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Many diabetic educators have abandoned the word “compliance” as one that is used as a diagnosis and may be used to judge a patient’s character or personal values--rather than a description of the obstacles they face. The purpose of the assessment is not simply to determine whether a patient is not adhering to recommended therapies, but to determine the barriers to adherence so that they can be addressed.

Clinical and Other Flags:
Persistent high levels of A1c
Erratic fluctuations of blood glucose and
     diabetic crisis episodes
Signs of medication ineffectiveness
Dietary non-adherence and weight gain
Inadequate self-monitoring of blood
Missed appointments



Non-adherence should not only be identified early, but carefully assessed in order for the patient, caregivers, and providers to determine the most suitable course of action to improve adherence and outcomes. A social worker can be most helpful in these situations, and should be asked to meet with the patient to determine if the issues surrounding their non-adherence are intentional, and therefore will need to be addressed.

Oftentimes, if the patient is non-adherent, the reasons could be due to other barriers they may have which prevent them from following their medication and testing regimens. These barriers may be self-imposed, and centered on fears or events which are influencing their behavior with regard to their therapy. The social worker can help to find the root cause of these problems and motivate them to become adherent using an analytical approach. The social worker should be invited to take part in health care team meetings in order to educate the other team members as to the best way to relate to this patient. 

Clinical signs can trigger an assessment. Laboratory values that are at odds with what should be seen in therapy-adherent patients suggest the need to investigate both adherence and the appropriateness of medications and dosing levels. Persistent hemoglobin A1c, erratic changes in blood sugar levels, and episodes of diabetic crisis resulting from lack of blood glucose control should be evaluated for possible non-adherence issues.

Other co-existing conditions that are medication-controlled, such as hypertension and hyperlipidemia, can be evaluated for effectiveness. If hypertension and hyperlipidemia are persistent despite prescribed medications and other therapies, an assessment for overall adherence to therapy recommendations should be completed.

If patients experience weight gain or continued elevated hemoglobin A1c levels despite dietary recommendations that should control those issues, then non-adherence should be explored. If the patient does not have adequate records of self-monitoring of blood glucose, routinely misses appointments, and fails to follow through on recommended clinical testing, a well-rounded assessment may identify barriers to adherence.


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