AdM Home Care Coaching (eBook)

Adherence Management (AdM) Home Coaching: Family Guide To Improved Health

Over my MANY years in nursing and as an audiologist, I cared for countless people and their endless array of illnesses and injuries. For the young and middle-aged, normal health is pretty much on automatic pilot. There are many colds, an occasional touch of flu, scrapes, bruises, a broken bone or two, and a few sutures to ensure wounds heal properly. Others have challenges with early-onset chronic illnesses such as diabetes or epilepsy. Still others lay the foundation for future chronic diseases by engaging in behaviors of smoking, drug use, over-eating, excessive drinking, and a lack of physical exercise.

Many years ago, Dr. Ivar Lovaas was fond of saying, “All behavior returns to baseline.” Baselines are the habits we form and the lifestyles we live. Taking pills, following restrictive diets, and exercising daily typically are not behaviors of our youth. They are not the baseline of habits necessary to achieve or maintain optimum health. As we approach middle age, the rituals required to follow a medical care plan are not in our book of life.

As you will read later in this book, most new behaviors needed to stave off bad habits or overcome genetic predispositions are not reinforcing. My colleague and friend Dr. Aubrey Daniels is fond of saying, “Behavior goes where reinforcement flows.” On the surface, nothing is reinforcing about taking a handful of pills. Medications can be inconvenient, expensive, and confusing. On top of that, some side-effects may make us feel sick while our disease may not have any symptoms. It is understandable why people give up taking pills.

You Are Not Alone.

In my early 30s, I was visited by a kidney stone and was introduced to bloody urine and enough pain to get my attention. The stone passed, and I was fixed. Over the next several decades, there were several more stone episodes to remind me that I was not super-human. I was human. On a 2003 return trip from Washington, DC to Dallas, I noticed a small amount of particular pain in my left shoulder. There was not the crushing sensation that I had seen in so many patients during my ER years. There was no profuse sweating, but I called my family practice doctor as I waited for my wife to pick me up. His advice was direct. Go to the ER; do not go home. I went to the ER, and one of my nurse colleagues greeted me and escorted me to an exam room. Cardiac enzymes were drawn, an IV was started, and I was comfortably uncomfortable. My nurse colleague advised me that my troponin level was high, and I was admitted to the CCU. The next morning, I had my first stent put in. That was 18 years ago.

I continued my regular exercises, coached ice hockey, and remained in excellent health. The following year we relocated to Orlando, Florida. As the years passed, I heeded my cardiologist’s advice and followed his medication regimen without missing a dose. Despite that, I had another two stents placed. On discharge each time, I filled my prescriptions and maintained my strict adherence to his plan of care.

I was the ideal patient. In fact, if you ask most physicians, they might tell you most of their patients are adherent. But with all due respect to their observations, studies show that more than 80% of all patients become non-adherent within a month or two after they are discharged from the hospital. Unless physicians are “cherry-picking” and “lemon dropping” their patients, at least half of them do not and will not follow their care plan. This book was written to recommend evidence-based methods for improving the behaviors of people who follow their care plans and for supporting family members who want the best for their “patient” once they come home from the hospital or care facility.

What Is A Patient?

“Patient” is a beautiful term that goes back to the early days of medicine several thousand years ago. The average patient is in the hospital less than a week, and then they are back to being whoever he or she was before they were tagged with the word “patient.” Another of Dr. Aubrey Daniels’ often used quotes is, “Past performance is the best indicator of future performance.” What that means is you or your family member is no longer a “patient” once you return home. You are once again who you were before the health community labeled you. Your lifetime of habits are still there. You are returning to the very environment that may have contributed to your illness.

Our best clinicians have patched you up. You have met the criteria and time limit for this hospitalization. As the great writer Mark Twain (Samuel Clemmons) stated back in the 19th Century, the hospital “…tossed you out the window.” His statement’s full text is, “Habit is habit and not to be tossed out the window by any man but, coaxed downstairs one step at a time.” Understanding Mr. Twain and relating it to the period after discharge from the hospital, is the essence of adherence management. If, as clinicians, we handed you a prescription and a care plan and sent you on your way, we have figuratively “tossed you out the window.”

Developing new habits requires, as the first step in this coaxing process, patient and family education. Further steps must be continued each day as new behaviors develop into adherent habits as outlined in the adherence improvement plan. There must also be sources of behavior reinforcement for the discharged “patient” and their supporting family members. A few minutes of “patient education” within moments of discharge and a handful of prescriptions and instructions to follow when you get home, does not a habit make!

The Patient’s Perspective.

In September 2017, I was in Dallas for a week. I continued my daily walking in the hill country with no episodes of discomfort or shortness of breath. Then, in January 2018, I began to notice a slight bit of pain in my shoulder when I walked up the small incline approaching our home in Florida. My shoulder was not a problem, I thought. I knew I had an appointment with my cardiologist in a couple of days. On my appointment day, I mentioned the discomfort. He cut our time short and directed that I return in the morning for a heart cath. I checked in at the appointed time, and, as is usual, I declined a sedative. I preferred to watch the procedure on the screen. My doctor, always the consummate professional, completed the procedure without incident and advised me that he found an area of concern in one of my arteries. Since I had had several stents, and this was a Thursday, I asked if he was going to place another stent on Friday. “No, it’s not in an area I’m comfortable stenting. I’m admitting you to the hospital.” The weekend was fast approaching, and I asked if I should plan on a Monday admission. “No, you are going to be directly admitted as soon as we can get you to the hospital. I’m scheduling you for a two-vessel cabbage.” (Coronary artery bypass graft - CABG) . It was Thursday, March 1, 2018.

No one can be sure of what might have happened during the almost 20 years between my first stent and this visit. I was confident in the reality that my adherence to the medication regimen likely contributed to the fact that I had not had a lethal event during that time. As a long-time nurse and clinician, I had concerns, but I was not overly worried. Within a short time, I would be in the cardiac care unit and monitored. I suppose I should have been afraid. I was not. I had a respectable level of concern. In my early career in nursing, I had been a cardiac ICU nurse. I assisted the recovery of numerous fresh CABGs, and now, forty years later, I was confident the bugs had been worked out over tens of thousands of procedures. My surgeon had an excellent reputation. As I spoke with the nurses in CCU and mentioned who my surgeon was, they all agreed they would want him to do their procedure.

I’ll spare you the details of the day-to-day events that lasted from Thursday until my surgery early on a Sunday morning. I met my surgeon early Saturday evening as he was headed home from finishing several CABGs that day. Our conversation was both professional and cordial. Most importantly, I knew he was going home early, and I would be his first case on Sunday. Sunday morning came, and there were the expected pre-surgery activities as I was transported to pre-op. My best friend and wife walked with me as I was wheeled into pre-op and stayed with me as the IV was inserted, blood pressure and other vital signs monitored. The anesthesiologist introduced himself, and the word came from the OR that the team was ready. Everyone was in place, except for me. My pre-op nurse was fabulous as she was professional, friendly, and supportive. I kissed Jude Ann as she gave me a brave smile, and the last thing I remember was going through the pre-op doors en route to the operating room.

I woke up sometime later, thinking that wasn’t too bad. I had no pain and was resting comfortably in the room where I would spend the next several days. Jude Ann and my youngest son Jefferson were in the room as I commented on how quickly the procedure went. Jefferson was the first to point out that it was now early Tuesday afternoon. I smiled and wondered what had happened to Sunday and Monday? The only proof anything out of the ordinary occurred was a photograph of me in the...