Risk Analysis: The Essence of Care Coordination

Transcription

1 Risk Analysis: The Essence of Care Coordination Lee Paton, RN, PhD Oregon Health Sciences University Today s Problems Began a Long Time Ago For the past 50+ years, we have encouraged patients to take on a passive role and view healthcare professionals as the experts. This was great when the problem was an infection and we had magical cures such as antibiotics. As such, patients have learned to seek these miraculous solutions, not collaboration with the healthcare team. However, as time went by, we discovered we don t have the ability to fix everything. Alienation & the Expert Model We have been forced to face the fact that we cannot cure everything, but we forgot to change our approach to patients. We have continued to promote the comfortable, expert model and to maintain discipline specific boundaries with patients and advise them rather than collaborating toward a mutually acceptable plan of care. However, the bad news is that this behavioral and philosophical perspective has served to alienate patients even more from their bodies and health. But it has also supported the idea that the medical world is responsible for health and well being. 1

2 Lookin for Love in All the Wrong Places As such, the U.S. healthcare system has created a monster. We tacitly promote magical thinking and all too often maintain that we are the omnipotent magicians. Patients learned to expect immediate solutions but also learned to maintain unrealistic expectations. Patients are now lookin for love in all the wrong places by expecting the healthcare industry to solve their problems with the world and with life. The Expert Model Has Fueled the Problem As long as patients are alienated from their bodies, their diseases and treatments, they will continually seek care and expensive care for their problems. The solution won t arise from patient education or from finding funding for prevention. The solution will arise from shifting the responsibility from the experts and create effective collaboration between patients and the people within the system. Continuity of Care is An Enormous Concept Care coordination implies an understanding that: Patients independently manage their chronic illnesses 5000 hours per year v. medical intervention of ~ 120 minutes. Continuity of care is not inpatient to outpatient, but includes continuity between the car and the house, the backdoor and the flower beds, the front door and the grocery store, schools, etc. We need a broader understanding and appreciation of what patients need to do and the limitation of our power. Unless we can see this, our expert model will continue to create disasters. 2

3 Patient Relationships & Engagement As we look at the causative elements behind the problem and at the patients role in health and wellbeing, we can recognize the need for stronger patient engagement that is based on positive, humane relationships. It is clear that this is the critical element missing and it is essential that we find ways to accomplish this. This is the role of the care coordinator. EBP Starts with Data However, being scientists, we love quantitative analysis. Thus, care coordination starts by looking at populations and identifying the disease and behavioral patterns that have created the problem (notice the healthcare professionals behavior is absent from this equation). This population based risk stratification provides a statistical inventory of clinic populations while also identifying patients who may benefit from specialty care through care management or through a community outreach or hot spotting emphasis. Relying on Evidence Based Practice This stratification process is based loosely on the process of differential diagnosis. Collect evidence based data Determine the statistical probability Identify the most likely diagnostic label Rule out the probabilistic diagnoses until the evidence supports the diagnoses Therefore, risk stratification matches our existing models. 3

4 Quantitative Analysis is Addictive Yet one of the challenges is that quantitative data is addictive. Most scientists love to muck around in data sometimes creating data junkyards to analyze and reanalyze and reanalyze what we know. Yet rehashing the quantitative data won t get us to definitions or processes. It may get us a bit closer to better predictive aggregate models. But this type of risk stratification doesn t explain what care management is or what a care manager should do to promote individualized, patient centered care. We Do What We Do Well... Again and Again Statistical analysis is relatively easy in comparison to the work of figuring out what we might do to move the Triple Aims forward. Thus, the well analyzed list goes to each care manager or coordinator to begin addressing the patients needs. The problem? What exactly is care coordination? Current State of Care Coordination 4

5 Primary Care Coordination Role Competency The process of care coordination can best be defined as moving beyond the aggregate risk analysis to determine the modifiable risks associated with individual patient behaviors. What behavioral risks increase utilization? What habit based risks impact poor outcomes? What engagement risks influence satisfaction? What belief patterns lead to risks that influence negative patient results? Identifying Trends and Concerns As we take clues from the aggregate data, we quickly discover that there are many social as well as behavioral and substance abuse factors underlying high utilization and poor outcomes. The challenge? Can these determinants be modified? Does the patient see these determinants as significant to health and well being? Or are these determinants part of well being? What interventions may make a difference in promoting higher levels of health? Just a Few Health Determinants Body Mind Spirit Disease Conditions Multiple comorbidities Pharmacology Genetics Age Prognosis Functionality Habits and patterns (e.g., smoking, lack of exercise) Psychological adaptation Mental health diagnoses Substance abuse Family structure Social networks and social functionality Finances and economics Shelter and food acquisition Access to healthcare World view Religious orientation Belief system Forms of mercy Meaning of life Sense of integrity Internal resources Degree of despair or hopelessness 5

