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Patient Centered Care | Unit 2c Lecture
- 1. Patient-Centered Care Behavior Change Strategies Lecture c This material (Comp 25 Unit 2) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0005. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 2. Behavior Change Strategies Learning Objective — Lecture c • Design individual behavior change interventions. 2
- 3. Designing Patient-Centered Interventions • Patient engagement methods, processes, and tools. • Patient engagement mobile-based interventions and self-monitoring. • Creating population-level interventions. • Patient-provider communications. 3
- 4. Areas Where Organizations Would Like to More Effectively Engage Patients In which areas of health care management would your organization like to more effectively engage patients? 88.9 66.1 47.2 85.0 65.6 85.0 0 20 40 60 80 100 Chronic disease management (e.g., diabetes, asthma, etc.) Medication adherence (e.g., compliance with prescribed treatment plans) Postacute care management (e.g., reducing the risk for preventable readmissions) Preventive care practices (e.g., screenings, immunizations, etc.) Public health interventions (e.g., smoking cessation, etc.) Wellness activities (e.g., nutrition, physical activity) Percent 2.09 Chart. Adapted by Eric W. Ford, PhD, 2016. 4
- 5. Identifying Tools • Most tools are designed for a specific form of patient engagement: – Care process phase — post discharge, medication adherence, etc. – Facility type — medical practice, hospital, etc. – Organizational type — patient-centered medical homes (PCMHs) and accountable care organizations (ACOs). – Disease- or behavior-specific — chronic illness (e.g., diabetes) or health improvement (smoking cessation). 5
- 6. Patient Engagement Strategies • Community – Providing health education, healthy cooking, physical education classes – Using patient navigators • Organization – Using volunteers and patient advocates – Including patients and families on advisory councils – Removing restrictions for family access • Health Care Team – Inclusive, structured change-of-shift reports – Involving families in rounds – Using multidisciplinary care teams • Individual – Pursuing health information and knowledge – Participating in shared decision making – Utilizing online personal health records Source: Health Research & Educational Trust, 2013. 6
- 7. Tools and Sources • Standard Internet search using the terms: – “Patient engagement programs.” – “Patient-centered care.” • Sources people may wish to start with: – Agency for Healthcare Research and Quality (AHRQ) — Guide to Patient and Family Engagement Environmental Scan Report. – Health Affairs (2013) special issue on the “New Era of Patient Engagement.” – American Hospital Association’s Pursuit of Excellence Guides. • There are numerous consulting and other types of organizations that are dedicated to improving patient engagement. 7
- 8. Patient Engagement Program Measurement Essentials • Patient engagement measures should include: – Assessment of the knowledge, confidence, and skills to prevent and manage chronic disease, plus the behaviors to do so. 8
- 9. Patient Engagement and Technology • Consumer adoption of personal health information technology (PHIT) is accelerating due to a convergence of social and economic forces: – Growing dependency on digital technologies in everyday life. – Expectation of real-time access to services. – Increasing clinical and financial responsibilities for patients. – Pressure on providers to embrace value-based payment and incentives for patient outcomes. – Regulatory and legislative mandates. 9
- 10. Patient Engagement and Technology: mHealth • Globally, reliance on mobile platforms is allowed thanks to increasing access to high-speed Internet. • Kaiser Permanente – allows patients access to EHRs on mobile devices – offers iPhone app for accessing personal health records, locating nearest facility, appointments, messaging, etc. (https://itunes.apple.com/) • iTunes, the Apple app store – Grew from ~1,000 mobile health apps in January 2011 to over 20,000 health and medical apps by July 2013. (BinDhim, N. F., et al, 2015) • Personal devices – The fastest-growing category at the 2013 Consumer Electronics Show was digital health: fitness trackers and heart monitors; Wi-Fi enabled weight scales; quarter-sized sensor devices that fit into pockets to track physical activity. (BinDhim, N. F., et al, 2015) 10
- 11. Patient Engagement and Technology: Improving Health Among a Targeted Population • Stage Three Meaningful Use criteria: – Promoting improvements in quality, safety, and efficiency, leading to improved health outcomes. – Focusing on decision support for national high- priority conditions. – Patient access to self-management tools. – Access to comprehensive patient data through robust, patient-centered health information exchange. – Improving population health. 11
