Understanding the importance of effective patient centered communication for patient engagement and improved health outcomes. Will discuss the importance of patient directed care and its relationship to the quadruple aim. Will discuss the barriers and a framework for conversations that are critical to patient directed care and cultural competency.

2. 2
Patient Directed Care and
Behavioral Health
Simin N Beg MD, MBA, FAAHPM
Division Chief Hospice/Palliative Care
Spectrum Health Medical Group
10/2019

3. Objectives
• Behavioral Health, Chronic illness and Patient Directed
Care
• Impact of Social Determinants of Health
• Why/how to have a “patient directed” conversation
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4. Behavioral Health vs Mental Health
• Behavioral health describes the connection between
behaviors and the health and well-being of the body, mind
and spirit.
• How behaviors impact someone’s health — physical and
mental.
• Mental health, as defined by the World Health Organization,
is “a state of well-being in which every individual realizes
his/her own potential, can cope with the normal stresses of
life, can work productively and fruitfully, and is able to make
a contribution to his or her community.”
•
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5. Behavioral Health and Chronic Illness
▪ Two thirds of all deaths and 81 % of hospital admissions
▪ 29 % of individuals that have a chronic illness also have
behavior health disorder
▪ 70 % that have behavioral health disorder have a chronic
comorbidity
▪ 25 % of patients with cancer also suffer from depression
▪ Successfully integrating behavioral and physical health
services requires some cultural shifts; it’s not just a matter of
embedding a psychologist or mental health professional
within a medical unit
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6. Social Determinants of Health
• Social determinants of health are the combined elements of an
individual’s social and environmental condition and experiences that
directly impact health and health status.
• Timely, convenient and affordable access to heath care services, such
as preventative care;
• Local living environmental issues such as neighborhood safety,
access to healthy food choices, transportation, physically
accommodating housing, access to green spaces and active lifestyle
choices;
• Social isolation and loneliness
• Access to Technology
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7. Race and Ethnicity
• Institute of Medicine’s publication “Unequal Treatment: Confronting Racial
and Ethnic Disparities in Health Care” and CDC Second Health Disparities &
Inequalities Report – United States, 2013 show that minorities receive lower
quality of healthcare and experience higher mortality, even when access to
care, insurance coverage, and income are controlled for.
• A large part of the disparity in care quality comes as a result of the patient-
clinician interaction.
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8. One day in August 2017
• 82 yo female with a dx of metastatic colon adenocarcinoma
• Diagnosed with small bowel obstruction
• Colectomy, chemotherapy
• Also a history of diastolic CHF, mild dementia, COPD, CAD
• In spite of aggressive treatments, malignancy continued to progress
• Recurrent hospitalization for weakness, anorexia, nausea/vomiting
• Goals of care unclear
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9. More of the Story
▪ Family arrived
▪ Security called
▪ Palliative care also called
▪ Report given ‘son aggressive…. Mental illness…..”
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10. Patient Centered Care
“…care that is respectful of and responsive to
individual patient preferences, needs and values,
ensuring that patient values guide all clinical
decisions”
IOM. (2001). Crossing the Quality Chasm: A new health system 21s century. Washington, DC: National Academy Press.
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“Effective, patient-centered communication is
key to quality care. Good communication is both
an ethical imperative, necessary for informed
consent and effective patient engagement, and
a means to avoid errors, improve quality, save
money and achieve better health outcomes.”
American Medical Association. The ethical force program: C-CAT Patient-centered communication. [Last
accessed on 2013a Oct 30].

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“It's not hard to make decisions
when you know what your values
are.” Roy Disney
The more knowledge we have
about the patient’s value system,
the more likely we are able to
establish a care plan that meets
the patient’s needs, allowing for
appropriate interventions as
symptoms change.
Wisdom

13. Patient-centered care: the key to cultural competence
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14. Summary
• Much of the early literature on ‘cultural competence’ focuses on
the ‘categorical’ or ‘multicultural’ approach.
• Culture is multidimensional and dynamic.
• Culture is a very elusive and nebulous concept.
• Focuses on foundational communication skills, awareness of
cross-cutting cultural and social issues, and health beliefs that
are present in all cultures. We can think of these as universal
human beliefs, needs, and traits.
D. E. Epner, W. F. Baile; Patient-centered care: the key to cultural competence, Annals of Oncology, Volume 23, Issue suppl_3, 1 April 2012, Pages 33–42,
https://doi.org/10.1093/annonc/mds086
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15. How?
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There is not one
right that fits all.
Are we asking the
right questions?

16. Three simple questions
1. What does your patient understand about disease process
AND treatment options
2. What do they hope/fear?
3. How can we align the two?
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17. The Problem
• Assumes good communication skills and emotional
intelligence.
• Blind spots and bias must be acknowledged
• EVERYONE already thinks they ask them.
• Not a “one and done”.
• Requires culture shift.
• Takes practice.
• Not just for end of life
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18. In the End
• We can get it right, we MUST get it right!
• Once we understand what matters to our patients, only then
can we guide them in the care plan.
• Hope is good, but it is not a plan and false hope is just plain
cruel.
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19. “We’ve been wrong about
what our job is in
medicine. We think our
job is to ensure health
and survival. But really it
is larger than that. It is to
enable well-being.”
Atul Gawande, Being Mortal: Illness, Medicine and
What Matters in the End
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21. Questions?
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