Jama A Systems Approach To Patient Centered Care

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A Systems Approach to Patient-Centered Care Steven C. Bergeson; John D. Dean JAMA. 2006;296(23):2848-2851 (doi:10.1001/jama.296.23.2848) Online article and related…
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A Systems Approach to Patient-Centered Care Steven C. Bergeson; John D. Dean JAMA. 2006;296(23):2848-2851 (doi:10.1001/jama.296.23.2848) Online article and related content current as of August 3, 2010. http://jama.ama-assn.org/cgi/content/full/296/23/2848 Correction Contact me if this article is corrected. Citations This article has been cited 35 times. Contact me when this article is cited. Topic collections Neurology; Patient-Physician Communication Contact me when new articles are published in these topic areas. Subscribe Email Alerts http://jama.com/subscribe http://jamaarchives.com/alerts Permissions Reprints/E-prints permissions@ama-assn.org reprints@ama-assn.org http://pubs.ama-assn.org/misc/permissions.dtl Downloaded from www.jama.com by Marcelo Villar on August 3, 2010 COMMENTARY A Systems Approach to Patient-Centered Care Steven C. Bergeson, MD management support and care coordination as key compo- nents. John D. Dean, MBChB, MD, FRCP Redesigning Systems P ROVIDING CARE CENTERED ON PATIENTS’ NEEDS AND As experienced clinicians know, the strength of their com- expectations is a key attribute of quality care.1 Un- mitment to provide patients with what they need and ex- fortunately, despite the intent and efforts of many pect and the quality of the relationships between clinicians to improve patient centeredness, the quality of pa- and patients is central to patients’ experience. What may be tient-clinician relationships, patient access, and continuity less obvious is the extent to which well-designed support of care appear to be worsening in the United States2 and lag and delivery systems are essential if care is going to center, behind other Organization for Economic Co-operation and reliably and consistently, on patients’ needs and priorities. Development (OECD) countries.3 Clinicians do not con- Current incentives produced by payment systems have fo- sistently address patients’ concerns,4 do not always assess cused tremendous responsibility and workload on physi- patients’ beliefs and understanding of their illness, and of- cians. However, asking clinicians to work harder or pre- ten do not share management options with patients.5 Pa- suming that lack of patient centeredness is due to a lack of tients frequently fail to recall basic elements of their care knowledge or training will not necessarily produce the re- plan.6 All this is occurring as care becomes increasingly com- sults that patients—and clinicians—want and need. In re- plex and as more costs of care are borne directly by pa- designing systems, a primary goal is to delegate to office staff tients. or patients those tasks that do not require direct physician In this Commentary, we propose 4 specific changes that involvement, thus freeing up time for physicians to build should help the medical profession meet patients’ needs and the kind of relationships with patients that directly address expectations. These changes involve redesigning the sys- patients’ needs and priorities. tems of care that both evidence and practice suggest are more Ensuring Access and Continuity. The redesigned sys- likely to succeed rather than relying on clinician rewards, tem of patient scheduling referred to as open access or feedback, or training alone. They are (1) improving access advanced access8 helps office practices reduce waiting times to and continuity with clinicians, (2) increasing patients’ par- and increases continuity by reducing backlog and match- ticipation in care by making it easier for patients to express ing the supply of appointments with demand. The goal is their concerns and involving them more actively in the de- for patients to have access to an appointment when they sign of their care, (3) supporting patient self-management want or need it and with the clinician they choose; as through systems that facilitate goal setting and that in- such, open access is also a tool to help build the relation- crease patient and family confidence in self-care, and (4) ship between caregiver and patient. Continuity of care establishing more efficient and reliable mechanisms for co- with a clinician is known to be a key factor associated with ordinating care among settings. patient satisfaction.9 In terms of specific clinical outcomes, The evidence for most of these system changes is robust increased continuity has been associated with better out- and supported by clinical trials that have demonstrated the comes of diabetes care; improved delivery of preventive desired outcomes. Some interventions have been widely care; reduced hospitalizations, emergency department vis- implemented in practice and appear promising but have not its, readmissions, and length of stay; and improved clini- been subject to clinical