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Case Management Adherence Guidelines (CMAGs): History, Content, and Impact

Pat Stricker, RN, MEd, Healthcare Consultant, Former SVP of TCS Healthcare Technologies

Did you know the Case Management Adherence Guidelines (CMAGs) had a significant update released in the summer of 2020? If you were not aware, do not be upset. There was certainly a lot going on during that time. We were facing the peak of the coronavirus pandemic and there was little else that seemed to matter. And if you were working, you were probably so overwhelmed with what was happening that you were not keeping up with anything else. 

Because the healthcare field has undergone significant and challenging changes in recent years, the Case Management Adherence Guide 2020 was updated to assure the adherence guidelines contained better skills, techniques, and procedures to help health professionals be able to assist their patients and families. The Guide provides improvements in comprehensive evidence-based assessments, care planning, care coordination, care transitions and intervention tools to help case managers (CMs) achieve better measurable outcomes, be more efficient and effective, be more valuable to their patients, clients and employers and prove case management’s clinical and financial worth. 


In the early 2000s, medication non-adherence was identified as a significant problem throughout the world. In fact, it was known as the “silent epidemic”. Studies at that time showed that non-adherence:   

  • Resulted in more than $100 billion in unnecessary healthcare costs each year (2005 study).
  • Caused more than 125,000 deaths for cardiovascular patients each year.
  • Caused 12% of patients to not fill their prescription, another 12% to not take their medication, and it stopped 29% from completing their entire course of treatment. (A study by the American Heart Association in 2005.)
  • Resulted in decreased quality of life, as well as earlier deaths, in about 50% of patients in the U.S. who did not take their medications as prescribed.
  • Was the reason for 10% of all hospital admission and 23-40% of all nursing home admissions.
  • Was the most powerful predictor of relapse in patients with schizophrenia.

On the positive side, studies showed that if patients with chronic diseases were just 1% more adherent with medications, the healthcare industry could save $1 billion and patients would see an increase in the quality of their lives and their longevity. Yes, that’s $1 billion savings for every 1% increase in adherence.

A Journal of the American Medical Association article published in 2013, indicated that non-adherence rates in the U.S. were 30-50% for long-term medications, which resulted in an estimated $100 billion cost each year. Given the cost of inflation over the years, that means there was a decrease in cost by 2013 since the cost then was the same as in 2005 — $100 billion. That is about a 19% decrease in 8 years, so it shows that the focus on medication adherence programs does work. That is a positive sign. 

Cost statistics for 2017 disclosed similar outcomes: 

  • 20% - 30% of prescriptions are never filled. 
  • Approximately 50% of medications for chronic disease are not taken as prescribed.
  • Medication non-adherence costs are $100 to $289 billion annually in the U.S., which represents 3% - 10% of the total U.S. healthcare costs.  
  • 10% of hospital admissions for older adults are caused by non-adherence. 
  • Medicare and Medicaid beneficiaries with congestive heart failure had healthcare costs that were as much as 23% less per year for adherent patients compared with non-adherent patients. 

Although some diseases and conditions are more affected by outcomes and costs, stakeholders agree that costs are affected by non-adherence and that increasing adherence would significantly improve health outcomes and save billions of dollars.  


Because non-adherence was a worldwide issue that required a multi-disciplinary effort, the World Health Organization (WHO) published a foundational model for medication adherence in 2002 identifying the needs for patient information, motivation, and behavior skills. This 211-page report, Adherence to Long-Term Therapies: Evidence for Action, provided a detailed review of adherence to long-term therapies; common system issues (structures, finance and operations) that needed to be addressed; professional training and reward systems; how to resolve barriers patients and their families face to maintain optimal health; analyses and solutions; recommendations for additional research; lack of awareness, knowledge and tools; disparity issues; and what we already knew, but did not apply.

The main objective of the project was to improve the rate of adherence to therapies used to treat chronic conditions. The four objectives were to:

  • Summarize the existing knowledge on adherence and use it for policy development
  • Increase awareness among policy-makers and health managers about non-adherence and its consequences (decrease in quality-of-life and increase in healthcare costs)
  • Promote discussions related to adherence issues
  • Provide a basis for consistent, ethical and evidence-based policy guidance on adherence and advocacy positions that would stimulate research and involvement

The report identified factors and interventions for specific diseases, social and economic issues, health system issues, team and patient issues, therapies and diseases/conditions.

The report also included “Take Home Messages” which summarized the main findings and how readers could use them to improve their programs and organization. I would highly recommend that you take a few minutes to read these “messages”(page 13) as they provide an excellent overview of recommendations for addressing non-adherence and how organizations can use the recommendations to develop meaningful improvements.   

According to the World Health Organization, “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”


This WHO landmark report spurred action throughout the world. For example, CMSA’s president at the time, Sherry Aliotta, developed a partnership with Pfizer to develop a medication adherence program built on the concepts and recommendations presented in the WHO report. That program became the Case Management Adherence Guidelines, a resource for case managers that provides a patient-centered approach to support adherence and self-management intervention tools to improve patient medication and treatment adherence. 

The Guidelines include planning, facilitation, evidence-based assessments, intervention tools, and advocacy, which focus on improving the patient's knowledge, attitude and motivation to take medications, as prescribed. The Guidelines also provide flexibility so individual patient needs can be addressed. 

The first adherence guideline program, Medication Adherence, was released in 2004. The ultimate goal was to create structured interactions based on patient-specific needs that would result in a high degree of knowledge and patient self-motivation to adhere to medication and treatment plans appropriately. The initial Adherence Guideline was focused on medication adherence, although concepts and tools incorporated in the guidelines make them easily adaptable to disease or condition treatment plans requiring adherence to achieve therapeutic goals.

