Approaches to Patient-Centered Interactions: Creating a Truly Patient-Centered Primary Care

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Presented By: Ariel Singer, Oregon Primary Care Association

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Patient-Centered Primary Care Institute History and Development

• Launched in 2012 • Public-private partnership • Broad array of technical

assistance for practices at all stages of transformation – Learning Collaboratives – Website (www.pcpci.org) – Webinars & Online Learning

• Ongoing mechanism to support practice transformation and quality improvement in Oregon

Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures • Access to Care

– “Be there when we need you” • Accountability

– “Take responsibility for us to receive the best possible health care” • Comprehensive Whole Person Care

– “Provide/help us get the health care and information we need” • Continuity

– “Be our partner over time in caring for us” • Coordination and Integration

– “Help us navigate the system to get the care we need safely and timely manner”

• Person and Family Centered Care – “Recognize we are the most important part of the care team, and we our

responsible for our overall health and wellness” Read more: http://primarycarehome.oregon.gov

PCPCH Model of Care

About OPCA

Vision: Health equity for all Oregonians. Mission: Lead the transformation of primary care to achieve health equity for all. • OPCA is a non-profit membership organization; our members are community health

centers (also known as Federally Qualified Health Centers, or FQHCs) and their supporters.

• OPCA provides expert technical assistance and training in key aspects of health care reform, including Patient-Centered Medical Home transformation, patient-centered communication, leadership and behavioral and oral health integration.

• OPCA also is a voice in Salem and Washington D.C. for accessible, high-quality primary care services for low-income and other vulnerable populations.

• Stay informed about our upcoming trainings by signing up for our PCMH newsletter, Transformations. To sign up, email Diane Lechner at dlechner@orpca.org.

LEARN MORE: www.orpca.org

Objectives

• Review system-level considerations in adopting patient-centered communication skills

• Provide an overview of key concepts and tools in enhancing patient-centered communication

• Discuss how to get started with strengthening relationships between patients and primary care clinics

Why Patient-Centered Care Matters

• Respect is the right thing to do. How do you want to be treated when you are a patient?

• Patient-centered care: – Improves the health status of patients – Reduces both overuse and underuse of medical services – Can reduce the chance of misdiagnosis or poor adherence to treatment

due to poor communication (AHRQ, 2005)

PCPCH Core Attribute 6: Person and Family Centered Care “Recognize that we are the most important part of the care

team - and that we are ultimately responsible for our overall health and wellness.”

Give a man a fish

Teach a man to fish

(Burden, Blue, Butterworth & Linden)

Changing Our Approach to Care

Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.

-Chinese Proverb

Tradition medical model: Expert treats health condition

Patient-Centered Care: Empowerment of the patient is a key treatment

goal

“I have come to believe that we – patients, families, clinicians, and the health care system as a whole – would all be far better off if we professionals recalibrated our work such that we behaved with patients and families not as hosts in the care system, but as guests in their lives.”

-Donald M. Berwick (Berwick, 2009)

Changing Our Approach to Care

Operational Definition: Patient-Centered Care

• Eliciting and understanding the patient’s perspective, concerns, ideas, expectations, needs, feelings and functioning

• Understanding the patient within his/her own unique psychosocial context

• Reaching a shared understanding of the problem and it’s treatment with the patient that is concordant with the patient’s values

• Helping patients to share power and responsibility by involving them in choices to the degree that they wish

(Epstein et al., 2005)

Useful Maxims

• “The needs of the patient come first.” – Mayo Clinic – Patient needs over convenience or habit

• “Nothing about me without me.” – Diane Plamping, U.K. health care organizational sociologist – Transparency and participation

• “Every patient is the only patient.” – Harvard Community Health Plan Hospital – Customization of care for each individual patient

(Berwick, 2009)

System-Level Recommendations

• Top leadership engagement • Strategic vision clearly and constantly communicated to every

member of the organization • Involvement of patients and families at multiple levels • Supportive work environment for all employees • Systematic measurement and feedback • The quality of the built environment • Supportive information technology

(Shaller, 2007)

Patient-Centered Interactions

• Reflective listening • Explore beliefs • Strengthen coping ability

• Goal setting • Problem solving • Confidence building • Behavior change reinforcement

Self management

support • Diagnosis • Education • Time management • Health literacy

Communication

• Listening • Empathy • Patients feel known • Building trust

Relationship

Therapeutic

-Fundamentals of a patient-centered office visit

-Behavioral Health -Motivational Interviewing -Brief Action Planning -Patient Activation

(Mauksch, 2013)

Inte

nsity

of T

rain

ing

Requ

ired

Examples of Patient-Centered Office Visit Skills

• Collaborative upfront agenda setting – Elicits agenda from patient – Acknowledges agenda items from other team members

• Maintain efficiency through transparent (out loud) thinking • EMR Use

– Describes use of EMR to patient – Positions monitor to be viewed by patient – Points to screen

• Physical Exam – Prepares patient before each physical exam action – Describes exam findings during the exam

• Sharing information – Avoids or explains medical jargon – Summaries cover biomedical and psychosocial concerns – Invites questions

(Mauksch, 2011)

Patient-Centered Observation Form

(Mauksch, 2011)

Patient-Centered Observation Form

(Mauksch, 2011)

Self-Management Support & Therapeutic Communication

Behavioral

Health

Motivational Interviewing

Brief Action Planning

Patient Activation

Level 1 Level 2 Level 3 Level 4

Inte

nsity

of T

rain

ing

Requ

ired

Patient Activation

Patients who scored higher on the Patient Activation Measure are significantly more likely to: • Adhere to treatment • Get preventive care • Participate in decisions about their care • Engage in healthy behavior • Seek out and use health information.

