Monday, August 15, 2005

PATIENT-CENTERED HEALTH CARE: 21ST CENTURY MEDICINE Part #1 (of 3 Parts) – WHY do we need it; WHAT is it?

PATIENT-CENTERED HEALTH CARE: 21ST CENTURY MEDICINE Part #1 (of 3 Parts) – WHY do we need it; WHAT is it?
This blog discusses the WHY and the WHAT of Patient-Centered Health Care. In the next blog, we will continue to discuss the why and what, using additional information. In Part #3 we will discuss HOW both patients and doctors can transition to this 21st Century Medicine concept. Wherever possible, I have copied directly from the current research documents, and will provide footnotes to that source. If you are interested in expanding your knowledge of this topic, I recommend that you seek out the source and read it. If you cannot find it, make a comment to this blog (and/or to Parts #2 and #3) and I’ll get the reference to you.

The research on this subject covers many factors. I have limited the information to that which discusses the patient and the doctor only.

The best way to use this information is to read it through and think about it. Then when you get a chance to review Part #2 of this Patient-Centered Health Care blog, you will find questions that you can ask yourself about whether or not you are participating in patient-centered health care with your doctor.

Less than 10 percent of medical decisions are made with participation of a fully informed patient.[1]

Physicians are being encouraged to involve their patients in decisions about medical tests and procedures. However, many of them have not embraced the concept in day-to-day office practice, according to a study supported in part by the Agency for Healthcare Research and Quality (HS07289). It found that less than 10 percent of medical decisions were actually made with the participation of a fully informed patient (i.e., doctors provided patients with the pros and cons of the test, procedure, or medication regimen; informed them of their options and any side effects; and helped them reach an individualized decision about the right course to take).

[2]An estimated 50% of the health status of the population and the majority of health care costs in America are accounted for by the presence and level of management of chronic illness and the lifestyle behaviors such as smoking, alcohol use and unhealthy diet that often contribute to these chronic conditions. (IFF 2000, Fishman 1997)

Studies show that up to one half of all recommended treatments are not followed by patients (Dimatteo 1994) and that the greatest weaknesses of existing disease management programs for people with chronic conditions are that they do not use modern, patient centered self management and support strategies. (Wagner 1999, Center for the Advancement of Health 2000, Goodall 1992, Sobel 1995) Instead these programs often focus only on providing information and do not address patient understanding and use of this information or the psychosocial and contextual factors in their motivation and ability to do so.

Statistics on patient nonadherence are big. "By and large, the research indicates that at least half the patients who've been given a prescription don't receive the full benefit of the drug because of not taking the drug at all, not taking the right dosage or stopping prematurely," says Debra L. Roter, DrPH, a professor of health policy and management at Johns Hopkins University School of Hygiene and Public Health. The figures for certain chronic diseases are just as scary, according to researchers. Between 40 percent and 50 percent of diabetic patients don't abide by their medication regimens. The comparable figure for hypertensive patients is 40 percent.

One study estimated that roughly 6 percent of hospital admissions -- almost 2 million a year -- could be traced to nonadherence.

A survey commissioned by Upjohn Co., for example, determined that 20 percent of the respondents had failed to have a prescription filled during the preceding 12 months. Of these individuals, 51 percent said they didn't think they needed the medication. Another 21.7 percent said they simply didn't want to take it. Similar findings surfaced in a survey on unfilled prescriptions sponsored by the American Association of Retired Persons (AARP). Twenty-one percent of the respondents thought the medicine wouldn't work. Side effects worried 22 percent. The issue of affordability arose for only 10.5 percent and 14 percent of patients in the Upjohn and AARP surveys, respectively. This suggests that nonadherence arises less from pocketbook issues than from patients' beliefs and attitudes.

Finally, and most shocking to me, when you study the traditional Illness-Centered approach to medical care, you find statistics like the following: A 1984 study of physician-patient interactions showed that a physician will listen to a patient’s concerns for an average of 18 seconds before interrupting.

