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Collaborative Strategies across the Healthcare Delivery System
Sheila Smith, RN BSN CDE, Director of Home Care and Behavioral Medicine Great Plains Regional Medical Center, Elk City OK
Sylvia Aruffo, PhD, President, Communication Science, Inc. Buffalo Grove, IL
Article published in the Remington Report, September/October 2009 Volume 17: Issue 5.
The Patient as Collaborator
The only element of the healthcare delivery system that touches each of its components is the patient. Yet the patient is the most underestimated and overlooked resource in the entire system. How do we collaborate with the patient? Providers have a tendency to do things for the patient, a labor-intensive model. Alternatively, we lean toward doing things to the patient in a technology-intensive model. The first tendency fosters "learned helplessness," where the patient comes to rely on the provider rather than becoming independent. The second tendency fosters genuine helplessness—that is, when the technology is removed, most patients have not learned how to manage and monitor independently. Both tendencies miss the opportunity to make the patient a partner in care. We need to stop thinking about the patient as the reason we do our work—its end—and start thinking of the patient as a collaborator, a means to get the job done. Redesigning healthcare for patient collaboration puts the patient at the center, rather than at the end.
How do we collaborate with the patient? Start by investigating the patients’ perspective on the healthcare delivery system. What elements of the system does the patient most want to improve? With many years of collecting patient satisfaction data Press-Ganey1, the California patient satisfaction survey2, and others3 indicate patients’ top concern is being prepared for self care, the transition from hospital to home. This gives home care the opportunity for a major impact on collaborating across the system.
What Does the Patient Need in order to become a Collaborator?
To collaborate, patients need to absorb knowledge and skills as rapidly as possible. And it is possible—after all, every provider at one point had no knowledge or skill. The three most important elements of preparation are: Explain the disease and medications, define the steps of self care and provide user-friendly tools.
Explain the Disease and Medications. Too often we providers give oversimplified explanations; that is, what passes for “simplification” is in fact vagueness in the name of “health literacy.” For example, a father and son with CAD were puzzled by an American Heart Association handout about triglycerides: “What does this mean,” they asked each other, ‘Another kind of fat?’”4 The phrase may be at a low reading level, but it doesn’t mean anything. We owe it to our patients to dig into our textbooks for explanations that have continuity with other elements of the teaching. An search of medical literature uncovers that triglycerides are also called VLDL, Very Low Density Lipoprotein. If we have taught our patients that High is good and Low is bad, then “another kind of fat” that is “very low” makes sense: of course it’s another bad fat if it’s low. There’s continuity and coherence in our explanation: HDL, LDL and VLDL: High, low and very low.
If we do not clarify their diseases and treatments, patients invent their own “meaning.” One woman was told she needed a Beta Blocker. “Will it heal my heart?” she asked. When told it wouldn’t, she concluded that “blocker” must mean the pill merely “blocks” or “masks” what is going on. She decided not to take it. To prevent this line of reasoning, we might even need to read FDA package inserts to find the mechanism of action. Then we can explain: Your heart has a tendency to race. The Beta Blocker blocks adrenalin, which can make the heart race. The heart stays beating steadily even when stressed. So there is value in taking the pill, even if it doesn’t “heal.” When she understands, the patient can collaborate.
Patients resent being shut out of collaboration. One woman related the story of asking her doctor, “Why do I have to take metformin, glyburide and Actos, when all three are for the same thing, diabetes? The doctor just said, ‘You need them.’ She just left it like that. That was when I decided to change doctors.”
Define the Steps in Self Care. Teaching how to do self care procedures should be straightforward. But patients can be confused when each nurse has a different method. We serve providers, not patients, by tolerating such variation.
One home care administrator lamented, “I have 15 different sets of instructions on self-catheterization. The nurses can’t agree, so I have the inventory headache and patients have the headache of starting over again with a different set of instructions every time they talk to a new nurse.
Patient education committees too often approve handouts that say to do a procedure “as you were instructed.” If the patient doesn’t remember how they were instructed, what good is the handout? Such a decision is not patient-centered but provider-centered, appeasing providers who refuse to come to agreement. Vagueness in instructions discourages patients from engaging in self care.
Provide User-Friendly Tools. Most devices and supplies are designed for hospital use by professionals, not self care at home by patients. This is in sharp contrast to the consumer products industry, where hundreds of millions are spent researching, designing, testing and redesigning products to make them maximally user friendly—even “idiot-proof.” One DME sales rep expressed concern that increasingly complex equipment goes home for nonprofessional use. She spends more time training, but on leaving, she is not sure they can do it. We in home care need to be aware that most tools patients must use are not user-friendly. We can be on the lookout for new tools to facilitate patients’ being collaborators.
Monitoring in the home is a hot topic. If our goal is to make patients independent, we should be sensitive to how a monitor might foster passivity, instead of preparing them for independence. On the one hand, patients are not always accurate in self-reporting results (whether deliberate or simply mistaken). On the other hand, automated monitoring may be an overreaction, creating as many problems as it solves.
