ASSESSMENT OVERVIEW

Part of Chapter 2 and Chapters 3-7 of the CMAG1-Guidelines

Sections		Download Survey Only
Overview of Assessments		Patient Summary Assessment
Health Literacy	pdf version	RealmR
Medication Knowledge	pdf version	Medication Knowledge
Willingness to Change	pdf version	Readiness-to-Change Ruler
Social Support	pdf version	FSSQ
Modified Moriksy	pdf version	Modified Morisky

Frequency of CMAG-1 Patient Assessments Top

The frequency at which CMAG-1 assessments are performed will vary by patient. Recommendations for the minimum number of CMAG-1 assessments are as follows:

· All patients – Full CMAG-1 assessment annually, followed by determination of an adherence intention quadrant and development/implementation of an adherence improvement plan.

· Patients new to the case manager – full CMAG-1 assessment, followed by determination of an adherence intention quadrant and development/implementation of an adherence improvement plan.

· Patients with a new diagnosis that results in new medication therapies and a CMAG-1 assessment within the past year – Medication Knowledge Survey for new medications and Readiness Ruler applied in context of behavior changes required to adequately self-manage the new disease state. Results from the most recent REALM-R and FSSQ may be used to complete the assessment, if available. Based on the results, a new adherence intention quadrant may be assigned, followed by development and implementation of a modified adherence improvement plan.

· Patients maintained on existing therapies and receiving a full CMAG-1 assessment in the past year – MMS at month 4 and month 8 post-assessment. Based on the results, a new adherence intention quadrant may be assigned, followed by development/implementation of a modified adherence improvement plan.

· Patients with significant living circumstance changes that may adversely affect ability to self-manage disease –Full CMAG-1 assessment, followed by determination of an adherence intention quadrant and development/implementation of a modified adherence improvement plan. Examples of changes in living circumstances would include situations such as:

§ Death of a spouse, close family member, or other persons significant to the patient’s social support network

§ Physical relocation to a new home

§ Change in finances that may be perceived to adversely impact the patient’s ability to live life as desired.

§ Change in mental status (emerging depression, senility, etc.)

§ Physical relocation of person significant to the patient’s social support network

§ Reduced ability to participate in activities and freedom of movement from which the patient derives enjoyment (driving, sewing, painting, hobbies, etc.)

The CMAG-1 guidelines are not intended to be “static.” Case managers will have the opportunity to participate in a Web-based Adherence Encounter Documentation Program (Appendix 6). This program is designed to capture information on adherence strategies and techniques employed by individual case managers for each adherence intention quadrant, and track improvements in patient adherence and outcomes. Through a continual analysis of information entered into the Adherence Encounter Documentation Program, evidence-based modifications will be made to future versions of the CMAG-1 guidelines.

Listed below are the general guidelines for interaction based on patient placement in any given quadrant of the CMAG-1 algorithm.

Adherence Intention Quadrant	Recommended Tools and Interaction
Quadrant 1 Knowledge low – Motivation low Adherence intention is LOW	Motivational interviewing (X1) Disease-specific education and consequences of nonadherence (X2) Medication regimen education · why medication is needed · dosage schedule and fit with patient’s schedule/lifestyle · what to do if doses are missed or delayed · common adverse effects that might occur (X3) · serious adverse effects that should be watched for (X3) “Teach back” – ask patient to repeat instructions Disease and medication education for spouse/family (X4)
Adherence Intention Quadrant	Recommended Tools and Interaction
Quadrant 2 Knowledge low – Motivation high Adherence intention is VARIABLE	Motivational support Reinforce/praise patient’s efforts to adhere to prescribed therapies Disease-specific education and potential consequences of nonadherence Reinforce medication regimen education · why medication is needed · dosage schedule and fit with patient’s schedule/lifestyle · what to do if doses are missed or delayed · common adverse effects that might occur (X3) · serious adverse effects that should be watched for (X3) e. Discussion on action to take BEFORE supplies of the present prescription run out ‘Teach back” – ask patient to repeat instructions Disease and medication education for spouse/family

Adherence Intention Quadrant

Recommended Tools and Interaction

Quadrant 3

Knowledge high – Motivation low

Adherence intention is VARIABLE

Motivational interviewing (X5)
Patient reminder systems (Appendix 1)
Social support plan
Family motivational assessment

Adherence Intention Quadrant

Recommended Tools and Interactions

Quadrant 4

Knowledge high – Motivation high

Adherence intention is HIGH

Continued knowledge and motivation reinforcement/support
Open-ended discussions to uncover any emerging concerns the patient may have about therapy or anticipated life-situation changes that may adversely impact ability to adhere to specific therapeutic plans

X1 In patients with low motivation and low knowledge, motivational interviewing should always be the first step in the adherence improvement process. This will allow the case manager to establish a level of rapport with the patient as well as an understanding of his or her motivational needs before any attempts are made to engage in knowledge improvement activities that may not yet be welcomed by the patient.

