The following article is republished below with permission from HC Pro.
On one hand, physicians are experts that people seek out because of their knowledge of human health. On the other, physicians are still their patients’ employees. While physicians can strongly encourage a course of action, they can’t force a patient to do it—nor can they compel patients to reveal extremely personal, sometimes embarrassing, details about their health.
With those limitations in place, how do you ensure your patients take their meds or show up to their appointments? How can you get them to listen to advice about diet and exercise, or make them comfortable enough to confide in you about their health concerns?
There’s been an increasing push in recent years to promote the idea of patient engagement. The idea is that by finding ways to help patients become more active, those patients will take a larger role in improving their health.
Does Patient Engagement Matter?
In 2016, seven of the leading causes of death in the U.S. were chronic conditions, including heart disease, chronic lower respiratory disease, and stroke. Said conditions, according to the Centers for Disease Control and Prevention (CDC), accounted for 86% of healthcare spending in 2010.
However, many of the levers to treat or alleviate these conditions aren’t complex or expensive, says Craig Deao, MHA, senior leader at Studer Group. Things like good nutrition, exercise, and not smoking can have a major impact on chronic conditions. Through patient engagement, he says, the healthcare system can encourage patients to look after their health even when a physician isn’t present.
More than 200 published studies have looked at how patient engagement affects health outcomes, and those studies are really profound, he says. “For example, more engaged patients are more likely to manage their cholesterol and diabetes, use preventive tests like mammography, appropriately use the emergency department, and not have as many hospitalizations. [They’re] less likely to smoke and be obese. So exactly the kind of thing that we are trying to affect.”
Joe Kiani is the founder of the Patient Safety Movement Foundation and chairman and CEO of Masimo. He says that from a quality standpoint, it’s a smart idea to get patients involved in their care. Patients are more knowledgeable about their health than ever before, he says, which puts them in a better position to take ownership of it.
“Years ago you had to go to the library, maybe even a medical school library, to learn what you can learn in a matter of minutes by being on the internet,” he says. “So you have a much more educated patient population that, of course, knows themselves better than anybody else does…Patients can certainly now be better educated and be a centerpiece [of their care].”
Benefits of Engagement
Kiani says that he’s not aware of randomized controlled studies on the effects of patient engagement. That said, there have been numerous case studies on the topic, some with promising results.
“For example, in the 2016 Healthcare Management Forum, there was a study from McGill University [on strong patient engagement] that showed a 20% improvement in patient experience of care, an 8% increase in nurse direct time and bedside care, a 25% decrease in C. diff and antimicrobial-resistant infections, and they calculated savings of $340,000 in one year,” he says.
Plus, engaged patients are more likely to follow physician instructions and take care of their health when they get home, he says. That means they’ll be less likely to do a U-turn back to the hospital.
An overlooked benefit of strong patient engagement is its impact on physicians and healthcare workers, Deao says. A study by the Mayo Clinic and the AMA found that 54.4% of physicians reported at least one sign of burnout in 2014, up from 45% in 2011. In this charred atmosphere, he says engaging patients can help ease the stress on healthcare workers.
“If you ask physicians about when they have good days, it’s not that those are the easiest days,” he says. “[It’s the days] that they made meaningful progress on something they care about. And nothing is stronger on that list than knowing they influenced a patient to take ownership of their health. [For example,] ‘Ms. Jones, she lost a couple pounds. Man, that’s great!’ You get to cheer on that success.”
Seeing their impact on another person, even if it’s something small like getting a patient’s blood sugar levels under control, makes that job more worthwhile for physicians and staff, Deao says. For healthcare staff who have devoted themselves to helping people improve their lives, small wins matter.
Measuring Patient Engagement
The first step toward facilitating patient engagement is finding out your current engagement levels. After all, Deao says, you can’t improve something without measuring it first.
He says many facilities mistakenly believe they can measure patient engagement based on personal appearance, demographics, or socio-economic factors such as Medicaid status. Multiple studies have disproven this theory, he says.
“It turns out that socio-economic status is not highly correlated to patient engagement,” he says. “So you shouldn’t assume whether a patient isn’t engaged looking at those basic measures.”
