The Patient Contract: Their Role in Their Plan of Care

The Patient Contract: Their Role in Their Plan of Care

By: Cheryl “Chae” Dimapasoc Canon, PT, DPT;  OptimisPT Director of Implementation and Compliance

One of the biggest challenges in therapy remains getting the patient to consistently adhere to their prescribed home exercise program (HEP).  We found some great articles that detail barriers to patient adherence, with the links posted at the bottom of this blog.  There is moderate evidence to suggest that a strong factor related to adherence is the individual’s belief that they are responsible for their own outcomes.¹ A study in the Journal of Rehab Medicine indicates that the patient-practitioner relationship is the best predictor of adherence to a HEP, and that improving patient perception of the clinician’s productivity, communication of information and trust during consultations may improve adherence to the HEP.²

The WHO defines adherence as, “the extent to which a person’s behavior…corresponds with  agreed recommendations from a healthcare provider”.  In a survey of 35 students mid-way through their clinical rotation as a self-reflection in how effective they felt they were in this communication, 85% indicated that they felt they educated the patient on the importance of their HEP, but didn’t feel they were effective based on the lack of patient compliance on return visits.  Upon practicing specific verbiage and having the patient acknowledge a “contract”, by the end of their clinical rotation 65% of those students indicated they felt their difference in words and using the “patient contract” improved the patient adherence to their HEP.

An example of the flow after the initial evaluation based on variables the research show help to improve patient adherence to their HEP is as follows:

1. Provide the patient education regarding their condition and your assessment of the impairments that are contributing to their problems with specific activities. The better they understand what is going and are empowered to do something to be in control of their impairments, the more likely they are to engage
2. Review the goals established with the patient that you hope to accomplish by the end of the episode of care and beyond; review them again at least every other visit in relation to objective change.
3. Establish the prognosis including the expected duration and expected percentage of return to prior level-of-function. Review this on a regular basis.
4. Delineate your role as the therapist for the intervention in the clinic that the 1-3 hours a week will “jump start”, complimented by the daily prescribed program (HEP, activities to avoid exacerbation, and activities that are encouraged) that the patient is responsible for. 
5. Emphasize to the patient their responsibility in their care and the importance of consistency on a daily basis

An Example For:  R Shoulder impingement

Patient Education:  The reason you’re having difficulty raising your arm and lifting objects is because of 3 of the 4 muscles that help your shoulder move; your rotator cuff. Right now those muscles are weak, as you saw when we tested the movement and I was able to move your arm easily.  Until those muscles get stronger, when you raise your arm the bone shifts up and pinches some of the structures that run through there. As we strengthen them and the muscles that stabilize your shoulder blade, the bone will start to glide and the pinching won’t happen any more.  

Goals: You’re currently having pain and difficulty reaching above shoulder height, lifting anything over 5 lbs and laying on your right side when you roll onto it.  Your goals are to be able to get back to these activities without pain, and together we’ll get you there.

Prognosis: Strengthening takes 6-8 weeks, if done consistently.  You’ll be here in the clinic twice a week for four weeks and taper to once a week for two weeks so we can progress your program.

Therapist responsibility: Here in the clinic we’ll work on your shoulder mobility without pain, progress strengthening, and different manual techniques to help the mobility and pain.

Patient responsibility: I’ll give you two exercises to start out with. These will help improve your mobility without pain. We’ll progress those exercises when you’re ready.  The most important thing is to do them every day; I can’t do them for you. You’ll reach your goals if you are consistent.

If these important aspects of your conversation are written up in a ‘patient contract’ it helps to hold the patient accountable and increase the likelihood of adherence to their HEP.  The factors that have been shown to improve patient adherence to their HEP that support the ideas above are:

• Leveraging technology and mobile apps with pictures and videos
• Teach back method
• Remote monitoring adherence rates
• Emphasizing the idea that exercise will lead to less pain, anxiety, and depression
• Use a graduated HEP
• Review exercises every visit

If you’re an OptimisPT client, the optimumME patient engagement app allows usage of all the features indicated above.  Combining all of these specific factors identified along with a patient contract and good communication, you may find that your patients’ adherence to their HEP may improve.

A consideration for your current practice:  How effective is your approach to promoting adherence to a HEP?  How do you gauge your effectiveness?  Have you found specific verbiage or changes you have implemented to be useful? Have you added additional techniques beyond education that research has shown to help improve the adherence to a HEP?  We’d love to hear what has worked for you as well!

OptimisPT.com

¹“Adherence to Home Exercise Programs.” Physiopedia, . 21 May 2020, 05:12 UTC. 4 Mar 2021, 19:17 <https://www.physio-pedia.com/index.php?title=Adherence_to_Home_Exercise_Programs&oldid=238871>

²Wright BJ, Galtieri NJ, Fell M. Non-adherence to prescribed home rehabilitation exercises for musculoskeletal injuries: the role of the patient- practitioner relationship. J Rehabil Med, 2014, 46: 153–158