Monday, August 15, 2005

PATIENT-CENTERED HEALTH CARE; 21st CENTURY MEDICINE Part #2 (of 3 parts) - What is it, cont'd?


In Part #1 of this series of blogs on Patient-Centered Health Care, we discussed Why this approach to health care is needed, and What it is. In this blog, Part #2, we will continue to discuss What Patient-Centered Health Care is. In Part #3, we will describe how you can determine if your health care support team approaches health care in a Patient-Centered approach; you will also be able to identify your roles and responsibilities, and that of your health care support team in a Patient-Centered Health Care approach system.

Consider the following observation about patients who are involved in Patient-Centered Health Care:

An abundance of literature confirms that patients who are more involved in active communications with their doctors, who participate in shared decision-making, and who understand their own responsibilities for managing their health achieve better outcomes and are more satisfied than others.

How many times have we discussed, in various blogs, the same concepts discussed above: “active communications with doctors”; “shared decision-making” (assuming that the patient has taken the time to research and learn about his/her chronic disease); and, “who understand their own responsibilities for managing their health”??

Care that is truly patient-centered considers patients’ cultural traditions, their personal preferences and values, their family situations, and their lifestyles. It makes the patient an integral part of the care team who collaborates with care providers in making clinical decisions. Patient-centered care puts responsibility for important aspects of self-care and monitoring in patients’ hands — along with the tools and support they need to carry out that responsibility.

Patient-centered health care is particularly important for patients who cope daily with a chronic disease. Chronic disease and its manifestations create many predicaments, challenges and fears for patients and families including (but by no means limited to) the following.
1) Decreased functional capacity to continue the things that are meaningful and valuable to them.
2) Loss of independence and control over their lives.
3) Changes in their capacity to continue their roles.
4) Tensions and changes in their familial and social relationships with the threat of abandonment and loneliness when their illness progresses. 5) An increased need for assistance to complete their activities of daily living. This can lead to a fear of being a personal and financial burden to loved ones.
6) Spiritual conflict and loss.
7) Inability/unwillingness to cope with the implications of a life-limiting illness.
8) Difficulty in making decisions about treatment choices.

Ok, we know the need, and agree. Now, how do we, as a society (in America) evolve toward a patient-centered health care model? Patients have more information today about their diseases and treatment options than ever before. But patients have not had tools to help them decide among these various options, and doctors have not had tools to help gauge how acceptable an option might be to a specific patient. As a result, the medical decision made, in hindsight, may not have been the most suitable one.


As we have discussed, America needs the health care systems evolve toward a patient-centered model. Health care has been evolving away from a "disease-centered model" and toward a "patient-centered model." In the older, disease-centered model, physicians make almost all treatment decisions based largely on clinical experience and data from various medical tests. In a patient-centered model, patients become active participants in their own care and receive services designed to focus on their individual needs and preferences, in addition to advice and counsel from health professionals.

As we have discussed in previous blogs, we ALWAYS “start with the end in mind” (advice from Tom Peters) when looking to effect a change. The rest of this blog will discuss patient-centered health care in global, generic, systemic ideas. In Part #3, we get far more specific: What should be the health care team’s roles and responsibilities; what should be the patient’s roles and responsibilities in a patient-centered health care mode.

Patient-Centered Health Care Defined

In general terms, health care is considered patient centered when the processes and culture (attitude and behaviors) of an organization, office, team, or individual practitioner address first and foremost the wants and needs of the patient.

Care that is truly patient-centered considers patients’ cultural traditions, their personal preferences and values, their family situations, and their lifestyles. It makes the patient an integral part of the care team who collaborates with care providers in making clinical decisions. Patient-centered care puts responsibility for important aspects of self-care and monitoring in patients’ hands — along with the tools and support they need to carry out that responsibility.

OK, again, we know generally that we in the United States need and want to transition to a patient-centered health care system. Where are we now? I found the following research results.


Primary Care And Health System Performance: Adults’ Experiences In Five Countries
(Cathy Schoen, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Karen Davis, Kinga Zapert, Jordan Peugh)
(This paper reports on a 2004 survey of primary care experiences among adults in Australia, Canada, New Zealand, the United Kingdom, and the United States.)

In the summary of this report on Adults’ Primary Care Experiences in Five Countries, America was found to have the following outcomes.
Ø Across multiple dimensions of care, the United States stands out for its relatively poor performance.
Ø With the exception of preventive measures, the U.S. primary care system ranked either last or significantly lower than the leaders on almost all dimensions of patient-centered care: access, coordination, and physician-patient experiences.
Ø These findings stand in stark contrast to U.S. spending rates that outstrip those of the rest of the world.

