B - Balance Resources in the Operational Risk Management (ORM) Approach to Medication Adherence

For those with a military background, the concept of operational risk management (ORM) may be familiar as a proven strategy used by the U.S. military to mitigate risks at the tactical level, ensuring safety and efficiency. This structured process has now been adapted for healthcare, particularly in addressing medication adherence, through the ABCD model--Assess, Balance Resources, Communicate, and Do and Debrief. By applying this framework, healthcare providers can systematically identify points along the adherence journey where improvements are needed, tailoring interventions to enhance patient outcomes. This is the second of four posts exploring how ORM can revolutionize medication adherence management, and I welcome your feedback as we delve deeper into this approach.

B - Balance Resources: A Strategic Starting Point
The second step, balancing resources, is pivotal after assessing adherence and determining whether non-adherence is intentional (e.g., deliberately skipping doses due to side effects or personal beliefs) or unintentional (e.g., forgetting doses or facing logistical barriers) using tools like the Morisky Medication Adherence Scale (MMAS-8). This process begins with prioritizing resources based on these domains, ensuring that interventions align with the patient’s unique challenges. The World Health Organization (WHO) has identified five key dimensions of adherence--patient-related factors, socioeconomic factors, therapy-related factors, condition-related factors, and healthcare system-related factors—which serve as the foundation for resource allocation. By strategically balancing these dimensions, providers can optimize the use of time, tools, personnel, and financial support to overcome adherence barriers effectively.
The Role of MAAP and the Three D’s
To enhance this resource-balancing process, healthcare providers can leverage additional validated scales or innovative AI mapping tools to develop a Medication Adherence Action Plan (MAAP), a framework inspired by resources like those on moriskyscale.com. The MAAP integrates the three D’s:
• Degree of Adherence: Quantifies the extent of non-adherence (e.g., low, medium, high) based on tools like MMAS-8.
• Domain of Intentional and Unintentional Non-Adherence: Identifies whether the issue stems from deliberate choices or inadvertent lapses.
• Dimension of WHO Adherence: Maps the specific WHO dimensions driving the non-adherence, guiding resource prioritization.
This structured approach ensures that resources are not only allocated but also tailored to the patient’s adherence profile, maximizing impact.
Prioritizing Resources Across the Five WHO Dimensions
1. Patient-Related Factors
• Intentional Challenges: Patients may intentionally skip doses due to misconceptions (e.g., believing medication is unnecessary after symptom relief) or fears (e.g., dependency on chronic medications).
• Unintentional Challenges: Limited health literacy or confusion about dosing schedules can lead to unintentional lapses.
• Resources for Intentional: Prioritize educational sessions with pharmacists or nurses using culturally sensitive materials, and invest in counseling (e.g., motivational interviewing) to address beliefs.
• Resources for Unintentional: Provide simplified guides or follow-up calls to clarify schedules as a secondary support.
• Example: A patient avoiding diabetes medication due to dependency fears receives prioritized counseling, while one confused about timing gets a follow-up call.
2. Socioeconomic Factors
• Intentional Challenges: Financial constraints might lead patients to deliberately reduce doses to stretch prescriptions.
• Unintentional Challenges: Lack of transportation or inability to afford refills can cause unintentional non-adherence.
• Resources for Intentional: Prioritize financial aid programs (e.g., discount cards) and social service referrals to address deliberate cost-saving.
• Resources for Unintentional: Implement mail-order services or community health worker support for transportation as a key intervention.
• Example: A patient cutting doses to save money gets a prioritized discount card, while one missing refills due to travel uses mail-order support.
3. Therapy-Related Factors
• Intentional Challenges: Side effects (e.g., nausea from chemotherapy) may prompt patients to intentionally skip doses.
• Unintentional Challenges: Complex regimens or frequent dosing can lead to unintentional errors.
• Resources for Intentional: Prioritize behavioral therapy and alternative medication options to minimize side effects.
• Resources for Unintentional: Distribute pill organizers or apps to simplify regimens as a primary resource.
• Example: A patient skipping doses due to nausea gets prioritized therapy, while one missing doses due to complexity uses a pill organizer.
4. Condition-Related Factors
• Intentional Challenges: Patients may avoid medication if they feel their condition is under control or stigmatized (e.g., mental health treatments).
• Unintentional Challenges: Symptom fluctuations (e.g., forgetting during asymptomatic periods) can disrupt adherence.
• Resources for Intentional: Prioritize support groups and family education to reduce stigma and reinforce treatment value.
• Resources for Unintentional: Provide wearable reminders or caregiver monitoring as a supplementary aid.
• Example: A patient hiding antidepressant use joins a prioritized support group, while one forgetting during remission uses a reminder device.
5. Healthcare System-Related Factors
• Intentional Challenges: Distrust or long wait times may lead patients to intentionally avoid follow-ups or adjustments.
• Unintentional Challenges: Missed appointments due to poor scheduling or lack of reminders can cause lapses.
• Resources for Intentional: Prioritize CCM services (CPT 99490, 20+ minutes monthly) and provider training for trust-building.
• Resources for Unintentional: Implement EHR-based reminders and streamlined referrals as a secondary support.
• Example: A patient avoiding visits due to wait times gets a prioritized coordinator, while one missing appointments receives automated reminders.
Balancing Resources Effectively
After prioritizing resources based on the intentional or unintentional domain, the next step is to allocate them efficiently using MAAP’s insights. For example, a patient with unintentional non-adherence due to forgetting might receive a pill organizer and app as a primary resource, while one with intentional non-adherence due to side effects might get counseling and a medication review as the focus. Providers should assess resource availability—staff time, budget, and technology—ensuring sustainability, especially in resource-limited settings, by targeting the most relevant dimensions first.
Practical Implementation
• Leverage MAAP Data: Use the three D’s to guide resource allocation, focusing on high-risk patients identified by MMAS-8.
• Integrate Technology: Deploy digital tools like apps and EHRs to support staff and enhance patient engagement.
• Collaborate Across Teams: Engage pharmacists, social workers, and community health workers to pool expertise and resources.
Conclusion
Balancing resources in the ORM approach starts with prioritizing the five WHO dimensions—patient-related, socioeconomic, therapy-related, condition-related, and healthcare system-related factors—based on intentional or unintentional non-adherence. By using MAAP and the three D’s, healthcare providers can create tailored action plans that optimize resource use and improve adherence. Stay tuned for the next post on “C - Communicate” to explore effective patient engagement strategies. I’d love to hear your thoughts—feel free to share feedback! For more on MAAP, visit www.moriskyscale.com.
Disclaimer: Use of the MMAS-8 requires permission due to copyright protection. Contact Dr. Donald Morisky via www.moriskyscale.com for licensing details.