Dr. Aworunse says patient educational presentations, like this video, can help the doctor explain a diagnosis and the treatment plan.
By Feyi Aworunse, OD, FAAO
Feb. 23, 2022
When we initiate a treatment plan, we are impacting the patient’s eye health and lifestyle. As clinicians, we understand the importance of following a prescribed plan, so it can be difficult to understand why some patients fail to follow through. By engaging with the patient on a deeper level, we may be able to gain insight into their daily routine. With this information, we can determine what will work well, and where adjustments should be made, either to the treatment plan or the patient’s daily routine.
No single strategy can improve patient adherence, but here are a few techniques that will allow you to efficiently utilize chair time to treat your patients more effectively.
Empower the Patient by Actively Engaging Them in the Treatment Plan
By taking a collaborative approach, patients tend to be more receptive to the proposed plan. Rather than me “telling them what to do,” I discuss the diagnosis, the goals (i.e. improved comfort or vision, preventing vision loss) and what we can do to meet those goals.
When I discuss the diagnosis, I emphasize the aspects of it that are most relevant to their complaint. I inform asymptomatic patients of the need for preventive measures to reduce the risk of worsening disease. I inform the patient of the potential treatment options and the associated risks and benefits of each. I ask the patient which treatment plan they think would best meet their needs, and if there are any issues which they foresee posing a problem for compliance. Some medications require frequent dosing. I make sure in those cases that the patient will be able to manage the dosing regimen.
If the plan involves a referral or further testing, I let the patient know what is expected of them beyond my care and the need for their accountability.
Enabling the patient to participate in the treatment planning process empowers them to follow through because they understand the plan and have agreed to it. As much as it is my goal for the patient to experience an improvement in symptoms or reduce the risk for vision loss, I emphasize to them that it is their goal as much as it is mine, if not more.
Patients and their families often voice their appreciation for feeling part of their treatment. I have heard patients say they have gotten used to doctors just telling them what to do without helping them understand why.
Use Teach-Back Method & Handouts/Medication Planners
As described by the Agency for Healthcare Research and Quality, the teach-back method checks for the patient’s understanding of their health and treatment plan. If they are unable to relay the information correctly, you have an opportunity to clear up confusion and emphasize important points.
Ask the patient to explain what they understand their diagnosis and treatment plan to be. Ask the patient to show you how they would administer their medication (i.e. eye drops).
In our practice, we utilize drop instruction handouts specific to each patient, especially when we are initiating multiple medications. Depending on the complexity of the diagnosis and treatment plan, this may take 5-15 additional minutes.
However, it may be something that your staff can be trained to continue after you leave the room. For diagnoses that involve risk of worsening disease, such as glaucoma or diabetic retinopathy, the time spent educating patients is worth the reduced risk of irreversible vision loss.
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This technique is helpful when dealing with patients who may have low health literacy, which tends to be prevalent among elderly patients, those of low socioeconomic status and individuals for whom English is a second language
One of my patients had an existing diagnosis of dry eye disease secondary to Sjogren’s Syndrome. Her condition was adequately managed with artificial tears twice a day, but there was concern about the number of eye drops she was taking, as she was also diagnosed with moderate stage open-angle glaucoma. In addition to her artificial tears, she had three bottles of different glaucoma medications, with one dosed as often as three times a day. She reported some confusion as to when she needed to take each drop, but was sure she used at least two of the three every day. When I asked her to tell me when she takes each drop, I realized that she was not taking her drops correctly.
We ultimately decided to reduce her total number of medicated drops from three to two, by prescribing a combination medication. We then created a printed medication planner, where she can write out which medication to take and when. By reducing her ophthalmic medications and need for frequent dosing, she was able to adhere to her medication regimen and achieve improved comfort and IOP control.
This is an example of why it’s beneficial to review how the patient is taking the medication versus just asking whether or not they are taking it. The use of the teach-back method is not just helpful at the initiation of the treatment plan, but also at follow-up visits when adherence is suspected to be poor.
Use Follow-Up Visits as an Opportunity for Redirection or Positive Reinforcement
Adherence warrants positive reinforcement, which can encourage the patient to continue with the plan as directed, reminding them that treatment adherence is still warranted for chronic disease.
Non-adherence warrants redirection. For non-compliant patients, ask if anything is hindering them from being able to follow through. Usually, the barriers to adherence are time, money and accessibility. Sometimes, the patient may not understand the nature of their disease and the importance of treatment adherence.
This question opens the floor for the patient to share issues they may have run into that prevented them from being able to follow through with the proposed treatment plan.
Patients are then able to share any issues they may have encountered since the plan was initiated. This is helpful even for patients who are adherent to the treatment plan, but may have had a change in their circumstances.
In the case of medications, I want to know if they have any difficulties filling prescriptions due to cost or ability to get to the pharmacy. I generally prescribe for 90-day supplies when possible to reduce the frequency of trips to the pharmacy. If the patient is having problems affording the treatment, staff can be trained to discuss medication assistance programs and help the patient to fill out and submit applications. Rather than shaming patients who may have difficulty adhering to their treatment or follow-up visits, you can aid in redirecting the plan toward one that works better for them.
I had a patient who had difficulty getting transportation to the pharmacy to pick up their medications on time. They relied on family members for help, but availability was always unpredictable. I did not know this was an issue until I asked her to bring in her eye drops and I saw that the label on the box was dated several months prior. She then admitted that she had not picked up medications from the pharmacy in some time. We discussed our options and decided to switch to home delivery of medications, which she was able to use for all of her prescriptions.
For the majority of ophthalmic medications that we prescribe, there are patient assistance programs that are sponsored by pharmaceutical companies. These programs help patients obtain medications at low or no cost. The application process may take an additional 10 minutes, and may require the patient to provide income or insurance coverage information. However, it’s worth the effort to help patients do this. I find that for the majority of my uninsured patients, medication adherence increases dramatically when they are able to obtain the medications for free. Some insured patients may qualify for programs that reduce the co-pay for certain medications as well.
My practice is an outpatient clinic for the community hospital, and we do not currently have an optical. For many of my patients, their treatment plan involves obtaining corrective lenses. When first I started at my clinic, I would see patients for follow-up visits who reported they were unable to obtain glasses due to cost or other accessibility barriers. Seeing that this was a recurring issue, I sought out options to help bridge the gap. Fortunately, we have been able to implement charitable programs for our patients to obtain glasses at no-cost. Programs such as Essilor Vision Foundation’s Changing Life through Lenses (CLTL) have become an integral part of my practice and have allowed us to meet a great patient need.
Bottom Line
By implementing the techniques outlined in this article, you have the opportunity to improve patient outcomes and increase patients’ confidence and satisfaction with your practice. In turn, you can potentially increase exam efficiency, reduce the rate of missed appointments and reduce the risk of provider and staff burnout.
Feyi Aworunse, OD, FAAO, practices at the Eye Clinic at Nashville General Hospital at Meharry. To contact her: feyi.aworunse@gmail.com
