Writing Patient Compliance Contracts for Wound Care & Diabetes Treatments

  The following scenario and conversation recently occurred with a staff nurse at this author’s Illinois-based outpatient wound clinic: “‘Mr. J’ has developed a new wound. He was almost healed, but then he went barefoot to the beach. How are we going to help him stay healthy? This is the third time he’s broken open in this spot!”

  Diabetes affects 29.1 million Americans, or 9.3% of the US population.¹ Of these patients, 10-20% will go on to have an amputation.² In this author’s outpatient clinic, the majority of patients live with diabetes and 15% are presenting specifically with a diabetic lower extremity ulcer, the most common complication for this patient group. Usually, patient and caregiver goals are focused on healing these wounds.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
RELATED CONTENT
Addressing Diabetes Control: What Clinicians Must Know
Avoiding Burnout with Both Your Patients and Your Staff
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

  But what are wound care clinicians to do when it seems (or is even blatantly obvious) that the patient’s goals are not quite in tune with his or her provider’s? This article will seek to answer that question by helping providers to establish action plans that are contingent on the alignment of healthcare goals.

Identifying the Noncompliant Patient

  We see many of our wound care patients on a weekly basis. Even with close follow up there is a portion of this population that does not progress along the path to wound healing. The causes for the lack of progress can be numerous; Social, economic, biological, and cultural differences all are factors that keep the patient from adopting and maintaining the healthier lifestyle that promotes wound healing. But some patients may seem unwilling to participate in their plan of care or may go so far as to admit their reluctance to follow care plans. Do they choose to be noncompliant? Are they truly noncompliant if they can’t afford to get their medications? These are tough questions with no easy answers. Additionally, healthcare providers must ensure they are asking the right questions about their patients’ daily living in order to uncover barriers to corrective and preventable care. For example, later in this article we’ll discuss one patient in our clinic who could not get her wheelchair into her house, but did not immediately communicate this with her providers.

  Schumaker, et al³ cite eight domains that may contribute to lack of compliance among patients living with chronic nonhealing wounds: absence or misinterpretation of biological cues, physical and behavioral limitations, cognitive limitations, motivational limitations, interference of healthful behaviors with quality of life, unpleasant side effects of treatment to enhance a healthy lifestyle, common biopsychological obstacles, and individual differences.³ This review of compliance is not specific to diabetic care, but to patient compliance in general.

  The patient may give any of these reasons at any time. We struggle with this issue on an almost-daily basis within our patient population. Rather than discharge these individuals on a path toward certain amputation or dismiss them outright from our service due to noncompliance, we’ve attempted an alternate approach at our clinic that has worked successfully over the past four years. Today, our limited-service contracts allow us to clearly explain the goals and expectations we have for patients and require their consent and signature in order to proceed with care.

Contract Particulars

  Not too long ago, there didn’t seem to be many alternatives to those patients we found were chronically ignoring our treatment protocols for their nonhealing wounds. After receiving phone calls from primary care physicians (PCPs) requesting the return of patients previously discharged due to lack of progress and/or regression, we knew we needed to come up with a tactic that would encourage patients to take control of their compliance and healing. The details of our contracts include patient assistance in developing treatment plans and ensuring the patient understands all facets of the clinical plan as well as follow up. When all parameters have been discussed, the patient signs an “agreement of understanding.” Visits are then scheduled in advance: A follow up to the initial visit is part of the agreed-upon terms. The patient also agrees at this time to comply with a schedule of subsequent visits to be determined by the provider. Treatment plans are revised as needed and an original copy of the signed treatment plan is provided to the PCP for confirmation of the visit and agreement terms. At discharge, the patient is released from the clinic to continue any treatment plan deemed necessary.

Ensuring Agreement Compliance

  To foster optimal results, we’re honest with the patient from the start regarding what he/she needs to do each day in order to achieve wound healing so that they understand the clinic will not be the only responsible party for the routine care of their wound. Our purpose is to provide the specific wound treatment plan that details types of dressings, frequency of dressing changes, techniques needed to conduct direct care, and recommended lifestyle changes (eg, glucose management, offloading). These are the usual areas that patients have failed to comply with in the past, in our experiences.

  An example of a recently written patient contract is as follows: “Ms. L” lives with diabetes, lower extremity edema, and uncontrolled glucose levels. The treatment plan includes leg elevation, glucose control, topical wound management, and compression. She historically “does not like compression” and “doesn’t feel like checking her blood sugar.” At her first return visit, the wound dimensions were smaller and her ankle and calf measurements were at least equal to the original measurements. We provided the update to her PCP and her final visit will be in 4-6 weeks. Her care will then return to her PCP. We also instructed her at-home care provider on the techniques for providing proper wound care.

More Patient Care Examples

  For the aforementioned Mr. J, his wound had received standard wound care for 16 weeks without healing. He was then placed in a total contact cast (TCC) and the wound healed in four weeks. Prior to graduating from the TCC, we received customized footwear. Because of the Charcot changes of his foot he is now in a CROW walker. Any other footwear did not adequately support his foot structure. The previous time his foot broke down he had required 45 hyperbaric treatments (nine weeks) with regular wound care and the wound had healed.

  A most interesting case is that of “Ms. K,” who presented to the clinic in 2011 for a diabetic wound on the right foot. She spent a total of 30 weeks in treatment to heal the wound. Skin substitutes and a postoperative shoe were part of the treatment plan. However, we eventually learned that at home, she was unable to use her wheelchair inside because she could not get it through the doorway. She instead left the wheelchair outside and walked around the small house to do her activities of daily living. In 2014 “Ms. K” returned to the clinic, the wound reopening three months prior. TCC was initiated and she healed in eight weeks, the TCC allowing for her limited walking needs without compromising the weight-bearing status on the foot.

  For “Mr. B,” a formerly noncompliant patient living with diabetes who continued to wear nondiabetic shoes outside the house and no shoes in his house, a contract including use of hyperbaric oxygen therapy has proven beneficial. Previous attempts at patient education had gotten to the point that his wife called the clinic to ask that we not “bug him anymore about wearing shoes; he won’t and there is no point in bugging him about it.” To date, he has lost three toes, but further amputations that were once feared are not needed.

  In all, we have found a compromise works for most noncompliant patients who have been willing to participate in the revised guidelines and new treatment plan.

Catherine Rogers is advance practice nurse/program manager, wound care and hyperbaric clinics, SwedishAmerican Health System, Rockford, IL.

References

1. 2014 National Diabetes Statistics Report. CDC. Accessed online at www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html.

2. Data from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011). Statistics about diabetes. American Diabetes Association. Accessed online at www.diabetes.org/diabetes-basics/statistics.

3. Predictors of patient adherence. In: Schumaker SA, Ockene JK, Riekert KA, eds. The Handbook of Health Behavior Change. 3rd ed. New York, NY: Springer Publishing; 2009:chap 28.