For example, the Medical Director of the AARP related a story of a HF patient whose son brought her a take-out Chinese dinner, complete with soy sauce. Afterward, the woman had difficulty breathing. The Medical Director reported with satisfaction that a telemonitoring device caught the decline and connected the woman to her PCP, preventing a trip to the hospital.5 But this is not a success of telehealth. This is a failure of patient education. Why had no one taught this woman about sodium?
Another criterion for choosing a tool is how well it fits the patients’ environment. Some patients enjoy tapping diet behaviors into a smart phone—but the majority of patients do not have smart phones. Patients with computers may do well entering glucose scores on a website, but the majority of older people are not comfortable on line—even if they own a computer. At a medical device conference, Boston Scientific reported they had a “very successful” e-newsletter for patients. An attendee asked how many patients ask for the paper version vs. the electronic. “Eighty-five percent ask for the paper edition to be mailed.”6
A Case Study in Collaboration
The home care agency of Great Plains Regional Medical Center addressed the three elements by adopting a SelfCareKit for the patients. The kit facilitated collaboration, using the patient as the element of continuity through transitions:
Collaboration with the hospital.
Communication with the hospital nurses was facilitated because the messaging to the patient was the same in both environments. Patients could build on the messaging from one provider to the next.
For example, one patient, after completing diabetic education classes at the hospital, reported he still felt confused, uncertain where to begin. When home care delivered his self care kit, he reported that seeing all the elements of diabetic self care in one organized package clarified the process for him. Many of the principles already taught in the classes “clicked” for the first time. “This is my ‘go-to’ box,” he reported. “It all seems much more do-able now.” The patient saw continuity across the transition from hospital to home care, appreciating that the home care staff knew how the kit linked back to what he had learned in the hospital classes. “We’re all on the same page,” he said.
Collaboration with the doctors.
The home care nurses showed the kits to the doctors. The sharing over the kit made the doctor more aware of the service, process and value of home care. All the doctors became more enthusiastic about home care, increasing the sense of collaboration. The hospital also collected the data on readmissions, using software that sorted the patients by doctor, comparing patients who received kits and home care to those who did not. The hospital reported to the doctors the superior outcomes of the patients who had received kits through the home care agency, promoting even greater appreciation of—and referrals to—home health.
Hospital Readmissions in Less Than 60 Days [nine month study, June-March]
| Condition |
Without Kit or Home Health |
With Kit and Home Health |
| HF |
13% |
0 |
| HTN |
0 |
0 |
| DIABETES |
0 |
0 |
| CAD |
3% |
0 |
During the study period, none of the patients who received kits through home health were readmitted. Of patients discharged without home health, 13% of HF patients and 3% of CAD patients were readmitted.
Collaboration with the patient directly.
Too often, a home care nurse tells a homebound patient they need a scale or a pillow encasing, but weeks later they still haven’t found a friend or family member to get it for them. Bringing a complete kit with all the tools needed to the patient’s home means the patient starts their self care immediately. “For us as professionals,” reported several nurses, “Instead of just ‘telling and leaving,’ hoping for the best, we see the patient actually begin successful self care. We use those immediate, positive results to reinforce the behavior. “
| Condition |
Average number of visits per patient before adopting kit |
Average number of visits per patient after adopting kit |
% Change |
Savings per patient |
| HF |
10.6 |
8.4 |
21% |
$187 |
| HTN |
11 |
8 |
27% |
$255 |
| DIABETES |
7.5 |
6.5 |
13% |
$85 |
| CAD |
10.8 |
11 |
-2% |
-$17 |
The improved outcomes were achieved at the same time fewer visits were necessary in three out of four conditions, allowing the home health agency greater profitability.
Comment
One irony in efforts to collaborate is that when do achieve smooth transfers of information from one provider to another, we neglect to make the patient aware of that transfer. Making the patient a collaborator means we do not merely check the chart (paper or electronic), but let the patient know we have checked the chart. Tell the patient about your noting what has happened in their treatment plan in the past. Allowing the patient to become aware of provider-provider collaboration relieves anxiety and fosters better provider-patient collaboration.
The improved outcomes were achieved at the same time fewer visits were necessary in three out of four conditions, allowing the home health agency greater profitability.
Conclusion
Collaborating across the healthcare continuum in a way that is patient-centered means creating continuity the patient can perceive. Expand our definition of the elements in the care continuum that need “continuity” if patients are to be successful at taking responsibility for self care: Continuity and clarity in the explanations of their diseases and medications, standardization in their instructions for self care and user-friendliness in their tools for self care. If we do not scrutinize the delivery system for means of collaborating with the patient, we actually—if inadvertently—discourage self care. On the other hand, if we dig deep for explanations, reach consensus on procedures and find tools best adapted for home use, we inspire patients to collaborate with providers across the health care delivery system.
1Clark, Paul. Patient satisfaction with discharge instructions for home care: a national study assessing quality. Press Ganey Associates, South Bend IN, 2002.
2Patients Evaluation of Performance Survey Results (California), California Health Care Foundation and California Institute for Health Systems Performance, 2001 Edition, page 1.
3Alt, Susan J. “Patient Satisfaction Rates are Too High.” Health Care Strategic Management, Volume 13, Number 8, August 1995.
4All patient quotations are from the Ethnographic Research Library, Communication Science, Inc. unless otherwise noted.
5Conference Washington DC
6Conference Chicago IL
