Best Care at Lower Cost The Path to Continuously Learning Health Care in America (2013) / Chapter Skim
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7 Engaging Patients, Families, and Communities
7 Engaging Patients, Families, and Communities
Pages 189-226
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From page 189... ...
Alvin's case highlights the critical importance of all members of the care team -- family members, clinicians, and other health care providers -- working together to overcome system complexity and poorly aligned incentives to ensure patient-centered 189
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From page 190... ...
As the complexity of the system continues to grow with advances in science (Chapter 2) , patient engagement takes on increased importance as a means of ensuring that patients can find the right care for their individual characteristics, needs, preferences, and circumstances.
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Patients bring unique and important perspectives on their own care, on the experience in health care organizations, and on the coordination and cooperation among various elements of their care. Unfortunately, patients, their families and other caregivers, and the public all too often are not meaningfully engaged in care or as partners in its improvement.
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The lack of patient focus in the health care system also is evident in patient transitions between care settings. Patients often report that care transitions, such as being discharged from the hospital, are abrupt.
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. This chapter builds on the definition of patient-centered care outlined in Crossing the Quality Chasm: "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions" (IOM, 2001, p.
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From page 194... ...
Benefits of Patient-Centered Care A growing body of evidence highlights the potential benefits of patientcentered care for clinical outcomes, health, satisfaction among health care workers, and providers' financial performance. For example, several hospitals that encourage patient-centered care by paying greater attention to patient needs and preferences, as well as care coordination, have found that adverse events decrease, employee retention increases, operating costs decrease, malpractice claims decline, lengths of stay are shorter, and the hospital's costs per case decrease (Charmel and Frampton, 2008; Epstein et al., 2010)
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Conclusion 7-1: Improved patient engagement is associated with better patient experience, health, and quality of life and better economic outcomes, yet patient and family participation in care decisions remains limited.
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. Moreover, the development of new models of care delivery, such as patientcentered medical homes, health homes, and accountable care organizations (ACOs)
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. Evidence also suggests that patient activation and self-management can be enhanced through such strategies as improved communication, motivational interviewing, shared decision making, ready access to personal health information and providers, and increased focus on goals that matter to patients and their families.
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Health literacy refers to an individual's ability to obtain, understand, and apply health information to make appropriate health decisions. Given the complexity of the field, even highly educated people may have difficulty finding and understanding health information and applying it to their own care or that of their loved ones (IOM, 2004)
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. Several organizations, including the International Patient Decision Aids Standards Collaboration, have developed standards against which to validate the quality of decision aids and ensure that they are accurate, unbiased, and understandable.
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Leveraging their knowledge can improve the experience of care through the application of their insights to the design and delivery of care in health care organizations -- from hospital design, to visiting hours, to care delivery (Bergeson and Dean, 2006; Groene, 2011; Johnson et al., 2008; Scholle et al., 2010)
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These tools include patient experience surveys, mechanisms for submitting complaints, and other feedback opportunities for patients. Beyond the information received, these tools convey the message that the voices of patients, families, and other caregivers are important (Shaller and The Commonwealth Fund, 2007)
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To monitor its efforts, MCG implemented several chan nels for measuring patient satisfaction, including patient and family councils, surveys, and direct feedback from patients and families to MCG leaders on their care experience. As a result of these efforts, MCG Children's Medical Center has consistently ranked in the 90th percentile in patient satisfaction among children's hospitals since opening in 1998.
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From page 203... ...
Despite the importance of assessing patient experience and rewarding institutions that perform well on measures of patient-centeredness, some uncertainty exists as to which aspects of the patient experience are most important to measure and best correlate with improved outcomes. Multiple terms exist for defining this aspect of the patient-centeredness of an institution, including "patient satisfaction," "patient experience," "patient perception," and "patient ratings of quality." Additionally, multiple factors affect patients' rating of their care experience, ranging from accordance with evidence-based processes, to staff care, to information availability (Gao et al., 2012; Sofaer and Firminger, 2005)
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From page 204... ...
. In terms of correlation with an institution's technical expertise, one study compared a hospital's overall patient satisfaction score with its clinical quality and mortality rates for heart attack patients, finding that higher satisfaction correlated with improved adherence to guidelines and lower mortality rates.