- 12. Patient Engagement and Technology: Capabilities — 1 • Communications: – Communicate securely with provider or care team (emails). – Complete virtual visit (telehealth). – Receive and schedule alerts and reminders electronically. • Convenient self-service: – Find physician or facility (webpages). – Make/change/cancel appointment (Patient Portal). – Check in and register for a visit. – Manage Rx refills. 12
- 13. Patient Engagement and Technology: Capabilities — 2 • Personal health information: – Review outpatient and inpatient clinical data. – Download or transmit health data. – Enter or track personal data. – Upload data from devices. – Review medication information. • Financial: – View and pay clinical bills. – Estimate cost of services. – Manage health financial accounts. – Reconcile bills and claims, file appeals to claim denials. – Order replacement health plan cards. 13
- 14. Patient Engagement and Technology: Capabilities — 3 • Education and support: – Educate oneself on health issues to make decisions about care and treatment. – Manage chronic condition(s). – Receive peer and community support. • General capabilities: – Administrative support (e.g., pre-registration). – Manage insurance and coverage. – Analyze health and health data. – Manage profile and preferences. – Manage proxy access to account. 14
- 15. Behavior Change Strategies Summary — Lecture c • There are many sources of information on best practices in patient engagement. • Many of the tools are specific to either care setting or disease type. • Numerous types of health information technologies are useful for supporting patient engagement. 15
- 16. Behavior Change Strategies References — Lecture c — 1 References Agency for Healthcare Research and Quality. (2013 June). Guide to patient and family engagement in hospital quality and safety. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved May 20, 2016, from http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/guide.html Agency for Healthcare Research and Quality. (2013 June). Information to help hospitals get started. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved May 20, 2016, from http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/howtogetstarted/ index.html BinDhim, N. F., Hawkey, A., & Trevena, L. (2015). A systematic review of quality assessment methods for smartphone health apps. Telemedicine and e-Health, 21(2), 97-104. Broderick, A., & Haque, F. (2015). Mobile health and patient engagement in the safety net: A survey of community health centers and clinics. Issue Briefs (Commonwealth Fund), 9, 1–9. Retrieved May 20, 2016, from http://www.commonwealthfund.org/publications/issue-briefs/2015/may/mobile-health- and-patient-engagement-in-the-safety-net 16
- 17. Behavior Change Strategies References — Lecture c — 2 References Dentzer, S. (2013). Rx for the ‘blockbuster drug’ of patient engagement. Health Affairs, 32(2), 202. doi: 10.1377/hlthaff.2013.0037 Health Research & Educational Trust. (2013 July). A leadership resource for patient and family engagement strategies. Chicago, IL: American Hospital Association. Retrieved May 18, 2016, from http://www.hpoe.org/Reports- HPOE/Patient_Family_Engagement_2013.pdf Maurer, M., Dardess, P., Carman, K. L., Frazier, K., & Smeeding, L. (2012 May). Guide to patient and family engagement: Environmental scan report. AHRQ Publication No. 12-0042-EF. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved May 20, 2016, from http://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final- reports/ptfamilyscan/ptfamilyscan.pdf Pai, A. (2015 July 30). Report: 4.9M members use Kaiser’s online health management platform. MobiHealthNews. Retrieved May 20, 2016, from http://mobihealthnews.com/45726/report-4-9m-members-use-kaisers-online-health- management-platform/ 17
- 18. Behavior Change Strategies References — Lecture c — 3 References Sarasohn-Kahn, J. THINK-Health and Health Populi blog: Personal health information technology — Paradigm for providers and patients to transform healthcare through patient engagement. Retrieved May 20, 2016, from http://www.dehitrec.org/Documents/Personal%20Health%20IT%20Consumer%20Eng agement.pdf Simmons, L. A., Wolever, R. Q., Bechard, E. M., & Snyderman, R. (2014). Patient engagement as a risk factor in personalized health care: A systematic review of the literature on chronic disease. Genome Medicine, 6(2), 16. http://doi.org/10.1186/gm533 Charts, Tables, Figures 2.09 Chart: Areas Where Organizations Would Like to More Effectively Engage Patients. Eric W. Ford, PhD, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University. (2016). Adapted from Broderick, A., & Haque, F. (2015). Mobile health and patient engagement in the safety net: A survey of community health centers and clinics. Issue Briefs (Commonwealth Fund), 9, 1–9. Retrieved May 20, 2016, from http://www.commonwealthfund.org/publications/issue- briefs/2015/may/mobile-health-and-patient-engagement-in-the-safety-net 18
