Foundational Routines of Patient Centered Care

Alexander Blount, EdDDirector, Center for Integrated Primary CareUniversity of Massachusetts Medical School

Professor of Clinical PsychologyAntioch University New England

Ronald Adler, MD, FAAFPDirector of Primary Care Practice Improvement

Center for the Advancement of Primary CareUMass Memorial Healthcare System

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session E5Saturday, October 17, 2015

Faculty Disclosure

The presenters of this session• Dr. Adler - Nothing to disclose • Dr. Blount - Has a consulting firm providing

services in Integrated Primary Care, practice transformation and evaluation.

– Integrated Primary Care, Inc.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• 1. Use language in ways that promote complete and respectful conversations about patients in their presence.

• 2. Negotiate a patient centered care plan, including facilitating the patient setting goals.

• 3. Use attributions in ways that promote patient activation and engagement in their own health and health care.

Bibliography / Reference

1. Chunchu, K., Mauksch, L., Charles, C., et.al. (2012). A Patient Centered Care Plan in the EHR: Improving Collaboration and Engagement. Families, Systems, & Health.2012, Vol. 30, No. 3, 199–209 2. Coulter A. (2002). The Autonomous Patient: Ending Paternalism in Medical Care. London: Nuffield Trust. 3. Council, L. S., Gefkin, D., Valeras, A. B. (2012). A Medical Home: Changing the Way Patients and Teams Relate Through Patient-Centered Care Plans. Families, Systems, & Health.2012, Vol. 30, No. 3, 190-198. 4. Guadagnoli E, Ward P. (1998). Patient participation in decision-making. Soc Sci Med;47(3): 329-39. Institute of Medicine. Crossing the Quality Chasm: A New Health 5. System for the 21st Century. Washington, DC, National Academy Press; 2001. Mechanic D. Issues in promoting health. Soc Sci Med 1999;48(6): 711-8. 

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Features of the Medical Home(http://www.pcpcc.org/about/medical-home)

1. Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care. 2. Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. 3. Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports. 4. Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations. 5. Committed to quality and safety: Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health.

Most conditions have:• an evidence based treatment • a standard recommendation for patient action

• take the medicine, get more exercise, eat healthy, stop smoking

• Protocols don’t usually have room for the patients’ preferences.•Recommendations are made based on the protocol, often with little hope it will be followed and without any sense of how the patient’s values, experiences and goals might modify the plan.•When the patient’s values, experiences and goals are part of the process, the likelihood of health behavior change goes up.

Decision making in healthcare is usually hierarchical.

Drivers of Expanding Patient Role in Decision-Making

• Evolving Clinician-Patient relationship:– Paternalism → Partnership– Increased comfort with patient autonomy

• Explosion of treatment and screening options• Broader access to information• Growing understanding of “gray zones”

– Preference-sensitive care• Growing concerns re: costs

3 Categories of Care

Effective care:• Evidence-based care that all with need should

receivePreference-sensitive care:• Treatment choices with multiple options; involves

tradeoffsSupply-sensitive care:• Visits, hospitalizations, ICU admissions and other

services where utilization is associated with supply of resources

Preference-Sensitive Care

• Procedures, tests, and surgeries or conditions for which there is more than one clinically appropriate treatment option.

• Without compelling scientific evidence favoring one strategy, the choice should depend on the patient’s own preferences– for example, having a mammogram at age 40 or

choosing lumpectomy vs. mastectomy for early stage breast cancer

Setting the Stage:Types of Primary Care Encounters

• Acute Episodic Care– 25 yo female with sore throat; intermediate

probability of strep.– Question: start PCN immediately or wait for Cx result?

• Health Maintenance– 55 yo male who has never had colon cancer screening. – Question: colonoscopy, stool test, or neither?

• Chronic Disease Management– 45 yo female smoker with diabetes and HTN.– Questions: A1c goal, glycemic management strategy,

statin, ASA?