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The advent of smartphones has led to the creation of numerous applications that enable people to become engaged more completely in their own health through greater access to health information and tracking tools such as built-in pedometers, diet management aids, and weight and blood pressure logs. A recent review of the use of mobile phones for chronic disease management found 23 articles describing interventions involving use of a mobile phone for disease prevention, diagnosis, management, and monitoring, as well as patient education.
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health care system toward continuous learning and improvement, the value, quality, and care coordination challenges faced by the system cannot be met by any single platform, organization, or entity acting alone. Rather, communities and coalitions are needed to drive improvement.
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Another natural focal point for patient engagement is the workplace. Workplaces have several attributes that make them conducive to community-oriented health and wellness programs: they host a group of employees who share a common goal; they have social, organizational, policy, and financial supports for employee behavior change; they have open and straightforward communication channels; and they have the ability to incentivize and monitor employee participation in sponsored health programs.
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One example is care transitions -- changes in the set of clinicians delivering care or in the setting of care that patients must navigate. In the current health care system, both the incentives that encourage health care spending and the increasing specialization of clinicians have led to a situation in which a growing number of patients are seeing an array of clinicians in a variety of care settings.
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From page 209... ...
. A review of 21 randomized controlled trials focused on improving care transitions for chronically ill adults found that, despite substantial heterogeneity among the populations and care transition interventions studied, all but one of the trials yielded positive findings with respect to health outcomes, quality of life, patient satisfaction, resource use, and costs.
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From page 210... ...
. Moreover, synergies can be realized in improving the quality and value of care by applying a population perspective to traditional medical practice, using clinical practice to identify and address community health problems, strengthening health promotion and health protection by mobilizing community campaigns, and improving health care by coordinating services for individuals (Lasker and Committee on Medicine and Public Health, 1997)
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Successful care coordination initiatives identify community needs and assets and system-level stakeholders and institutions that define parameters for community action (Craig et al., 2011; McKnight, 1978)
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These teams are typically composed of nurse coordinators, social workers, and behavioral health counselors working to improve health outcomes while containing costs through the provision of coordinated care. By extending health care delivery to services not typically provided in the primary care setting, these community health teams are able to provide individual care coordination, health and wellness coaching, and behavioral health counsel ing as an integrated and coordinated set of services.
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From page 213... ...
. • Although results for care coordination programs are mixed, there are effective interventions for improving care transitions.
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• Clinicians should employ high-quality, reliable tools and skills for informed shared decision making with patients and families, tai lored to clinical needs, patient goals, social circumstances, and the degree of control patients prefer. • Health care delivery organizations, including programs operated by the Department of Defense, the Veterans Health Administration, and Health Resources and Services Administration, should moni tor and assess patient perspectives and use the insights thus gained to improve care processes; establish patient portals to facilitate data sharing and communication among clinicians, patients, and 4Note that in Chapters 6-9, the committee's recommendations are numbered according to their sequence in the taxonomy in Chapter 10.
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Beyond patient-centered care, this chapter has described how integrating services among and across health care organizations and communitybased organizations can improve health and address complex care needs. Further, partnerships between health care organizations and public health systems can advance community health goals.
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• Health economists, health service researchers, professional specialty societies, and measure development organizations should develop and test metrics with which to monitor and evaluate the effective ness of care transitions in improving patient health outcomes. • Public and private payers should promote effective care transitions that improve patient health through their payment and contracting policies.
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From page 217... ...
As noted in this chapter, there are differences between patient involvement in care and measures such as patient satisfaction. However, these challenges do not prevent a focus on patients in care, and each can be overcome to allow for a health care system that continually improves patient care.
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Measuring patient experience as a strategy for improving primary care. Health Affairs (Project Hope)
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Driving quality gains and cost savings through adoption of medical homes. Health Affairs (Millwood)
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2010. Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction.
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Benefit-risk preferences in Crohn's disease management. Journal of Managed Care Pharmacy 16(8)
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Health Affairs (Millwood)
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2012. Lessons from Medicare's demonstration projects on disease management and care coordination.
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Health Affairs (Millwood) (Suppl.
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2011. Accountable care organizations and community empowerment.
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