https://www.ajmc.com/journals/supplement/2017/beyond-charitable-assistance-sustainable-strategies-for-providing-access-to-critical-medications/reducing-barriers-to-medication-access-and-adherence-for-aca-and-medicaid-participants-a-peer-to-peer-community-based-approach
Reducing Barriers to Medication Access and Adherence for ACA and Medicaid Participants: A Peer-to-Peer, Community-Based Approach

Andrea Baer, MS, and Marcia Baker, MS Ed

According to CMS, in 2016, 72.8 million Americans had health coverage through state Medicaid programs1; another 20 million Americans were covered by the Affordable Care Act (ACA) exchange programs. Not only do these Americans face specific barriers to accessing healthcare, but in many cases, they also lack access to external resources and social supports. Medication adherence is a problem that plagues many of the nation’s most vulnerable, and with 90 million-plus Americans falling under these programs, the social and economic costs are staggering. Individuals who are prescribed self-administered medications typically take only about half their prescribed doses; thus, efforts to assist those patients with adherence to medications might improve the benefits of prescribed medications.2 Understanding how a community-based approach could improve medication adherence through peer-to-peer support could establish a system of support for all Americans that would benefit the overall outcomes and reduce morbidity and mortality without burdening the healthcare industry with high-cost programs.

Peer-to-Peer Support
Peer-to-peer support is vital to improving the lives of individuals across multiple social platforms. These social platforms can take shape in hospitals, through local chapter support groups, or with community events, advocacy events, or online support groups. The most commonly recognized peer-to-peer support organization, Alcoholics Anonymous, uses an individualized “been there, done that” theory of support to help individuals recover from addiction.3 How exactly peer-to-peer support works has not been effectively studied to date, but it is generally understood that social influence seems to be the key. As an individual is attempting to make a lifestyle change (eg, weight loss, addiction, recovery from a medical event, medication adherence), surrounding himself or herself with others who encourage and support new and positive behavior may improve long-term outcomes of success.

Charles Duhigg writes in his book, The Power of Habit, keys to social habits and why they are important. According to Duhigg, a movement starts because of the social habits of friendships and strong ties to close acquaintances; it grows through the habits of the community, and it endures because individuals give each other new habits that create a fresh sense of identity and a feeling of ownership over their well-being.4 In personal health, individuals must be educated, empowered, and supported to make changes in their own care, and they should also feel they have some semblance of control. However, these habits are difficult for the healthcare industry to ingrain in such a fast-paced, impersonal world, as clinicians are often overwhelmed with caring for the complex medical needs of patients, which leaves them little time to provide personal support.

Social support systems are more likely to produce the social networks that can encourage an individual to adhere to treatment and make positive lifestyle changes, and provide additional resources for services for patients. This is where peer-to-peer support enters into the healthcare equation: peer supporters can be the social system that patients need to become educated on the importance of medication adherence and to provide encouragement for lifestyle changes that will impact their healthcare outcomes. It is easy to tell someone what they should do, but providing real-life answers to the question “How?” is where the social support especially comes into play. Establishing these important community support groups in local areas to work with clinicians to support patients could change outcomes. Building those positive social structures within communities is vital to empowering patients—an empowered patient is more engaged in their healthcare and more likely to make the right healthcare decisions.

Mended Hearts, a peer-to-peer support organization for cardiovascular patients has been providing this support for 65 years. The ability to educate and empower patients and caregivers is the cornerstone of the success of the community-based chapters. In a landmark study completed in 2014, hospitals with a Mended Hearts visiting (peer-to-peer support) program were significantly more likely to have fewer readmission rates for heart failure than a hospital without, based on national averages.5 The results of this study showed that peer-to-peer support gives patients the ability to feel in control of their situation. Involving them in social support systems can encourage lifestyle changes and health benefits. Emotional health is an important part of this process, and the ability to support patients from a peer perspective is the cornerstone to success.

When discussing the barriers to medication adherence, it is important to examine the social and community programs that could be accessed. These programs could enhance the care that is provided to patients from the medical community while focusing on patient satisfaction and the quality of care they receive. The cost of the programs would be relatively low for the healthcare industry, yet incredibly effective in reducing the overall cost burden on the healthcare system.

