Customizing Your Approach to Improve Client Compliance

Client compliance is one of the most challenging obstacles a physical or occupational therapist faces on a daily basis. Dealing with non-compliance can be frustrating, and ironically, it is not a subject they teach us in school.

When I was a new grad, I was so naive that I actually believed all patients wanted to see their therapists walk through the door. The first day I worked in a rehab hospital, a patient refused therapy. I was devastated. Almost 20 years later, the challenge of getting my clients motivated and compliant has become much easier and is actually a part of the treatment I enjoy.

Our Part of the Compliance Effort
I have realized that client compliance is as much my responsibility as it is the client’s. Once we realize this as health-care providers, it begins to happen naturally.
As health-care professionals, we are taught to evaluate and develop treatments to enhance the quality of our clients’ lives. This is a huge responsibility, and one that we have chosen to accept when we became therapists. The energy we waste getting frustrated with our clients would be better spent on figuring out the best possible method to make our clients compliant.

There are several factors that should be addressed when treating our clients to help make their treatment successful. One important factor is our confidence and true compassion for clients when treating them.

I often have students as well as new grads working in the clinic, and what I preach on a daily basis is confidence when communicating with clients. If we are vague, inconsistent or maybe tired that day, how can the client become motivated? They are the ones injured or ill, and their lives have therefore been impaired at some level. Think of how frustrated or depressed they are to begin with, and now, by striving to work with them, we are adding more to their plate.

So how do we motivate them at a time in their lives when they probably feel overwhelmed and stressed out? We need to help them comprehend what we are doing and why. Remember, everyone’s learning skills are different, so it is our job to modify our explanations to their needs. If you can get clients to understand their goals, risks and potential complications, and treat them with sincere compassion, then you have accomplished the first step. This is how you develop a relationship with them, one of trust and confidence. Once you have this, you are golden. The key is to maintain it throughout their treatment.

Helping Clients Find Their Motivation
The second factor is creativity. We need to assess each client and figure out not only our treatment, but how we are going to get this person, this particular individual, to respond appropriately. Obviously, each person’s physical limitations are going to be different, but so is his or her personality. The challenge lies in figuring out how to communicate with, teach and motivate each client. That’s where creativity comes in.

For instance, I love when a client comes in and asks why the back pain he’s suffered for 10 years is not better after the first treatment. I then ask, “Did you do your exercises?” I get a “Yes,” but he doesn’t look me in the eyes. By the end of the treatment, I feel like the local priest, because he is confessing
his non-compliance.

So when clients admit non-compliance, what’s my next step? I might use a comparison that everyone can relate to. I tell them that therapy is like a diet: It only works if you are consistent and faithful. You can cheat every now and then, but you have to be disciplined overall if you want to see results.
I also tell them their rehab is a marathon, not a sprint, so they need to pace themselves. We don’t want them to burn out.

Creatively using those kinds of comparisons can help clients to understand why compliance is important. At the same time, I might have to be creative when devising my treatment strategy. For instance, if someone has never exercised before, I am certainly not going to give them 10 new exercises; they are going to go home and leave the exercises in the car. But if I can give them just two or three exercises, they’re more likely to add them to their schedules because that scenario is not as overwhelming.

Granted, there are clients who are just going to be difficult, no matter what we do. But as I tell my staff: You do not have to marry them, just treat them. The first thing I tell anyone I hire is to treat every client the way you would want your parents to be treated. If you stick by this you will never fail… as long as you like your parents!

This is one of the reasons I love my profession. Every hour of my day is different and challenging in a new way.

A Gradual, Escalating Solution

As a real-life case study, let’s discuss Judy, a 50-year-old female diagnosed with fibromyalgia two years before I met her. She had attended physical therapy at another facility for one year, but had received manual therapy only. After that time, Judy started to work with me.

Problem one: The therapists at the other facility had given Judy some exercises, but they were too advanced for her, which made her more frustrated. So she did not do them.

