Nurses: they’re not just in hospitals anymore

UBC's Jennifer Allen and Charlie Bell discuss the ever-changing role of nurses within the healthcare industry. They specifically look at how nurses today are not only limited to helping patients within hospitals, but provide medical education and adherence services via the phone as well.

For many years, patients were primarily limited to two sites of care: the physician's office or the hospital. In 1965, Medicare for the first time began including home health nursing as a covered benefit. Since then, nurses have been providing patient care in a variety of settings including the patient's own home. In recent years, the role of nurses has changed even more and they now provide patient education and adherence services via phone. These changes have created the opportunity for nursing services to be integrated with Specialty Pharmacy to provide home infusion services, as well as to support compliance programs.

Non-adherence; an expensive healthcare challenge

Research shows that non-adherence costs the nation $329 billion in unnecessary pharmacy and medical expenses. Overall, waste from suboptimal pharmacy behaviors ranged from $1,004 to $1,623 per person – a total of $418 billion.

Cost to the pharmaceutical industry

About 70% of patients discontinue medication therapy within one year, costing the pharmaceutical industry an estimated $30 billion annually, according to one estimate in research conducted by Dr. Andree Bates. The study, Benchmarks in Improving Medication Adherence, by Jan Berer, Beth Chester, Thom Stambaugh and Janet Tomcavage, published in Health Intelligence Network, states that annually, 125,000 deaths are attributable to non-compliance with therapeutic regimens.

Patients on medications for specialty conditions – complex, chronic diseases – are among those most non-adherent to their medications including:

• Nearly 41% of cancer patients

• 40% of those with inflammatory conditions

• Nearly 23% of HIV patients

"About 70% of patients discontinue medication therapy within one year, costing the pharmaceutical industry an estimated $30 billion annually..."

As our available healthcare dollars are stretched further and further to meet the needs of a larger and older population, we can no longer afford the costs of non-adherence.

Figure 2: The problem of non-adherence

Many causes of non-adherence

The barriers to adherence vary from patient to patient and most patients have multiple reasons for being non-compliant. These can include:

• Cost of the medication

• Lack of understanding of the importance of following dosing schedules

• Inability to administer self-injections properly

• Administration anxiety

• Therapy fatigue

• Lack of personal support or changes in caregivers

With the exception of medication cost, all of these barriers to adherence can be impacted with educational and support programs with minimal costs incurred.

The value of nursing

Nursing support programs can be designed to address the various barriers to adherence experienced by patients. Support programs should be designed by first assessing the medication-specific drop-off rate and the reasons for patient discontinuation over the therapy lifecycle. Once the barriers have been identified, the appropriate interventions should be timed so that the patient's needs are addressed before the barrier leads to non-adherence. After the program is implemented, periodic assessment of the effectiveness of interventions should be performed, with appropriate revisions of the program strategies.

Specific interventions that we have found to be impactful include:

• Medication reminders

• Home education visits

• Education regarding efficacy

• Side-effect management

• Reminders to follow up with the prescriber

Risk assessment tools can help identify the level of support needed for the patient. High-risk patients may require more frequent and aggressive interventions, while low-risk patients may need minimal follow up.

"The barriers to adherence vary from patient to patient..."

Providing the appropriate level of support when the patient needs it decreases overall spend for adherence programs and increases the effectiveness of the interventions provided. Risk assessment tools may include the Morisky Scale using either of the four or eight question scales, the Beliefs about Medications Questionnaire, or a customized scale designed to elicit the patient's adherence patterns and risk for future non-adherence.

These scales rely on patient self-reporting, making it critical that program design include consideration for the relationship built between the patient and the personnel placing the calls. Patients must trust the employee reaching out to them. Because the patient-counselor relationship must be built in a short time on the phone, adding a nursing component to a Specialty Pharmacy-based compliance program can bring a level of high-touch care that further engages a patient in their treatment and effective disease management.

Nurses provide an important resource for the development and execution of adherence programs. Nurses have consistently outranked other professions, for honesty and ethical standards, in Gallup's Honesty and Ethics survey since they were added to the survey in 1999. Since that year, the only other group to rank higher was firefighters after the attacks of September 11, 2001.

Figure 3: 2010 Gallup Poll Results, Jones, Jeffrey M. Nurses Top Honesty and Ethics List for 11th Year; Gallup Economy, December 3, 2010. Accessed May 20, 2013.

Http://www.gallup.com/poll/145043/Nurses-Top-Honesty-Ethics-List-11-Year.aspx