X2 If motivational interviewing and the Readiness Ruler reveal that the patient is not ready to change behaviors or is apathetic about his or her disease, discussions on the consequences of nonadherence should be deferred until a later date so as not to disturb rapport building.

X3 Information on adverse effects should always be tempered with a discussion of the benefits of prescribed regimens, so that the patient receives a “balanced” presentation of the risks and benefits of any prescribed therapy. Discussions of adverse effects should include expected duration of transient side effects and actions to be taken by the patient for unanticipated side effects that do not resolve in a timely manner.

X4 For newly diagnosed patients, one may consider an assessment of the family’s acceptance of the patient’s disease state and their willingness to change prior to engaging in disease and medication education.

X5 The patient with a high disease and medication knowledge level combined with a low motivation level provides an additional challenge to the case manager in developing an effective adherence improvement strategy. There is often an attempt to “convince” these patients of a needed course of action, owing to the high level of knowledge required. Such plans of action can easily alienate the patient from any suggestions for adherence improvement. A better initial strategy is to spend additional time with the patient participating in motivational interviewing to develop a rapport that will ultimately open him or her to new ideas and suggestions for improving self-management of disease. It is also vitally important that the case manager be honest and open regarding the intended goal of motivational interviewing (improvement of self-management), so that the high-knowledge patient does not feel “coerced” in the process, with consequent rejection of the plans and ideas offered to improve adherence.

Health Literacy Top

Health literacy is defined as the ability to read, understand, and act on health information.

Poor health literacy results in medication errors, impaired ability to remember and follow treatment recommendations, and reduced ability to navigate within the healthcare system. Additionally, poor health literacy puts patients at an increased risk for hospitalization compared with patients who have adequate health literacy (Bass, 2003).

Assessment of Health Literacy – the REALM-R (Bass, 2003)

The Rapid Estimate of Adult Literacy in Medicine (REALM-R) is a brief screening instrument used to assess an adult patient’s ability to read common medical words. It is designed to assist medical professionals in identifying patients at risk for poor literacy skills. The REALM-R is a word recognition test consisting of 8 items. Words that appear in this tool are:

Fat Anemia

Flu Fatigue

Pill Directed

Osteoporosis Colitis

Allergic Constipation

Jaundice

Fat, Flu, and Pill are not scored and are positioned at the beginning of the REALM-R to decrease test anxiety and enhance patient confidence. The following steps describe the approach that can be utilized to execute the test:

1. The case manager should give the patient the list of REALM-R words.

In the case manager’s own words, introduce the REALM-R to the patient. Note that the words “read” and “test” should be avoided when introducing and administering the REALM-R to the patient. These words may make the patient feel uncomfortable and unwilling to participate. The following can be utilized to introduce the REALM-R:

“Sometimes in healthcare we may use medical words that patients aren’t familiar with. We would like you to take a look at this list of words to help us get an idea of what medical words you are familiar with. It will help us know what kinds of patient education to give you. Starting with the first word [point to 1^st word with pencil], please say all of the words you know. If you come to a word you don’t know, you can sound it out or just skip it and go on.”

If a patient takes more than 5 seconds on a word, they should be encouraged to move on to the next word (eg, say “Let’s try the next word”). If the patient begins to miss every word or appears to be struggling or frustrated, tell the patient, “Just look down the list and say the words you know.”

Scoring: The REALM-R Examiner Record (Appendix 2) is used to record the outcome of the test. Count as an error any word that is not attempted or is mispronounced. Place a check mark (“Ö”) next to each word the patient pronounces correctly and an “X” next to each word the patient does not attempt or mispronounces. Those patients scoring 6 or less correctly (“Ö”) should be considered to be at risk for health literacy issues.

Telephonically administered REALM-R: If it becomes necessary to administer the REALM-R remotely by telephone, the following procedure should be employed.

a. Ask the patient to obtain a piece of paper and pencil.

b. Explain the purpose of the REALM-R to the patient as described in step 2.

c. Slowly spell each word and ask the patient to write it down on the piece of paper.

d. Ask the patient to pronounce the word.

e. Proceed with the next word as described above (c) and continue until the examination is complete. Score the REALM-R and record the result on the Patient Assessment Summary Form (Appendix 2).

