You can lead a horse to water but you cannot make him drink. I am sure that many of you are familiar with this old saying, but how can it apply to healthcare. Perhaps you can guess; maybe not. I am thinking about getting patients to follow our directions for care, whether it is for an acute incident, chronic care or some other area of care. As the saying indicates, it can be very difficult to get some patients to follow directions.
Getting patients more involved in their own care is becoming more important in healthcare today. It has always been necessary, but now and in the foreseeable future patient involvement will become more important as physicians and healthcare organizations financial success will depend more on patient involvement. For instance, the patient-centered medical home involves the patient at many levels and Medicare and private payers will be rewarding primary care physicians and organizations for the level of involvement of clients in their own care.
In the Institute of Medicine’s Crossing the Quality Chasm several of the ten recommendations for modern healthcare call for more patient input. For instance, under customization based on patient needs and values, the IOM recommends that the system of care should meet the most common types of needs, but have the capability to respond to individual patient choices and preferences. Under patient as the source of control, it recommends that patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them.
The patient-centered medical home, a new concept in primary care growing out of the IOM’s recommendations, further details the level of involvement of patients, especially in the area of chronic care. In its guide for becoming a NCQA accredited patient-centered medical home the NCQA makes these recommendations:
• Writing individualized care plans
• Writing individualized treatment goals
• Reviewing self-monitoring results and incorporating them into the medical record at each visit
Obviously, the patient has a major role in his/her own care in this model.
If you accept that a patient must become more involved in her own care, then you probably also realize that the involvement of the patient becomes more complex as the patient’s disease becomes more complex. For instance, the involvement of a patient with a simple broken finger isn’t very complex. A few simple instructions will suffice. The involvement of a patient who is pregnant is much more complex. Not only is the physician directly involved, but there are also classes that the patient needs to attend so that she can better care for herself and the fetus. Yet, this prenatal care has a definite beginning and ending, a successful one, we hope. The involvement of a patient with a chronic disease is much deeper and more complex. In fact, because patients with chronic diseases often need to make significant life style changes, the planning of care and execution of the plan require a delicate orchestration of activities, including a major part for the patient himself.
Now that I have made my point that patients need to be more involved in their own care in order to insure positive health outcomes and also to help physicians to meet performance goals, I must ask again, “How do you get the horse to drink?” The answer can be complex.
Perhaps we can borrow from examples of other businesses or services that are successful with their customers or clients. I don’t think that a business which provides a physical product would be of much use, as there is not a lot of direct communication between the business and customer usually. For instance, I don’t go on at length with a salesperson from J.C. Penny about a shirt that I buy. Too, a model based upon purchase of a service usually doesn’t require a lot of interaction between business and client. I certainly don’t need a lot of instruction from the person who cuts my lawn. The best model that I can think of is that of teacher and student. In both healthcare and schooling there is a lot of trust between those with the knowledge-teacher or healthcare provider-and the recipient of the application of the knowledge-student or patient. Too, the student and patient should be very involved. The best students and patients follow the directions of teacher and doctor closely. Of course, there are those who aren’t as successful. For these, the outcomes are not always so good.
If you accept that the teacher-student model is a good one to use for techniques in involving patients, what are some of the things that good teachers do? Having been a teacher myself, I think that I can confidently comment on this. First, be clear what you expect of the patient-that she follow your directions explicitly if she is to expect positive outcomes. You as the healthcare provider should set your expectations high and let the patient know that. Of course this means that you deeply care what happens to the patient. It has been shown in many studies that patients respond better to physicians who demonstrate that they care what happens to them.
Be sure that the patient understands your directions and is able to carry them out. That is, you should assess the patients understanding and capabilities. Teachers do this all the time. Assessment by the teacher is not only to find out what the student knows but also how well the teacher has taught the lesson. I suggest that after a patient is given directions for self-care, that you ask the patient to explain to you the directions. For instance, if you are providing a pregnant woman directions for her diet, you might ask her what meals she would plan for her next week to see if they fit the guidelines.
For patients who have a complex diagnosis, such as a chronic condition, the healthcare provider and patient and, perhaps, family members, should design a care program that fits the needs of the patient, provider and family. For instance, if the patient needs physical therapy, the plan should include how often the patient should go to the physical therapy site, how the patient gets to the site, how progress is reported to the primary care physician and the capacity of the patient to pay for the services. There may be other factors in this plan; it depends upon those involved in the process.
I believe that it makes good sense for patients to be very involved in their own care. A variety of payers will be rewarding providers for more involvement of patients and health outcomes will generally be better. A recent article in the Grand Rapids, Michigan newspaper illustrated just these improved outcomes for a diabetic whose care was provided by a physician whose office used the patient-centered model. Adapting the NCQA’s guidelines for the patient-centered medical home for your healthcare site and borrowing from the principles of good teaching will help you reach your goals for being more patient-centered.