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.

Medication non-adherence is a critical issue in healthcare, contributing to approximately 125,000 deaths and $100 billion in costs annually in the United States alone, particularly for chronic diseases. Some of you may have a military background and are familiar with operational risk management (ORM). ORM has been successfully deployed by the US military at the tactical level to minimize risks to an acceptable level. Tactical ORM includes the ABCD approach--Assess, Balance Resources, Communicate, and Do and Debrief—healthcare providers can systematically tackle adherence barriers. Over the next 4 posts I will discuss how to apply ORM to medication adherence. I welcome your feedback. By using the ABCD model healthcare providers can pinpoint along the ABCD path where improvements need to be made.

A: Assess
The first step to apply ORM to medication adherence is to Assess the patient for medication adherence. The minimum healthcare outcomes should include the degree of non-adherence, and the dimension of intentional or unintentional non-adherence. There are several methods to assessing this risk. Analyzing prescription refill patterns provides an objective measure of adherence. For example, frequent gaps between refills may indicate unintentional non-adherence due to forgetfulness or financial constraints, while consistent early refills might suggest hoarding or intentional overuse. Tools like smart pill bottles or medication event monitoring systems (MEMS) track the exact timing and frequency of dose-taking. These devices offer real-time data, revealing unintentional non-adherence (e.g., missed doses) or intentional patterns (e.g., skipping doses on weekends), and are ideal for patients with complex regimens. Measuring drug levels in blood or urine provides a direct assessment of adherence. For instance, low levels of an antihypertensive medication might indicate non-adherence, whether intentional (due to side effects) or unintentional (due to missed doses). In controlled settings, such as nursing homes or clinical trials, observing patients taking their medication can confirm adherence. This method is expensive and less practical. There are validated tools that can explore adherence barriers in depth.like the MMAS-8, a widely validated 8-item self-report scale, and the gold standard for measuring medication-taking behavior. It categorizes adherence as low, medium, or high and distinguishes between intentional non-adherence (e.g., deliberately skipping doses due to side effects or beliefs) and unintentional non-adherence (e.g., forgetting doses or logistical challenges).

If you haven’t uncovered the degree of medication non-adherence and the intentional or unintentional domain of non-adherence then you need to redo the assessment.

​By starting with a detailed assessment, providers can lay the groundwork for tailored interventions, addressing both intentional and unintentional barriers. Stay tuned for the next post, where we’ll explore how to “Balance Resources” to support these efforts. For more on MMAS-8 and 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.

Medication Adherence Training: Clearing the Air If you’re exploring medication adherence training, you may have come across a linkden post from Philip Morisky. We want to be clear: any Expert training provided by Philip Morisky’s is a personal linkden post initiative and not formally sanctioned or certified by MMAR LLC or Dr. Donald Morisky. The training content is offered solely for informational and educational purposes by Philip in his individual capacity. The MMAR LLC board including Dr. Morisky has not reviewed or approved any materials related to the Expert training. MMAR does not endorse or certify this training. This training is carried out in Philip Morisky’s individual capacity.

The Morisky Medication Adherence Scale (MMAS), developed by Dr. Donald Morisky, is a globally recognized tool for assessing medication adherence in research and clinical settings. Available in two versions, the MMAS-4 and MMAS-8, these scales are widely used to evaluate patient adherence to prescribed medication regimens. However, it is critical to emphasize that both versions of the MMAS are protected by copyright owned exclusively by Dr. Donald Morisky.
Copyright Protection
The MMAS-4 and MMAS-8 are proprietary instruments, and their use is strictly regulated under copyright law. Unauthorized use, reproduction, or distribution of these scales—whether in print, digital, or any other format—without explicit permission from Dr. Morisky constitutes a violation of intellectual property rights.
Licensing Requirements
Researchers, clinicians, and organizations seeking to use the MMAS in any capacity, including academic research, clinical practice, or digital applications, must obtain a valid license directly from Dr. Donald Morisky or his designated licensing agent. This requirement applies to all uses, including but not limited to:
• Academic and clinical research studies
• Integration into electronic health records or digital health platforms
• Use in clinical trials or healthcare interventions
• Educational or training purposes
To ensure compliance, users must secure a signed license agreement from Dr. Morisky. Any license or agreement that does not bear Dr. Morisky’s signature is invalid and does not grant permission for use.
Why Licensing Matters
Obtaining a proper license ensures that users are adhering to legal and ethical standards while supporting the continued development and validation of the MMAS. The licensing process also provides access to the most current and validated versions of the scale, ensuring accuracy and reliability in your work.
Avoiding Unauthorized Use
Unfortunately, there have been instances of entities falsely claiming ownership or authorization to distribute the MMAS. To protect the integrity of your research or clinical practice, we strongly advise verifying the authenticity of any MMAS-related materials or agreements. Only licenses signed by Dr. Donald Morisky are legitimate.
How to Obtain a License
To request permission or inquire about licensing the MMAS-4 or MMAS-8, please contact Dr. Donald Morisky or his designated licensing agent directly. Ensure that all agreements are formalized in writing and signed by Dr. Morisky to avoid any legal or ethical issues.