Special considerations when using the REALM-R

1. Examiner Sensitivity

Many low-literacy patients will attempt to hide their deficiency. Ensure that you approach each patient with respect and compassion. You may need to provide encouragement and reassurance. A positive, respectful attitude is essential for all examiners. (Remember, many people with low literacy feel ashamed.) Be sensitive.

2. Visual Acuity

If the patient wears glasses, ask him or her to put them on for this test. The REALM-R is designed to be read by persons with 20/100 vision or better. The patient word list should be set in a font size of 18. In the studies utilizing the REALM-R, patients with worse vision were excluded. The REALM (long version of the REALM-R) has a visually impaired version using a font size of 28. The REALM-R is produced here in font size 28 and can be found in Appendix 2.

3. Pronunciation

Dictionary pronunciation is the scoring standard.

4. Dialect, Accent, or Articulation Problems:

Count a word as correct if it is pronounced correctly and no additions or deletions have been made to the beginning or ending of the word. For example, a patient who says “jaundiced” would not receive credit for the word “jaundice”; “directs” would not receive credit for the word “directed”; “colon” would not receive credit for “colitis.” Words pronounced with a dialect or accent should be counted as correct, provided there are no additions or deletions to the word. Particular attention should be paid to patients who use English as a second language.

Medication Knowledge Top

In addition to the REALM-R, the Medication Knowledge Survey (Appendix 2) is used to assess the patient’s knowledge and ability to read and comprehend information necessary for appropriate medication use. The Medication Knowledge Survey is considered as a potential “modifier” of the final assignment of a patient to a high or low knowledge category. A patient who scores highly on the REALM-R may not necessarily understand vital information for appropriate medication use. Thus, a low score on the Medication Knowledge Survey combined with a high health literacy score would likely result in the case manager placing the patient in the low knowledge category when constructing an adherence improvement program.

On the day that the Medication Knowledge Survey is to be conducted, patients should be asked to have all of their medication bottles readily available in one place for purposes of discussion. The case manager should also review any prior documentation of the patient’s current medication regimens before conducting the medication survey, because this may reveal any “oversights” on the patient’s part, as well as streamline the entire survey process. Sources of documentation may include the physician’s records and/or claims, and medication payment information available through the patient’s healthcare provider.

Before beginning the Medication Knowledge Survey, the case manager may wish to sort medications into 2 categories – “routine use” and “as needed” (prn) medications. Although it is important to uncover any potential overuse of prn medications, agents typically falling into this category are of lesser concern when performing a medication knowledge assessment. Also, some patients take so many medications that the depth of medication knowledge often becomes readily apparent by limiting the survey to “routine use” medications.

Additionally, before beginning the Medication Knowledge Survey, it is important for the case manager to ascertain that he or she is speaking to the person who takes (or will take) responsibility for the patient’s medication administration and management.

Referring to the Medication Knowledge Survey form (Appendix 2) and each container of medication, ask the patient the following questions about every one of their medications:

a. Name of the medication? (Can the patient read the label? Note: Incorrect pronunciation is not considered a failure on the patient’s part to identify medication.)

b. Why is the medication being taken? (for what disease or condition?)

c. How much medication (number of pills) are to be taken each time?

d. When is the medication to be taken? (morning, before meals, twice a day, etc.)

e. What effects should the patient be looking for ? (both positive and negative)

f. Where is the medication kept? (to ascertain special storage conditions needed)

g. When is the next refill due? (and plan or methods for obtaining refills of the medication)

As the question-and-answer session with the patient or caregiver progresses, list the medications being reviewed in the left-hand column of the Medication Knowledge Survey form. Place check marks in the boxes relative to each question when the patient adequately responds.

The questions are designed to provide insight regarding the patient’s medication knowledge level, and ability to read and comprehend medication information. In the process of completing the Medication Knowledge Survey, gaps in medication knowledge across multiple medications (eg, how often to take) will become readily apparent and can serve as the basis for a focused CMAG-1 knowledge improvement plan.

Willingness To Change Top

Very often, the case manager is faced with a dilemma. The patient knows that a change in lifestyle or habits is needed to improve health, but is unwilling to do so. Smoking is a prime example. All of the convincing arguments that the case manager can provide regarding the benefits of not smoking will be in vain if the patient is not willing or ready to change (motivation). The same is true of medication-taking behavior.

Some research suggests that traditional biomedical information–based efforts to convince patients to lead healthier lifestyles may do more harm than good. If the patient is not willing or ready to change a specific behavior, arguments to change that behavior may damage rapport between the patient and the case manager. The unintended consequence can often be psychological reinforcement for continuing the behavior in the patient’s mind. When talking about change, if the patient’s responses mostly begin with words such as “Yes…but…” followed by reasons for not changing, this is a sign that the patient is probably not yet ready or willing to change his or her behavior.