trials and require further evalua- cian satisfaction.10 tion. Consolidating these approaches into a coordinated se- Implementing open access is a substantial challenge, but ries of practical system changes is the purpose of this Com- organizations that have done so have seen substantial im- mentary. The magnitude of their combined effect is unknown but should be intensively studied. Author Affiliations: Institute for Healthcare Improvement, Cambridge, Mass (Drs Although the proposed system changes could be applied Bergeson and Dean); Allina Hospitals and Clinics, Shoreview, Minn (Dr Berge- son); and Bolton Primary Care Trust, Bolton, England (Dr Dean). to all patients, the chronic care model7 is an example of an Corresponding Author: Steven C. Bergeson, MD, Allina Hospitals and Clinics, 4194 evidence-based system approach that includes self- Lexington Ave N, Shoreview, MN 55126 (steven.bergeson@allina.com). 2848 JAMA, December 20, 2006—Vol 296, No. 23 (Reprinted) ©2006 American Medical Association. All rights reserved. Downloaded from www.jama.com by Marcelo Villar on August 3, 2010 COMMENTARY provements in patient satisfaction, better utilization of ser- tions or symptoms—and “What matters?”—that is, pa- vices, and improved staff and physician satisfaction.11 Vis- tients’ interests, concerns, and fears about specific condi- its scheduled with the desired clinician include more tions or symptoms. Technology can also help in assessing preventive services than those with a clinician who does not the value of the care provided; determining patient confi- know the patient, and open access can improve financial re- dence to self-manage and control health problems, as well turn on clinician time in fee-for-service reimbursement sys- as barriers to self-care; and learning about patient expecta- tems. Maintaining open access is also a challenge because tions for visits. Helping patients articulate their concerns office staff must continuously balance demand and supply and expectations for visits greatly increases active patient and plan for contingencies. Open access has typically been participation in a particular consultation and in the care pro- implemented in primary care, but specialty practices are in- cess generally. creasingly interested in using this approach to improve ac- Many clinicians may become bothered when patients cess to care. bring lists of concerns to their appointments, primarily Creating multiple routes of practice access has been ob- because of the perception that dealing with the list can pro- served to increase patient centeredness and safety by en- long the visit. However, clinicians can negotiate with abling multiple contact methods based on patient prefer- patients about which concerns have priority. The use of ences. Access to nonphysician members of the care team is such lists has been demonstrated to increase patient- observed to reduce work for clinicians and increase conti- centered care by making sure that patients’ primary con- nuity; contact methods can be by telephone, e-mail, or cerns are addressed.18 It is possible that the time physicians drop-in visit (either individual or group). When tasks are need to address multiple patient concerns can be reduced delegated more widely within a practice, the roles of all mem- by relying on nonphysician members of the health care bers of the care team and methods of patient contact need team to handle appropriate items. to be particularly clearly defined. Clinicians often express Tools to facilitate agenda setting for patients with chronic concern that e-mail will increase their workload. The evi- disease might help patients become more active, especially dence about the effect of e-mail on workload is mixed, but for those who present without a new complaint. “Agenda in some practices evidence shows that it has decreased the cards” developed in the United Kingdom are an example of number of telephone calls from patients.12 Telephone care an application in this area. A deck of cards is created con- for depression and diabetes has resulted in improved satis- taining statements about issues commonly faced by pa- faction and outcomes.13,14 tients with a particular chronic condition; the cards help pa- Many patients want access to information through elec- tients verbalize the key concerns they want to address during tronic medical records (EMRs), and such access is increas- the visit. This innovation is currently undergoing evalua- ingly available. A small study showed that access to the tion of its effectiveness. Hospice programs in the United States EMR enhanced patient understanding of their conditions have used a similar approach. Using a tool (paper-based or and improved communication between physicians and in an EMR) that lists both patient and clinician issues and patients.15 Viewing abnormal laboratory results can be that documents agreed-upon priorities for a given visit could upsetting to some patients and access to such information enable a more patient-centered consultation, particularly if therefore needs