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Using Social Determinants of Health to Drive Medication Adherence

Programs to address the social determinants of health have the potential to improve medication adherence rates.

Prescribed medication is essential to treating and managing disease, but a lack of medication adherence is limiting the effectiveness of treatment and costing patients their lives and contributing to hundreds of billions of dollars in avoidable costs.

While medication reminders and management strategies have a part to play in resolving this problem, challenges often go beyond a patient organizing her pills. Providers must acknowledge the role that the social determinants of health play in medication adherence. In other words, medication adherence is a more complex challenge than addressing non-compliance.

"People don't wake up in the morning and think ‘I'm not going to follow what my doctor told me to do today,'  "Lisa Roome-Rago, the executive director of Outpatient Care Management and Medical Operations at AdvocateAurora Health, said in a previous interview. “It’s a matter of figuring out what’s actually going on and then trying to create a plan around that and minimize as many barriers as you can.”

Patients face a litany of societal challenges, those not necessarily tied to their health or their understanding of healthcare, that keep them from taking their medications.

High costs keep patients from taking their medications on schedule or even filling their prescriptions altogether.

Limited mobility and inability to get to the pharmacy to fill or pick up a prescription represent another challenge for patients.

And for patients who come from traditionally disadvantaged social groups or who have limited educational attainment, self-efficacy medication management is likely a hurdle.

Providers and pharmacists alike must screen their patients for the social determinants of health to understand the barriers the latter face to care management. In doing so, they can move on to identifying the strategies that will help their patients remain adherent to their medication plans.

Countering high medication costs

Data from a 2015 study of oncology treatments revealed that high costs are the top barriers to strong medication adherence. When a medication is too costly, a patient may ration her pills, skip doses when she no longer feels symptoms, or forego filling the prescription altogether.

In 2017, nearly 60 percent of all adult patients were prescribed a medication, according to data from the Centers for Disease Control (CDC). But 11 percent of patients did not fill those prescriptions, citing high costs as the primary reason.

Ensuring patients access their pills — and use them — will require considerable change in the pharmaceutical industry, most experts agree. An overhaul of drug pricing will ideally make medications more affordable.

But providers cannot wait for such a significant industry overhaul. They need to identify patients experiencing cost barriers right now and develop strategies to circumvent those challenges.

Uncovering cost barriers is a complicated process for most providers. Patients may be reticent to discuss their finances, and providers may be hesitant to ask. Establishing trust and positive rapport will be essential, according to Stuart Goldberg, MD, a practicing oncologist.

“Medication adherence is certainly a very important part of taking care of patients today,” Goldberg said in a previous interview. "It starts with, hopefully, getting trust between you and the patient, that when the patient comes in to see you for their appointment, they will give you a true answer."

Goldberg recommended providers ask their patients about rebates or paying for medications. Patients who don't know how they pay (or appear unfazed by the cost) likely don't know about the cost and has not filled the prescription.

Providers also need to partner with patients to identify low-cost medication options. This process is challenging, especially for providers treating patients with complex chronic illnesses who require costly treatments or numerous prescriptions.

In these cases, Goldberg said concessions are necessary. Compromising on which medications a patient takes, choosing a less effective but cheaper generic, or reducing the dose of a prescription is not ideal. After all, a provider wants to put his patient on the best path toward wellness.

But a less frequent dosage is more effective than no medication at all, Goldberg said, and a patient faced with exceptional cost barriers usually isn't filling her prescription in the first place.

Other providers work to connect their patients with subsidy programs, although these opportunities can be limited. Additionally, many clinicians will research which area pharmacies tend to charge lower rates for the same medication and refer their patient when applicable.

Connecting patients to pharmacy services

The next piece of the puzzle is ensuring patients can actually access their pharmacy services. In most cases, this will involve getting the patient to the pharmacy to meet with their pharmacy provider and fill or pick up their prescriptions.

Over 3 million patients experience transportation barriers to their healthcare, according to data from the American Hospital Association. Although that figure also includes patients facing obstacles to their clinical encounters, this issue represents a genuine hurdle for patients visiting the pharmacy.

For non-disabled patients who lack access to a car or public transportation, ridesharing options are usually the best fit. Healthcare organizations across the country have forged relationships with Uber and Lyft to help connect patients with a ride to resources that help them manage their health, including pharmacy appointments.

