Patient Engagement and Coaching Models

Rebecca DurhamProject Coordinator, HealthInsight

Incorrect Assumptions

Incorrect Assumptions • Patients want to

change behavior• Advising optimal

health is motivator for change

• Patients are either motivated to change, or not

Change Our ThinkingFrom

• Patients are Non-Compliant

To • Patients are

unsuccessful at managing their own care

• Patients are not yet engaged in their own care

Consider…• Chronically ill patients make many

daily health decisions • Sometimes make unwise decisions • Don’t fully understand implications

of particular health decisions• Lack support to make better choice• 9/10 patients lack skills to manage

their health/prevent disease1

1. Advocate for Health Literacy in your organization (n. d.). Quick Guide to Health Literacy. Retrieved from http://HHS.com

How to Not Engage Patients

• Tell patients what to do (give advice)• Misjudge sense of importance

regarding behavior change• Use scare tactics, argue, blame them

for no willpower and self-concern• Overestimate readiness to change

and degree of confidence • Take away control, generating

resistance

How To Engage Patients

• Listen: Don’t jump on first things patients say

• Understand behavior change and motivation

• Change clinical visits from “to-do” lists to helping patients identify and establish care priorities

• Help patients develop a care plan to improve outcomes (Shared Care Plan)

Can We Be Engaged?• 23% adopted new health

behaviors (but unsure could maintain if stressed)

• Remaining 77%: -- Remain passive recipients (12%) -- Lack basic facts to follow treatment recommendations (29%) -- Have facts, no skills/confidence (36%)

Hibbard, J. H., Mahoney, E. R., Stock, R., & Tusler, M. (2007). Do increases in patient activation result in improved self-management behaviors? Health Services Research, 42, 1443-1463.

Polling QuestionWhat is the most important determinant to advance patients’ with diabetes healthy behaviors?

1. Increasing patient education

2. Spending more time with patients

3. Developing a shared relationship between patient and provider

Norris, S. L., Engelgau, M. M., & Narayan, K. M. V. (2001). Effectiveness of self-management training in Type 2 diabetes. Diabetes Care, 24, 561-587

Ideal PCC Approach

Tennison, J. (2012)

Education

+• Information,

technical skills• Problems due to

poor disease control

• Disease-specific knowledge

• Goal is behavior compliance to improve outcomes

Self-Management

• Skills to act on problems

• Patients ID problems in self-management

• Improving patient confidence to change

• Goal is increased self-efficacy to improve outcomes

Bodenheimer, T., & Abramowitz, S. (2010). Helping patients help themselves: How to implement self-management support. Oakland, CA: California HealthCare Foundation.

The Facts• 40-80% medical information given forgotten immediately; half retained is incorrect1

• Physicians thought 89% of patients understood medication side effects, only 57% of patients understood2

1. Kessels, R. P. (2003). Patients' memory for medical information. Journal of Social Medicine, 96(5), 219-222. 2.Training to Advance Physicians‘ Communication Skills. (n. d). Retrieved from AHRQ Website.

Medication Adherence?Take 3 tablets by mouth 2 times per day, with food for 14 days, then take 2 tablets 2 times per day with food for 14 days, then take 1 tablet every morning, 30 minutes before meal for 14 days, then take ½ tablet every morning, 30 minutes before meal for 14 days

Teach-Back Method• Method to confirm patients understand

their medication/treatment: – “Tell me why you need this medication”– “Tell me how you take this medication”

• Teach Back not a test of patients’ knowledge

• Is a test of how well we explain something Kessels, R. P. (2003). Patients' memory for medical information. Journal of Social Medicine, 96(5), 219-222.

Health Literacy• The capacity to

obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Healthy People. (2010). Cited in What is Health Literacy? Retrieved from www.chcs.org

• Only 12% of adults have proficient health literacy

• Lower literacy = more admissions, ER visits, costs, higher risk of poor health

Advocate for Health Literacy in your organization (n.. d.) Quick Guide to Health Literacy. Retrieved from http://HHS.com

Keep Your Glucose in Normal Range

Watch Your WordsProblem Word Consider UsingAilment Sickness, illnessAdverse BadBenign Won’t cause harm, isn’t

cancerCondition How you feel; health

problemLesion Wound, soreOral By mouthVertigo Dizziness

Ask Me 3. Retrieved from www.npsf.org.

What is Coaching?• Managing: Making sure people do

what they know how to do• Training: Teaching people to do what

they don’t know how to do • Mentoring: Showing how those who

are good at doing things do them• Coaching: Helping identify skills and

capabilities, and empowering people to use them as best they can

Motivational Interviewing

A collaborative, patient-centered form of guiding to elicit and

strengthen motivation for change

Miller, W. R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural and Cognitive Psychotherapy, 37, 129- 140.

Motivational Interviewing• Non-judgmental, non-confrontational,

non-adversarial• Explore and resolve ambivalence• Help patients envision a better future,

and become increasingly motivated to achieve it

Miller, W. R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not.. Behavioural and Cognitive Psychotherapy, 37, 129- 140.

Four Principles of MI1.Express empathy (not pity) - Put yourself in patients’ shoes 2. Develop discrepancy (ambivalence) - Explore how they want their life to be and how it is now3. Roll with resistance (expect it)4. Support self-efficacy (empower)

OARS• Open-ended questions• Affirmations• Reflections• Summaries

Care Transitions Coaching Model

• Improve transitions of care• Transitions Coaches encourage

patients and caregivers to take a more active role in their own self-care

• Not doing for, but empowering patients to do for themselves

• Involves pre-discharge and then follow-up, in-home visits

Transitions Coaching in Your Practice

• A tool everyone can use• Patients engaged in coaching have better outcomes• Effective to avoid downward trends, or

keep patients at new “normal”• Program consistently reduced 30-day

hospital readmissions and costs, and 180-day hospital readmissions

Discussion Question #1

How will I use patient engagement techniques to improve patient outcomes?

Discussion Question #2

Name two times during an encounter when you might engage a patient using a patient engagement or

coaching model