Medication compliance

Medication compliance

Daily telephone counseling can maintain medication complianceGary Allen RNChamberlain College of NursingNR451 RN Capstone CourseNovember 2016

Change Model OverviewTo enact change we must first determine which type of change we wish to enact.

To enact effective change we learn that The use of rating scales assists the critical appraisal of evidence. (Dearholt & Dang, 2012).

Rating scales present a structured way to differentiate evidence of varying strengths and quality (Dearholt & Dang, 2012).

One of the most effective rating scales is the John Hopkins Nursing Evidence-Based Practice Process it provides the structure to allow the team to determine if the evidence is high, good or low/flawed

One of the most effective rating scales is the John Hopkins Nursing Evidence-Based Practice Process. From this tool we can determine if the evidence we are presented is of high quality and more likely to present best practice vs evidence of lesser quality. As higher quality ingredients leads to a better meal so do higher quality evidence lends credence to our practice. This tool provides the structure to allow the team to determine if the evidence is high, good or low/flawed yet allowing the team to use its own clinical and critical thinking skills to extrapolate and apply it to their own situation. Using this tool validates the information presented to show that Daily telephone counseling can maintain medication compliance.

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Process of evidence-based practice How to increase compliance using PICO

Act

Process of evidence-based practice How to increase compliance using PICO

Act

As irregular medication adherence is a significant predictor of relapse (Fenton, Blyler, & Heinssen, 1997)

Scope of the problem

outpatients with schizophrenia reported a median default rate of 41 percent (range, 10% to 76%) with oral medications(Fenton, Blyler, & Heinssen, 1997).

Another study shows medication compliance of 20-45% within the first 6 months (Beebe, Smith, & Phillips, 2014; Montes, Maurino, Diez, & Saiz-Ruiz, 2010).

Daily telephone counseling can maintain medication compliance

In the realm of mental health the interventions are as varied as the diagnosis themselves. Of primary concern is the area of medication compliance of a patient with the diagnosis of SchizophreniaRemaining compliant outside of a structured environment on medications can mitigate the negative symptoms of the disease process. Current research has shown that daily telephone compliance calls have shown a marked decrease in noncompliance in the outpatient setting (Beebe, Smith, & Phillips, 2014; Montes, Maurino, Diez, & Saiz-Ruiz, 2010).

Within the realm of mental disorders Schizophrenia is considered the most challenging to treat due to the nature of the disease process. This is primarily due to the majority of the patients believed they did not have a serious mental illness or, that they could function adequately with a mental illness (Kanahara, 2009). With current practice models medication compliance in the outpatient setting is poor and these numbers vary widely from 20-45% within the first 6 months (Beebe, Smith, & Phillips, 2014; Montes, Maurino, Diez, & Saiz-Ruiz, 2010). Adequate compliance with atypical psychotropic medication is defined as 80% oral compliance according to one study (Montes, Maurino, Diez, & Saiz-Ruiz, 2010). At the lower compliance rate multiple risks for complications related to the disease process occur from increased time hospitalized and the subsequent costs incurred and up to death (Lindstrm, Eberhard, Neovius, & Levander, 2007).

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Recruit Interprofessional TeamThe Interprofessional team that will be utilized will consist of the following classifications Registered Nurse, Social worker, Primary Psychiatrist and database coordinator. The four classifications will be organized on the micro scale for ease of use yet can be scaled upwards or downwards depending on acuity of clientele serviced. For the initial intervention the ratio will be a six to one with each individual in the team overseeing six patients in an outpatient setting. (California Safe staffing law AB-394)

(Music will start control of points more precise note to presenter)7

Your team

The RN will be engaged in the assessment and intervention with the patient coordinating information with the Psychiatrist, Coordinator and Social worker.

Lastly the Coordinator will be responsible for facilitation of information amongst the disciplines as well as recording relevant patient data obtained from each discipline.The Social worker will address any concerns that prohibit medication compliance examples include but not limited to, obtaining Rx, Transportation, finances. The Psychiatrist will address any concerns outside of the RN scope. Such as side effects, the evaluation for increase or decrease of medications etc. Information being recorded by Coordinator.

Patients suffering from Schizophrenia

Providers of Service

Medical Professionals: Doctors, Nurses etc.