TheNextLevel

VeryProtocolDriven

Clinician-Patient Encounters …

should be approached as a dialog between two experts:– The health care professional who has

medical knowledge and expertiseand

– The patient who is an expert in his or herself and has a unique set of personal and cultural values

Many patients and their families find it difficult to take an active part in healthcare decisions.

• Some lack the confidence to question health professionals.

• Many have only a limited understanding about health and what keeps you healthy (literacy)

• Many do not know where to find information that is clear, trustworthy, and easy to understand.

• Some have had experiences with the healthcare system that they found frustrating or humiliating.

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Source:The Salzburg Statement on Shared Decision Making

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TRANSPARENCY• Passing the relationship• Speaking in front of the patientACTIVATING LANGUAGE• Basics of positive attribution• Basics of solution talkSHARED DECISIONMAKING • Patient centered care plan for most complex

patients who can participate• Learning to do goal setting

Foundational Practices of Patient Centered Care Team

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TRANSPARENCY

• Passing the relationship

• Speaking in front of the patient

Foundational Practices of Patient Centered Care Team

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Passing the RelationshipHow to describe the involvement of a BHC (or any new team member) to the patient so that the relationship with you is

passed.

• Situation

• Skill Set

• Relationship

• Indicators

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Situation

What is the situation in the patient’s care that

makes the Primary Care Provider (current team

member) want to involve a Behavioral Health

Provider (new team member)?

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Skill Set

What are the particular skills that the BHC (new

team member) brings that can be helpful in the

overall treatment of the patient?

BHC (new team member) defined as the one with the right skill for member’s needs:

Actual case note:“KB (15yo) F/u for depression.Kathy would like to be in better control of her emotions. She gets angry often when people are mean to her about her weight.She can’t talk to her mother.She would agree to counseling as long as the counselor is not ‘all nice and happy.’Refer to Dr. Blount, who is neither nice nor happy.”

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Relationship

What relationship will the work of the BHC

(next team member) have to the overall

treatment of the patient?

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Indicators

What outcomes would indicate that the

involvement of the BHC had been useful to

the overall treatment of the patient?

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To do all your work in the presence of the Patient: Change your language to engage with and activate your patient.

Negative/passive words Positive/active words

Suffers from Struggles withRefused to take Decided againstDidn’t keep apt Was unable to be hereWas non-compliant with Had not seen value ofArrived late Was determined not

to miss• Help me with the list.This takes practice, and you will laugh as you practice together.

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Working Together Transparently15 min

37 y.o. woman working as a forklift operator in a warehouse. She strained her lower back 6 mo. ago. Unable to work since, she has had severe depression in relation to loss of role functioning in family (breadwinner, parent of small children, partner). In effort to return to work she began overusing pain meds, she re-injured her back and now feels she cannot function without them, though she would give them up if her pain went away. Has augmented her supply with an old prescription of her mother’s.

• Shares with MA that she has borrowed mom’s medications.

• PCP hears about the family situation and depression, wants to add BHC to care.

• Talk over what MA should could be taught to say to PCP in front of patient. Enact the meeting with MA, pt and PCP, and then add the BHC. Pick someone to observe and jot down the phrasings that were used. Someone play the patient and observe when you feel activated and if you feel blamed. We want your reaction to the phrasings of the team.

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ACTIVATING LANGUAGE

• Basics of positive attribution

• Basics of solution talk

Foundational Practices of Patient Centered Care Team

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Attributions for Activation

• Attribution is one the most powerful forms of influence.

• A physician’s opinion becomes more valuable if s/he makes positive attributions about patients.

• Attributions have to be believable to the patient.

Statements that engage without judging content:

• You have really been thinking about that!

• I think you are really paying attention to your health.

• Thanks for being so clear. It helps a lot.

• You know, I wish a lot more of my patients could be so _______ .(direct, thoughtful, open, helpful, honest, determined. . . )

Give us some more.

