This document discusses using daily telephone counseling to maintain medication compliance for patients with schizophrenia. It finds that medication noncompliance is a significant issue, with rates around 20-45% within the first 6 months after being prescribed medication. However, studies have shown that daily telephone compliance calls can significantly decrease noncompliance. The document proposes a pilot program using a multidisciplinary team to provide daily telephone counseling to patients using a standardized assessment tool. The goal is to increase compliance and decrease hospitalization rates and costs compared to patients not receiving calls.

1. Running head: TELEPHONE COUNSELING CAN MAINTAIN COMPLIANCE 1
Daily telephone counseling can maintain medication compliance
Gary Allen RN
Chamberlain College of Nursing
NR451 RN Capstone Course
November 2016

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Daily telephone counseling can maintain medication compliance
In the realm of mental health the interventions are as varied as the diagnosis themselves.
Within the realm of mental disorders Schizophrenia is considered the most challenging to treat
due to the nature of the disease process. This is primarily due to the majority of the patients
believed they did not have a serious mental illness or, that they could function adequately with a
mental illness (Kanahara, 2009). Of primary concern is the area of medication compliance of a
patient with the diagnosis of Schizophrenia; remaining compliant outside of structured
environment on medications can mitigate the negative symptoms of the disease process. With
current practice models medication compliance in the outpatient setting is poor and these
numbers vary widely from 20-45% within the first 6 months (Beebe, Smith, & Phillips, 2014;
Montes, Maurino, Diez, & Saiz-Ruiz, 2010). Adequate compliance with atypical psychotropic
medication is defined as 80% oral compliance according to one study (Montes, Maurino, Diez, &
Saiz-Ruiz, 2010). At the lower compliance rate multiple risks for complications related to the
disease process occur from increased time hospitalized and the subsequent costs incurred and up
to death (Lindström, Eberhard, Neovius, & Levander, 2007). Current research has shown that
daily telephone compliance calls have shown a marked decrease in noncompliance in the
outpatient setting (Beebe, Smith, & Phillips, 2014; Montes, Maurino, Diez, & Saiz-Ruiz, 2010).
Practice Question & Model Overview
To enact change we must first determine which type of change we wish to enact. To
enact effective change we learn that “The use of rating scales assists the critical appraisal of
evidence. Rating scales present a structured way to differentiate evidence of varying strengths

3. TELEPHONE COUNSELING CAN MAINTAIN COMPLIANCE 3
and quality” (Dearholt & Dang, 2012). One of the most effective rating scales is the John
Hopkins Nursing Evidence-Based Practice Process. From this tool we can determine if the
evidence we are presented is of high quality and more likely to present best practice vs evidence
of lesser quality. As higher quality ingredients leads to a better meal so do higher quality
evidence lends credence to our practice. This tool was utilized to allow the team to determine if
the evidence is high, good or low/flawed yet allowing the team to use its own clinical and critical
thinking skills to extrapolate and apply it to their own situation in this scenario our Inter-
professional team will consist of the following classifications Registered Nurse, Social worker,
Primary Psychiatrist and database coordinator. The four classifications will be organized on the
micro scale for ease of use yet can be scaled upwards or downwards depending on acuity of
clientele serviced. For the initial intervention the ratio will be a six to one with each individual in
the team overseeing six patients in an outpatient setting.
A concern which has been consistent in the field of mental health is the compliance of
patients’ prescribed anti psychotropic in the outpatient setting. Most notably is the
noncompliance of prescribed medication which leads to said patient’s regression in status and
increase in symptoms. In the outpatient program there is potential to mitigate and even reverse
this trend with interventions one of which has been studied is the use of Telephone compliance
counseling. The question is as follows will P=Schizophrenic patients prescribed anti-psychotics
in outpatient setting I=Receiving daily telephone compliance counseling, remain compliant on
their medication vs those C= patients who did not receive any telephone compliance counseling.
It can then be O= demonstrated if the intervention is effective by the de-compensation of mental
status requiring acute psychiatric hospitalization. As irregular medication adherence is a
significant predictor of relapse (Fenton, Blyler, & Heinssen, 1997)