Many organizations foot the bill for these rides (or offer rides at a considerably subsidized rate) because they are less expensive than treating a patient experiencing a costly medical episode.

But ridesharing is not always a viable option, especially for patients who are homebound or have severe physical limitations. Home delivery programs address these challenges when free or subsidized rides do not.

Home delivery programs allow patients to request refills to their prescriptions and receive those prescriptions as a package at their door. Patients, their providers, and their pharmacists may consider how these packages will be delivered and ensure patients will be present to receive them, lest the medications fall into the wrong hands.

Driving self-efficacy, chronic care management

For some patients, the actual medication management piece can be a challenge. While clinicians would agree that most patients can struggle with medication management, some groups are more likely than others to be non-compliant.

Educational attainment, for example, can predict challenges with care management and self-efficacy. Patients who do not speak English or who have other barriers to patient-provider communication may also feel disempowered in the healthcare space.

Those vulnerabilities can often lead to poor medication adherence.

Many pharmacists have developed products that can support patients with medication management. Blister pill packs, for example, can help patients who take multiple medications for their illnesses.

“The adherence packaging and the co-mingled packaging makes it very simple for patients to understand,” said Alec Gillies, general manager at Buffalo Pharmacies in New York, which uses blister packs. "It's a pretty easy sell for us. Some people still like their pills, and that's fine, but to be able to have all their medications in one simple packet or pouch or blister, with the date, with the time on it couldn't make it any easier for patients."

Offering 90-day prescriptions, as opposed to the traditional 30-day order, can improve the likelihood that a patient will refill her prescriptions, according to data in the American Journal of Managed Care.

And medication synchronization, or the practice of setting all of a patient’s medications to the same refill date, will help patients stay more organized. Patients in a medication synchronization program had medication adherence rates that are 3 percent higher than those not in the program, according to a Health Affairs study.

Pairing these medication management tools with ongoing health coaching will be essential, according to Peter Goldbach, MD, chief medical officer at Health Dialog. Health Dialog, a Walgreens subsidiary focused on population health management, uses health coaches to understand the motivational factors that influence medication adherence.

“It's been made clear that we all respond to prompts in our environment,” Peter Goldbach, MD, told last year. “There are programs that can be based on things like texting people, but what we're highlighting is the fact that — especially for people with chronic illness that are facing challenges like depression, or transportation, or complexity of medication regimens — that these interpersonal, trusted interactions with a nurse tend to be very effective.”

Health coaches touch on the factors that will motivate the patient to adhere to her treatments and make healthy behavior change. Additionally, coaches work with patients to address barriers in the way of that behavior change.

As more healthcare professionals recognize the role that social health barriers play in medication adherence, pharmacists will play a more prominent role in the care management team, according to Sarika Aggarwal, MD, chief medical officer at the Beth Israel Deaconess Care Organization (BIDCO).

“Medication management treatment is rapidly progressing,” Aggarwal said. “In the future, pharmacists are going to be playing an important role as independent practitioners. This is the beginning of a pathway where, just as we have nurse practitioners, we’re going to have to see pharmacists as independent practitioners.”

Pharmacists or other health coaches focusing on medication adherence should acknowledge the social issues keeping the patient from taking their medications. As noted above, rarely does a patient not want to be healthy; instead, they are experiencing other problems that are keeping them from medication adherence.

Focal points for addressing medication adherence

Understanding the cost, transportation, or social barriers a patient may face to achieving persistent medication adherence will be essential to improving patient care in a meaningful way.

Address cost: Medical providers should first identify patients who may be experiencing cost barriers to their medications using patient-provider communication skills. From there, providers can prioritize different prescriptions, refer patients to subsidy programs, and flag lower-cost pharmacies.

Connect patients to pharmacy services: Primary care clinicians and other providers and help patients who may experience transportation barriers access the pharmacy through the use of rideshare partnerships, other non-emergency medical transportation, or home delivery pharmacy options.

Aid medication management and self-efficacy: Patients experiencing specific social issues, including low socioeconomic status, language barriers, or low educational attainment may have more difficulty managing medications than other, less vulnerable populations. Connecting patients with management tools while providing health coaching and patient education may help improve self-efficacy.

Increasing medication adherence has the potential to improve patient outcomes and eliminate avoidable healthcare costs, two tenets of effective population health.

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