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Scripts from the Activation Therapies

• Solution Focused Interviewing -Highlighting the patient’s effectiveness that is not in their consciousness

• Coping Questions

• I know that things are not going well, but I am interested in how you cope as well as you do?

• How do you keep things from getting worse?• How did you manage to get yourself here today? I

have known several people who would not have made it today if they faced what you face.

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Scripts from the Activation Therapies

• Solution Focused Interviewing -Highlighting the patient’s effectiveness that is not in their consciousness

• Exceptions:• I know you have bad days and not so bad days. Can you

give me an example of a day you thought was going to be really bad and it wound up being a not so bad day?

• What did you do to help that happen?

• Ever have a day that was as bad as can be, but it didn’t derail you as much as you would have expected?

• What did you do to help that happen?

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What does an “activated” patient* report?

- When all is said and done, I am the person who is responsiblefor taking care of my health.

- I am confident I can help prevent or reduce problems associated with my health.

- I am confident that I can tell whether I need to go to thedoctor or whether I can take care of a health problem myself.

- I am confident that I can follow through on medical treatments I need to do at home.

- I know how to prevent problems with my health. - I am confident that I can maintain lifestyle changes, like

eating right and exercising, even during times of stress. *Taken from the Patient Activation Measure’s 13 items.

Column A Column B• You are determined to:• You are learning to:• Your values are helping you to:• You are improving at being

able to:• For your sake and for your

family your are going to:• You’re getting back on track

to:

• Take care of your health.• Work on goals to make

yourself healthier.• Prevent health problems

down the road.• Follow through on

treatments at home.• Maintain lifestyle changes.

Script Generator: “It looks like” (any A) (any B)

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Column A Column B• You are determined to:• You are learning to:• Your values are helping you to:• You are improving at being

able to:• For your sake and for your

family your are going to:• You’re getting back on track

to:

• Take care of your child’s health.

• Work on goals to make her healthier.

• Prevent health problems for him down the road.

• Follow through on treatments at home.

• Maintain lifestyle changes to make her healthier.

Child Script Generator: “It looks like” (any A) (any B)

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Exercise: 10 minutes

In your group: Come up with scripts for the MA/RN, the PCP, the BHC and/or the Care Manager based on common attributions that they can use fairly regularly (nothing is appropriate in all cases) in their roles in the workflow. Don’t feel constrained to use only our examples.

Shared Decision Making is a part of Encouraging Patient Activation

In general, when we are talking about helping the patient be a part of developing his/her treatment plan, we are describing “shared decision making”.

When the patient is taking responsibility for the behavior that improves or maintains their health, we talk about “patient activation.”

Patient Activation

Shared Decisionmaking

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SHARED DECISIONMAKING

• Bringing the patient in on choices about treatment and screening, and health goals.

• Patient centered care plan for most complex patients who can participate

• Learning to do goal setting

Foundational Practices of Patient Centered Care Team

IOM: Crossing the Quality Chasm (2001)10 Rules for Redesign

1. Care is based on continuous healing relationships.

2. Care is customized according to patients’ needs and values. 3. The patient is the source of control. 4. Knowledge is shared, and information flows freely. 5. Decision-making is evidence-based. 6. Safety is a system property. 7. Transparency is necessary. 8. Needs are anticipated. 9. Waste is continuously decreased. 10. Cooperation among clinicians is a priority.

SDM

“Patient values should guide all clinical decisions.”

Shared Decision-Making(SDM) Defined:

Decisions shared by clinicians and patients, informed by the best evidence available and the specific characteristics, preferences, and values of the patient.

• Decision aids do a better job than usual care in:• Improve patients’ knowledge about options• Reduce their decisional conflict• Stimulate patients to take a more active role

in decision making without increasing their anxiety

• “Compared with simpler versions, more detailed aids improve patients’ comfort with decision making and marginally improve knowledge”

• CM can assess these for clarity and suggest good ones. Assume you had no medical knowledge when choosing.