- 19. Patient-Centered Care Behavior Change Strategies Lecture c This material (Comp 25 Unit 2) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0005. 19
Editor's Notes
- Welcome to Behavior Change Strategies. This is Lecture c.
- The objective for this lecture is to: Design individual behavior change interventions. So this is for those of you who are in the workforce and are trying to get an organization, such as a school, a health system, or some other organization, to create an intervention program. Methods for designing individual change interventions include identifying existing patient engagement programs, using patient-reported outcomes to tailor interventions for the population, and potentially using mobile technologies to improve patient engagement.
- In designing patient-centered interventions, we do not recommend you start from scratch. Many people are working on this problem in a variety of settings. You should really go to the Internet and search very specifically related to either the disease, the population, or the setting that you're working in, and actually type in the words “patient centered,” and you're likely to get much better resources and outcomes, including the Centers for Medicare and Medicaid Services Office, which often has some best demonstrated practices you may want to look into. With that said, what do you need for designing patient-centered interventions? Well, you need a method, a process, and tools. Oftentimes, these are tools for things like teaching patient self-management that you will want to draw down from other places where they've been vetted — tested for their language clarity, for example — and are already known to be successfully fielded. More and more, we see patient engagement in mobile-based technologies, either through cell phones, smart watches, computers, etc. And this also enables a great deal more self-monitoring to occur. And that's worthwhile. Another thing that many organizations are moving toward is creating more population-level interventions. And this is where they're actually starting to think about groups of people rather than individual patients to try and see if they can deliver care in a more efficient, effective, and, hopefully, even more pleasant setting, so we see lots of group interventions and those sorts of things. The last thing we're seeing a bit of a revolution in is patient-provider communications. The Internet, emails, Patient Portals, personal health records — all of these communication media are actually improving patient-provider interactions fairly dramatically.
- On this slide is an exhibit that demonstrates where people are working most actively, as of 2013. One is chronic disease management — diabetes, asthma, chronic obstructive pulmonary disease, et cetera. These are very serious chronic illnesses that people need to improve on dramatically. Another is medication adherence. You would be surprised how many people do not take medications as they're prescribed, and they may do this for a variety of reasons. The medication has unpleasant side effects. The medication may be expensive, and we see something called pill splitting, where the person will reduce their dosage by half. Another common medication adherence issue is people start to feel better and will cease the medication rather than completing the course of treatment as prescribed. Particularly for things like antibiotics, this can be damaging. Another big area is post-care management. As part of the value-based purchasing that's been discussed elsewhere in the ONC HIT curriculum, we are no longer paying organizations when patients are readmitted. Therefore post-acute care, meaning after discharge, is often a very active area that health systems, in particular, are trying to improve. We suspect you'll see the amount of post-acute care management increasing dramatically in the near future. One hopeful sign is preventive care practices, such as screenings, immunizations, etc., are on the rise. It's always good for those of us in public health, and that's why public health interventions are mentioned next, things like smoking cessation, weight loss, those sorts of bad habits that we're always trying to get people to reduce, and good habits that we're trying to get them to increase. And lastly, wellness activities. Often, we see these being employer-based activities. Employers are one of the payer groups that often take care of actually underwriting the health care that most of us receive. Therefore, wellness is of key interest to those types of organizations.