Family members caring for those afflicted with Schizophrenia

Your stakeholders

EvidenceMany avenues of research were utilized to obtain information that was of high quality in nature. All sources of information were peer reviewed and were able to shed some light on this subject. Several sources were shown to have good-quality and one of high-quality; all were randomized, controlled trials and case studies all of them yielding consistent results.Finally another source was able to use statistical modeling based on closed loop system where all care both inpatient and outpatient was monitored by the government (Lindstrm, Eberhard, Neovius, & Levander, 2007).

EvidenceAs stated previously the majority of the patients believed they did not have a serious mental illness or, that they could function adequately with a mental illness (Kanahara, 2009).

This in turn leads to the noncompliance of the patient population with one study showing that outpatients with schizophrenia reported a median default rate of 41 percent (range, 10% to 76%) with oral medications and 25 percent (range, 14% to 36%)(Fenton, Blyler, & Heinssen, 1997).

Many reasons are given for why patients dont take their medication as one writer put it; they forgot to take their medications (Fenton, Blyler, & Heinssen, 1997).

This in turn leads to the noncompliance of the patient population with one study showing that outpatients with schizophrenia reported a median default rate of 41 percent (range, 10% to 76%) with oral medications and 25 percent (range, 14% to 36%)(Fenton, Blyler, & Heinssen, 1997).

Still another study shows medication compliance of 20-45% within the first 6 months (Beebe, Smith, & Phillips, 2014; Montes, Maurino, Diez, & Saiz-Ruiz, 2010). As can be seen compliance remains poor especially in the compliance of oral medications. Without consistent medication compliance acute hospitalization was required leading to higher costs and greater chance of negative outcome with any secondary diagnosis (Lindstrm, Eberhard, Neovius, & Levander, 2007).

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EvidenceHospitalization of recurrent noncompliant patients factored into the greatest cost with increase medication compliance decreasing these costs (Lindstrm, Eberhard, Neovius, & Levander, 2007). Lastly TIPS (Telephone intervention Problem solving for Schizophrenia) a qualitative study tool was utilized with great effect as detailed in (Beebe, Smith, & Phillips, 2014). Using this tool it could be determined if the client needed medication adjustment, education or evaluation by the primary psychiatrist.

A controlled trial using a large pool of subjects from multiple hospitals in Spain over a four month period was able to have patients with schizophrenia receive telephone based intervention than those without; with the results overwhelming showing that compliance increased in those receiving the phone call (Montes, Maurino, Diez, & Saiz-Ruiz, 2010). 12

Action Plan

To implement our intervention effectively we must utilize effective communication across different disciplines. The role of the individual team members assembled would be no different than what the individual team members are usually assigned to. The RN will be engaged in the assessment and intervention phase of the intervention utilizing standardized tools for assessing mediation compliance and knowledge of the patient regarding their medication. The standardized tool will be the TIPS (Telephone intervention Problem solving for Schizophrenia) model as detailed in (Beebe, Smith, & Phillips, 2014).

There are two ways in which communication can be improved; standardization tools and establishing a culture of supportive communication (Week 3 Lesson).

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Action Plan Continued

Area to be arranged to include at minimum appropriate office supplies, Computer, telephone and ancillary equipment for team members.Voluntary consent and disclosure discussed with both primary psychiatrist and patient and both agreeing to listed interventions as well as data collection.Participants will have diagnosis of Schizophrenia and taking one or more anti psychotics orally, age 18 and older and willingness to participate (Fenton, Blyler, & Heinssen, 1997).

There are two ways in which communication can be improved; standardization tools and establishing a culture of supportive communication (Week 3 Lesson).

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Plan TimelineInitial stage of preparation includes screening of applicant and gathering appropriate staff estimated time to complete one month.A three month timeline will be projected for the start and end timeline of the pilot project with it being divided into one month increments for management of data. Wrap up stage will conclude a the end of the pilot and will be composed of reviewing of data obtained during the previous three months of data collection.

The nurses role and responsibility Overseeing six patients in an outpatient setting. Assessment and intervention with the patient.

Coordinating information with the Psychiatrist, Coordinator and Social worker.

Procedure

To implement the plan on a larger scale will require only a scaling of the pilot minus the exclusion group. The exclusion group is only necessary for validation of data. To enable continue funding and validation of results a cost comparative analysis will be conducted based on quarterly expenditures and revenues and will validate returns and continued funding.

