017/S1352465809005128.

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SPECIFIC MI STRATEGIES

Re -framing: Clinician offers a possible new meaning when

patient denies a problem.

• Example: “My spouse thinks I’m unsteady and nags me about

it, but I don’t have any problems getting around” (when patient

is visibly unsteady and has had falls). How might you re -

frame this?

“It sounds like your spouse really cares about you and is

concerned, although it is expressed in a way that makes you

upset. “

OVERSHOOTING/UNDERSHOOTING

These are techniques where the clinician can reflect back what the

patient has said to them but adjust it with use of low or high intensity

words.

Example of overshooting:

• Patient: “I don’t like the way my husband nags me about being

unsteady”

• Clinician: “It sounds like you’re really mad at your husband”

• The patient may back pedal such as : “Well, not really mad, just bugs

me sometimes”

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LOOKING FORWARD

Technique which asks the patient to consider their future

both with and also without the desired adherence to a

health strategy.

1. What do you think your life might look like in 5 years if

you do not make this change?

2. What do you think your life might look like in 5 years if

you do make this change?

HEALTH LITERACY AND ADHERENCE

• Health Literacy as defined by

the IHI is “the degree to which

individuals can obtain, process,

and understand the basic

information and services they

need to make appropriate

health decisions.”

Ref: http://www.ihi.org/communities/blogs/8-ways-to-improve-

health-literacy

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ACCORDING TO THE CDC---

WHAT CAN BE DONE TO IMPROVE HEALTH LITERACY?

The IHI recommends:

• Use simple language

• Use teach back/show back

method

• Include pictures/graphics such

as stop light tools

• Speak slowly enough for

patient to follow you

• Use open ended questions

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TOOLS TO ASSESS HEALTH LITERACY

A great repository for health literacy assessments can be found

here:

• http://healthliteracy.bu.edu/

• It contains at least 191 different health literacy and numeracy

tests.

EXAMPLE: BRIEF HEALTH LITERACY SCREENING TOOL

• Sample question:

How often do you have a problem understanding what is

told to you about your medical condition?

1. Always

2. Often

3. Sometimes

4. Occasionally

5. Never

BRIEF Score Skills and Abilities

Limited 4-12 Not able to read most low literacy health materials; will need repeated oral

instructions; materials should be composed of illustrations or video tapes. Will need

low literacy materials; may not be able to read a prescription label.

Marginal 13-16 May need assistance; may struggle with patient education materials.

Adequate 17-20 Will be able to read and comprehend most patient education materials.

Ref: Haun J, Luther S, Dodd V, Donaldson P. Measurement variation across health literacy assessments:

implications for assessment selection in research and practice. J Health Commun. 2012;17 Suppl 3:141-

59. doi: 10.1080/10810730.2012.712615

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SHARED DECISION MAKING (SDM)

1. At least 2 parties involved

2. Both participate in treatment decision

process

3. Information sharing is pre requisite

4. Both parties discuss preferences

5. Both parties agree on treatment decision

Ref:2 Charles C, Gafni A, Whelan T. Decision making in the physician patient encounter-revisiting the shared

treatment decision making model. SocSci Med. 1999. 49;651-661

BENEFITS FOR THE PATIENT IN SDM

Studies show patients reporting

multiple benefits when treating

clinicians use a SDM approach

with them. These include:

• More realistic expectations

• Less decisional conflict

• Increased adherence

• Greater satisfaction

Ref:Elwyn et al. Implementing shared decision-making: consider all the consequences

Implementation Science (2016) 11:114DOI 10.1186/s13012-016-0480-9

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RESEARCH ON SHARED DECISION MAKING UTILIZATION

MOST OFTEN STUDIED USING O.P.T.I.O.N.

• The clinician assesses patient’s

preferred approach to receiving

information to assist decision making

(e.g. discussion in consultations, read

printed material, assess graphical

data, use videotapes or other media)

SCALE OF RESPONSES

• 0 There is no attempt to perform the behaviour

• 1 There is a perfunctory or unclear attempt to perform the

behaviour

• 2 The behaviour is performed at baseline skill level

• 3 The behaviour is performed to a good standard

• 4 The behaviour is performed to a high standard

Ref: Coue”t N, et al. Assessments of the extent to which health-care providers involve patients in decision

making: a systematic review of studies using the OPTION instrument. 2013 John Wiley & Sons Ltd Health

Expectations, 18, pp.542–561

EXAMPLES OF SDM BEHAVIORS FROM O.P.T.I.O.N.