O’Connor el al., 1999 from BMJ

Decisional Aids - Evidence

SDM: Context(Cancer Screening Example)

Messages to convey• You are a potential

candidate for cancer screening.

• There are choices to be made about this.

Info to be elicited• To what extent are

you comfortable making these decisions?

• Do you wish to involve anyone else?

SDM: Information

Messages to Convey• Cancers are heterogeneous, ranging from

harmless to deadly.• Screening tests sometimes don’t identify

how bad a cancer is.• There are potential benefits to screening.• There are potential harms from

screening.• There are different screening techniques.• Screening can be done at different time

intervals.

Info to be elicited

• Do you understand this information?

• Do you understand these options?

SDM: Process/Action

Messages to Convey• These are personal

decisions.• There are no right or

wrong answers.• When making a

decision, you should consider your own values and preferences.

Info to be elicited• Is there anything else

you would like to tell or ask me?

• Are you ready to make a decision?

• What would you like to do?

Barriers to SDM• Clinicians

– Challenge to autonomy; feel threatened by sharing power– “Over-certain:” fail to recognize preference-sensitive

situations– Knowledge/Evidence Deficits

• Difficult to keep current, interpret, and communicate• Patients

– Variations in role preference• Among patients and within individuals for different decisions• Socialized to expect the doctor to make treatment decisions

– Literacy/Numeracy Challenges• Practice

– Lack of time/compensation– Logistical challenges:

• Availability of appropriate decision aids

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Setting Health Goals: Scripts for the Conversation

• A lot of folks in our practice are setting health goals.

• It turns out that when people set even a small goal and work on it, they tend to get healthier, sometimes in ways they didn’t plan on.

• People have been trying to eat a little healthier, or to be a little more active, or to cut back some on habits that aren’t good for them.

• Have you considered any health goals up to now?

• Are you willing to talk about it?

• What would be a reasonable goal?

• Is it OK if we keep track and try to support you?

Goal Setting

• Pick something in your life that you actually want to change.– Hint: It can be something you want to do more as well

as something you want to do less, perhaps something you want to pay less attention to as well as something you want to pay more attention to.

• If you are sitting in a room with other folks, pick a partner and each of you interview the other. We will give each interviewer 5 minutes to help their partner set goals. I will tell you when to change interviewers.

• If you wish, tell us your plan, what, when, how often.

Let’s Practice – 10 minutes

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Why focus on the care plan?• Required by NCQA for Level 3 PCMH for 75% of patients in

chronic illness protocols and “complex patients.”• An expected piece of documentation for providers.• Makes sense to patients as a type of conversation.• Opportunity for input by multiple team members.• The structure of the Care Plan form becomes a structure for

the conversation.• A new sort of conversation becomes a new sort of

relationship.• Start with patients where the fit between care and patient is

poor.– Over serviced and underserved– “Heartsink” patients

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Elements of the care plan

• Medical summary – Patient info and team members • CM or staff or nursing

• Medical synopsis (sign out) • Provider

• External team (Who else is involved in your care?)• Patient Snapshot

• Important people• People who can be included in information• What do you want the healthcare team to know about you?

• Provider input for the care team.47

Elements of the care plan – cont.

• Urgent care plan (How should care team respond if you are in a crisis?)

• Action Plan• Pt short term goals• Prov short term goals• Pt long term goals• Prov long term goals• Goals in action – next steps and person responsible for each

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Script for a care plan. (If there is time)

• What would you say to get it started?• Consider a workflow for getting it done.• Consider how it would stay a useful document over

time.

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PCCP can be a nodal point in care And a nodal point in practice transformation

Patient Care• New resources added• Access to own data• Contribute information

about self• Perspective taking on

own upset behavior• Induce activation for

health• Plan in EMR informs

the whole system for pt

Practice Transformation• Learn team work• Work transparently• Understand patients in

context• Reduce polarization

from upsetting behavior

• Learn to expect patient involvement and leadership

• Achieve Meaningful Use

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Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!