Direct Patient Care

1. Shared Decision Making

The first level is direct patient care where patients receive information and answer questions regarding their treatment preferences. This form of engagement allows patients and providers to make decisions based on medical evidence, patient preferences, and clinical judgment. The conversation and perspective should shift from “What’s the matter?” to “What matters to you?” This process involves a shift from focusing on each condition to the whole person. Having meaningful conversations with the patient and understanding their lives (not just their diseases) is central to true patient-centered care. This takes time and will require clinicians to optimize the balance between workload and capacity.

One strategy for achieving patient-centered care is shared decision making. Patients, families, and providers together consider the patient’s conditions, evidence-based treatment options, cost, risks and benefits of treatment or non-treatment, and patient preferences, and then arrive at and execute a treatment plan.

Dr. Victor Montori and colleagues at the Mayo Clinic developed the Diabetes Medication Choice decision aid cards to provide information that would help people on medications commonly used to treat type-2 diabetes to choose the medication that is best for them. The information gathered from relevant research studies is organized into seven issues that may be of interest to the patient, shown in the image below.

This strategy is also used with "Preference Sensitive Conditions" in which people can make a choice based on risks and benefits and determine if they want the treatment or would rather live with the condition. The table below shows examples of conditions in which there is more than one treatment option that should be chosen in conjunction with the patient (Bazell & Fitch, 2018).

*Removed from the hospital Outpatient Prospective Payment System (OPPS) inpatient-only list in CY 2018.

Using this strategy, you will often list the costs, risks, benefits, recovery time, and so forth to assist in decision making. Moreover, studies demonstrate the potential for wider adoption of SDM to reduce healthcare costs because as many as 20% of patients who participate in SDM typically choose less invasive surgical options and more conservative treatment than do patients who do not use decision aids. While few studies have specifically measured the effects of the use of decision aids on the rates of surgery and healthcare costs, the introduction of decision aids at Group Health for hip and knee osteoarthritis was associated with 26% fewer hip replacement surgeries, 38% fewer knee replacements, and 12% to 21% lower costs over six months.

EXAMPLE

One patient with knee pain may wish to have surgery to avoid significant loss of function and mobility, while another may worry that surgery would not relieve their pain and opt for non-invasive treatment. In such cases, multiple treatment options are available, and the correct path forward should be guided by the patient’s unique circumstances and needs.

Numerous decision aids are available on sites such as the Mayo Clinic, Johns Hopkins, and the National Health System. Precision medicine is also delving into being able to show risks and benefits specifically for an individual patient rather than generalized to the population, which further aids in SDM for the best treatment options.

2. Patient Goal Setting

Goal setting with patients is essential to determine what is important to the patient and is a method of engaging them in the development of positive sustainable behaviors. It is important to “focus on a patient’s individual health goals within or across a variety of dimensions—symptoms; physical functional status, including mobility; and social and role functions) and determine how well these goals are being met.” (Reuben & Tinetti, 2012) Say, for instance, that the patient wants to be able to walk in their house after they are discharged. A plan with daily walking goals in the hospital can teach the patient to walk daily and begin building a habit that can be included in the discharge plan and continued at home.

Before setting goals, it is important to assess a person’s willingness to change. Several tools are available; however, the gold standard is the "Patient Activation Measure™" (PAM). A patient is asked a series of questions to determine their status on the readiness scale and what actions to take to foster goal setting. The measure scores the patient from 1 (lowest activation) to 4 (highest activation). A study analyzed the relationship between the scores and healthcare costs of 30,000 patients at Fairview Health Services in Minnesota. The study demonstrated that those with the lowest activation scores had average costs of 8 to 21 percent more than those with a higher activation level, even after risk adjustment.

They concluded that patient activation scores were significant predictors of healthcare costs.

In the hospital, nurses can routinely ask patients and family members to establish daily goals—the concerns they want addressed and the most important thing they want to accomplish that day. The patient’s goals for the day should be put on the whiteboard at the bedside to communicate to all members of the team and to be available for discussion during multidisciplinary rounding. Nurses may be reluctant at first to ask patients to voice their needs or they may feel they can’t honor patient requests. Customizing care to patients' unique needs and preferences requires the commitment of the entire care team to provide patient-centered care.

Providers in an office setting can partner with care coordinators and the patient to set goals the patient would like to achieve. Using this system, they can frame the discussion in terms of individual needs rather than applied health states. Additionally, this process simplifies decision making for patients with multiple conditions by focusing on outcomes that span the conditions, and it aligns treatments toward common goals. For instance, a patient with CHF and diabetes may have a goal of eating healthier to better control both these conditions. Following this plan will also prompt the patient to identify which health states are important to them and their relative priority. With clarity around the desired health states, patients and clinicians can agree on steps to take to meet these goals and monitor progress in reaching them.

Always remember to meet the patients where they are at. Even if they only have one goal they are invested in, it will improve their health and confidence to begin to self-manage their disease. Celebrate every achievement with them, and be there to mentor and coach them on their journey. The ultimate goal is to improve their quality of life.

3. Patient Data

Patients become more engaged when they see their own data. Providers can share electronic medical records to show patients graphs of their blood pressure and annotate when they started and stopped medications. Additionally, patients with congestive heart failure or kidney disease can track their weights each day using a log, and the physician can work with them on a strategy based on parameters to self-manage their condition. They will have greater self-confidence if they can be educated from the start about the process and be mentored and coached until they feel confident.

4. Health Education

Patient engagement in health education is a growing avenue. Patient "actors" are used in simulation exercises to improve physician-to-patient communication by providing feedback following a scenario. Physicians who participated in these scenarios indicated that patient perspective helped them build better relationships with patients and resulted in improved patient satisfaction scores. Including patients in medical education improves trust between clinicians and patients. Exposure to patient stories is also valuable and encourages physicians to improve safety.

5. Patient- or Family-Activated Rapid Response Teams

Hospitals have enacted a system for a family member to call for help if they have concerns that are not being addressed or to alert the care team of clinical changes that require medical attention.

6. Patient and Family Participation in Change-of-Shift Report and Multidisciplinary Rounds (MDR)

Family members are a great resource because they intimately know the patient and can provide critical information that can impact the patient’s care and treatment. During multidisciplinary rounds, patients and families are important members of the team and participate in the plan of care discussion. MDR is common in most hospital Intensive Care Units and ensures a high level of collaboration and communication among doctors, nurses, and others involved in developing daily goals for every patient every day.

7. Healthcare Technology

The table below describes different types of healthcare technology.

Authored by Cindy Ebner, MSN, RN, CPHRM, FASHRM

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