To get a true measure of patient engagement, Deao recommends a tool called the Patient Activation Measure (PAM) survey, a self-reported questionnaire that categorizes respondents into four levels of “activation” (another word for engagement). Since its creation in the early 2000s, PAM has been used as a key variable in 265 peer-reviewed, published research papers.
Healthcare is now focused on producing value, he says, and measuring patient engagement allows facilities to see the potential gains in quality and costs.
“On the cost side, we’ve [got] some very interesting data out of Fairview [Hospital in Minneapolis] using PAM scores that show the level of a patient’s engagement this year predicts their healthcare cost to the system next year,” says Deao. “So how engaged I am today influences how much money is spent on me next year. If you can impact engagement, you’re driving both quality and costs in the right direction.”
In this vein of measurement, Deao says the most common mistake that facilities make is not using analytics. Facilities have already spent a huge amount of time and money collecting data on individual patients. Analyzing and applying that data to facilitate patient engagement would be a huge step forward for healthcare.
“We know which patients are less likely to show up on time for their appointments, yet we treat them the same,” he says. “We know which patients … use public transportation, yet we still refer them out to appointments in the suburbs that they can’t get to. We need to know the plans for an individual person to fill out their medication, and if we have that data, [we should do] something different with it.”
For many industries, predictive analytics and behavioral understanding of patients (i.e., customers) have been the norm for years. He points out that Target and Uber probably know more about patients’ behaviors than the patients’ physicians do.
“There are so many other interesting industries that have customer engagement as a core competency,” he says. “So if we’re going to learn customer engagement instead of patient engagement—not quite the same thing—then we got to make sure we’re learning from the best.”
Define Your Terms
Deao says that facilities often make a common linguistic mistake when discussing patient engagement: They speak of engagement as something that can be done to a patient. The reality is that you can’t force engagement—it’s ultimately a choice that patients make on their own. What physicians and healthcare workers can do instead is create an environment that encourages and promotes engagement.
“It would be very paternalistic and sort of in the old model to say that the job of the healthcare system is to engage their patients,” he says. “We want to create an environment where they can become engaged with their own healthcare. And that’s subtle but important when we think about who’s in charge and how we facilitate.”
Another problem is that patient engagement is often conflated with similar-sounding measures. As Deao notes, it’s impossible to make systematic improvements if you’re working with the wrong definitions.
“My favorite quote is from [German philosopher Ludwig] Wittgenstein who says you cannot enter any world for which you don’t have the language. And it’s the same with engagement,” he says. “Too often when I ask people [about] their engagement strategy, what they are telling me is a strategy around patient satisfaction or patient experience. And all three of those are valid measures, but they are very different things.”
Creating a Patient Engagement–Friendly Environment
Once you acknowledge that you can’t make a patient engage, how do you proceed to create an engagement-friendly environment?
Kiani’s advice is, first, to make sure patients know you want them to engage with you. Going to a physician can be unnerving, so making sure patients know their input is valued can be crucial.
“I think [the physician needs to] communicate with the patient that, by being engaged, we’re not going to ‘spit in your food’ or take offense, like worried waiters might do, if the patient gets ‘too involved,’ ” he says. “In fact, we need to assure patients that being engaged and having their family engaged is very important.”
He recommends that a charge nurse be assigned to promote engagement between staff and patients.
The second step is educating and talking with patients about their disease and their treatment. This is important from two standpoints: It can take some of the mystery away, easing patients’ anxiety while being treated, and it can help patients provide more pertinent information. For example, if you tell patients you’re testing for tetanus and what causes it, they might be able to tell you that they cut their finger on a rusty nail in the attic.
“We also need to understand that not all patients want to be engaged, though I think the majority do,” Kiani says. “Not everybody has the same skills. Some have difficulties with the language, so we can’t have a one-size-fits-all [approach]. Instead, we should try to have a very relaxed, conversational discussion instead of a very technical discussion, that can become more technical as the patients become more and more knowledgeable and more comfortable with those who are engaging them.”
The issue of education goes both ways, says Kiani; nurses and physician need training on patient engagement too.
“Optimum levels of patient engagement are not something that is taught in medical schools or schools for nursing, and I think it should be,” he says. “I think it’s a vital skill that should be taught to every doctor, nurse, therapist, pharmacist before they graduate.”
There are two times when patients need to be engaged, Deao says. The first is engaging patients while they’re in the presence of a physician or healthcare worker. The second is keeping them engaged between appointments.
