At one point or another, all clinicians will encounter patients who have nonmedical obstacles to following care plans. “Often these patients get labeled as being noncompliant,” says Patricia Czapp, MD, a family physician working with underserved patients at the Anne Arundel Medical Center in Annapolis, MD.
In fact, many are experiencing substantial financial, psychological, cultural, literacy, or work-related barriers. Caring for disadvantaged patients can be challenging, but clinicians can take meaningful actions to improve these patients’ health outcomes.
Screen for Barriers to Care
Who is a disadvantaged patient? It’s not always obvious, says J. Lloyd Michener, MD, chairman of the Department of Community and Family Medicine at Duke Health. “The best way to identify a disadvantaged patient is to ask them,” he says. “If it’s a new patient, I say, ‘Tell me a little bit about yourself. Do you work? Where do you live? Do you have kids?’ This will quickly give me a sense of his or her background and issues—and it’s part of building the rapport that we all need to have with our patients.”
Michener is also the principal investigator for The Practical Playbook, a successful national initiative that facilitates the integration of public health policies and primary care practice.
Czapp finds it helpful to ask her patients whether the medication she prescribed them is too expensive. She says that it's a very effective way to identify patients with limited resources. An alternative to directly questioning the patient is to post a patient-friendly sign listing similar questions in the waiting or treatment rooms, offering to put patients in touch with the appropriate community resources.
Problem-Solve to Overcome Barriers
Identifying a patient with limited resources is only the first step. The challenge is then to find practical ways to solve a patient’s individual obstacles to care.
For example, you may have a male patient who is prescribed warfarin but routinely misses appointments to get his international normalized ratio checked. In this scenario, Czapp suggests saying to the patient, “Help me understand why you can’t get that test done.” This simple statement may unearth a variety of reasons.
Limited transportation, work-related difficulties, and child-care issues are frequently the reasons behind why disadvantaged patients are unable to attend appointments and show up on time. In this instance, Czapp says, a finger-stick test might be substituted or the patient should be offered a more convenient appointment time, perhaps during evening hours.
The cost of medication is another profound barrier for patients with limited financial means. Michener recommends asking patients about their pharmacy benefits before prescribing medications.
For example, patients receiving Medicaid generally have good access to medications with low co-pays. However, for patients with less-than-optimal insurance or no coverage at all, clinicians should be aware of what medications are available at local pharmacies, which may offer low-cost, generic drugs. Pharmaceutical companies frequently offer savings cards or assistance programs for trade-name drugs.
Health care professionals should also become familiar with local community resources available to disadvantaged patients. For example, Partnership for a Healthy Durham maintains an extensive list of public-assistance programs and medical services in Durham County, NC, for the uninsured and underinsured.
Simplify Management of Complex Medical Problems
Many disadvantaged patients have multiple, complex health problems. Rather than trying to cover all of these complications in a single visit, Michener recommends querying patients on what health issue is interfering the most in their lives, allowing his patients to decide what to focus on—although he weighs in heavily on more serious conditions or risk factors. “If I give them 5 or 7 things to work on, the recall on that is going to be close to zero,” Michener says.
Patients with literacy, cultural, or language barriers may also struggle with long-term disease management. For example, a female patient with diabetes and low-level literacy may have difficulty adhering to a complicated insulin regimen—not because she is “noncompliant” but because she doesn’t understand how to use the insulin pen or syringes or when to administer insulin.
In these instances, it’s best to simplify the treatment regimen, even though that may not be the ideal standard of care. “However, the right type and dose of insulin delivered at the right time—even once a day—is far safer than no insulin or the wrong amount and type of insulin delivered at the wrong time,” Czapp says.
Provide a Patient-Centered Medical Home
Successfully caring for disadvantaged patients requires a team-based approach to help improve outcomes as well as reduce the burden on any one clinician. A method of doing this is to train current staff or employ a dedicated expert in care coordination and to form liaisons with community resources that provide assistance to disadvantaged patients. Some insurance companies now reimburse certain practices to help pay for costs associated with care coordination and staff training.
A team-based approach is particularly critical when referring disadvantaged patients for specialty care so that they follow through with appointments and treatment. “The remedy to that is a close-knit medical community where the primary care doctors and specialists know each other really well,” says Czapp. “They’re not just passing pieces of paper back and forth but having discussions.”