Managing Nonadherent and Difficult Patients

August 17, 2021

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Chiropractor showing spine model to patient.

Healthcare providers face many challenges when patients are difficult or do not follow their treatment plans. These behaviors can compromise the provider–patient relationship and may potentially lead to suboptimal outcomes and liability risk.

One study, for example, showed that clinicians were 42 percent more likely to wrongly diagnose a complex medical issue and 6 percent more likely to wrongly diagnose a simple medical issue when dealing with difficult patients.1

Although these situations can be frustrating, a number of strategies can help healthcare organizations and providers address difficult and nonadherent behaviors and attempt to better engage patients in their care.

  1. Create a policy that specifically defines patients’ rights and responsibilities. Display the policy within the organization and make it available to all patients (e.g., on the practice’s website or via the patient portal).
  2. Be aware of the difference between informed refusal of care and patient nonadherence to an agreed-on treatment plan. A patient can refuse care even if the consequences might be dire.
  3. During each patient encounter, emphasize the importance of following the agreed-on treatment regimen, even if symptoms subside. Explain the possible consequences of not following the prescribed treatment plan.
  4. Provide patients with education about their treatment plans both verbally and in writing — especially if a patient has serious health problems.
  5. With patients’ permission, include family members, caretakers, and significant others in education about the importance of following treatment plans. These individuals might help reinforce the significance of adhering to treatment.
  6. Consider that a patient-centered approach seeks to get patients more involved in their care. During patient encounters, ask open-ended, probing, and nonjudgmental questions to identify factors influencing nonadherence.
  7. Try various communication techniques, such as motivational interviewing, to empower patients to set goals they believe are attainable. Understanding a patient’s stages of changing behavior and dealing with discouragement will support a mutually agreed-on care plan.
  8. Use a technique such as teach-back to ensure that patients fully understand the information and instructions provided. Patients from all racial, ethnic, socioeconomic, and educational backgrounds might have limited health literacy, which can contribute to nonadherence.
  9. Consider patients’ lifestyles and medication costs when prescribing. A variety of situational, geographic, economic, and cultural issues can contribute to what might be perceived as difficult or nonadherent behavior.
  10. If a patient has financial, physical, or emotional limitations that lead to nonadherence, determine whether any community services are available to help the patient overcome treatment barriers.
  11. Consider using patient agreements that detail both provider and patient responsibilities relative to the treatment regimen. Both parties should sign the agreement.
  12. If a patient is missing appointments, try to determine the reason (e.g., family care, transportation, or financial issues). After several missed appointments, consider sending the patient a letter stressing the importance of keeping the appointments and adhering to the treatment plan. Keep a copy of the letter in the patient’s health record.
  13. Document missed or cancelled appointments by noting either “patient no-show” or “cancelled” in the patient’s health record. If possible, document the reason for a cancellation — e.g., “no transportation” or “child care issues.”
  14. Do not delete original appointment entries; the appointment log might become a valuable tool if you have to demonstrate a patient’s continued nonadherence to appointments.
  15. Document a description of all clinical nonadherence in the patient’s health record, as well any education provided to the patient, family, caregiver, and/or significant other regarding the possible consequences of not following the treatment regimen.
  16. When documenting, use subjective statements from the patient or others and objective information obtained through patient encounters. Avoid disparaging remarks or editorializing when documenting information related to patients’ nonadherent behaviors.


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This document should not be construed as legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.

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