Understanding one’s own role in the care process and having the knowledge, skills, and confidence to take on that role

(Mosen et al., 2007)

Patient Activation

Retrieved from: http://www.insigniahealth.com/solutions/patient-activation-measure

Brief Action Planning

Retrieved from: http://www.comprehensivemi.com/about

/brief-action-planning

• Adheres to the spirit of MI

• Appropriate for more ready and more activated patients

Motivational Interviewing

• Based on the idea that change is a natural and ongoing human experience.

• By using the spirit and techniques of MI, we are helping people speed up their own trajectory of change and self-improvement.

• Evidence-based approach for a wide variety of populations and settings.

When a person feels accepted for who they are and what they do, it allows them the freedom to consider change rather than

needing to defend against it.

Motivational Interviewing

Spirit

Partnership

Acceptance Compassion

Evocation

The Heart of Patient-Centered Care

(Miller and Rollnick, 2013)

Basic MI Toolkit

Open-ended Questions

Affirmations

Reflections

Summaries

O

A

R

S (Miller and Rollnick, 2013)

Making your Primary Care Home More Patient-Centered

• PCMH transformation involves a lot of important operational changes. Even as you improve access, empanelment and care coordination, don’t delay improving the nature of your relationships with patients.

• Create organizational alignment by connecting patient-centered care to your organization’s mission and vision.

• Invest in training and time in-clinic for clinicians and staff to practice and learn.

• Facilitate discussions with employees about their motivation and personal inspiration for providing patient-centered care.

• Together with your staff, create your own operational definition of patient-centered care.

• Measure your progress and celebrate success! • Involve patients on QI projects and committees.

Training Resources

• Patient-Centered Office Visit Skills – Larry Mauksch - lmauksch@gmail.com – http://courses.washington.edu/pove/resources.html

• Motivational Interviewing – Ariel Singer - asinger@orpca.org – Denise Ernst - http://deniseernst.com/ – http://motivationalinterviewing.org/

• Patient Activation Measure – Insignia Health - http://insigniahealth.com/

• Brief Action Planning – http://www.comprehensivemi.com/

References

Agency for Healthcare Research and Quality, National Healthcare Quality Report, Publication No. 06-0018 (Rockville, Md.: AHRQ, Dec. 2005). Berwick, D. (2009). What ‘patient-centered’ should mean: confessions of an extremist. Health Affairs, 28(4), w555-w565. Blash, L., Dower, C. & Chapman, S. (2011). PeaceHealth’s Team Fillingame uses patient activation measure to customize

the medical home. Research Brief by the Center for the Health Professions at the University of California, San Francisco. Retrieved from: http://www.insigniahealth.com/wp-content/uploads/2011/11/PeaceHealth-Medical-Home-Case-Study.pdf

Burden, V., Blue, L., Butterworth, S. and Linden, A. Taking charge: what is the relationship between patient activation and motivational interviewing? Retrieved from: http://www.insigniahealth.com/docs/Rel_MI_PA.pdf

Epstein, R., Franks, P., Fiscella, K., Shields, C.G., Meldrum, S.C., Kravitz, R.L., Duberstein, P.R. (2005). Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues. Social Science and Medicine, 61(7):1516-28.

Hibbard, J., Greene, J. & Overton, V. (2013). Patients with lower activation associated with higher costs: delivery systems should know their patients’ ‘scores.’ Health Affairs, 32(2), 216-222.

Mauksch, L. (2011). Patient-centered observation form. {PDF Document]. Retrieved from: http://courses.washington.edu/pove/files/PCOF_5_16_2011.pdf

Mauksch, L. (2013). Building communication and confidence in care teams: integrating self-management support. [PDF Document]. Retrieved from: http://test.orpca.org/images/stories/mauksch%20communication%20slides%204%2025%202013.pdf

Miller, W. and Rollnick, S. (2013). Motivational interviewing: helping people change (3rd ed.). New York, NY: The Guilford Press.

Mosen, D., Schmittdel, J., Hibbard, J., Sobel, D., Remmers, C., Bellows, J. (2007). Is patient activation associated with outcomes of care for adults with chronic conditions?. Journal of Ambulatory Care Management, 30(1), 21-29.

Reims, K., Gutnick, D., Davis, C. and Cole, S. (2013). Brief action planning: a white paper. [PDF Document]. Retrieved from: http://www.centrecmi.ca/Centre_for_CMI/Brief_Action_Planning_files/BAPWhitePaper2013-01-07.pdf

Shaller, D.Patient-Centered Care: What Does It Take?, The Commonwealth Fund, October 2007. Retrieved from: http://www.commonwealthfund.org/Publications/Fund-Reports/2007/Oct/Patient-Centered-Care--What-Does-It-Take.aspx

Thank you!

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