As hospitals and health systems grapple with the changes brought on by healthcare reform and other efforts toward healthcare delivery transformation, they may understandably become overwhelmed — a similar feeling our patients may experience when facing a chronic illness or new diagnosis. For health systems, success under our soon-to-be value-based delivery system will require strategic analysis, informed decision-making and careful execution. The same can be said for the processes we use to engage our patients in their own care.
Patient engagement, or the efforts we take to get patients involved in all aspects of their care both within and outside our facilities and physician offices, is more than a nice thing to do. Engaged patients are more likely to comply with their treatment and prevention plans, which results in higher quality care, fewer medical errors and lower cost. If you think about the key goals of the healthcare reform law, improved patient engagement is a key theme throughout the regulation. That's fitting because the other goals of reform including payment reform and population management will be extremely difficult to achieve without patients who are actively engaged in managing their own health.
While every clinician plays an important role in helping to engage patients, the primary care team is critical because they are focused on the patient's whole picture of health. While patient engagement can be achieved in some cases with simple patient education or other straightforward efforts, patient engagement across a population requires more sophisticated efforts. At Mercy, we’re using the following six steps to drive patient engagement, an effort we believe will position us well for both value-based reimbursement and population health management.
1. Expand access. The first step to improving patient experience is to increase their access to care. The most obvious example of this is extended office hours, including early morning, evening and weekend hours. But, access goes beyond that. Increasingly, patients crave electronic, asynchronous ways to communicate with healthcare providers. Earlier this year, a survey by Intuit found that up to 73 percent of Americans were interested in using a patient portal for a variety of physician communications, such as requesting new prescriptions and obtaining lab results. At Mercy, we now offer an interactive patient portal where patients can access health information, make appointments, request refills and email physicians and their staff with questions. We want to offer patients a way to engage with physicians, even if their physicians aren't physically available at the time they have a question. Our belief is anything we can do to enhance two-way communication improves the likelihood a patient will get engaged.
2. Identify patients to engage. Identifying patients can be very simple when the patient is sitting in front of you or calling to request services, but healthcare reform requires providers to get less compliant patients engaged in their care. Under new models, we can't wait for patients to make the first move; we have to proactively identify patients who are at risk for not getting care and reach out to them. Doing this is the focus for the patient-centered medical home model and for population management within a clinically integrated system. Going forward at Mercy, for example, we can use our system-wide EHR to identify which of our diabetic patients are lacking standards of care such as hemoglobin A1c testing. Then, using a variety of communication options including our patient portal, we can work to engage patients in our developing patient-centered medical homes.
3. Assess patients' ability to engage. Patients' ability to engage in and self-manage health care varies greatly, and clinicians need to assess what obstacles may impact a patient's engagement as they develop the care plan. For example, a college professor with newly diagnosed diabetes may engage well with a physician-recommended book about diabetes management. However, a patient with a less scholarly personality, perhaps not having graduated from high school, has a lower likelihood of following through on that recommendation. Instead, this patient might do better in a diabetes educational program that engages the patient and others in his household in group visits.
Cost also plays a factor in patients’ ability to engage. A 2009 study by Harvard researchers found 28 percent of patients did not fill new prescriptions, and cost is often the driving factor. As a physician, I may be thinking I've done my job by recommending what I believe is the best treatment. However, if the patient can't afford what I have recommended, have I helped? The second best treatment, if affordable, is usually better than no treatment at all.
So how can a physician begin to gauge these obstacles? First, activate the entire care team. Patients may say something to a nurse or medical assistant that they feel uncomfortable revealing to their doctor, so it's important to raise the awareness of the staff to understand the importance of patient-self management and assessing patients. As a physician assessing a patient’s ability to engage, I tend to draw the patient into the discussion using non-threatening examples. I might say, "I've had patients in the past stop this medicine because of side effects.” or "I know this is an expensive medication and often difficult to afford." When the physician opens the conversation, patients find it easier to speak up.