“When the patient is in front of us, the evidence is clear that we need to do things that help build trust with patients,” he says. “Listening for 90 seconds instead of interrupting at 17 seconds, as is the national norm. Sitting vs. standing when we’re visiting with our patients. Using paraphrasing to ensure they understand what we’re talking about. Cheering on small wins, instead of labeling and blaming, and appreciating those barriers and helping solve with the patient.”
However, those efforts only work when a patient is in the office. A 2016 study by Medscape found that on average, physicians spend 13–16 minutes with a patient during an appointment. The average American has four physician appointments a year, which adds up to 52–64 minutes with a doctor annually.
“That’s one hour with a doctor, but there’s 8,759 other hours [in a year] without a doctor in front of them,” he says. “We have to make sure that we’re helping patients have a system of care that surrounds them even between that. That’s where technology can really come into play. But even the other roles, this is where case managers and coaches all come into play: the old-school technology of calling them in between visits and new technology around the portals, apps, and other things that can really support a patient in between visits.”
Columbia Valley Community Health
When asked about good examples of a strong patient engagement culture, Deao points to the work done at Columbia Valley Community Health (CVCH) in Wenatchee, Washington. CVCH is a federally qualified health center (FQHC), which gives it an advantage when it comes to patient engagement, he says. Because of its FQHC status, 51% of the hospital’s board of directors are required to be members of the community that CVCH serves. And given the health center’s location, that means the board is partially composed of migrant farmworkers.
“[CVCH] did two things I thought were really profound,” says Deao. “One, knowing they had a lot of physicians they were bringing in who didn’t speak Spanish as a primary language, even though their patients did. And [new physicians] didn’t really understand the conditions that those patients faced. They actually send new physicians to Guatemala for a cultural and language immersion program upon hiring, which I think is just phenomenal.”
When designing a new clinic, CVCH also strove to create spaces where patients would feel more comfortable. “Rather than adding five clinical exam rooms, they only added two, and they created three family room–type environments,” he says. “They call these ‘conversation rooms’ where it’s just a comfortable setting with dimmable lighting. You can do most of the stuff you can usually do with a patient, but it doesn’t require that sterile environment of the exam room. And that creates that level playing field of engagement that can help.
“And when you think about that population [at CVCH],” notes Deao, “this might be the first time all day that person sat down in an air-conditioned environment, and to have someone with that level of authority show that level of respect, it can just transform the care outcome.”
Making a Plan
Facilities don’t have to reinvent the wheel when it comes to patient engagement, says Deao. Their strategy should be guided by evidence rather than just getting a committee together. Luckily, evidence and materials on patient engagement already exist; they just need to be adapted to fit each facility’s needs.
Deao admits that reading through hundreds of articles to build a successful patient engagement model can be daunting. He suggests facilities start by creating a simple framework around the four key pieces of an engaged healthcare system: the patient, the physician, the leader, and the care team (employees in any role).
“The way that fits together [is] if you sort of think about patients as being at the bottom of this model,” he says. “If you want to create an environment where patients can take ownership for their health and engage, then above that you need to have physicians and other caregivers who give that discretionary effort when no one is watching.
“[Physicians] have to be engaged themselves” and express empathy, says Deao. “And if you want caregivers to do that and be engaged, then you have to have leaders who create environments for those physicians and employees to work and practice medicine and can bring their best. We [at Studer Group] call that the engagement waterfall.”
The terms “patient engagement” and “patient portal” arose pretty much in tandem, says Deao. The hope was that providing a quick and easy online platform would boost patients’ investment in their health. However, that hasn’t been the case.
“Turns out it’s only the most engaged patients who are going to want to use that in the first place,” he says. “‘Portal’ is just a doorway; think about the origin of the word. It doesn’t mean there’s anything engaging about it. In fact, when you ask most patients these days, almost all of them say they want this, but very few of them say it’s a strategy that will help them take ownership and engage with their own healthcare.” "
Patient engagement is often mistaken as a different measure. It’s important to remember that the following three terms aren’t synonyms and can’t be used interchangeably:
- Patient satisfaction measures whether patients are happy
- Patient experience measures the quality of care patients receive
- Patient engagement measures how involved patients are in their care