Causes of medication nonadherence are multifaceted with no clear answers. Some successful interventions are reportedly complex and unlikely to be implementable in routine clinical settings.6 Therefore, looking outside of the clinical setting to community based programs, such as peer-to-peer support services, is a first step in a new generation of healthcare management.

A Review of the Literature
It is well documented that peer support programs are effective in the areas of mental health, addiction recovery, and weight loss. Developing evidence-based programs for support to enhance the healthcare system is a viable option, and the research shows this to be correct. What is noted throughout the review is that peer support programs need to be developed within communities, with specific guidance, oversight, and training to be successful. Guidelines and program development must be structured.

In 2006, the California Healthcare Foundation released models for successful peer support integration within the healthcare community; these case studies provide an in-depth look at how peer led interventions are successful. Using peer-led self-management programs, patients can learn about problem-solving skills, treatment adherence, and the health system.7 Peers who are living with chronic conditions and have been trained can execute support group meetings, provide 1-on-1 support, and develop communitystrengthening activities that improve outcomes.

Heisler studied 1 program—Project Dulce—that provided a peer support program in San Diego, California, for Latino patients living with diabetes. The program participants showed significantly improved outcomes compared with those who were not engaged in the support program. More impressively, a 100% adherence to the American Diabetes Association guidelines for follow-ups and testing was documented.7 This is significant to the theoretical platform that peer support improves adherence and self-managed care.

In 2011, the National Institutes of Health (NIH) conducted a systematic review of barriers to medication adherence in the elderly population. Throughout the study, it came to light that very little was known about the nonfinancial barriers to adherence; common patient-related factors found to be associated with adherence included sociodemographic factors, the psycho-social profile, comorbidities, cognitive ability, and health beliefs.8 Health literacy also plays a role in this equation. If patients are unaware of the importance of the medication or lack basic disease education, they will be less likely to adhere to the treatment.

The patient–prescriber relationship and lack of social support were also noted within the NIH review as causes for nonadherence. One study within the review focused on medication adherence in the elderly population and reported factors outside of cost to be notable. It was reported, through a telephone survey of 202 individuals, that patients with hypertension who gave lower priority to discussing their hypertension with their physician were significantly more likely to be nonadherent to their blood pressure medication.8 Building relationships with providers and social support systems would likely improve adherence to the treatments prescribed.

Another review of evidence shows that there are 3 basic contributions of peer support that seem to be unique to, or at least especially well-suited for, peer staff: 1) instillation of hope through positive self-disclosure, 2) role modeling to include self-care of one’s illness, and 3) the nature of the relationship between peer provider and recipient, which is thought to be essential for the first 2 components to be effective.9 It is well noted that an individual who can speak from personal experience can be powerful in providing this hope. Peer support organizations within the local community can do this effectively.

A small pilot study with stroke survivors who received peer support was completed in 2013. Although further research is needed to determine the preferred format and timing of peer support, the study showed that this type of support can potentially enhance the experience for both the survivor and the peer supporter. One key finding from the research was that information received from a peer regarding the experience of living with the effects of a stroke was generally regarded with more significance than that received from a healthcare professional.10 With the notion that patients value peer perspective and guidance, community-based peer support programs for medication adherence would be beneficial to the overall patient experience.

Another study looked at targeted training in illness management (TTIM) to improve outcomes for patients with mental illness and diabetes. Peer support was shown to be an important route to empowerment that improves health and is a particularly successful method for disseminating patient-level self-care innovations to those with costly chronic diseases.11 Peers with chronic health conditions have access to lay expertise that is typically inaccessible to healthcare providers; therefore, peers are perfectly poised to provide guidance toward self-empowerment.

Throughout the weeks and months of the TTIM study, the group became very cohesive and members began to regard each other as “almost like family.” This is an important feature of the peer support system: having the ability to receive support and feel empowered can be a life-changing experience to individuals who are facing chronic disease. It is important patients want to adhere to the treatments, however. Once the patient desires adherence, the other steps will be easier to accomplish.

Case Studies
At Memorial Healthcare System in Hollywood, Florida, Memorial Regional Hospital has implemented an intensive patient education program at their Cardiac and Vascular Institute that includes a discharge class that all cardiac patients must go through before being discharged from the hospital. Mended Hearts is a part of this educational program. Within this 2-hour program—offered in English and Spanish, with other translators available if needed—the patient learns from a pharmacist, a nutritionist, and a cardiac rehab specialist about the important parts of their recovery plan.

