Transcript Nothing About Me Without Me - Indian Nurses Association of New York

Nothing About Me
Without Me
Improving Health and Wellness
Through Patient Engagement
Cathy Rick, RN PhD (h) NEA-BC FAAN FACHE
Senior Advisor Jonas Center for Nursing and Veterans Healthcare
Former Chief Nursing Officer, Department of Veterans Affairs
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Objectives
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Current Aspects of US Healthcare
Define Patient Engagement
Nursing Practice Related to Patient Engagement
Envisioned Impact of Patient Engagement
Academic and Research for Patient Engagement
Q&A
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Patient Centered Care
long history
• Covered in the literature for more than 50
years (Hobbs, 2009)
• actual processes and how they relate to
patient outcomes is not well understood.
• Institute of Medicine (IOM) put forth PCC
as one of its six objectives for improving
health care in the 21st century (IOM, 2001),
many health care organizations have
embraced the notion of PCC as central to
their strategic missions and values
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• With health care reform in the United States,
attention has turned toward innovative
delivery systems that involve aspects of PCC,
such as the patient centered medical homes
and accountable care organizations
(Rittenhouse, Shortell, & Fisher, 2009).
• PCC encompasses providing care that is
compassionate, empathetic, and responsive
to the needs, values, and expressed
preferences of each individual patient;
patients should be informed decision makers
in their care (IOM, 2001).
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Current Aspects of Patient Engagement
• PCC should consider the patient as an
experiencing individual beyond being just an
object of disease (Mead and Bower 2000)
• care providers must have an understanding
of the patient’s context
• A “therapeutic alliance” must be established
between care providers and patients.
• Rather than care providers acting as “hosts”
for patients in the health care system, true
PCC would mean that providers are “guests”
in patients’ lives (Berwick (2009)
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“The experience (to the extent the
individual patient desires it) of
transparency, individualization,
recognition, respect, dignity, and
choice in all matters, without
exception, related to one’s person,
circumstances, and relationships in
health care” Berwick
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The Affordable Care Act permits the introduction
of incentives for healthy behaviors that are
potentially worth up to half of total insurance
premiums, providing unprecedented opportunities
for innovation in incentives and health benefits
design to affect health behaviors.
61% of employers identify employees’ poor health habits as top
challenge to maintain affordable health benefits
Health Affairs July 2013
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Guide to Patient and Family Engagement in
Hospital Safety and Quality
• Encourage patients and family members to participate as advisors.
• Promote better communication among patients, family members, and health care
professionals from the point of admission.
• Implement safe continuity of care by keeping the patient and family informed
through nurse bedside change-of-shift reports.
• Engage patients and families in discharge planning throughout the hospital stay.
http://www.ahrq.gov/research/findings/final-reports/ptfamilyscan/index.html
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An environmental scan was conducted that serves as an evidence based
foundation for the development of the Guide. In conducting this environmental
scan, the intent was to reflect the concepts of consumer engagement and
patient- and family centered care around the issues of patient safety and
quality in the hospital setting; and incorporate diverse input and perspectives
from multiple individuals and organizations representing patients, families,
health professionals, and hospitals.
http://www.ahrq.gov/qual/ptfamilyscan
Nov 2009-Feb 2010
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Barriers and Facilitators
for Patients and Families
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fear,
uncertainty,
low health literacy,
and provider
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self-efficacy,
information,
invitations to engage,
and provider support.
reactions.
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Barriers and Facilitators for Healthcare Team to
Support Patient Engagement
• professional norms
• experiences,
• fear of litigation,
• and perceived level of
effort.
• desire to imitate competitors
• health care legislation or mandated policies,
• leadership from influential bodies,
• alignment of financial incentives; public
reporting, and accreditation and awards
• occurrence of a sentinel event,
• the business case,
• the desire to improve quality and safety
performance,
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• stories from patients and families, and altruism.10
Organizational Factors
• organization’s understanding of and
• absorptive capacity (ability to identify,
• the existing quality and safety culture,
• the strength of leadership at all levels,
• the hierarchy (whether rules, regulations, and
• internal alignment (consistency of plans,
experience with patient and family
engagement,
reporting relationships are emphasized),
• the existence of slack resources (cushion of
capture, interpret, share, reframe, and
recodify new knowledge to link it with its
own knowledge base, and to put it to
appropriate use),
processes, information, resource decisions,
actions, results, and analysis to support
and/or change key organizational goals).
resources that can be used in a discretionary
manner),
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Need to shift approaches
from patients being
passive recipients of care
Improving the way healthcare clinicians
communicate with patients is essential to
providing and excellent patient AND clinician
experience.