The ratio will remain the same as it is in line with California Safe staffing (1999). Other areas of the United States will have to follow applicable laws related to staffing based on their respective locations. As this intervention will be under the arm of outpatient psychiatric services it will not need a large implementation strategy only localized to that area. 17

Procedure for Evaluating and Reporting OutcomesDesired outcomes will be documented as having a compliance percentage equal to and or greater studies of similar interventions.Medication compliance will be validated via pill count at a time unbeknownst to subject at two random times during each month which is a variation on the work of Beebe, Smith, & Phillips, (2014); who received a compliance percentage as high as 87.5%. Results will be collated and presented to the chief nursing officer for final review of data who will in turn will be bring it up during the next policy meeting which is held on a semiannual basis. During the policy and procedures meeting the Chief financial officer will be able to validate the cost savings to private medical insurance providers as well as other entities that have a vested interest and be able to see the benefit of this intervention.

Procedure on Decimation of FindingsInformation will flow through email as a form of communication tool as well as access of data and results of compliance and interventions through centralized database. Database will be accessible to all members of the team and will be in the form of electronic medical record as currently kept of a patients file in outpatient program. This in turn can be printed if necessary to allow information to be conveyed to additional facility or other programs as appropriate for continuous care across different hospital platforms.

Forms that will be used The standardized tool will be the TIPS (Telephone intervention Problem solving for Schizophrenia) model as detailed in (Beebe, Smith, & Phillips, 2014).

ResourcesPrimary PsychiatristSocial WorkerNursing ManagementLead Pilot Author (Gary Allen RN)

Resources available John Hopkins Nursing Evidence-Based Practice Process

Telephone intervention Problem solving for Schizophrenia (Beebe, Smith, & Phillips, 2014).

Electronic databases for data entry

Conclusion

Medication noncompliance is not only a detriment to the patients well-being in the form of physical, emotional and financial cost it is also a strain on limited resources in an already impacted system.

With a low cost intervention of a phone call the return to investment in regards to the physical, emotional health of the patient is improved, as is strain on limited resources.

All sources of information utilized in implementing this intervention were peer reviewed and were able to shed light on this subject. With several sources having shown good-quality and one of high-quality it can be said with certainty that we can answer our question about improving our practice with evidence that we can translate into current practice with minimal cost and maximum benefit to the emotional and physical health of the Schizophrenic patient.

ReferencesBeebe, L., Smith, K. D., & Phillips, C. (2014). A Comparison of Telephone and Texting Interventions for Persons with Schizophrenia Spectrum Disorders. Issues In Mental Health Nursing, 35(5), 323-329. doi:10.3109/01612840.2013.863412 California Safe staffing law AB-394 retrieved from http://www.leginfo.ca.gov/pub/99-00/bill/asm/ab_0351-0400/ab_394_bill_19991010_chaptered.htmlChamberlain College of Nursing. (2015). NR-451 Week 3: Solving the Problem. [Online lesson]. Downers Grove, IL: DeVry Education Group Retrieved from www.chamberlain.edu

ReferencesDang, Deborah ; Dearholt, Sandra L. . Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines, Second Edition (Kindle Locations 1993-1994). Sigma Theta Tau International. Kindle Edition.)Fenton, W. S., Blyler, C. R., & Heinssen, R. K. (1997). Determinants of medication compliance in schizophrenia: empirical and clinical findings. Schizophrenia Bulletin, 23(4), 637-651. doi:10.1093/schbul/23.4.637Kanahara, S. (2009). The Outcome of Behavioral Intervention with a Person Living with Schizophrenia Who Exhibited Medication Noncompliance: A Case Study. International Journal Of Behavioral Consultation And Therapy, 5(3-4), 252-263. Doi:10.1037/h0100886

ReferencesLindstrm, E., Eberhard, J., Neovius, M., & Levander, S. (2007). Costs of schizophrenia during 5 years. Acta Psychiatrica Scandinavica, 116(S435), 33-40. doi:10.1111/j.1600-0447.2007.01086.x Montes, J., Maurino, J., Diez, T., & Saiz-Ruiz, J. (2010). Telephone-based nursing strategy to improve adherence to antipsychotic treatment in schizophrenia: A controlled trial. International Journal Of Psychiatry In Clinical Practice, 14(4), 274-281. doi:10.3109/13651501.2010.505343