After the release of the initial Adherence Guidelines in 2004, CMSA continued to build upon past versions and add specific disease-related treatment adherence guidelines for diabetes, deep vein thrombosis, cardio-metabolic, COPD, depression, pain, asthma, cancer (palliative care), epilepsy, HIV-AIDS, hypertension, tobacco smoking and tuberculosis. 

The 2012 update added new models for care delivery and accountability associated with the needs of the Patient Protection and Affordable Care Act (PPACA). It reflected the evolving landscape of case management in a more technological environment and included socio-economic aspects. The information and tools enhanced the goal of ultimately improving care delivery and patient outcomes.


The 2020 update built upon this strong foundation and added up-to-date tools and strategies that are needed for today’s changing healthcare landscape. A preview of the Case Management Adherence Guide 2020 provides a sneak-peek at the Guide and the information it contains. (Click the “Open Preview” button located under the book icon to view the details.) The Guide includes:

  • The forward is written by past CMSA president Susan Rogers
  • Chapters 1 and 2 include articles written by:
    • Past CMSA president Kathleen Fraser, who describes the "Challenges in Today’s Health Care System."
    • Current president Melanie Prince, who describes "The Important Role Case Managers Play in Improving Outcomes."
  • Chapters 3 and 4 describe the business case for "Adherence" and "How to Improve Adherence."
  • Chapter 5 describes how "Care Coordination and Care Transitions Support Adherence" that includes discussions on outpatient care, telehealth, engagement, skill sets for interprofessional teams and preventing admission and readmissions.
  • Chapter 6 describes "Medication Adherence" that includes discussions on the atmosphere for adherence, costs, technology, and strategies to improve adherence.

In addition, there are seventeen appendices that provide tools and references: 

Appendix 1: PRAPARE: Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences

Appendix 2: Health-Related and Quality of Life Scales

Appendix 3: Accountable Health Communities Health-Related Social Needs Screening Tool

Appendix 4: Patient Activation Measure

Appendix 5: Shared Decision-Making

Appendix 6: Emotional Intelligence

Appendix 7: Motivational Interviewing 

Appendix 8: LACE Tool

Appendix 9: “Ask Me Three”

Appendix 10: Rapid Estimate of Adult Literacy in Medicine— Short Form (REALM-SF)

Appendix 11: Financial Resources for Access to Medications and Medication Assistance

Appendix 12: Morisky Medication Adherence Scale (MMAS)

Appendix 13: STEPSforward

Appendix 14: Ten Principles of Patient-Centered Care

Appendix 15: Care Transition Worksheet

Appendix 16: Medication Adherence Worksheet

Appendix 17: Telehealth Resources 


So, do the CMAGs really work? Do they improve patient knowledge and motivation? Do they result in healthcare savings?

CMSA conducted a training program for case managers to support them in using the CMAG tools that focused on approaches to improve patient knowledge and motivation. In 2007, up to one year from the initial training, CMSA surveyed 750 trained case managers from all settings to evaluate the tools and strategies used in the Medication Adherence CMAG. The survey results indicated:  

  • 43% of respondents reported there had been a very or fairly big improvement in patient adherence
  • 42% reported that CMAGs had a very or fairly significant impact due to new skills learned in CMAG training that increased their effectiveness in helping patients reach their outcome goals
  • 39% did not see any major impact
  • 43% indicated that the CMAG training was very valuable, while 39% reported it was fairly valuable
  • 26% said they use some of the skills taught in the training sessions very often, while 49% reported using them fairly often 
  • 66% of respondents indicated they specifically use motivational interviewing to help address patient knowledge and motivation for medication adherence 

The survey also identified implications for case management practice:

  • Medication adherence is a key issue in CM practice. 
  • The CMAG training had some effect on self-reported case manager effectiveness in addressing medication adherence. 
  • Many respondents reported that they continue to use the skills they learned and have observed changes in patient outcomes.
  • Additional training, skill-building, and reinforcement may help case managers apply CMAG and motivational interviewing effectively. 

In 2012, CMSA said that CMAGs have proven to be a valuable resource to the community since they have been downloaded over 500,000 times since their release in 2004.

CMAGs have been added to case management documentation systems to make the process easier for CMs to use. Some organizations have added them to their legacy systems, while other commercial software companies have added them to their product line. Having the CMAGs online makes using them much quicker and easier, allows them to be included as part of the documented treatment plan and facilitates the ability for comprehensive reporting on outcomes and all other aspects of the program.   


Adherence to medication and other disease or condition treatment plans is essential in improving health outcomes, maintaining quality of life and reducing risks and untoward outcomes. It is an essential component of case management. If non-adherence occurs, the medication or treatment plan may not be effective, care coordination will be affected because the patient is not involved and treatment plan goals will not be attained. It may also cause risks to the patient’s overall health outcomes.  

CMs are at the forefront, facing a myriad of changes and challenges that impact patient care and outcomes. This makes CMs ideal partners to work with physicians, pharmacists and other healthcare team members to help patients understand the importance of adhering to their medication or treatment plan to achieve positive outcomes. Non-adherence is a multifaceted problem, and this type of team-based case management is already recognized as an effective care strategy that improves adherence and health outcomes and has the ability to decrease overall healthcare costs.  


The Case Management Adherence Guide 2020 is an essential resource for all case management professionals. The 142 page eBook is on sale now and the hardcopy book is also available.   


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