- Most tools are designed for particular types of care engagement or patient engagement. And these include: care processes, post-discharge. This might be continuity of care, where we're trying to make sure that the person gets to see the social worker or that they're going back to their primary care physician after discharge, those sorts of interventions. We also see programs that are fairly closely related to the facility emergency rooms and trying to keep people from coming back to the emergency room repeatedly when they don't truly have an emergency condition. Those are very expensive ways to treat people, and there's often a better setting. So often, we're trying to move them from one facility to a more efficacious treatment location. Again, this goes back to the organizational type. There's something called the patient-centered medical home, and this is actually taking in a larger swath of providers than just medical groups. The PCMH, or patient-centered medical home, is often based out of medical offices, whereas accountable care organizations (ACOs) are often focused on hospitals and health systems. When you hear those two programs, a lot of that is trying to increase the value, and when you start to search for programs, you might think about PCMHs or ACOs as a starting point to find great demonstrations. We’ve talked several times about disease or specific behaviors. Diabetes is a very serious illness; coronary illnesses, cardiovascular illnesses, and cancer are some of the big ones that you often hear people discuss. And again, if you'll search on those specific terms, you'll often see very good programs that have already been created. They may even have some forms of either financial or technical support that they will give you if you make contact with them. So don't recreate the wheel if you don't have to.
- A few different patient engagement strategies that we often see being undertaken with greater and greater regularity are community engagement, where we're trying to provide health education, healthy cooking classes, physical education, the use of patient navigators or wayfinders, where actually you, as the patient, call up a navigator and say, “Here's the state of health or wellness I'm in. Where should I go in order to seek care more effectively?” And we, as health care organizations, may actually assign navigators to patients to help make sure that they have that outreach and support going forward. Organizations — both employers and health systems — are doing more and more, using volunteers and advocates, trying to remove restrictions in the hospital so that the family can come. Often, at time of discharge, for example, the patient may be coming out of sedation and may not have good memory or recall at this particular moment. Having a family member or someone else who can help take those discharge instructions and act on them in the following days can be very powerful, although we've often been reticent to have families in the hospital because of a variety of reasons. Forming more cohesive or coherent health care teams, where the primary care physician, the hospitalist, the nurses, the social workers, and other community agents are more engaged. And lastly, the individual. We're truly empowering individuals with more and more information on the Internet and through sources such as this.
- Again, don't recreate the wheel. Use the Internet. It's your friend. Other people who've had successful programs want to share their programs, want to share their expertise and experiences. So don't go it alone. Typing in “patient engagement programs” and “patient-centered care” are two very good places to start your searches. And then you can build more terms in to those search engines as you go. There are also a few other reports that have been published. The Agency for Healthcare Research and Quality, AHRQ, has a guide to patient and family engagement you may want to look at. Health Affairs produced a special issue, and the American Hospital Association also has guides. These are fairly dynamic sites; don't take these as being the end all, by any means. They're continually being added to, changed, and updated to show the best state of the art in terms of management.
- Now let’s turn, for just a few moments, to talking about measurement essentials. Patient engagement measures should include assessments of the patient's knowledge (and the caregiver’s knowledge may also matter), confidence, and skills to prevent and manage chronic disease and other behaviors are critical. In particular, health information technology provides a lot of tools, more and more every day. We mentioned in another lecture the Cochrane Collaborative, which has best demonstrated practices. You can use those resources, et cetera.