Defining
Patient Engagement
Many Terms Surround the Topic
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Patient Experience
Patient Satisfaction
Patient Engagement
Patient Activation
Patient and Family Centered Care
Voice of Nursing Leadership May 2014
Mary-Michael Brown Medstar Health, Columbia, MD
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Patient Experience, Patient Satisfaction
Patient experience represents the patients’ perceptions of the care they received
… influenced by patient’s opinion of hospital environment & culture as
well as interactions with and observations of healthcare team
Patient satisfaction is the degree to which their care met their expectations
…CMS Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS); results posted on CMS website “Hospital Compare”.
Eight domains highly affected by nursing interventions
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Patient Engagement
Actions a patient takes to manage his/her health and gain the greatest benefits
from available health care services.
Inclusive of patient experience and satisfaction
Incorporates direct care, governance and policy making
Three phases: consultation, involvement, partnership/shared leadership
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Patient Activation
A patient’s willingness and ability to participate in their health and healthcare and is
influenced by patient’s knowledge, motivation and confidence to do so.
Four levels:
Stage 1: believes active role is important but remains passive
Stage 2: has confidence and knowledge and is thinking of doing so
Stage 3: is actively involved in managing own health
Stage 4: fully managing own health and will likely stay the course even if stressed
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Patient and Family-Centered Care
Ideal partnership that honors patient preferences,
makes certain that patients have requisite information, and support to make
decisions about their care
and places the patient and family at the center of all decisions about their care.
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Patients define PCC
eight dimensions
Picker Institute/Commonwealth Fund
(a) respect for patient preferences,
values, and expressed needs;
(b) information, education, and
communication;
(c) coordination and integration of
care and services;
(d) emotional support;
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e) physical comfort;
f) involvement of family and close
others;
g) continuity and transition from
hospital to home;
h) access to care and services
(Gerteis, Edgman-Levitan, Daley, & Delbanco, 1993; Gerteis, Edgman-Levitan,
Walker, et al., 1993)
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Nursing Practice related
to Patient Engagement
Nurses Play a Fundamental Role
Honor patient wishes by centering interventions around patient values,
hopes and needs.
Nothing About Me…Without Me
Eliminate labeling patients as non-compliant or non-adherent
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Role of Nurses
Front line of quality improvement initiatives
Responsible for real impact on patient/family engagement
Nurses at the intersection of everything and everyone
Dearth of tools specifically for nurses on how to better
communicate with patients and vice versa
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What is your experience?
What are your stories?
What tools work for you?
Nursing Practice Supporting
Patient Engagement
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Bedside rounds & Shift Reports
Coordinating transitions of care
Patient/family initiated rapid response teams
Open visitation, family presence during procedures
Open access and contribution to medical records, committees, focus groups…
White boards for communication: shared daily plans/plan for life
Pre-visit coaching, transition planning
Just-in-time information/explanations… options and consequences of choices
Blameless apology
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Let Patients Help by Dave DeBronkart
• Allow patients to proofread their medical records
• When patients or families want to check the medications that you’re giving
them… welcome it
• When patients say, “I didn’t see you wash your hands”, thank them and do it
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Practical tips for nurses
Dave deBronkart
• Stop referring to patients in the third person as if
• Work to clarify and simplify your messages when
• Let patients and families fill in the blanks on
• See the value in patient networking—patients with
they are not in the room.
things that might be missing from their records.
• Recognize that Googling about one’s diagnoses is
giving patients information.
similar problems know what patients want to
know.
• Adopt the belief that patients will perform better
• Welcome family interest in the patient’s care.
• Let patients scour the earth for information on
• Understand that information alone is not
• Let patients help with quality and safety by valuing
a sign of patient engagement.
in managing their care if they are better informed.
enough—make it easier for patients to do the right
thing by designing easy interventions and
reminders.
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their health problems and appreciate their efforts.
their questions and reminders.
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Important Ingredients
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Motivational Interviewing
Wellness Coaching
Worksite Wellness
Integrate Wellness into
Value Based Healthcare
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Technology Support
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Putting Patients in the Drivers Seat
Secure Messaging
Open Notes
Prescription management
Appointment and Diagnostic Test Results
Health Calendars and Journals
Health Information Library
Blue Button
Smart Phones
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How do we know when its working? OPTION
www.optioninstrument.com Cardif University, UK
Did the nurse…
• draw attention to an identified problem as
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one that requires decision-making?
state that there’s more than one way to
deal with it?
assess patient’s preferred approach?
list options which include choice of “no
action”?
explain pros and cons of options?
explore patient’s expectations or ideas?
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• explore patient’s concerns/fears?
• check that patient understands?
• offer patient explicit opportunities to ask
questions throughout?
• elicit patient’s preferred level of
involvement?
• indicate the need for a decision making
stage… “time to make a decision”?
• indicate the need to review the decision?
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Resources
• Joint Commission “Speak Up”
• Cleveland Clinic REDE Model
• National Alliance for Quality Care
(NAQC) Guiding Principles for
Patient Engagement
• www.ahrq.gov Links to resources
• MyHealtheVet www.myhealth.va.gov
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• National Patient Safety Foundation
“Ask Me 3”
• American Hospital AssociationSecond Curve of Population Health
• Institute for Patient- and FamilyCentered Care
• HIPAA Rights www.hhs.gov/ocr
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A nursing role as navigator versus all
nurses navigating
…something to think about!
