Patient Engagement and Coaching Models

Janet Tennison, PhD, MSW Larry Garrett, PhD(C), MPH

Presenting with the 5 I’s • Interactive

• Informal

• Imperfect

• Iterative

• Informative

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 for the 21s century. Washington, DC: National Academy Press.

PCC Components

1. Respect for patient’s values, preferences, & expressed needs

2. Coordination & integration of care 3. Information, communication, education 4. Physical comfort 5. Emotional support 6. Involvement of family and friends 7. Transition and continuity Picker Institute. (n. d.). Picker Institute FAQ. Retrieved from the Picker Institute Website at: http://www.pickerinstitute.org/about/FAQ.html

Lucy’s ACL Surgery

Needs, Preferences, Information, Support

• Text message Tuesday: “We look forward to seeing Lucy Friday!

• Friday: “Do you prefer text message, email, patient portal, or phone call?”

• Monday call: “How is Lucy?”

Do We Really Provide PCC?

• Resurgence of PCC nationwide • In Mission, Vision, Values statements • Studies—Health professionals tend to

overestimate provision of PCC • Rank care priorities differently than patients • “Sometimes the CARE in healthcare is NOT

EVIDENT”

Ideal Patient Approach

PCC Patient Engagement

Self-Management

Shared Decision -

Making

Coaching

Consider… • Chronically ill patients make many daily

health decisions - Diet, exercise, medication, when to seek medical care • Sometimes make unwise decisions • Don’t fully understand implications of

particular health decision • Lack support to make better choices

Why Patient Engagement?

• To assist “high-risk” patients who have been unsuccessful at managing their own care

• To engage patients in improving self-care

• To improve the relationship between providers and patients

Most Important Determinant

Shared relationship between patient

and provider most important to advance healthy behaviors

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.

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, but 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.

Education + Self-Management

• Information, technical skills

• Problems due to poor disease control

• Disease-specific

knowledge, technical skills

• Goal is compliance with behavior to improve outcomes

• Skills to act on problems

• Patients identify problems in management

• Improving patient confidence in abilities to make changes

• Goal is increased self-efficacy to improve outcomes

Education + Self-Management

• Information, technical skills

• Problems due to poor disease control

• Disease-specific

knowledge, technical skills

• Goal is compliance with behavior to improve outcomes

• Skills to act on problems

• Patients identify problems in management

• Improving patient confidence in abilities to make changes

• Goal is increased self-efficacy to improve outcomes

Education + Self-Management

• Information, technical skills

• Problems due to poor disease control

• Disease-specific

knowledge, technical skills

• Goal is compliance with behavior to improve outcomes

• Skills to act on problems

• Patients identify problems in management

• Improving patient confidence in abilities to make changes

• Goal is increased self-efficacy to improve outcomes

Patient Self-Management

• Facilitating healthy behavior change • Training problem-solving skills • Assisting with emotional impact of a

chronic condition • Maintaining regular, sustained follow-up • Encouraging active participation in

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

Transcript Studies • Providers tend to take control of communication,

direct topics away from patient concerns, avoid offering empathy or validation

• Have strong desire to dive into first problem patients’ mention

• Reasons: Cited fear that patient verbalization will extend length of interaction; lacked awareness

Epstein, R. M., Mauksch, L., Carroll, J., & Jaén, C. R. (2008). Family Practice Management , 15(3), 35-40.

Effective Communication

• Literature review (1949-2008): Communication positively correlated with patient adherence

• Decreases potential for errors; promotes patient engagement

• “Talk to me like you would to your friends”

Zolnierek, K. B., & Dimatteo, M. R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47(8), 826-34.

Health Coaching

• Method to guide patients to address health, make needed behavior changes

• Involves goal setting, identifying obstacles, using support systems

• Relationship between coach and coachee is accountability partnership focused on health goals defined by both

Health Coaching. (n. d.). Retrieved from Wikipedia Website at http://en.wikipedia.org/wiki/Health_coaching

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

Medication Adherence

• 40-80% medical information given forgotten immediately; half retained is incorrect[1]

• Physicians thought 89% of patients understood medication side effects, only 57% of patients understood[2]

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.

How would you engage your patient to take this medication correctly?

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 what we tell them – “Tell me why you need this medication” – “ Tell me how you would take this medication”

• Teach Back not a test of patient's 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.

Teach-Back Method

“View this DVD and be ready to show us you can do the ROM exercises for Lucy”

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.

Why We Need MI

No matter what reasons we might offer to convince individuals of the need to change their behavior, or how much we want them to, lasting change is more likely to occur when they discover their own reasons and determination to change.

