Shaping garments of care: Tools for maximizing adherence potential

There is a tendency in health care to treat clients' maladies in accordance with two basic premises: (1) the medical needs of the client (as perceived by the clinician) can be successfully addressed by focusing solely on that aspect of the client's life and (2) if the client is not able or ready, then there will be someone in the client's support system to take responsibility for administering prescribed therapy. In many cases these assumptions hold true, but for certain sub-populations they do not, notably: individuals with substandard/chaotic lives, those with multiple confounding diagnoses (mental health, substance abuse, disability, addiction, domestic violence) who have neither personal adherence ability nor adequate support systems. They are rarely seen in ambulatory care settings, engaging with the health care system only through emergency rooms and hospital admissions. Such a group makes up a large proportion of urban, HIV positive clients. For them, successful adherence can only be accomplished by rethinking what constitutes 'care' and 'tailoring' that care to the individual. In this context adherence requires the interweaving of three sets of needs: (1) needs perceived by the client, (2) client needs as observed by an objective recorder and assessed for impact on the client's ability and willingness to be adherent and (3) medical needs identified by a clinician. Extensive work with this population has led to the creation of a Cluster of Tools (HIVCOT), designed to quantitatively assess the severity of the varied needs (Health Importance Level or HIL), the adherence ability of the client (Adherence Functional Level or AFL) and how difficult it is to adhere to a given treatment (Level of Adherence Difficulty or LAD). Through the application of these tools it becomes possible for the medical providers to make individual adjustments to the design of care so that it closely fits the needs and abilities of the client. In this way the likelihood of adherence is maximized.