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Schizophrenia has a high ratio of noncompliance of the patient population with one study
showing that “outpatients with schizophrenia reported a median default rate of 41 percent
(range, 10% to 76%) with oral medications and 25 percent (range, 14% to 36%)” (Fenton,
Blyler, & Heinssen, 1997). Still another study shows medication compliance of 20-45% within
the first 6 months (Beebe, Smith, & Phillips, 2014; Montes, Maurino, Diez, & Saiz-Ruiz, 2010).
As can be seen compliance remains poor especially in the compliance of oral medications.
Without consistent medication compliance acute hospitalization was required leading to higher
costs and greater chance of negative outcome with any secondary diagnosis (Lindström,
Eberhard, Neovius, & Levander, 2007). To implement our intervention effectively we must
utilize effective communication across different disciplines. “There are two ways in which
communication can be improved; standardization tools and establishing a culture of supportive
communication” (CCN, Week 3). The RN will be engaged in the assessment and intervention
phase of the intervention utilizing standardized tools for assessing mediation compliance and
knowledge of the patient regarding their medication. The standardized tool will be the TIPS
(Telephone intervention Problem solving for Schizophrenia) model as detailed in (Beebe, Smith,
& Phillips, 2014). The Social worker will act as a liaison for facilitation of the visitation if
necessary of the patient to the primary psychiatrist if the data indicates intervention per TIPS is
necessary as well as, address any secondary concerns that hinder medication compliance. The
Primary Psychiatrist will meet as necessary to encourage and address any compliance issues
discovered during the TIPs if the score is low or to address any concerns brought forth during
TIPS that can be addressed i.e. non-compliant related to side effect an adjustment could be
ordered outpatient and monitored through TIPS. Lastly the database coordinator will be
responsible for recording information into the statistical model to track progress.

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Evidence
Many avenues of research were utilized to obtain information that was of high quality in
nature. This was complicated due to the very nature of the disease process makes Qualitative
research difficult. Also experimental studies are complicated by the very nature of the subjects
they are working with this must also be factored into the data obtained. All sources of
information were peer reviewed and were able to shed some light on this subject. Several sources
were shown to have good-quality and one of high-quality; all were randomized, controlled trials
and case studies all of them yielding consistent results. This was demonstrated by the use of
control groups to compare data of those with and without interventions. Finally another source
was able to use statistical modeling based on closed loop system where all care both inpatient
and outpatient was monitored by the government (Lindström, Eberhard, Neovius, & Levander,
2007). Many reasons are given for why patients don’t take their medication as one writer put it;
“they forgot to take their medications” (Fenton, Blyler, & Heinssen, 1997). Yet there were more
than simple forgetfulness there were other factors at play from lack of education regarding
consequences to mitigation of side effects. The recommendation of this study also talks about
how the problem is multi-faceted and is in need of a comprehensive approach to medication
compliance. That there is no single factor that makes a patient compliant or noncompliant.
Another study that yielded useful data was the cost of implementing care of patients diagnosed
with schizophrenia over a five year term in Sweden. They measured the costs of care both in the
inpatient and outpatient setting as well as secondary cost factors utilized in management of their
care. Since Sweden utilizes socialized medicine the controls on data were easier to manage than
if they were undertaken in the United States. It showed that hospitalization of recurrent
noncompliant patients factored into the greatest cost with increase medication compliance

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decreasing these costs (Lindström, Eberhard, Neovius, & Levander, 2007). A controlled trial
using a large pool of subjects from multiple hospitals in Spain over a four month period was able
to have patients with schizophrenia receive telephone based intervention than those without;
with the results overwhelming showing that compliance increased in those receiving the phone
call (Montes, Maurino, Diez, & Saiz-Ruiz, 2010). Lastly TIPS (Telephone intervention Problem
solving for Schizophrenia) a qualitative study tool was utilized with great effect as detailed in
(Beebe, Smith, & Phillips, 2014). Using this tool it could be determined if the client needed
medication adjustment, education or evaluation by the primary psychiatrist.
Based on evidence presented there is ample proof that positive change can be
implemented if there was a system in place for a patient to receive telephone call on a weekly
basis to encourage medication compliance either through education or counseling based on the
multiple peer reviewed papers. This has been demonstrated in prior studies that utilized a
variation of the PICO question as outlined above that yielded positive results and increased
compliance. (Montes, Maurino, Diez, & Saiz-Ruiz, 2010; Beebe, Smith, & Phillips, 2014). With
compliance in patients medication for those diagnosed with Schizophrenia significant savings in
health care costs can be obtained (Lindström, Eberhard, Neovius, & Levander, 2007).
Translation
The specific steps of implementation of the telephone intervention will be as follows. A
team will be assembled for the pilot project which will be composed of the categories as listed
previously. A three month timeline will be projected for the start and end timeline of the pilot
project with it being divided into one month increments for management of data. An inclusion
criteria list will be established based on the following criteria: Primary diagnosis of
Schizophrenia and taking one or more anti psychotics orally, age 18 and older, no secondary