6 Coordination Competency: Risk & Stability Analysis Modifiable is not in the eye of the clinician avoid the expert model that instructs the patient without engagement. Modifiable is in the eyes and minds of the patients. Determining modifiable risks is an exercise in identifying what is meaningful and what the patient is willing and able to do. People Just Want to Be Happy Behavior is generally goal directed. But the goal may not be obvious! People make choices based on what they perceive will further their well being and reduce stress. Often these decisions don t create long term well being, but are geared toward relieving short term stress. And there s nothing quite like a beer after a long day and another one... And another. And so it goes with our human habits. Our Annoying Change Algorithm The medical and nursing model has historically focused on a relatively simple algorithm to address behavior change. We identify the problematic behaviors, habits or patterns. We develop a basic educational plan to teach the patient about why their habits are wrong. We tell them things that they already known and are then surprised when the patients don t follow our advice. 6

7 Factors Behind Decision Making Patients make decisions in order to: Enhance happiness or Reduce stress or Maintain coping patterns or Just make it through another day To repeat: Patients will not change unless that change will increase happiness or reduce stress. Willing and able is patient specific and related to the need for meaning, power and coping. Behaviors Are Coping Devices As with our usual teaching style, we may identify problem behaviors, but if we don t understand the patients perspective, we run the risk of being annoying at best and alienating at worst. Thus, risk analysis isn t important because we can identify risks... It s important because it allows us to enter into a meaningful dialogue about health, being fully alive and happiness through the patients eyes. Motivation is Determined By Meaning Patients know the things that negatively impact their health. They just haven t found the right antidote to those behaviors. Behavior change arises from relationships, respect and a sense of growing integrity. Care coordination isn t coming up with a laundry list of other behavioral options for the patient. Care coordination asks that we learn how to engage in relationships that stimulate the patient to investigate personally meaningful options. 7

8 Meaningful, Modifiable Risks are Hard to Quantify Remember: We love being scientists with double blind, controlled clinical trials. But care coordination requires expertise in qualitative analysis. The challenge? To substantiate our role, we must find ways to measure our role in modifiable risks. This will not be immediately obvious. We must come together to share our knowledge and skills in order to develop tools. Care Coordination = Intimacy Qualitative analysis is a process of deepening intimacy in order to understand the patients perspectives. This does NOT mean poor boundaries. It means trust and listening closely to what is meaningful to the patient. It means the ability to listen with unconditional positive regard. Coordination asks that we engage with the patients in order to fully understand the patients existing strengths, limitations and resources. Learning to Listen is Essential The average clinician interrupts the patient within 23 seconds and continues talking for the rest of the encounter. Listening doesn t take more time true listening is the key to efficiency. Listening provides a window into the meaning of patients behaviors and patterns without making assumptions and imposing prejudice. Remember: Our agenda is usually the biggest time waster. 8

9 Suffering: Not Being Heard Patients will continually seek to be heard especially when we interrupt and behave rudely. The most effective way to relieve suffering is to listen. If we ignore or talk over the talk of them, patients suffer and will continually look for someone to hear them. As such, care coordination requires learning to listen as qualitative researchers rather than someone who gives advice or teaches. The Willing and Able Listener What do YOU want out of the patient encounter? If you don t know what you are seeking, you will push an unconscious agenda and never get to the patients actual needs. What does the patient want out of the conversation? If you know this, you can shape the conversation toward that goal. Can you keep an open mind and allow patients to be confused and uncertain about their needs? Can you avoid premature closure? Shutting down a conversation too soon will guarantee a call back and another ding on the patient satisfaction scale. Listening as a Spiritual Practice Practicing listening is a critical element in learning to be an expert care coordinator. Find a willing and able partner and learn to listen to each other. Notice how often you want to interrupt with a great idea. Take note of all the times you move into problem solving rather than listening. Keep your humor. We ve taught you well to interrupt. It takes energy to overcome a lifetime of training. 9

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