For many hospital executives and health system leaders, the promise of "Patient Engagement" is vague and the ROI opportunity is unclear. Can Patient Engagement strategies improve clinical outcomes? Will engagement reduce both direct costs as well as provide protection from legislated reimbursement penalties?
If so, how does my system even begin the Patient Engagement process?
The reality is that both on a national scale and for your specific population, the tremendous potential of healthcare reform (both in terms of health and costs) will never be fully realized unless a significant portion of patients accept greater "ownership" of their health maintenance and disease prevention. What is obvious to most of us is that people spend virtually no time interacting with doctors, nurses, or other clinicians. Studies demonstrate that even patients with chronic health conditions spend on average just twelve hours annually under the direct care of healthcare professionals. And the limited influence of traditional providers on patient health-related behavior is clear: approximately 50 percent of people suffering from chronic conditions do not take their medications as prescribed; Type II diabetes, obesity, and heart disease are at epidemic levels; and far too few people participate in preventative care activities.
The tragic state of the Patient Engagement today begs the question: why legislate reimbursement penalties that target traditional providers (individuals and hospital systems) when the overwhelming health problems facing our nation can best (or only) be addressed by patients themselves? That is, why are you at risk when you have such little influence on your patient population?
There are several credible reasons why providers are the initial targets of reform law. First, compared to the patient population (that is, the entire population, as everyone is a current patient or a future patient), providers represent a small and homogenous group. There is limited variability in how different providers deliver care, whereas the general health behavior of the general population is tremendously varied. Thus, starting with providers increases the likelihood of relatively rapid and successful value improvement. Second, the cynic in me believes that it takes far less political courage to financially threaten providers than it does to directly threaten voters. Simply look at the timid individual penalties associated with failing to comply with the "Individual Mandate" section of the ACA. Hospitals and doctors, on the other hand, are "rich," garnering little sympathy from the general population when potentially heavily "taxed" for poor outcomes. And finally, we must accept as providers that we unintentionally cause significant harm. 400,000 American inpatients are inadvertently killed every year at the hands of doctors, nurses, pharmacists, and other hospital caregivers. And preventable medical errors result in 10,000 serious complications every single day. In conclusion, "engaging" providers through reimbursement penalties is simpler and more politically palatable than legislating that individual patients (voters) engage in their own healthcare, while also offering opportunities for meaningful outcome and cost improvements.
It's important to understand that the ROI of Patient Engagement has been studied, and the results are clear. Engaged patients have better clinical outcomes and decreased costs of care. You must also appreciate that validated instruments are available to measure engagement, both at baseline and following intervention. The Patient Activation Measure® (PAM) may well be the most commonly utilized engagement measurement tool. Higher PAM scores are associated with better health behaviors (exercise; diet; control of blood pressure, cholesterol, and HgA1c; preventative screenings; etc.), while those with lower scores are more likely to be hospitalized, visit the emergency department, and require hospital readmission soon after discharge.
Successful Patient Engagement requires that you first recognize that your specific patient population is not homogeneous. The simplest stratification of your patients can be achieved by utilizing credible instruments like the PAM. Such easy-to-use tools allow you to quickly appreciate how your population is distributed across the engagement spectrum. However, this is not enough! Given that your resources are limited (both human and financial), it is critical that you gather a deeper understanding of your patient population. Just because a cohort of individuals has a low engagement score does not mean that you must allocate greater resources to that group. Likewise, sub-populations with higher baseline engagement may still require significant resources to move them farther along. Successful Patient Engagement requires a combination of technology (engagement measurement tools, EHRs, educational systems, patient portals, etc.) and human-to-human interaction. Based on their medical records and direct experiences with your providers, patients can be broadly categorized so that you can most efficiently and successfully allocate your human and financial resources.
I see patients as falling into one of three broad categories in terms of engagement strategies and resources. First are the Shark Surfers. Like the teenage surfer whose love for the waves outweighs his fear of the danger lurking below (despite recent shark attacks), some patients simply refuse to participate in their own care despite knowing that their behavior risks their health and even their life. The alcoholic cirrhotic who continues to drink, the diabetic who repeatedly fails to control her blood glucose, the heart failure patient who simply won't take his medications...While you must (and should) continue to care for these Shark Surfers when they inevitably appear in your emergency department, allocating significant staff or money in a futile attempt to engage them is simply a waste of resources. Quickly identify your small Shark Surfer population (through their medical history and engagement score) and move on.
Credit Carders represent a large group of unengaged but engage-able patients, whose behavioral philosophy is "enjoy now – pay later." Like the asymptomatic hypertensive who (by definition) has no symptoms and, therefore, doesn't see the benefit of accepting the side effects, annoyance, and cost of taking blood pressure medications, Credit Carders respond to the human touch. By developing a personal connection with a Credit Carder, a caring nurse or other clinician can help create a dialogue specific to that patient, by (1) appreciating the patient's personal future goals and plans, (2) then explaining that those goals and plans are at risk due to the patient's current health behavior, and (3) working with the patient to develop a plan of care. For example, simply provide a Credit Carder with the URL for a heart attack risk calculator and that patient will likely never go to the on-line site. But have a caring provider first talk with the patient and then sit with the patient as, together, they use the on-line risk calculator, and you are much more likely to end up with an engaged (and healthier) patient.
Finally, there's the last large group of engage-ables, the Different Drummers. These patients simply do not have adequate communication with their providers. Elderly patients, for example, have often been raised never to question their physicians, even if they don't understand a doctor's instructions. And many patients of all ages do not clearly understand what their provider is saying, either challenged by language skills or educational level. Not to mention numeracy (even educated individuals often don't know the difference between "b.i.d" and "q12 hours" on their prescription label). As with Credit Carders, Different Drummers can only be engaged when human resources are combined with technology. Understanding your sub-populations in terms of language, education, culture, and other socio-demographics will allow for meaningful engagement strategies. Again, trained nurses, social workers, and others are critical to this process and should be combined with appropriately designed educational materials.
Patient Engagement offers your health system an enormous opportunity to improve the value of the care you deliver, both in terms of quality and costs. There are validated instruments to simply and easily measure the success of your engagement strategies. And by recognizing the critical importance of involving a team of human engagement specialists to empower your technology, you will maximize your Patient Engagement success.
Peter Edelstein, MD is Chief Medical Officer of Elsevier Clinical Solutions.
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