• The clinician states that there is more than one way to deal

with the identified problem (‘equipoise’)

• The clinician explores the patient’s concerns (fears) about how

the problem(s) are to be managed.

• The clinician checks that the patient has understood the

information.

• The clinician lists ‘options’, which can include the choice of ‘no

action’.

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HOW OFTEN IS SDM USED CLINICALLY?

Many clinicians fail to use SDM. One large review of various

medical practitioners found:

• A majority of studies reported an average total score <25.

(0-100 scale)

• The two least-observed behaviors were assessing the patient’s

preferred approach and eliciting preferred involvement.

• Good news! SDM can be learned and when clinicians were

given teaching, scores improved to > 50.

SDM USE BY PHYSICAL THERAPISTS

13 PT’s participated. A total of 210 consultations were assessed using OPTION and

the Control Preference Scale (CPS).

• I prefer to make the treatment decisions on my own.

• I prefer to make the treatment decisions after hearing the opinion of the therapist.

• I prefer to share the treatment decisions with the therapist.

• I prefer the therapist to make the treatment decisions after hearing my opinion.

• I prefer to leave the decisions to the therapist.

Ref: Dierckx K. et al, Implementation of Shared Decision Making in Physical Therapy: Observed Level of Involvement and Patient

Preference. Physical Therapy 2013. Volume 93 Number 10 1321-1330.

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SO HOW DID THE PT’S DO?

• Vast majority of consultations showed only perfunctory or

unclear attempts to perform the SDM behaviors.

• Mean OPTION score was only 5.2% (on 0-100% range).

Ugh!

• In only 28% of the cases, did the PT’s correctly gauge the

patient’s preferred level of autonomy in the decision

making process.

RECOMMENDATIONS TO IMPROVE USE OF SDM

1. Draw attention to a problem that needs a decision.

2. Share information by listing all of the different options

and exploring the concerns and ideas of the patient.

3. Indicate the need for a decision-making stage.

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TEST YOUR KNOWLEDGE

Which of the following is true regarding health literacy?

1. Health literacy refers to how well a patient can

pronounce the names of their pills.

2. Patients health literacy improves when you talk to them

using technical jargon.

3. Teach back and show back are proven methods to raise

health literacy.

THE ROLE OF TECH

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CAN TECHNOLOGY HELP ENHANCE ADHERENCE TO EXERCISE PROGRAMS?

• A review of 22 studies found 10 directly comparing traditional

exercise programs to technology-based programs.

• Interestingly, both types of exercise showed high adherence

rates in the study (91% vs 83%), with tech-based programs

coming out on top regardless of other factors.

• Many of the tech-based programs used gaming software to

enhance participant enjoyment

Ref:Valenzuela T Okubo Y, Woodbury A, Lord SR, Delbaere K. Adherence to Technology-Based Exercise Programs in Older Adults. A Systematic Review.J Geriatr Phys Ther. 2018

Jan/Mar;41(1):49-61. doi: 10.1519/JPT.0000000000000095.

USE OF AN APP VERSUS HAND –WRITTEN HEP

Australian study involving 80 patients with LLMSD’s-half received a

paper handout of their HEP-half received the HEP on an app plus f/u

phone calls and motivational texts.

• Self reported adherence at 4 weeks favored the app group by

approx. 11%

• Overall functional improved in the app group by average of 8% >

vs the control group

• Other secondary outcomes did not approach significance

Ref: Lambert TE, et al. An app with remote support achieves better adherence to home exercise programs than paper handouts in people with musculoskeletal conditions: a

randomised trial. J Physiother. 2017 Jul;63(3):161-167. doi: 10.1016/j.jphys.2017.05.015. Epub 2017 Jun 26

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IN CONCLUSION……

• The problem of patient adherence to care is multi faceted

• We have multiple strategies at our disposal to improve the

chances of our patient being a full participant in their care.

• However, we have a ways to go in terms of fully utilizing these

strategies.

• Universities should increase emphasis on these techniques when

providers are in training.

THANKS FOR LISTENING IN!

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