PATIENT CENTERED CARE. Barbara E. Weinstein & Jennifer Gilligan

Transcription

1 PATIENT CENTERED CARE Barbara E. Weinstein & Jennifer Gilligan

2 DISCLOSURE STATEMENT We have no relevant financial or nonfinancial relationship(s) with the products or services described, reviewed, evaluated or compared within this presentation. Jennifer Gilligan, Doctoral Student in Audiology, CUNY 16 Barbara E. Weinstein, Ph.D.

3 GOALS FOR OPTIMIZING HEALTH OF OLDER AMERICANS (AGS, 2012) Ensure that every older adult gets high quality PATIENT-CENTERED CARE Increase number of healthcare professionals who employ the principles critical to caring for older adults Collaborate to influence public policy to continually improve the health and health of older adults Core value should be excellence in care

4 Patient Provider Family Member

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6 INTERPROFESSIONAL PROFESSIONALISM COLLABORATIVE ( 2_3_COMPILATION%20OF%2043%20OBSERVABLE%20BEHAVIORS%20IPC _GANDY.PDF) consists of 10 doctoral health professions collaborating since 2006 to develop and make available resources for the health professions associated with inter-professional professionalism Practitioners from various professions learn from and about each other to improve collaboration and the quality of care Assesses patients readiness to learn, motivation to change and provide self-care, and matches education and plan of care to their level of readiness Educate and empower patients, caregivers, and family members for managing their health care

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9 GOAL To call attention to the need for clinicians, staff, and health care systems to shift their focus away from diseases and back to the patient and family

10 INSTITUTE FOR FAMILY CENTERED CARE Patient- and family-centered care - innovative approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among patients, their families, and health care providers information sharing is key

11 PATIENT CENTERED CARE? Information, communication and education; shared decision making and support for self care, involvement of family and friends, respect for patient s values, preferences and expressed needs (Gerteis, et al., 1993) Understanding the disease and the patient experience (Stewart, et al., 1995) Placing patient at the center of the system and developing good systems that revolve around the patient (Mallett, 1996)

12 PATIENT-CENTERED CARE? Health care that is closely congruent with and responsive to patients wants, needs and preferences (Laine & Davidoff, 1996 Providing care that is respectful of and responsive to patient preferences, needs and values, and ensuring that patient values guide all decision making (IOM, 2001)

13 PATIENT-CENTERED CARE IOM : Patient values guide all clinical practice Stresses the importance of clinicians and patients working together to produce the best outcomes possible.

14 KEY ATTRIBUTES OF PATIENT- CENTERED CARE (PCC) (CRONIN, 2004) Education and shared knowledge Involvement of family and friends Collaboration and team management Sensitivity to nonmedical and spiritual dimensions Respect for patient needs and preferences Free flow and accessibility of information

15 PRINCIPLES OF PATIENT CENTERED CARE (SHALLER, 2007) Respect for the patient and family preferences which balances the burden of therapies with potential benefits All team members and everyone in the workforce considered a caregiver Care is customized and reflects patient needs, values and choices Systematic measurement and feedback

16 Knowledge and information are freely shared between and among patients, care partners, physicians and other caregivers. Families and friends of the patient are considered an essential part of the care team The patient is the source of control for their care. Evidence-based medicine must guide decision making. Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication

17 HUMAN BEING VALUED Education and Shared Knowledg e Involvement of Family and Friends PCC Respect for Patient Needs Collaboration and Team Management

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19 ASHA VISION Making effective communication, a human right, accessible and achievable for people from all cultural and socieoeconomic backgrounds

20 LISTENING TO THE PATIENTS unique story is not just one of the most interesting aspects of being a health care professional but one of the most necessary to being a good one. At the heart of this is the give and take - the fulcrum being communication and health literacy.

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22 Health Literacy is: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions The capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions A PRESCRIPTION TO END CONFUSION

23 VALUE OF GOOD PATIENT CENTERED COMMUNICATION (IOM, 2005) Influences patient perceptions Imbues trust in health care professional and health care system Promotes patient loyalty Overall positive health outcomes Assures patient engagement in care

24 CONSEQUENCES OF GAPS IN COMMUNICATION Medical Errors Increased Costs Oveall Poor Quality Health Care

25 PCC AND SLP - ROLE SLP as part of team: Aphasia Swallowing Dementia TBI Hearing loss Tracheostomy Other professionals must know how to communicate effectively in order to effectively deliver patient centered care SLPS have a major role to play in advocating for PCC

26 Information, communication, and education clinical status progress prognosis processes of care discharge planning end of life care