to be carefully planned. However, giving the tool specifies how and when other issues will be ad- patients the ability to view the results of their laboratory dressed, including by other members of the care team or in work could improve the safety of care by decreasing the a nonvisit format. likelihood that abnormalities will “slip through the cracks” Because families play such a vital role in helping unobserved. patients manage their medical conditions, particularly Increasing Opportunities for Patients to Participate in chronic illnesses, involving families in the design of care the Care Process. Designing office visits specifically to ad- systems improves both the quantity and quality of family dress patients’ concerns encourages patients to share in con- involvement and can be instrumental in helping prevent trol of their care. Patients often come to their visits with mul- error.19 An approach in which self-assessment of health tiple concerns, many of which remain unspoken or status is used could activate patients by identifying specific unrecognized, resulting in reduced patient satisfaction and gaps between their current and ideal health. Self- poorer outcomes.16 To date, most efforts to improve the abil- management skills education could be linked to these self- ity of patients to voice concerns have centered on training assessments. Such assessments can be offered at defined clinicians. There is reason to believe, however, that strate- intervals to patients who are well and seeking preventive gies to enhance the patient’s role in the consultation will health information or when a new patient enters the care be more successful. system. The assessments can also be designed for patients Moore and Wasson17 have advocated the use of technol- with chronic conditions and incorporated into routine ogy to help make care increasingly patient centered. More care. Gaps in health and functional status are thus identi- specifically, technology can help with the previsit work of fied, and patients can help ensure that these gaps are identifying “What’s the matter?”—that is, specific condi- addressed by being prompted to seek care. Web-based ©2006 American Medical Association. All rights reserved. (Reprinted) JAMA, December 20, 2006—Vol 296, No. 23 2849 Downloaded from www.jama.com by Marcelo Villar on August 3, 2010 COMMENTARY assessment tools have been developed for this purpose. vocacy roles of individuals, and group education in self- Most of these ideas have promise, but they will require fur- management skills led by patients with chronic disease. ther testing. Acquiring self-management skills through group educa- Providing patients with information about the care they tion has been demonstrated to improve well-being, self- should be receiving informs patients and actively involves efficacy, behavior change, and health outcomes21; it has been them in getting the care they need, particularly by provid- particularly helpful for patients with arthritis and diabetes. ing reminders to the care team.20 For example, encourag- Such positive peer effects have also been seen in group medi- ing patients to ask questions that concern them such as “Doc- cal visits.23 tor, shouldn’t I be on aspirin?” could help improve the Coordinating Care Between Settings. Many patients, reliability and quality of care. Patient access to EMRs may particularly those with chronic disease, require care from a make this reminder function easier but does not seem to be variety of health care professionals, often at different loca- essential. tions. Poor information flow between care settings is frus- Providing Self-management Support. Patients provide trating to patients and clinicians alike and reduces safety themselves with the vast majority of care they receive margins. Repeated requests to patients for information can outside of hospitals, and the importance of organizing, be distressing. Identifying a specific care coordinator role supporting, and planning for that care has been well within the primary care team can help minimize these demonstrated, particularly for patients with chronic dis- communication problems. Such a person, either a clinical ease.7 Educating patients about their condition is not or nonclinical staff member, functions as the patient’s effective by itself; patients also need to develop skills and advocate, helps the individual patient navigate the system, confidence to manage their condition. Two key compo- and can ensure that information is in the right place at the nents that support self-management and behavior change right time. Practical measures that have been observed to are collaborative goal setting and action planning. To be ensure coordination of care include providing standard- effective, goals and action plans must be specific— ized referral and hand-off information, as through the use agreeing on what, when, where, and how often specific of templates developed collaboratively by primary care actions are needed—and must detail the barriers. 