4. Provide appropriate tools. In addition to patient education, clinicians should provide patients other "tools" to keep them engaged and on-track. Clinicians should put things in writing; outline specifically what the doctor's office is going to do and what is the patient's responsibility. At Mercy, every clinician is able to enter notes about the patient's visit and next steps into the After Visit Summary of our EHR. These notes can be standard protocols but they can also be very personal notes about what the patient is responsible for before his or her next visit. The After Visit Summary is reviewed with the patient by staff in the exam room and a final printed copy is offered at the front desk before he or she leaves the office. I can even add a graphic such as a star for a job well done on previous goals.
5. Set appropriate goals. Next, the care team, which includes the physicians, other providers and most importantly the patient, needs to agree on goals. The goals must be measurable and should be achievable, which may mean giving the patient smaller steps. For example, a patient with an A1c level of 14 percent is so far off from the 6-7 percent goal that some number in between would be a more achievable starting goal over a defined period of time. When treating patients with multiple comorbidities, the care team should set priority goals. Listing every recommended goal for every condition can be overwhelming and result in patient disengagement.
6. Establish follow-up protocol. Finally, the care team must establish protocols to monitor patients' progress and to maintain engagement. If a treatment regimen is not working as expected, the regimen should be reconsidered but patient engagement, including ability to adhere to the regimen should also be reassessed. If there is suspicion the patient isn't engaged in the care, clinicians should back up and restart the steps described here, paying special attention to the assessment of the patient’s ability to engage in self-management of care. Maybe the patient didn't understand the importance of taking the medication; maybe he or she couldn't afford it. They key for providers is to cultivate open communication so that our patients feel comfortable sharing these issues with us so we can better personalize their care.
Rule of thumb
While each of these six steps are important, they all boil down to a simple guideline: offer care that provides the highest quality outcomes at the best value and remember to engage the patient at every step. To encourage compliance and deeper engagement, encourage two-way communication and engage patients with providers at all levels, giving the patient even more connection points for their care.
Kenneth Bertka, MD, is a family physician and vice president of physician clinical integration at Mercy, a seven hospital and physician group system based in Toledo, Ohio. Mercy is a member of Catholic Health Partners, the largest healthcare system in Ohio.
Patient engagement, or the efforts we take to get patients involved in all aspects of their care both within and outside our facilities and physician offices, is more than a nice thing to do. Engaged patients are more likely to comply with their treatment and prevention plans, which results in higher quality care, fewer medical errors and lower cost. If you think about the key goals of the healthcare reform law, improved patient engagement is a key theme throughout the regulation. That's fitting because the other goals of reform including payment reform and population management will be extremely difficult to achieve without patients who are actively engaged in managing their own health. While every clinician plays an important role in helping to engage patients, the primary care team is critical because they are focused on the patient's whole picture of health. While patient engagement can be achieved in some cases with simple patient education or other straightforward efforts, patient engagement across a population requires more sophisticated efforts. At Mercy, we’re using the following six steps to drive patient engagement, an effort we believe will position us well for both value-based reimbursement and population health management.
1. Expand access. The first step to improving patient experience is to increase their access to care. The most obvious example of this is extended office hours, including early morning, evening and weekend hours. But, access goes beyond that. Increasingly, patients crave electronic, asynchronous ways to communicate with healthcare providers. Earlier this year, a survey by Intuit found that up to 73 percent of Americans were interested in using a patient portal for a variety of physician communications, such as requesting new prescriptions and obtaining lab results. At Mercy, we now offer an interactive patient portal where patients can access health information, make appointments, request refills and email physicians and their staff with questions. We want to offer patients a way to engage with physicians, even if their physicians aren't physically available at the time they have a question. Our belief is anything we can do to enhance two-way communication improves the likelihood a patient will get engaged.