So, in essence, the United States spends more that the rest of the world on health care, is very good with preventative measures, but ranks #5 out of 5 participating countries when it comes to patient-centered health care! Seems that we REALLY have work cut out for us.

In Part #1 blog in this series, we described the 2004 Picker Institute’s Patient-Centered Care Visit Summit’s 12 “audacious goals” or “stretch targets”. If those targets are what we should aspire as a Nation to achieve, how about discussing some process components to get there. Then, in Part #3, we’ll get more specific to a patient and his/her health care team’s roles and responsibilities.

Below, you will find the “10 Simple Rules for the 21st Century Health Care System (a Patient-Centered Health Care System), followed by six essential interactive components of the patient-centered process.

(from” The IOM Report (Institute of Medicine, “Crossing the Quality Chasm”)
1. Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This rule implies that the health care system should be responsive at all times (24 hours a day, every day) and that access to care should be provided over the Internet, by telephone, and by other means in addition to face-to-face visits.

2. Care is customized and reflects patient needs, values, and choices. The system of care should be designed to meet the most common types of needs, but have the capability to respond to individual patient choices and preferences.

3. The patient as the source of control for their care. 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 health system should be able to accommodate differences in patient preferences and encourage shared decision making.

4. Knowledge and information are freely shared between and among patients, care partners, physicians, and other caregivers. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.

5. Evidence-based decision making. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.

6. Safety is a visible priority. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

7. Transparency is the rule in the care of the patient. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system's performance on safety, evidence-based practice, and patient satisfaction.

8. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events. Care is provided in a healing environment of comfort, peace and support. All Team Members (health care support team members) are considered as Caregivers. Families and friends of the patient are considered essential parts of the care team.

9. Continuous decrease in waste. The health system should not waste resources or patient time.

10. Cooperation among clinicians is a Priority. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care. All Caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient.

Six essential interactive components of the patient-centered process are described below. Each health care organization looking to transition to the patient-centered approach must address these processes.
1. Exploring both the disease and the illness experience:
the traditional approach of history taking, physical examination to produce a differential diagnosis.
Illness: at the same time the physician should respond to cues as to what the patients ideas, feelings and fears are concerning this illness experience and the effect it has on functioning. Knowledge of past illness experiences and the effect of the family on previous illnesses can be useful to gauge the degree of disease the patient is going through.
The physician usually maneuvers back and forth between the doctor/disease and the patient/illness agendas.

2. Understanding the patient as a “whole person”:
What do you the physician know about the patient’s life in terms of development and experiences and how does this illness impinge on it? It may help to answer the question why does the patient have these symptoms now? Previous contacts with the patient over the years can provide the physician with valuable insights into the present problem (a mutual investment plan between doctor and patient!).

3. Finding common ground:
An effective management plan requires cooperation between the physician and patient in the areas of a) the nature and priorities of the problems, b) the goals of treatment, and c) the roles of the doctor and the patient. Finding common ground rather than bargaining or negotiating requires an understanding of the patient’s ideas, fears and expectations regarding the problems.

4. Incorporating prevention and health promotion:
Health promotion, disease prevention and risk reduction issues should always be incorporated into every contact with the patient whenever possible not just at health maintenance visits. An effective patient-centered relationship enhances the patient’s acceptance of suggestions from the physician for appropriate lifestyle modifications. The provision of optimal continuing and comprehensive care requires this approach and should be supported with a record system (i.e., flow sheets for chronic diseases) and office protocols (such as computer reminder systems) that facilitates this philosophy .

5. Enhancing the doctor-patient relationship:
At every visit the physician strives to build an effective long-term relationship with the patient so that the patient sees the benefit of this growing mutual investment plan between the two. It should be noted that different patients need different approaches such as the dependent patient in need of extra support versus the assertive involved patient. The physician should always monitor his/her own feelings regarding the relationship in terms of sharing power and transference/counter transference issues for instance.

6. Being realistic:
Physicians should always manage their time so that they can provide optimal patient care. This requires priority setting, resource management and teamwork. The strategy taken at one consultation may well be tempered by the number of patients still waiting to see the doctor. Physicians should also respect their limits of emotional energy.

Stay Tuned for Part #3: Your and your Health Care Team’s Roles and Responsibilities in establishing and maintaining an effective and efficient Patient-Centered Health Care process.


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