Table 11

Ten Considerations to Improve Adherence

1. Capitalize on opportunities when patients are most disposed to adherence
  • In-hospital/pre-discharge initiation following decompensation

2. Consider the patient’s perspective
  • Start with the goals of therapy (feeling better and living longer) and then discuss how specific actions (medication initiation, intensification, monitoring, and adherence) support those goals

  • Use decision aids when available

  • Ask patient how they learn best and provide education accordingly

3. Simplify medication regimens whenever possible
4. Consider costs and access
  • Become familiar with and advocate for systems that help make cost sharing automatic, immediate, and transparent

  • Prescribe lower-cost medications if of similar efficacy

  • Facilitate access to copay assistance

  • Discuss out-of-pocket copays proactively

  • Prescribe 90-day quantities for refills

5. Communicate with other clinicians involved in care, ideally facilitated by electronic health records
6. Educate using practical, patient-friendly information
  • Provide a written explanation of the purpose of each medication prescribed

  • Plan pharmacist visits for complex medication regimens

  • Use the “teach back” principle to reinforce education

7. Recommend tools that support adherence in real time
  • Pill boxes to be filled by patient or caregiver a week at a time

  • Alarms for each time of the day medications are due

  • Smartphone M-Health applications that provide an interactive platform for education, reminders, warnings, and adherence tracking

8. Consider behavioral supports
  • Motivational interviewing

  • Participate in engaged benefit designs

9. Anticipate problems
  • Communicate common side effects

  • Provide instructions on when to call for refills or problems

10. Monitor adherence and target patients at risk
  • Ask patients directly (e.g., “How many times in a week do you miss taking your medications?” “Have you run out of your medications recently?”)

  • Carry out medicine reconciliation at visits, with focus on discrepancies

  • Assess remaining dosage units (i.e., count excess remaining tablets)

  • Monitor pharmacy fills, using available databases (e.g., https://www.colorado.gov/pacific/dora/PDMP) or automated alerts for failed fills and refills

  • Review available drug levels (e.g., digoxin, INR) or concentrations of BNP/NT-proBNP

  • Plan home-based nursing visits for appropriate patients

BNP = B-type natriuretic peptide; INR = international normalized ratio; NT-proBNP = N-terminal pro–B-type natriuretic peptide.