The following reference is fantastic! It really discusses the need for American Health Care to evolve to Patient-Centered Health Care.

FACCT—The Foundation for Accountability
Patient-centered Care Measures
for the National Health Care Quality Report
(Defining Patient-centered Care)
Christina Bethell, PhD
May 2000
Copyright © 2001 by The Foundation for Accountability

Definition of Patient Centered Care
The preliminary definition of patient centered care set forth by the Institute of Medicine Committee on the National Health Care Quality Report is:

Health care that respects and honors patients’ individual wants, needs, and preferences, and that assures that individual patients’ values guide all decisions.

This definition requires the systematic inquiry about and responsiveness to patients’ needs, wants and preferences at both the clinical and system level. However, it does not fully recognize the importance of the partnership-based style of health care that is the true hallmark of patient centered care. As such, an expanded definition is offered as the basis for the identification of candidate patient centered care quality measures for the National Quality Report on Health Care:

Health care that establishes a working partnership with patients and their families to ensure decisions are made that respect and honor patients’ wants, needs, and preferences and to ensure that patients have the education and support they need to act as a central resource in their own health and/or the health of their family.

Using this definition, a practice of patient centered care will incorporate into each health care encounter explicit communication strategies to elicit, understand and take as relevant, patients’ own understanding of their needs, wants, preferences and values, even if, and perhaps especially if, they run counter to the those of their providers.

When applied to health care for people with an established chronic condition, who are at risk for disease or who experience an acute event such as infection or injury, this definition of patient centered care will require many health care providers to shift to a collaborative model of care whereby they work in partnership with patients and their families in defining health care needs, making health care treatment decisions, selecting and implementing treatments and managing care over time.”

Patient-Centered Care 2015: Scenarios, Vision, Goals and Next Steps

In February 2004, the Picker Institute convened the Patient-Centered Care Vision Summit. A group of 27 key leaders used these scenarios as input to a shared vision for patient-centered care. In using the scenarios, participants observed that what is most likely is not the futures they want.

The vision statement they proposed for a community of individuals is as follows:
Our vision of care is that each of us is in charge of our health. Healthcare providers are there to help us gain the skills and knowledge to enable us to take charge. Each of us gets the care we need, not less and not more. Our care is efficient and respectful of the value of our time. It integrates ethics and compassion with science. Each of us learns from an early age to be healthy throughout our lives. When we are sick, our care reduces fear and aids healing. When we live with chronic disease, our care and our own health practices bring quality to life. Our care at the end of life honors our values. Our caregivers treat us with respect even if we do not know what they know or do not come from the same background.

The Summit then developed “audacious goals” or “stretch targets”. These twelve provide significant opportunities for making patient-centered care the norm and the standard of care. These audacious goals are as follows.