The patient also learns from a peer supporter who discusses topics like depression, the art of positive thinking, and the importance of taking care of themselves and adhering to the treatments and medications they are prescribed. The patient is sent home with a lot of information, including practical tools, such as a medication card (and extra copies) to fill in about their medications and when to take them.

The Mended Hearts peer supporter follows up with the patients, provides 1-on-1 support, and invites them to meetings and other community events to keep them involved. These steps have helped the hospital to be in the top 1% of cardiac care in the nation and receive a 3-star rating from the Society of Thoracic Surgeons. Scoring above average in all areas of patient satisfaction is also something that Memorial Healthcare System has achieved; in areas like access to care, follow-up care, and communication, the hospital performs higher than the state average in all areas.12 With Broward County being home to a high rate of underserved patients, it is important that this hospital takes the time to provide such outstanding patient education and support throughout their hospital stay and beyond. Embracing the total heart and total healthcare of the patient is working well in this hospital.

CaroMont Regional Medical Center in Gastonia, North Carolina, much like Memorial Regional Hospital, is a top-ranking cardiac care hospital system. US News & World Report ranks the hospital as "above average" in areas such as survival and patient services.13 An additional similarity to Memorial Regional Hospital is that CaroMont also has a strong peer support network with a Mended Hearts chapter. At this hospital, Mended Hearts has over 60 peer supporters who provide in-patient visits to patients who are recovering from cardiac events. Providing education and support to patients is so important to CaroMont that their hospital system sought out Mended Hearts and helped to get the chapter running in the hospital. Understanding that support systems are critical to their patients’ success, CaroMont provides support to the Mended Hearts chapter with in-kind services that include meeting room space, newsletter distribution, and meals for meetings.

These small things can make a big difference in the success of the local support group chapter. The chapter spreads awareness through a monthly newsletter that includes a heart-healthy recipe, a heart patient story, visiting (peer-to-peer support) reports, chapter events, and ways to get involved.14 The newsletter is distributed to each floor of the hospital and at each CaroMont facility in Gaston County.

Discussion
The research shows that peer support that focuses on education and empowerment through a structured system is vital to improved outcomes in chronic disease management. With community-based programs that work closely with healthcare teams, medication adherence can be addressed in a cost-effective way. Disease-specific nonprofit organizations can be funded to execute their programs to provide peer support in a variety of settings in the community.

Support meetings and functions, 1-on-1 meetings and visits, social events, educational materials, and other support programs can be operated in the community at a fraction of the cost of healthcare professionals. Although the costs will vary depending on the community, the overriding costs can be absorbed by simple “in-kind” donations from health systems. Such items can include use of meeting space, free parking for volunteers, food and beverage for meetings and events, printing and mailing of organizational materials, and educational speakers. In return, health systems could see a reduction in readmission rates, lower healthcare costs across the spectrum, and adherence to treatments that will improve the health of the community. The cost of the programs is a minimal cost to the healthcare system and could enhance the ability of patients to truly be empowered to adhere to the treatments they prescribed.

There is a gap in notable research in medication adherence and peer-to-peer support programs, and patient reported outcomes are difficult to quantify. Creating a multicenter pilot program to follow patients over the course of a 12- to 18-month period to compare with patients who do not receive peer support services would be a valuable undertaking. In designing this study, one would need to work within that same hospital system and compare subgroups of patients within the same system to assure that the variables of care provided are controlled through the study.

Conclusions
For healthcare to truly be patient centered and to address the barriers of patient care that currently plague the healthcare system currently, peer support and personal empowerment of the patient are keys to success. When managing chronic disease, the socioemotional toll can be devastating on patients and their caregivers. Providing support and educational resources can provide patients with the ability to make better healthcare choices and become more adherent to treatment plans and can improve their overall emotional and physical health.

When patients are empowered and supported, barriers can be removed with critical thinking skills, lifestyle changes, and social services programs within the community. However, the first area to address must be the patient’s emotional health. Once their emotional health is cared for, patients can focus their energy on the desire to become healthy and adherent.

Reducing barriers and improving medication adherence can be done with a low-cost community strategy that focuses on patient support, education, and empowerment. These programs can help to improve the quality of the patient experience, reduce hospital readmission rates, and reduce overall healthcare costs. Investing in peer support programs in local communities could have a positive, long-term effect on the health of patients.
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