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Organizational role
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Vision and values related to patient engagement
Leaders serve as role models
Resources and infrastructure
Involve and support clinicians and all staff in patient and family engagement
initiatives
• Integrate patient and family engagement into personnel policies and practices
Source: AHRQ Guide to Patient and Family Engagement
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Envisioned Impact of
Patient Engagement
Impact
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Reduced need for telephone calls and waiting on hold
Avoid duplicate tests, readmissions and procedures
Move more easily from provider to provider, system to system
Improve efficiency and safety
Respond to Joint Commission standards
Personalized health & wellness reminders
Bottom line: Improve patient outcomes
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Joint Commission Standards
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Effectively communicates with patients
Coordinates care, treatments etc.
Patient education based on patient needs
Follow up care, treatment, services
Patient’s rights to receive understandable information
Patient’s rights to participate in decisions about care, treatment, service
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Examples
Georgia Health Sciences Medical Center implemented changes to visitation policy to promote
patient and family engagement:
62% reduction in medication errors
40% reduction in falls
50% decrease in length of stay
Veterans Health Administration
Patient Aligned Care Teams
National Program Office & Board Committe: Patient Engagement
National Program Office: Health Equity
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Patient outcomes
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Emotional health
Symptom resolution
Functioning
Pain control
Physiologic measures such as blood pressure and blood sugar levels
Reduced rate of preventable admissions/readmissions
Source: AHRQ Guide to Patient and Family Engagement
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Improved financial performance through
patients engaged and serving as early warning
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Decreases in litigation and malpractice claims
Fewer complications leading to shorter length of stay
Improved patient flow and bed capacity
Reduced overcrowding
Reduced call volume
Decreased need for referrals
Source: AHRQ Guide to Patient and Family Engagement
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Your thoughts about
desired impact…
Nursing priorities??
Anticipated Outcomes
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Improved communication
Improved care team/patient partnerships
Improved quality of care/patient safety
Improved patient experiences of care
More efficient use of resources
Improved provider satisfaction
Improved patient outcomes/health
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Academic and Research Priorities
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Research shows that when patients are
engaged in their healthcare, it can lead
to measureable improvements in safety
and quality.
Agency for Healthcare Research and Quality (AHRQ)
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Current Research
• patients who experienced more
PCC in the hospital had better
outcomes, it is possible that
better PCC leads to patient trust
in the system, which could in
turn motivate patient adherence
and actions that lead to better
outcomes. (Meterko 2010)
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• positive relationships between PCC
processes and patient satisfaction and wellbeing.
• patient satisfaction with the care
experience has become an important
outcome in its own right.
• some research suggests that patient wellbeing and satisfaction may be related to
mediating variables, such as adherence and
self-management behaviors
• (Kahn et al., 2007; Lemmens et al., 2008).
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Academic-Practice Partnerships
• Important mechanism to strengthen nursing practice and positions nurse to
lead change and advance health
• Prepare nurses of the future to practice and lead, provide mechanisms for
lifelong learning
• AACN-AONE resources
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Suggested Academic and Research Initiatives
• structural factors impacting
organization’s ability to adopt and
sustain innovations
• nurse-patient communication
• implementation information on the
specific tools and strategies used in
the patient and family engagement
efforts.
materials
• key pre-implementation and
implementation steps
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Closing comments
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Shifting the model
Historically, many patients have been dependent on their primary care providers and
their nurses to direct their care. The implementation of the Affordable Care Act is
shifting this paradigm. The age of the Internet has also enticed patients to get more
involved. One has only to look at a website such as Patients like Me™ where more
than 200,000 patients connect with one another for information on more than 1500
diseases.
As nurses, our focus needs to shift to health coaching that goes way beyond our
current patient education model, which is more passive. If you truly listen to patients,
you will be amazed at what the patient knows about themselves and their disease
process. Getting patients more engaged in their care will reduce healthcare costs,
improve outcomes, and make our care environments safer. It is a win-win for
everyone involved.
American Nurse Today Issue Date: February 2014 Vol. 9 No. 2
Author: Rose O. Sherman, EdD, RN, NEA-BC, FAAN, and Nancy
Hilton, MN, RN, NEA-BC
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Patient engagement makes a
difference in population health
Care coordination, care delivery transformation,
equity, operational excellence, patient safety and
quality
“The Second Curve of Population Health” Hospitals in Pursuit of Excellence (HPOE.org)
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“Patient engagement is the blockbuster
drug of the 21st century”
Susan Dentzer, editor of Health Affairs
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Ten Important
Two-Letter Words:
If it is to be…
it is up to me
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Thank You
[email protected]
[email protected]
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