27 An integral part of clinical practice Facilitate understanding of condition (e.g. hearing loss) PATIENT CENTERED COUNSELING Help with acceptance of circumstances Empowering towards selfefficacy Must be culturally and linguistically appropriate. Facilitate compliance with recommendations

28 SCENARIOS? Health care that establishes a partnership among SLPs, patients, and their families (when appropriate) to ensure that decisions respect patients wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care Speech and language treatment or no treatment for an individual with aphasia as a result of stroke Use of stimulation or social support to improve receptive and expressive language skills Functional SLT was found to improve functional tasks but in more general measures of communicative activities of daily living the conventional SLT approach was better Intensive versus conventional speech and language treatment Group versus conventional speech and language treatment for addressing expressive or receptive language skills. services provided by a speech-language pathologist and those provided by a volunteer with Supervision and training from a speech-language pathologist.

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30 CHARACTERISTICS OF PERSONS WITH LOW HEALTH LITERACY

31 More than 22 million people speak English less than very well More than 34 million people are from another country More than 95 million people living in the US (43% of adults) have literacy levels below what they need to understand even basic written health information such as how to take a medicine (IOM, 2004) Limited health literacy is an especially serious problem for Americans over 65 (40million) *33 % of patients have limited health literacy *12 % have proficient health literacy *AMA

32 Functional Health Literacy Risks Inadequate health literacy is more prevalent in older populations (Baker et al., 2000, 2002; Benson & Forman, 2002; Gazmararian et al., 1999; JAMA: Health Literacy Lacking, 1999) Cognitive Impairment Physical Impairment Hearing Loss Depression Hypertension Diabetes Vision Loss

33 As the number of older adults with chronic conditions continues to increase, health systems can not cope if they focus on disease rather than the patient. The patient must be involved to insure behavioral change, compliance, and self management

34 LITERACY & HEALTH At risk populations for low health literacy include: Literacy Speech, language, hearing, vision disorders Cognitive or mental disorders Non-English speaking & immigrants Elderly Ethnic minority & cultural differences Poverty Homelessness Health knowledge Health Status Income level, occupation, housing Access to medical care Institute of Medicine (2004) Access to health services

35 WHY HEALTH LITERACY IS IMPORTANT (AMA)

36 Health literacy Affects People s Ability to: Navigate the healthcare system, including locating providers and services and filling out forms Share personal and health information with providers Engage in self-care and chronic disease management Adopt health-promoting behaviors, such as not smoking and eating a healthy diet Act on health-related news and announcements

37 Functional Patient Education & Use of the Health System Communicative / Interactive Helping individuals to act independently in taking responsibility for their health., with a focus on development of personal skills in a supportive environment. AREAS OF HEALTH LITERACY RELEVANT TO PCC (NUTBEAM, 1998) Empowerment (Critical) Improving individual and community potential to respond to social and economic factors that affect health status.

38 Functional Health Literacy Basic reading comprehension and writing skills to understand health information. Interactive Health Literacy Higher level communicative and social skills required to extract and discuss health information with others. Critical Health Literacy Skills necessary to analyze health information and make informed decisions.

39 Functional health literacy: patients with aphasia & their families must know about aphasia symptoms & availability of treatment / services. General information & brochures regarding aphasia made available to the public. Communicative/interactive health literacy. accessing the service by making the appointment, arriving for the scheduled appointment, interacting with the provider, & understanding assessment findings. Critical health literacy: lobbying for legislation to maximize reimbursement for aphasia assessment & rehabilitation encouraging professional & community support of relevant legislation(jackson Hester & Stevens-Ractchford, 2009).

40 Functional Health Literacy Risks Inadequate health literacy is more prevalent in older populations (Baker et al., 2000, 2002; Benson & Forman, 2002; Gazmararian et al., 1999; JAMA: Health Literacy Lacking, 1999) Cognitive Impairment Physical Impairment Hearing Loss Depression Hypertension Diabetes Vision Loss

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43 What is the predicted health literacy of patients receiving audiological services? Are there significant differences present in the level of language used by patients and the average level of reading among U.S. adults? Are there significant differences present between the level of language used by audiologists and patients? Are there significant differences present in the level of patient education materials (i.e. hearing aid instruction guide) and the level of language used by audiologists? Are there patient demographic variables present that are good predictors of the language used by audiologists?