21 providers and specialists. Involving care managers for Action planning tools have been observed to increase the patients with depression has been shown to improve out- likelihood that obstacles to best performance will actually comes in primary care.24 Patient-held records help coordi- be addressed. nate care, avoid duplication, and ensure that the correct Observation and clinical practice have shown that using information is always where it needs to be—with the tools to guide goal setting and action planning and then iden- patient. tifying other nonphysician members on the care team who can perform these activities helps to incorporate these ac- Conclusions tivities into clinical encounters. Patients who are com- Most systems that support clinicians would benefit from re- puter literate and have access to computers can use Web- design that aligns care more completely with patients’ needs based tools—for example, the “How’s Your Health?” Web and interests. Redesigning the systems of care to increase site (http://howsyourhealth.org/cgi-bin/pblmslv.py)—to help the support of clinicians in their work may be more suc- them develop action plans for health problems. Incorpo- cessful in improving patients’ experience than relying only rating action planning as an explicit, purposeful goal of an on training. Ensuring open access to and continuity with office visit (for instance, a planned visit to monitor chronic clinicians; improving opportunities for patients and fami- illness) will encourage this to occur more reliably. Collabo- lies to participate in the care process; providing active self- rative care planning does improve satisfaction with care, al- management support; and coordinating care between set- though its effects on biomedical outcomes have not been tings are among the basic system redesign components that established; the possibility that collaborative planning re- can result in optimal care from the patient’s point of view, duces physician workload makes intuitive sense but also re- as well as the clinician’s. quires testing.22 Financial Disclosures: None reported. Clear and agreed-upon follow-up plans are essential for Funding/Support: The time spent as fellows at the Institute for Healthcare Im- provement (IHI) was supported by The Health Foundation, London, England, Al- effective care and are an important component of the chronic lina Hospitals and Clinics, Minneapolis, Minn, and the George W. Merck Fellow- care model. Practice shows that incorporating these plans ship. into a patient-held record ensures understanding by pa- Role of the Sponsor: The sponsors had no role in the preparation, review, or ap- proval of the manuscript. tients and families. Providing patients and their families with Acknowledgment: We thank Val Weber, BA, and Jane Roessner, PhD, for their a written or printed postvisit summary can support patient assistance in preparation of the manuscript, Frank Davidoff, MD, for his wise ad- vice and tireless editorial assistance, The Health Foundation, Allina Hospitals and understanding, although the level of health literacy can limit Clinics, and the George W. Merck Fellowship for support of their fellowships at the effectiveness of printed materials. IHI, as well as their colleagues at the IHI and the numerous opinion leaders through- out the United States who have helped to develop and refine these concepts dur- Peer support also improves self-efficacy. This type of sup- ing our fellowships. The IHI team: Drs Roessner and Davidoff and Ms Weber were port can be achieved by patient-to-patient mentorship, ad- paid by IHI for their work. 2850 JAMA, December 20, 2006—Vol 296, No. 23 (Reprinted) ©2006 American Medical Association. All rights reserved. Downloaded from www.jama.com by Marcelo Villar on August 3, 2010 COMMENTARY REFERENCES depressant treatment: a randomized controlled trial. JAMA. 2004;292:935- 942. 1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for 14. Young RJ, Taylor J, Friede T, et al. Pro-active call center treatment support the 21st Century. Washington, DC: National Academies Press; 2001. (PACCTS) to improve glucose control in type 2 diabetes: a randomized controlled 2. Montgomery JE, Irish JT, Wilson IB, et al. Primary care experiences of Medi- trial. Diabetes Care. 2005;28:278-282. care beneficiaries, 1998 to 2000. J Gen Intern Med. 2004;19:991-998. 15. Cimino JJ, Patel VL, Kushniruk AW. The patient clinical information system 3. Schoen C, Osborn R, Huynh PT, et al. Taking the pulse of health care (PatCIS): technical solutions for and experience with giving patients access to their systems: experiences of patients with health problems in six countries [published electronic medical records. Int J Med Inform. 2002;68:113-127. online ahead of print November 28, 2005]. Health Aff (Millwood). 16. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced doi:10.1377/hlthaff,w5.509. agendas in general practice consultations: qualitative study. BMJ. 2000;320:1246- 4. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: 1250.
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