However, the case manager must also recognize that the decision by a patient to change behavior can happen at any time. Change often happens for reasons that are not always clearly understood by anyone but the patient. A primary goal of the case manager in constructing an effective adherence improvement plan lies in recognizing where a patient is on a continuum of willingness to change any given behavior.

Knowledge of willingness to change helps the case manager to determine if an adherence improvement plan needs to be focused on motivation issues to help prepare the patient for change, or on concrete steps to achieve actual changes in behavior.

The Readiness-to-Change Ruler (Zimmerman, 2000)

Many times, behavioral change is necessary for successful management of long-term illness, and relapse can often be attributed to lapses in healthy behavior by the patient. Motivation is a key component in the process of change. The assessment of a patient’s willingness to change can help providers gauge the likelihood that the patient will adopt and adhere to a given therapy.

The readiness-to-change ruler (or Readiness Ruler, Appendix 2) is a tool that can assist a provider in assessing a patient’s “willingness or readiness to change.” The Ruler is a simple, straight line drawn on a paper that represents a continuum from the left “not prepared to change” to the right “already changing.” Patients are asked to mark on the line their current position in the change process. Providers should then question patients about why they did not place the mark further to the left (which helps to determine what motivates their behavior) and what it would take to move the line further to the right (which helps to determine their perceived barriers). Providers can ask patients for suggestions about ways to overcome an identified barrier and actions that might be taken before the next visit.

When patients contemplate change, it typically happens in a sequence that ranges from not thinking about change at all (ambivalence or precontemplation), to consideration of the pros and cons of making a change, ultimately making small steps to “test the waters” regarding a change, and finally the actual change, where it becomes a sustainable part of the patient’s life. Sometimes, patients need to “relapse” or “fall off the wagon” several times before completely committing to and adopting a lifestyle change. It is important for the case manager to be able to identify where the patient is on the stages of change continuum at any given point in time to appropriately match an adherence improvement plan to the patient’s willingness to adopt that plan (Figure 5) (DiClemente, 1998).

Relapse

Figure 5. The stages of change continuum (DiClemente, 1998).

The Readiness Ruler and Motivational Interviewing

In the CMAG-1 guidelines, the Readiness Ruler can perform 2 functions. In its simplest form, this tool can be used as a quick assessment of a patient’s present motivational state relative to changing a specific behavior. Information gained from the Readiness Ruler can also be used as a springboard to employing the technique of motivational interviewing to elicit behavioral change.

Often when using the Readiness Ruler to assess a patient’s willingness to change, it will become readily apparent that immediate use of motivational interviewing techniques will provide value in moving a patient toward change. When such situations arise, the case manager should give priority to motivational interviewing before completing other assessments that may be required (Medication Knowledge Survey, REALM-R, FSSQ) to determine an adherence intention quadrant.

The Readiness Ruler is a valuable tool that can be used with patients other than those who are contemplating change relative to improved medication adherence. It has applicability to a wide range of lifestyle changes such as smoking and alcohol cessation, weight loss, exercise, etc.

Social Support Top

Patients who are ready to make behavioral changes that result in improved adherence to therapeutic regimens can often benefit from family or social support networks. In situations where a patient is about to make a significant change in behavior, the presence of a viable social support network (such as family) can mean the difference between success and failure.

Consequently, an assessment of a patient’s perception of, and need for, a social support network can be as important as making an assessment of the patient’s readiness to change when determining level of motivation. If the patient has a history of depending upon others for assistance with self-care, this may be especially true.

The Duke-UNC Functional Social Support Questionnaire (FSSQ) (Broadhead, 1988) will allow you to make a quick assessment of the patient’s social support network and determine if this should be considered a “modifier” to findings of the Readiness Ruler for any planned or desired behavior change.

The FSSQ (Appendix 2) is an 8-question form that asks about the patient’s perceived level of confidence in affective support. When summaries of the affective and confident domains are combined into one average score, the tool can provide a good indication as to the patient’s level of social support.

Each question on the FSSQ is scored on a 1 to 5 scale, with 3.0 being an average score. A sample question on the FSQQ is:

I have people who care what happens to me….

The patient is asked to read each statement on the FSSQ and supply a check mark next to the response that best matches his or her feelings about the question. Possible responses and their corresponding scores are:

Response	Score
As much as I would like	5
Almost as much as I would like	4
Some, but would like more	3
Less than I would like	2
Much less than I would like	1

All questions on the FSSQ must be answered before scoring. If the patient skips a question, it will need to be answered to complete the scoring process. To score the FSSQ in its entirety, simply add up the numeric score that corresponds with the patient’s response to each question and divide by 8 to generate an average score. The patient is perceived to have greater social support as the number increases.