- So let's talk just a little bit more about this technology. Consumer adoption of personal health information technology, or PHIT, is accelerating dramatically. FitBit, which is a particular brand, can measure heart rate, how many flights of stairs someone has gone up and down in a given day, average heart rate, etc. And that's really giving people the power to change some of their behaviors, to try and walk up the stairs more often rather than take the elevator, to try and walk around the block rather than cut through the building. And people are using those technologies with greater and greater regularity. There are expectations for real-time access. We see more and more clinics being open on weekends and after normal working hours in order to accommodate individuals. Those are changes in your organization you may wish to consider. There's a lot of pressure on the providers to embrace value-based payment systems, and again, the policy world is changing dramatically. The Centers for Medicare and Medicaid Services control Medicare and Medicaid, which are the two largest payers, and they're only paying for value-based care more and more.
- So let’s discuss a couple of technical terms on patient health IT. One term you're going to see a great deal of is something called mHealth, or mobile platforms, particularly if you're outside the U.S., where people are more reliant on their mobile phones to conduct other forms of activities, like banking. When people are connected to businesses and institutions through their phone, they're also more likely to use mHealth or applications on those phones to increase their ability to manage their own health. A couple notable examples here in the U.S. are Kaiser Permanente, which is largely based on the West Coast, although it does also have East Coast operations. They now give all their patients access to their electronic health records, EHRs, and you can even download it onto your mobile device. In 2016, Apple’s App Store had over 20,000 applications currently available, everything from exercise and diet to healthy vacations, applications where you take pictures of your dinner plate and it'll tell you how many calories it thinks you're consuming, etc. We're really in a rapidly changing and dynamic era for mHealth, and it's something that you might build a program around, because it's very easy for programs to build their own apps that help connect the consumer back to your organization or your program. So this is a very important part for the government.
- The Stage Three Meaningful Use, which was a government program, will also have criteria focused on improving health outcomes, and that includes engaging patients in decision making.
- So what are some of the patient engagement technologies? As mentioned earlier, email is an obvious one; the ability to schedule appointments without having to make the phone call and go back and forth can be very useful. Virtual visits, sometimes referred to as telehealth, are where you might use an application like Skype and talk to your doctor that way. Those have great promise, and more and more of the insurance companies and payers are now compensating the doctors for those types of virtual visits, which is likely to help reduce one barrier to doctors adopting those. Convenient self-services, such as finding a physician's office that's open and can see you quickly, managing your prescription refills. Some patients can get their prescriptions mailed to their house, and when the pharmacy thinks the patient is running out, the patient gets a text message and only has to reply “yes” to get a refill. That really reduces some of the barriers to patients adopting that, or following that medication regime, because they no longer have to go to the drugstore and wait for the pharmacist to fill the prescription.
- Other personal health information that you're going to see more and more of is patients using their outpatient and inpatient clinical data to change how they act daily. And their daily activity may be fed back into that personal record. So that's where we see this “Enter or Track Personal Data.” Financial capabilities include being able to view and pay clinical bills online. Many people don't know what services cost. Therefore, you're getting a better estimate of what you're doing prospectively, so people aren't unhappy when they get the bill. You can also dispute bills more readily, actually look at what you paid for, and those sorts of things.
- A few other things that are on the forefront as we increase our use of information are education and support. YouTube and other outlets have not merely hundreds but thousands of video lectures that you may wish to go look at, and patients are already using those. With that said, some are better than others. We need to train people to be discerning consumers of such information, and also how to use peer and community support. So again, the general capabilities for patient engagement and technology are increasing dramatically, and it's something we should be very hopeful for as we go forward.
- This concludes Lecture c of Behavior Change Strategies. In summary: There are best practices in patient engagement. You should actively seek those out and actually try to talk to the people who are using those things. And they may help you. Many tools are specific to care settings or disease types, so you should be able to search for those and find a much more fruitful search if you think about your keywords carefully. There are numerous types of health information technologies that are already available. You may want to use those.
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