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Techniques for Non-Compliant Patients

Lynn Pierce, BSN, RN, CPHRM, Jennifer L. Flynn, CPHRM

May 24, 2018

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Question

Can you advise of some techniques to help with non-compliant patients?  

Answer

Some of the techniques that may help you deal with noncompliant patients include sound documentation, policies for dealing with missed appointments, and your communication with the patient. If the situation does not improve, you may need to employ stronger tactics such as having them sign a refusal-to-consent form, or even making the decision to terminate the patient-provider relationship in order to protect yourself from litigation. We will take a look at each one of these in more detail.

Often, sound documentation is the best defense a PT can provide when dealing with a non-compliant patient. Are you familiar with the old adage, "Not documented, not done"? In situations where you may need to prove consent, prove your clinical thoughts for that specific treatment plan, prove any instructions or education you provided to the patient, or even any interventions you took with the patient (including documenting missed appointments or how you followed up with the patient), your documentation and the patient record is the best defense you have against disproving a patient's allegations of negligence or abandonment. The documentation and the patient's record will also help you identify at an early stage any signs of non-compliance before the situation worsens. 

What should you document? Your documentation should include missed appointments. Too often, healthcare practices treat a missed appointment merely as an annoyance and fail to note the occurrence in the patient's healthcare record. However, as missed appointments may indicate potential non-compliance and require follow-up and documentation. Healthcare businesses should have a formal written policy for managing missed appointments. What should your policies include regarding missed appointments? You may have your staff prepare a daily list of missed appointments, and they should be documented in the patient's record.  It should also include how the staff is to follow up with these patients. It may include calling the patient, to either remind them of their appointment or to reschedule. Depending on the situation, you may choose to send a reminder card or something in the mail. If the patient is habitually missing appointments and these remedies have failed to change behavior, you may need to send a certified letter or other written correspondence.

Remember to document these types of communications in the patient's record and keep a copy of what was sent. Spelling out basic expectations are key when communicating with patients. Studies have found that the patient satisfaction and patient adherence are enhanced by the patient's involvement and participation in their care. The behavior of providers and patients tends to be reciprocal when they strive toward a partnership. Patients who want to be more involved tend to ask more questions and display more confidence. Providers who are willing to have a more collaborative relationship with their patients tend to act in ways that prompt their patients to be involved and active. When you're communicating with patients, another important factor influencing non-adherence is a patient's ability to remember the details of the recommendations made to them. Not surprisingly, when patients are presented with instructional information, they tend to forget a large portion of it. Having standardized educational materials and using other teaching and memory aids can help foster a better rapport with patients.

If written reminders fail to improve compliance, perhaps it may be time to escalate your efforts and schedule a face-to-face discussion with the patient to remind the patient of your mutual concerns and expectations. Again, you would want to document this meeting in the healthcare record. Your ultimate goal with each patient is to deliver quality care for optimal results. With that, any communication you have with your patient, either spoken or written, should be clear and direct but also polite and sympathetic. In these communications, you can spell out your concern and emphasize how compliance is a key factor in achieving those goals.

Beyond a face-to-face meeting, there may be a need to communicate with non-compliant patients by letter. If sending a letter by certified mail, place a copy of what was sent in the patient's record. You would want to instruct the patient on key elements, such as how to contact the office, who to speak with to reschedule, and what steps may be needed to improve the relationship and continue with treatment. It's also important to note that perfect agreement on adherence will not always be reached. The acknowledgment of differences is an important part of building respectful and trusting relationships between providers and their patients. No single intervention strategy can improve adherence of all patients. Success depends on tailoring interventions to the unique needs of the patient. For example, some patients may be unable to maintain a complicated treatment plan without a strong social support system or even the need for multiple prompts to remind them of what needs to be done. Other patients may have problems keeping appointments because they don't have access to reliable transportation, or may have family emergencies arise from time to time. The provider in each of these provider-patient relationships, however, remains at the core of all successful attempts to improve adherent behaviors.


lynn pierce

Lynn Pierce, BSN, RN, CPHRM

Lynn Pierce, RN, BSN, CPHRM, is a risk control consultant for CNA. Prior to joining CNA, she worked in such clinical settings as emergency, surgical and critical care, and cardiac and orthopedic rehabilitation services. She has served as a director of risk management in acute care hospitals and integrated health care systems and has held leadership positions in risk management, quality, HIPAA privacy, environmental and patient safety, case management, corporate compliance, Workers’ Compensation and infection prevention. She earned her BSN from the University of West Georgia in Carrollton, Georgia and is currently pursuing a MSN-FNP with an expected graduation of Fall 2019.


jennifer l flynn

Jennifer L. Flynn, CPHRM

Jennifer Flynn, CPHRM, is Risk Manager for Healthcare Providers Service Organization in the Healthcare Division of Aon’s Affinity Insurance Services, Inc. Specializing in risk management and having worked in the healthcare insurance business for over 17 years, Jennifer is dedicated to educating healthcare professionals on professional liability risks and offers strategies to mitigate those risks. Working at HPSO, she was instrumental in bringing the most recent healthcare claim reports to the healthcare community; created self-assessment tools, website content and other materials on healthcare risk management issues. She has presented at professional organization meetings on healthcare risk management & other insurance related topics. Jennifer has earned her Certified Professional in Healthcare Risk Management (CPHRM) designation and is a licensed Property & Casualty agent.  She earned a BA in Psychology from Arcadia University in Glenside, PA.  


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PTs and Patient Non-Compliance
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