The blog of the Urban Institute
October 24, 2019

Untangling Medication Management for Low-Income Patients in Harlem

October 24, 2019

A man with diabetes in New York City’s Harlem neighborhood experienced a severe hypoglycemic episode and was rushed to the emergency room. After receiving treatment, his health care providers learned that he had run out of food for the month but had continued to take his prescribed insulin injections.

This incident, based on the experience of a real client of City Health Works in Harlem, represents an all-too-common occurrence among people with low incomes who also have chronic health conditions. Since 2012, City Health Works has provided valuable support to these community residents and their health providers by hiring clinically supervised, neighborhood-based health coaches.

Medication can help treat chronic illness, but at least half of patients with chronic health conditions likely have inadequate medication management. They may have conflicting prescriptions, or they may be unable to adequately follow their regimens.

A fragmented health care environment is often the root of these challenges. Patients with multiple conditions and medications may interact with multiple health care providers, increasing the risk of miscommunication and errors. For those also struggling with other challenges such as food insecurity, language barriers, low literacy, and unstable work, navigating complex medication regimens can be even more daunting.

In a new brief, we explore the barriers City Health Works clients encounter in managing medication regimens to keep chronic conditions in check and the ways community health workers and health coaches help identify problems, bridge communications with health care providers, and support better self-management of chronic conditions.

Stigma and misconceptions surround medication management

Medication adherence is critical to care delivery and management. If patients can’t stick to a medication plan, manageable conditions can quickly escalate into emergencies.

Yet the conversation among providers around medication adherence can easily slide into paternalism: “My patient isn’t taking the medications I prescribed. They’re not adhering to my plan. Don’t they realize what’s at stake?”

But patients rarely stop taking their medications because they’re forgetful or unmotivated. Their efforts are often undermined by difficulties communicating with the various parts of the health care system, miscommunication between providers and pharmacies, and a lack of understanding of complex regimens.

Among low-income patients, material hardships frequently stand in the way of clients adhering to often extremely complex medication regimens. Because coaches meet with clients in their homes or other community settings, they are often better positioned to identify when these obstacles contribute to poor health outcomes.

What medication mismanagement looks like

Here are two more examples from our interviews with City Health Works staff and coaches about what they’ve seen when supporting real clients:

A client’s apartment building experienced a gas leak and a prolonged utilities shutoff, so she was unable to prepare full meals for an extended period. Taking her oral medications without sufficient food resulted in significant symptoms, including vomiting, so she stopped taking her medication. As a result, her blood glucose rose to unhealthy levels, requiring clinical intervention.

Another client reported to her health coach that, despite taking her medication, she was experiencing unusually high blood sugar and blood pressure readings. During a home visit, the coach detected that the client had been using expired insulin—a problem that would have been difficult to identify for a provider only seeing a patient in an office setting.

Many patients, including those at all income levels, need greater support and ongoing education to manage multiple medications in their homes. They may also need help coping with other self-care and management skills such as monitoring their blood sugar, planning and preparing meals, and managing depression or anxiety. For those coping with financial challenges, they also need assistance finding solutions to avoid forgoing meals, medications, or both.

Enter the community-based health coach

Health care providers rarely see these challenges, and they’re only now beginning to gain an appreciation for how these stressors can jeopardize a patient’s health.

But tackling these challenges from the health care side only, without robust supports based in the community, means that many patients will likely continue to face significant barriers to medication adherence.

Health care professionals increasingly appreciate that community-based groups like City Health Works provide comprehensive, one-on-one chronic disease self-management education and coaching for patients with complex chronic diseases while emphasizing self-efficacy and medication knowledge for patients at a higher risk of medication-related escalations.

Though coaching can benefit clients from all backgrounds, clients with low incomes, who have limited English proficiency, or who may already face disparities in accessing health care may particularly benefit from a coach’s more proactive support.

Photo by Jose Luis Pelaez Inc./Getty Images.

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