44 METHODS 3 experienced audiologists from the university clinic (2 had graduate level counseling courses) 12 adult hearing impaired participants: 8 male, 4 female; mean PTA 36.1 db HL; mean age 70.6 (57-75) 5 first-time hearing aid users, 7 experienced hearing aid users Each participated in a hearing aid orientation appointment. The dialogs were videotaped and transcribed. Some were given printed educational materials (Hearing aid guides). Transcribed dialog was analysed using the Flesch-Kincaid grade level formula (FKGL) The formula translates writing samples into a U.S. grade level equivalent; theoretically, specifying the education level generally required to understand the sample. For example, a score of 5.3 would indicate that the writing sample should be understood by an average fifth grade student.

45 RESULTS All of the patients in this study had a predicted health literacy that was below a fourth grade reading level based on the analysis of the counseling sessions. The audiologists language was significantly different from predicted patient health literacy. The audiologists language was found to be significantly lower than the language used in the hearing aid instruction guides.

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47 IMPLICATIONS Access to information starts with being able to hear it, ask questions, and understand the responses. In this regard, hearing-impaired patients are at a disadvantage." At the heart of PCC is the patient as driver Nair & Cienkowski (2010) Poor understanding of information costs time, money and frustration E.g. needing to make additional appointments for clarification of hearing aid function. Poor understanding can lead negative outcomes E.g. failure to complete home based assignments Poor understanding can affect self esteem Psychological consequences can be far-reaching if person to whom was is speaking can not understand what is said for expressive or receptive reasons Poor understanding can negatively impact overall health A hearing impaired person without some form of amplification will not thrive in group or individual slt.

48 TIPS FOR IMPROVING COMMUNICATION AND PATIENT CENTERED CARE: WHAT WE NEED TO SHARE WITH MEMBERS OF THE TEAM

49 Use Actionable Communication: tell patient what to do and how to do it use content that is actionable focuses on behavior.

50 EXAMPLES OF ACTIONABLE COMMUNICATION??

51 Dysphagia Diet recommendations Strategies to help the individual swallow more effectively, comfortably and safer

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54 Shared Decision Making The Pinnacle of Patient-Centered Care The most important attribute of patient-centered care is the active engagement of patients when important health care decisions must be made especially where the diverging paths have different and important consequences with lasting implications Not involving patients in decisions about their care can have a detrimental effect on both the quality of care received and patient safety. The authors urge clinicians to (Barry & Edgman-Levitan, 2012)

55 Shared Decision Making An intervention should be considered a standard only if there is virtual unanimity among patients about the overall desirability... of the outcomes. For the vast majority of decisions there is often no intervention that meets this high bar so our patients need to be involved in determining the management strategy most consistent with their preferences and values (Eddy).

56 The goal of patient based decision aids: *illuminate available options to patients in an unbiased way *explain the risks and the benefits of each option based on evidence and inform patients about potential outcomes *help patients to think about their personal values and attitudes about risk *provide pertinent facts so that when they meet with their health professional, they will be able to make a more informed decision *tailor to meet the needs of each individual illness and situation. *help patient to understand condition and possible outcomes

57 SHARED DECISION MAKING THROUGH DECISION AIDS (BARRY & EDGMAN- LEVITAN, 2012) shared decision making, both parties share information the SLP offers options and describes their risks and benefits, and the patient expresses his or her preferences and values Each participant is thus armed with a better understanding of the relevant factors and shares responsibility in the decision about how to proceed

58 VALUE OF DECISION AIDS Leads to increased knowledge More accurate risk perceptions A greater number of decisions consistent with patients' values A reduced level of internal decisional conflict for patients Fewer patients remaining passive or undecided Helps address the problems of overdiagnosis and overtreatment.

59 SIX STEPS IN SDM (INFORMED MEDICAL DECISIONS FOUNDATION, 2012) Invite patient to participate Present options Provide information on benefits and risk Assist patient in evaluating options based on their goals and concerns Facilitate deliberation and decision making Assist with implementation

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62 PROMOTING PCC IN MULTI DISCIPLINARY TEAMS Acute care; long term/rehabilitation; residential In-service presentations Active collaboration with all staff Committees Research

63 INFORMATION ALONE IS NOT PATIENT EDUCATION Fran London, MS, RN (2013) Behavior change Information is passive Education individualizes the needs of the learner Interaction INTERACTION facilitates improved health outcomes Education Information

64 HOW TO EFFECTIVELY COUNSEL? Answer these three essential questions in patientcentered language re: Diagnosis Treatment Context What is my main problem? What do I need to do? Why is it important for me to do this? Ask Me 3 is a registered trademark licensed to the National Patient Safety Foundation Health professionals may converse easily with colleagues in their specialized field, but find it difficult to communicate with patients or the public.