Four Principles of MI 1. Express empathy

– See things through the client’s eyes 2. Develop discrepancy

– Explore how they want their life and how it is now

3. Roll with resistance – Do not fight client resistance, but "roll”

with it 4. Support of self-efficacy

– Embrace client autonomy

OARS

• Open-ended questions • Affirmations • Reflections • Summaries

Reality and Practicality

• It takes time to engage patients; you may have to adjust your workflow

• Promote planned care, and team-based care

• Don’t try to fix patients’ problems, help them fix their own

• It works—start with small changes

Engaging Patients Through Coaching: A Method to Consider

Larry Garrett, PhD(c), MPH, BSN HealthInsight

Fractals Fractals are self-similar patterns, that are "the same from near as from far" Fractals may be exactly the same at every scale, or they may be nearly the same at different scales.

Fractals Fractals are self-similar patterns, that are "the same from near as from far" Fractals may be exactly the same at every scale, or they may be nearly the same at different scales.

Fractals Fractals are self-similar patterns, that are "the same from near as from far" Fractals may be exactly the same at every scale, or they may be nearly the same at different scales.

Fractals

Fractals are challenging to work with as you are never sure if your working characteristic is far or near.

Fractals

Fractals are challenging to work with as you are never sure if your working characteristic is far or near.

Presenter

Presentation Notes

Until we solve the recurring patterns surrounding what we often term non-compliance – which is the easy way out of not dealing with patint quality - and determine the best methods to engage an individual in their own care we will not solve the larger healthcare issues that Marc outlined earlier to us this morning. In essence, we can view any individual we work with during any type of encounter as a near fractal and the entire healthcare system a distant fractal. We must find our solutions in the near if we are going to influence the far.

“Even people with chronic conditions rarely spend more than 1% of their life at a healthcare provider’s facility. It is the other 99% of one’s life - when an individual is at home - that determines whether they return to full health or not.” -unknown-

What is Coaching

What is Coaching

Managing is making sure people do what they know how to do.

What is Coaching

Managing is making sure people do what they know how to do. Training is teaching people to do what they don’t know how to do.

What is Coaching

Managing is making sure people do what they know how to do. Training is teaching people to do what they don’t know how to do. Mentoring is showing people how the people who are really good at doing something do it.

What is Coaching

Managing is making sure people do what they know how to do. Training is teaching people to do what they don’t know how to do. Mentoring is showing people how the people who are really good at doing something do it. Coaching is helping to identify the skills and capabilities that are within the person, and enabling them to use them to the best of their ability.

Care Transitions Model

• The Care Transitions, utilizes a Transitions Coach to encourage patients to assert a more active role in their own self-care.

• The program has consistently reduced 30-day hospital readmissions and costs as well as 180-day hospital readmissions.

Four Pillars • Medication self-management: Patient is knowledgeable

about their medications and has a medication management system.

• Use of a Personal Health Record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care plan across providers and settings. The PHR is managed by the patient.

• Medical Visit: Patient schedules and completes follow-up visit with the primary care physician or specialist physician and is prepared to be an active participant in these interactions.

• Knowledge of "red flags": The patient is knowledgeable of indicators that his or her condition is worsening and demonstrates knowledge of how to respond.

Personal Health Record • Personal health record:

– Maintained by the patient and brought to each appointment;

– Medications and allergies; – Advance care directives; – Warning symptoms or signs.

• Space to record the patient's questions for next medical encounter.

• Maintained by the patient.

Coaching, Encounters

• Initial meeting in hospital: The Coach, meets with the patient in the hospital to establish an initial rapport, introduce the personal health record, and arrange a home visit.

• Home visit: The home visit ideally takes place within 48 to 72 hours of discharge.

Coaching, Encounters • Medication reconciliation: Actively engages

patients in reconciliation of all medications taken and models behaviors for how to address common medication discrepancies.

• Education on how to communicate: Through role playing and other methods educates patients on how to communicate care needs effectively during encounters with health care professionals.

• Review of warning signs: Reviews a list of "red flags" that indicate a worsening condition and educates patients on how to respond, should they occur.

Coaching, Encounters • Three telephone patient visits during the first

28 days after discharge. • Focus:

– Reviewing the patient's progress toward established goals;

– Discussing any encounters with health care professionals;

– Reinforcing the importance of maintaining and sharing the personal health record;

– Supporting the patient's self-management role.

Coaching in your Practice

• Coaching is a tool that everybody can use: – It is evidence based and shows that those that

are engaged in the coaching process have better outcomes.

• Coaching can be used to help prevent patients going into long-term downward trends or to keep them at their new “normal”

Presenter

Presentation Notes

I started today talking about fractals, a term meaning to break or fragment and often graphically portray the notion of "worlds within worlds". If we can work within the a patient’s world, it is my belief that many of the health care challenges we face will be solved. Coaching is one method we can used to have a positive influence on our patients world.

Presenter

Presentation Notes

I started today talking about fractals, a term meaning to break or fragment. Basically, a fractal is any pattern that reveals greater complexity as it is enlarged. Thus, fractals graphically portray the notion of "worlds within worlds". If we can work within the a patient’s world, it is my belief that many of the health care challenges we face will be solved. Coaching is one method we can used to have a positive influence on our patients world.

Questions?

Larry Garrett, HealthInsight, Project Coordinator lgarrett@healthinsight.org

801-892-6665