1. Patients Share in Decision Making. By 2015, at least 50 percent of patients will participate in shared decision-making processes that lead to a measurable
improvement in decision quality. We will have developed, implemented, and responded to an array of measures of “concordance” between healthcare interventions and what people value, first as individuals and then as communities.
2. Enable Patients to Direct Their Care. By 2010, 80 percent of patients and families believe they have the knowledge, supports and confidence necessary to direct their own health and healthcare.
3. Patients Use Performance Data to Choose Supportive Providers. By 2010, patients will be able to choose their healthcare providers based on comparative performance data that shows how well providers support the patients and their family’s role in care.
4. Measure and Reward Providers for Achieving Patient Empowerment. By 2010, health professionals and healthcare facilities will be rewarded according to their patients’ sense of empowerment and self-efficacy, which will be measured routinely.
5. Make Patient Perspective a Priority in Policy and Planning. By 2010, all policy and planning decisions will consider patient perspective first. Patients and/or their families will be present and actively participate in all decision-making bodies.
6. Adopt (Institute of Medicine) IOM’s Simple Rules for Healthcare. By 2015, access, quality and safety will be the organizing principle of every community’s healthcare. Communities nationwide will implement IOM’s Simple Rules for the 21st Century Healthcare System in every organization, institution and care setting.
7. Provide Access to Patient-Centered Care Information and Care. By 2015, everyone will have information and access to patient-centered healthcare and 50 percent will receive their care through a Picker patient-centered care practice.
8. Include Patient-Centered-Care Tenets in Licensing Requirements. By 2015, every health professional licensed to practice in the U.S. is competent, agrees with the major tenets of patient-centered care, and is honest in compliance with standards agreed to between the public and the health profession. Healthcare professionals who cannot or will not comply are removed and no longer practice.
9. Train Healthcare Professionals to Support Patients. By 2010, all healthcare professionals will receive training in how to support patients and enable them to play an active role in their care.
10. Promote Joint Contracting for Care and Prevention in Diabetes. By 2015, all patients with Type 2 Diabetes will “contract” or “sign” a joint care and prevention agreement with their caregivers. (Disabilitykey note: we’d like to see this “contract” apply to all chronic illnesses, to be an agreement between all Chronic Illness Self-Managers and their caregivers.)
11. Provide Healthy Living Skills Education. By 2015, all school-age children will receive education to enhance lifelong skills for living a healthy life.
12. Anticipate Late Life Care Needs. By 2015, education will be available to everyone 50 years and older on realistic scenarios regarding health, long-term care, and the end of life of life through videos, CDs and interactive media.

This next reference from the Johns Hopkins School of Medicine provides us with a great comparison of the “traditional” illness (pathology) focused health care as compared to the desired patient centered (they call it “Health Enhancement”) focused health care. (Disabilitykey note: I have paraphrased some of the criteria to make it easier to understand, using words we’ve used before.)

Who is in Charge? Or
Taking Charge!
Stephen T. Wegener, PhD
Department of Physical Medicine and
Johns Hopkins School of Medicine

Illness or Pathology focused Health Care
1) Focused on germ theory.
2) Diagnosis means identifying the pathology involved.
3) Treatment method is treating the deficit (germ).
4) Goal is to return the patient to baseline functioning.
5) Patient is characterized as a passive “victim”.

Contrast that picture to this one.

Patient-Centered (Health Enhancement focused) Health Care
1) Focused on human potential (of the patient).
2) Diagnosis means identifying the patient’s strengths.
3) Treatment method is building on the patient’s strengths.
4) Goal is enhancement of functioning.
5) Patient is a Chronic Disease Self-Manager (Active manager patient).

In otherwords, “Health Enhancement” (as Johns Hopkins calls it) and the Patient-Centered approach to health care really represents part of an evolution in health care that has expanded our focus to:
– Eliminating pathology;
– Functional Status;
– Quality of Life; and
– Enhancement of functioning/well-being.

[1] See "Informed decision making in outpatient practice: Time to get back to basics," by Dr. Braddock, Kelly A. Edwards, M.A., Nicole M. Hasenberg, M.P.H., and others, in the December 22, 1999, Journal of the American Medical Association 282(24), pp. 2313-2320.

[2] Copyright © 2001 by The Foundation for Accountability
[3] Copyright © 2001 by The Foundation for Accountability
[4] Copyright © 2004 by the Picker Institute
Permission is granted free of charge to any organization or individual working to advance patient-centered care to use the text of the scenarios, vision statements and audacious goals for education and planning purposes.
Reprint of this material should include the statement, Reprinted with Permission from Patient-Centered Care
2015: Scenarios, Vision, Goals & Next Steps, Copyright © The Picker Institute.
[5] Institute of Medicine’s Simple Rules for the 21st Century Health Care System, “Crossing the Quality Chasm” report. The rules are: Care is based on continuous healing relationships. Care is customized according to patient needs and values. The patient is the source of control. Knowledge is shared and information flows freely. Decision-making is evidence-based. Safety is a system property. Transparency is necessary. Needs are anticipated. Waste is continuously decreased. Cooperation among clinicians is a priority.

[6] John’s Hopkins School of Medicine


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