Managing Nonadherent and Difficult Patients

Nonadherent and difficult patients present an ongoing challenge for chiropractors. In addition to being frustrating, these patients might be at increased risk of misdiagnosis and more likely to have negative outcomes.

Despite the challenges that nonadherent and difficult patients present, chiropractors can take a number of proactive steps to engage these patients and address potentially problematic behaviors.
 

  1. Establish a policy defining the basic rights and responsibilities of each patient.  This policy provides a foundation on which to build an effective chiropractor–patient relationship. Display or make this information available to all patients.
     

  2. Be aware of the difference between informed refusal of care and patient nonadherence to an agreed-upon treatment plan. A patient can refuse care even if the consequences might be dire.
     

  3. During each patient encounter, emphasize the importance of following the prescribed treatment regimen, even if symptoms subside. Explain the possible consequences of not following the agreed-upon treatment plan.[A1] 
     

  4. Employ a method such as motivational interviewing to engage patients in their care and encourage behavioral changes.
     

  5. Use a technique such as teach-back to ensure that patients fully understand the information and instructions provided. Patients from all racial, ethnic, socioeconomic, and educational backgrounds might have limited health literacy, which can contribute to nonadherence.
     

  6. With patients’ permission, include family members, caretakers, and significant others in education about the importance of following treatment plans. These individuals might help reinforce the importance of adhering to treatment.
     

  7. Provide nonadherent patients with education about their treatment plans both verbally and in writing — especially if a patient has serious health problems.
     

  8. If a patient has financial, physical, or emotional limitations that lead to nonadherence, determine whether any community services are available to assist the patient remove treatment barriers.
     

  9. Consider using patient agreements that detail both chiropractor and patient responsibilities relative to the treatment regimen. Both parties should sign the agreement.
     

  10. If a patient is missing appointments, try to determine the reason (e.g., transportation, family care, or financial issues). After several missed appointments, consider sending the patient a letter stressing the importance of keeping the appointments and adhering to the treatment plan.
     

  11. Document missed or cancelled appointments by noting either “patient no-show” or “cancelled” in the patient’s health record. If possible, document the reason for a cancellation — e.g., “no transportation” or “child care issues.”
     

  12. Do not delete original appointment entries, as the appointment log may become a valuable tool if you have to demonstrate a patient’s continued nonadherence to appointments.
     

  13. Document a description of all[A2]  nonadherence, as well any education provided to the patient, family, caregiver, and/or significant other regarding the possible consequences of not following the treatment regimen. When documenting, use subjective statements from the patient or others and objective information obtained through patient encounters.
     

  14. Avoid disparaging remarks or editorializing when documenting information related to patients’ nonadherent behaviors.