65 PLAIN LANGUAGE ORAL WRITTEN OTHER

66 PLAIN LANGUAGE - ORAL Speak slowly, loudly and clearly Use jargon-free language Be specific, not general Categorize, organize and prioritize information Use repetition and clarification Utilize simple diagrams/graphics Minimize embarrassment and shame Maximize respect and cultural sensitivity Use amplifier if necessary

67 DEVELOP PRINTED MATERIALS Short sentences, active voice Concrete examples Use "you" and "we" No jargon. Define acronyms Chunk information Include white space Use bulleted lists Use graphics that are relevant to message

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71 Teach-back Ask patient open-ended questions to elicit comprehension of the information.

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73 PCC IN ACTION Clear Communication / optimal communication mode???? Emotional Connection / QOL / Grieving Process of Hearing Loss Patient Self Efficacy / Readiness Talk-back Confirmation of Patient s History / Communication Repair Motivational Interviewing techniques

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75 IF WE VIEW THE HEALTH CARE EXPERIENCE THROUGH THE PATIENT'S EYES, WE WILL BECOME MORE RESPONSIVE TO PATIENTS' NEEDS AND, THEREBY, WE WILL ALL BECOME BETTER CLINICIANS BARRY & EDGMAN- LEVITAN, 2012)

76 Patient-Centered Care Awareness Month is a global awareness-building campaign that occurs every October to commemorate the progress that has been made toward making patientcentered care a reality and to build momentum for further progress through education and collaboration. Hospitals and health care organizations around the world are encouraged to celebrate by making a commitment to develop more compassionate care practices and by publicly proclaiming to their patients and communities their commitment to patientcentered care.

77 REFERENCES AGS (2012). Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society. Retrieved Nov. 4, American Academy of Audiology (2012). Standards of Practice for Audiology American Speech- Language-Hearing Association. (2004). Scope of Practice in Audiology [Scope of Practice]. Available from American Counseling Association (2013, March) A Vision for the Future of Counseling. Retrieved from American Medical Association. (2006). An ethical force program consensus report: Improving communication improving care. Chicago (IL): AMA. Baker, D., Gazmararian, J., Williams, M., Scott, T., Parker, R., Green, D., et al. (2002). Functional health literacy and the risk of hospital admission among Medicare managed care en- rollees. American Journal of Public Health, 92, Chien, W. & Lin, F.R. (2012). Prevalence of hearing aid use among older adults in the United States. Archives of Internal Medicine, 172(3): doi: /archinternmed Cruess & Cruess (2011) Whole Person Care, Professionalism, and the Medical Mandate. In Hutchinson, T. A. (Ed.). (2011). Whole person care: A new paradigm for the 21st century. Springer.

78 REFERENCES, CONT. Davis, K., Schoenbaum, S. C., & Audet, A. M. (2005). A 2020 Vision of Patient Centered Primary Care. Journal of General Internal Medicine, 20(10), Gerteis, M., & Picker/Commonwealth Program for Patient-Centered Care. (2002). Through the patient's eyes: Understanding and promoting patient-centered care. San Francisco: Jossey-Bass Health Literacy: A Prescription to End Confusion - Institute of Medicine. (2004). Retrieved from Health Literacy. (n.d.). Retrieved from Health Literacy Glossary CommunicateHealth. (n.d.). Retrieved from Hester, E. & Stevens-Ratchford, R. (2009). Health literacy and the role of the speech-language pathologist. American Journal of Speech-Language Pathology, 18, International Alliance of Patients Organizations (2005). What is Patient-Centered Healthcare? A Review of Definitions and Principles. Retrieved from Laine C, Davidoff F. (1996). Patient-Centered Medicine: A Professional Evolution. JAMA. 275(2): London, Fran, RN. "Information Is Not Patient Education." Web log post. Patient Education Blog No Time To Teach RSS. N.p., n.d. Web. 03 July <

79 REFERENCES, CONT. Nair, E. L., & Cienkowski, K. M. (2010). The impact of health literacy on patient understanding of counseling and education materials. International Journal of Audiology, 49(2), National Assessment of Adult Literacy (NAAL) - Health Literacy (2003). Retrieved from Nutbeam, D. (1998). Health promotion glossary: Health Promotion International, 13, Patient-Centered Care: An Introduction to What It Is and How to Achieve It -Discussion Paper for the Saskatchewan Ministry of Health (2009). Retrieved Nov. 4, 2013 Schaller, D. (2007). Patient-centered care: what does it take?. Commonwealth Fund Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR (1995). Patient-centred medicine transforming the clinical method. Thousand Oaks: Sage Publications Planetree.org Inspiring Caregivers to Transform the Health Care Experience. (n.d.). Retrieved from U.S. Department of Health and Human Services (2000). Healthy People Washington, DC: U.S. Government Printing Office