AMGA and Pfizer Inc. present the Models of Excellence Collaborative on Patient Adherence and Health Literacy

Watson Clinic, Lakeland, FL
Cardiovascular Conditions and Diabetes

EXECUTIVE SUMMARY: Cardiovascular disease and diabetes mellitus are chronic, progressive disorders that lead to significant morbidity, mortality and economic burden in the United States. These disease processes have accounted for the Clinic's highest volume of adult patient visits in recent years and have been the focus of significant analysis for quality improvement over the past 3 years.

In 2001, the Quality Improvement Risk Management (QIRM) Department conducted a retrospective review of 536 randomly selected patients with these diagnoses to obtain a baseline evaluation of clinic performance with respect to nationally recognized evidenced-based clinical practice standards. Findings demonstrated multiple opportunities to improve patient care. The QIRM Department subsequently collaborated with providers on several interventions with the goal of improving treatment goal attainment among clinic patients.

Findings from a follow-up review in October 2003 demonstrated significant improvements in many of the clinical indicators from baseline, but multiple opportunities to improve remained. Chart documentation of patient nonadherence, a key assessment not addressed in the baseline review, was also collected during this follow-up review. The data confirmed the pervasiveness of this problem among clinic patients. Nearly one third of the patients evaluated had documentation of nonadherence to medications, therapeutic lifestyle changes, follow-up appointments, and/or self-monitoring practices. There was also speculation that the actual prevalence of this barrier to care may have been much higher due either to underreporting or to lack of problem recognition.

Primary and secondary prevention play critical roles in decreasing morbidity and mortality related to cardiovascular disease and diabetes. Recognizing that patient adherence is vital to the success of strategies for treatment and prevention and fueled by the data demonstrating an overwhelming problem of nonadherence among clinic patients, Clinic leaders identified this issue as a critical quality initiative for 2004. The collaborative patient adherence project is a product of this priority quality initiative.

The overall goal of this project is to measurably improve treatment goal attainment rates in clinic patients with cardiovascular conditions and/or diabetes. Built on the theory that the problem of patient nonadherence is one for which there is shared accountability between patients and their health care providers, the project features both patient- and provider-focused strategies to facilitate patient adherence. Provider strategies include: 1) training classes in methods to identify low health literacy and/or nonadherence, as well as techniques and communication skills to enhance adherence behaviors; 2) clinical updates; and 3) physician profiling reports with specific comparative data about overall treatment goal attainment rates in their patients. Patient strategies include: 1) health awareness activities; 2) educational classes and mailings; 3) "Roadmap to Wellness" case management program for patients not at treatment goals and/or with acknowledged or suspected nonadherence issues.

The collaborative patient adherence project is unique in its components to support behavioral change: 1) Repetition of health information from providers at multiple points of patient contact; 2) Health information designed for patients at each point along the health awareness to adherence continuum (i.e., general health awareness information and classes teaching specific skills to enhance functional health literacy); 3) Case management follow-up to reinforce adherence behaviors; and 4) A support group to assist with maintenance of adherence behaviors.

Improvement in adherence behaviors and treatment goal attainment rates among clinic patients is expected. A case management model for patients with health literacy and/or nonadherence issues will be implemented and refined, producing applications that can translate to patients universally.

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