Many times I have heard physicians and other providers lament that the outcomes for their patients would be so much better if they could “get them to listen and follow instructions.” They understand that they can be most effective in treating patients if the patients would follow all of their directions.
Do the physicians’ or care providers’ responsibilities end with this wish? Can physicians do more than just hope and pray for best outcomes after they deliver directions to their patients? Should providers be more actively involved in helping patients achieve optimal outcomes, providing support after an office visit or after discharge from a hospital? At present more care providers are becoming increasingly involved in helping patients follow orders and in helping them alter lifestyles as needed. This can be seen especially in patient-centered medical homes.
Recent studies provide good reasons why providers should be active in helping patients follow directions. Consider the following facts pulled from various sources:
- Only 1 in 10 patients are health literate enough to adequately care for their own health, according to a report from the National Center for Biostatistics.
- The Commonwealth Fund in several studies has found that a growing number of adults avoided a doctor or did not fill a prescription. In 2010, 23.1% reported not filling a prescription in the previous 12 months and 27% skipped tests or treatments.
- According to a December 7, 2013 report in Modern Healthcare Dr. Warren Licht of North Shore-Long Island Jewish Health System stated that "When patients are in doctors' offices they (might) hear 50% of what's being said and maybe their relative hears another 30%, but thwy walk away without 20%.
There are many other sources stating that it is very difficult for patients to follow physician directives and that physicians should not be surprised when they find out a patient has not followed orders.
Because of the advent of payment bonuses based upon the quality of outcomes and because of the growth of payers demands that reimbursement be partially based upon quality outcomes, it is becoming financially necessary for physicians to become more involved in helping patients achieve optimal outcomes for treatment, becoming more patient-centered. Additionally, according to Dr. Victor Montori of the Health Care Delivery Research Program at Mayo Clinic, it is the “ethical obligation to better inform patients” for physicians and care givers.
So what are some of the things that providers can do help patients adhere to physician directives? There are many approaches and there is a great deal of research being done in this area. In patient-centered medical homes there is often a nurse who acts as a case manager for patients with chronic conditions. The nurse helps manage the care of patients who are the mostly costly to provide care to by directly intervening with the patient on a regular basis to see that care directives are being followed. Some hospital groups are doing this too. Modern Healthcare in three part series, Channeling Choices, in late 2013, provided this guidance:
- Survey patients' knowledge and confidence in their ability to manage an illness, and tailor education and services based on the individual responses.
- Let patients be a part of decision making.
- Invite questions and discussions from patients about their fears.
- Don't shy away from discussing with patients what they can afford.
- Use health coaches to identify gaps in knowledge and draft questions for doctors.
Along with adopting new approaches to helping patients follow directives, I believe it is necessary for the provider to know if he or she is being effective with their more active interventions. It is not enough to just try several approaches to improve outcomes, it is necessary to know if the approaches are effective. An approach that may be effective for one provider may not be so effective for a different provider. In other words, care support should be tailored to strengths of the provider in providing such support and to the abilities of the patient in working with the physician.
Can a provider know his or her effectiveness in providing support other than just by observing long-term outcomes? Fortunately, there is an accurate and easy way to measure patient engagement in his or her own care, to measure whether the provider is making it easier for patients to follow directives and be smarter in managing their own care. In August 2004 Dr. Judith Hibbard and colleagues published in Health Services Research a scholarly review of research that they had done in developing a ‘Patient Activation Measure’. They reviewed their approach to developing and validating a 21 question patient questionnaire that accurately placed patients into one of four levels of activation: (1) Starting to take a role, (2) Building knowledge and confidence, (3) Taking Action and (4) Maintaining Behaviors.
With this instrument, physicians could easily assess a patient’s level of engagement and activation during an office visit or during inpatient care. The goal of the measure is to help physicians move a patient along the activation scale until he is effective in managing his own care, until he is an effective partner with the physician. Using this activation measuring instrument over time a physician can accurately gauge whether she is effective in helping a patient improve in managing his own conditions. As Dr. Hibbard states measurement can help us:
- To know who needs more support
- To target the types of support and information patients need
- To use our resources more effectively
Summarily, the best outcomes of care occur when patients are engaged in their own care. Studies have shown that without extra support from providers most patients cannot effectively assist in such care management. With new research several effective approaches are being identified as ways for providers to engage patients. Along with this the Patient Activation Measure can be used to accurately measure the success of providers in helping patients become more engaged.