Problem two: All Judy knew about her fibromyalgia and the prescribed treatment was what her PT had told her. Her functional activity level was minimal. She did not drive, pour a teapot or do any household activities. Basically, getting dressed was her only independent activity.

My first goal was to educate Judy about fibromyalgia and convince her that a more physical program might be more appropriate. But she had a look of panic and apprehension as I made that suggestion, so I knew our second goal was just to get Judy to make a second appointment!

With that in mind, I gave Judy only two basic exercises, ones I was sure she could manage. Since I knew Judy could perform those exercises, I hoped that doing so would boost her self-confidence.

The next step was to encourage Judy to keep a daily journal of her activity level. We reviewed it each week, and it was a great method for her to monitor her progress independently. The journal also gave her motivation to do more.

Today, Judy is walking four miles a day, is driving and is basically unrestricted in all activities. She continues to have good and bad days with her condition, but she has learned to manage her symptoms independently and is now living a very functional life.
Judy is a great example of a client who needed a little extra attention and compassion during our first visit. Because I was willing to tailor her therapy so it personally fit her, she eventually learned that a big part of therapy is her responsibility.

I actually believe one of the biggest issues with our clients is their loss of independence, whatever their injury or condition is. If we can help them become more a part of their rehab and gain some independence, I believe we will have a more motivated and compliant client.

Starting with a Single Step
I am not an inherently organized person, with one exception: When I feel overwhelmed by a vast amount of work that needs to be done in a short time, I create very detailed to-do lists. Breaking a gargantuan project into smaller, more assailable bits keeps me from panicking and helps me to maintain a “one-step-at-a-time” focus.

Though we didn’t overtly plan it that way, this November issue seems to have a similar theme. For instance, this issue’s Clinically Speaking column by physical therapist Sue Soscia discusses strategies for improving compliance. Client compliance, of course, is a very big and evolving end goal for any clinician or provider. And from some clients — perhaps those overwhelmed by a new diagnosis or discouraged by a new prognosis — complete and instant compliance is hoping for too much. In her column, Sue recalls a new client so disheartened that Sue knew her immediate goal was simply to get the woman to make a second appointment. But by breaking this client’s therapeutic regimen into more attainable goals, Sue and her client were able to succeed. Read their story on page 14.

Similarly, our cover feature this month — Surviving Medicare’s 9.5-Percent Payment Cut — attacks a big problem by breaking it down into smaller steps.
Come January, the Centers for Medicare & Medicaid Services (CMS) will be reducing Medicare payments for all products that were part of competitive bidding’s first round. Given the other payment reductions that mobility dealers and rehab providers have had to live through recently, it’s obvious that most suppliers will not be able to absorb that 9.5-percent cut easily or by simply taking a red pen to one department or expenditure. To offset such a significant cut, we anticipate that suppliers will need to “work smarter” in a number of ways.

So we enlisted the help of experts throughout mobility, rehab and DME whose specialties range from continuing education to repair to billing to retail sales. And we asked for their advice: How would they suggest suppliers combat this upcoming payment cut?

As you’ll read in this special editorial section, these experts were quite honest in discussing the difficulty of the situation for suppliers who’ve already “given back” so much of their funding. The experts didn’t always agree with each other, and in general, there wasn’t a lot of sugar-coating in the opinions they offered.

For instance: “Many providers have expressed a concern about meeting payroll,” says Bob Harry, ATS, owner of Aabon Home Health Care in Ozark, Ala., and VP of the Alabama Durable Medical Equipment Association. “A good way to do that is to reduce your amounts payable. Well, how do you do that with declining revenue? Buy cheap; you don’t have any other choice.”

Mr. Harry also touts the value of joining state associations, because “The key is learning from somebody else who’s doing it right and doing it better than you.” While not all the expert advice here will fit your personal situation, we hope you will find enough take-aways to help your business move past this latest funding challenge.

This article originally appeared in the November 2008 issue of Mobility Management.

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