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medical diagnosis that would exclude participation in study (Insulin dependent diabetes,
Polysubstance abuse) ability to utilize and or provide a primary consistent contact number and
patients health belief model that includes the use of medication in treatment of their disease
(Fenton, Blyler, & Heinssen, 1997). Voluntary consent and disclosure discussed with both
primary psychiatrist and patient and both agreeing to listed interventions as well as data
collection. Location to be determined based on available space and resources but minimum will
be one computer one telephone and assorted supplies based on six to one ratio of six patients to
one team. After patients have been evaluated for feasibility they will be randomly assigned into
the inclusion and exclusion group. Results of intervention will be tabulated in one month
intervals against those in the exclusion group and on completion of intervention. Desired
outcomes will be documented as having a compliance percentage equal to and or greater studies
of similar interventions. Medication compliance will be validated via pill count at a time
unbeknownst to subject at two random times during each month which is a variation on the work
of Beebe, Smith, & Phillips, (2014); who received a compliance percentage as high as 87.5%.
In another study Montes, Maurino, Diez, & Saiz-Ruiz, (2010) the compliance ratio of the
inclusion group was at 97% although it didn’t have patients on multiple anti-psychotic
medications. Results will be collated and presented to the chief nursing officer for final review
of data who will in turn will be bring it up during the next policy meeting which is held on a
semiannual basis. During the policy and procedures meeting the Chief financial officer will be
able to validate the cost savings to private medical insurance providers as well as other entities
that have a vested interest and be able to see the benefit of this intervention.
To implement the plan on a larger scale will require only a scaling of the pilot minus the
exclusion group. The ratio will remain the same as it is in line with California Safe staffing law

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(1999). Other areas of the United States will have to follow applicable laws related to staffing
based on their respective locations. As this intervention will be under the arm of outpatient
psychiatric services it will not need a large implementation strategy only localized to that area.
To enable continue funding and validation of results a cost comparative analysis will be
conducted based on quarterly expenditures and revenues and will validate returns and continued
funding.
Information will flow through email as a form of communication tool as well as access of
data and results of compliance and interventions through centralized database. Database will be
accessible to all members of the team and will be in the form of electronic medical record as
currently kept of a patients file in outpatient program. This in turn can be printed if necessary to
allow information to be conveyed to additional facility or other programs as appropriate for
continuous care across different hospital platforms.
Conclusion
Medication noncompliance is not only a detriment to the patient’s well-being in the form
of physical, emotional and financial cost it is also a strain on limited resources in an already
impacted system. With a low cost intervention of a phone call the return to investment in regards
to the physical emotional health of the patient is improved, as is strain on limited resources. All
sources of information utilized in implementing this intervention were peer reviewed and were
able to shed light on this subject. With several sources having shown good-quality and one of
high-quality it can be said with certainty that we can answer our question about improving our
practice with evidence that we can translate into current practice with minimal cost and
maximum benefit to the emotional and physical health of the Schizophrenic patient.

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References
Beebe, L., Smith, K. D., & Phillips, C. (2014). A Comparison of Telephone and Texting
Interventions for Persons with Schizophrenia Spectrum Disorders. Issues In Mental
Health Nursing, 35(5), 323-329. doi:10.3109/01612840.2013.863412 (Beebe, Smith, &
Phillips, 2014)
California Safe staffing law AB-394 retrieved from http://www.leginfo.ca.gov/pub/99-
00/bill/asm/ab_0351-0400/ab_394_bill_19991010_chaptered.html
Chamberlain College of Nursing. (2015). NR-451 Week 3: Solving the Problem.
[Online lesson]. Downers Grove, IL: DeVry Education Group Retrieved
fromwww.chamberlain.edu
Dang, Deborah ; Dearholt, Sandra L. . Johns Hopkins Nursing Evidence-Based Practice Model
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International. Kindle Edition. (Dearholt & Dang, 2012)
Fenton, W. S., Blyler, C. R., & Heinssen, R. K. (1997). Determinants of medication compliance
in schizophrenia: empirical and clinical findings. Schizophrenia Bulletin, 23(4), 637-651.
doi:10.1093/schbul/23.4.637 (Fenton, Blyler, & Heinssen, 1997)
Kanahara, S. (2009). The Outcome of Behavioral Intervention with a Person Living with
Schizophrenia Who Exhibited Medication Noncompliance: A Case Study. International
Journal Of Behavioral Consultation And Therapy, 5(3-4), 252-263.
Doi:10.1037/h0100886 (Kanahara, 2009)
Lindström, E., Eberhard, J., Neovius, M., & Levander, S. (2007). Costs of schizophrenia during
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0447.2007.01086.x (Lindström, Eberhard, Neovius, & Levander, 2007)

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Montes, J., Maurino, J., Diez, T., & Saiz-Ruiz, J. (2010). Telephone-based nursing strategy to
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