2. Identify patients to engage. Identifying patients can be very simple when the patient is sitting in front of you or calling to request services, but healthcare reform requires providers to get less compliant patients engaged in their care. Under new models, we can't wait for patients to make the first move; we have to proactively identify patients who are at risk for not getting care and reach out to them. Doing this is the focus for the patient-centered medical home model and for population management within a clinically integrated system. Going forward at Mercy, for example, we can use our system-wide EHR to identify which of our diabetic patients are lacking standards of care such as hemoglobin A1c testing. Then, using a variety of communication options including our patient portal, we can work to engage patients in our developing patient-centered medical homes.
3. Assess patients' ability to engage. Patients' ability to engage in and self-manage health care varies greatly, and clinicians need to assess what obstacles may impact a patient's engagement as they develop the care plan. For example, a college professor with newly diagnosed diabetes may engage well with a physician-recommended book about diabetes management. However, a patient with a less scholarly personality, perhaps not having graduated from high school, has a lower likelihood of following through on that recommendation. Instead, this patient might do better in a diabetes educational program that engages the patient and others in his household in group visits.
Cost also plays a factor in patients’ ability to engage. A 2009 study by Harvard researchers found 28 percent of patients did not fill new prescriptions, and cost is often the driving factor. As a physician, I may be thinking I've done my job by recommending what I believe is the best treatment. However, if the patient can't afford what I have recommended, have I helped? The second best treatment, if affordable, is usually better than no treatment at all.
So how can a physician begin to gauge these obstacles? First, activate the entire care team. Patients may say something to a nurse or medical assistant that they feel uncomfortable revealing to their doctor, so it's important to raise the awareness of the staff to understand the importance of patient-self management and assessing patients. As a physician assessing a patient’s ability to engage, I tend to draw the patient into the discussion using non-threatening examples. I might say, "I've had patients in the past stop this medicine because of side effects.” or "I know this is an expensive medication and often difficult to afford." When the physician opens the conversation, patients find it easier to speak up.
4. Provide appropriate tools. In addition to patient education, clinicians should provide patients other "tools" to keep them engaged and on-track. Clinicians should put things in writing; outline specifically what the doctor's office is going to do and what is the patient's responsibility. At Mercy, every clinician is able to enter notes about the patient's visit and next steps into the After Visit Summary of our EHR. These notes can be standard protocols but they can also be very personal notes about what the patient is responsible for before his or her next visit. The After Visit Summary is reviewed with the patient by staff in the exam room and a final printed copy is offered at the front desk before he or she leaves the office. I can even add a graphic such as a star for a job well done on previous goals.
5. Set appropriate goals. Next, the care team, which includes the physicians, other providers and most importantly the patient, needs to agree on goals. The goals must be measurable and should be achievable, which may mean giving the patient smaller steps. For example, a patient with an A1c level of 14 percent is so far off from the 6-7 percent goal that some number in between would be a more achievable starting goal over a defined period of time. When treating patients with multiple comorbidities, the care team should set priority goals. Listing every recommended goal for every condition can be overwhelming and result in patient disengagement.
6. Establish follow-up protocol. Finally, the care team must establish protocols to monitor patients' progress and to maintain engagement. If a treatment regimen is not working as expected, the regimen should be reconsidered but patient engagement, including ability to adhere to the regimen should also be reassessed. If there is suspicion the patient isn't engaged in the care, clinicians should back up and restart the steps described here, paying special attention to the assessment of the patient’s ability to engage in self-management of care. Maybe the patient didn't understand the importance of taking the medication; maybe he or she couldn't afford it. They key for providers is to cultivate open communication so that our patients feel comfortable sharing these issues with us so we can better personalize their care.
Rule of thumb
While each of these six steps are important, they all boil down to a simple guideline: offer care that provides the highest quality outcomes at the best value and remember to engage the patient at every step. To encourage compliance and deeper engagement, encourage two-way communication and engage patients with providers at all levels, giving the patient even more connection points for their care.
Kenneth Bertka, MD, is a family physician and vice president of physician clinical integration at Mercy, a seven hospital and physician group system based in Toledo, Ohio. Mercy is a member of Catholic Health Partners, the largest healthcare system in Ohio.