Modified Morisky Scale Top

In the mid-1980s, Morisky and colleagues developed a brief questionnaire to aid practitioners in prospectively predicting adherence with antihypertensive medications (Morisky, 1983). Subsequently, the instrument was validated in a number of studies and demonstrated to have good psychometric properties. Independent researchers have further expanded the application of this instrument to other disease states including diabetes and chronic obstructive pulmonary disease (Simpson, 2002; Gregiore, 2002; Knobel, 2002; Ren, 2002; Matthees, 2001; Pratt, 2001; Gao, 2000; Sen, 2000; Miller, 1997). The 4 items and their scoring algorithm are shown in Table 3.

1. Do you ever forget to take your medicine? Yes No

2. Are you careless at times about taking your medicine? Yes No

3. When you feel better do you sometimes stop taking your medicine? Yes No

4. Sometimes if you feel worse when you take your medicine,
do you stop taking it? Yes No

Table 3. Original Morisky Scale

To score the Morisky Scale, each question that is answered with a NO receives a score of 1. The possible scoring range is therefore 0 to 4. Patients with higher scores are predicted to be more adherent to prescribed medication therapies. Patients with lower scores are at greater risk for nonadherent behavior.

The Modified Morisky Scale

In considering application of the original Morisky Scale to the CMAG-1 guidelines, several potential deficiencies were noted. Specifically, although the original Morisky Scale had demonstrated the ability to predict medication-taking behavior as well as outcomes, it was not designed to explain persistence (the patient’s long-term continuation of therapy), which is a significant factor in the long-term management of chronic diseases. Also, the scale was not originally designed to classify patients into a high/low continuum for knowledge and motivation. Consequently, 2 new questions were added to create the Modified Morisky Scale (MMS). The MMS is shown in Table 4.

The MMS is used for patients who are already receiving medication therapies and for those who have been previously assessed with CMAG-1 tools described in earlier chapters of these guidelines. When the MMS is used, patients are assigned to an adherence intention quadrant as follows:

Questions 1, 2, and 6, which measure forgetfulness and carelessness, are considered to be indicative of motivation (or lack thereof) and consequently impact the motivation aspects of adherence intention.

Questions 3, 4, and 5, which measure if patients stop medications and understand the long-term benefits of continued therapy, were considered to be indicative of knowledge (or lack thereof) and consequently impact the knowledge aspects of adherence intention.

By using the MMS as an indicator of both motivation and knowledge, it is possible to use the scale ratings when assigning an adherence intention quadrant for the evaluated patient.

Question	Motivation	Knowledge
1. Do you ever forget to take your medicine?	Yes(0) No(1)
2. Are you careless at times about taking your medicine?	Yes(0) No(1)
3. When you feel better do you sometimes stop taking your medicine?		Yes(0) No(1)
4. Sometimes if you feel worse when you take your medicine, do you stop taking it?		Yes(0) No(1)
5. Do you know the long-term benefit of taking your medicine as told to you by your doctor or pharmacist?		Yes(1) No(0)
6. Sometimes do you forget to refill your prescription medicine on time?	Yes(0) No(1)

Table 4. Modified Morisky Scale

Scoring

All questions on the MMS are answered on a “yes” or “no” scale.

For the motivation domain, each “no” answer (questions 1, 2, 6) receives a score of 1 and each “yes” answer receives a score of 0. This provides a scoring range of 0 to 3 for the motivation domain. If a patient’s total score is 0 to 1, the motivation domain is scored as low. If the score is >1, the motivation domain is scored as high.

For the knowledge domain, “no” answers for questions 3 and 4 receive a score of 1 and “yes” answers for questions 3 and 4 receive a score of 0. On question 5, a “no” answer receives a score of 0 and a “yes” answer receives a score of 1. This provides a scoring range of 0 to 3 for the knowledge domain. If a patient’s total score is 0 to 1, the knowledge domain is scored as low. If the score is >1, the knowledge domain is scored as high.

After MMS scoring is completed, an adherence intention quadrant for the CMAG-1 guidelines is identified, along with recommendations for an adherence improvement plan. Similar to the quadrant assignment procedure for new patients, many disease states and patient types (eg, HIV, schizophrenia) may require modification of adherence improvement plans. Chapter 8 provides the case manager with specific adherence-plan modifiers for patient types who may benefit from modified adherence improvement interactions.