Strategies to Enhance Patient Engagement in Primary Care
(November 2017)
Patient engagement has emerged as an essential element of effective care. Health care leaders around the country have begun to recognize that engaging patients through collaborative, personalized care is key to reducing costs and improving outcomes.
MHQP is in a unique position to learn about structural programs and innovative practices that help empower patients to be active in their own care. With support from CRICO, we recently completed a first-of-its-kind statewide study of patient engagement activities in primary care practices in Massachusetts. As an extension of that work, we are highlighting successful strategies for others to adopt.
What does it take to increase patient engagement? Many of the ideas outlined below are on the cutting edge of innovation, while others are already gaining widespread adoption as standard practice. In either case, we hope you will consider implementing these strategies in your practice if you have not done so already. Click below to learn about each of these promising strategies:
Pre-Visit Planning
Featuring Hilltown Community Health Center
Involving Patients and Families in the Practice
Featuring Yogman Pediatrics
Motivational Interviewing
Featuring Valley Medical Group
Team Approach/Care Coordination
Featuring North Shore Physicians Group
Community Outreach
Featuring Hilltown Community Health Center
Integrated Behavioral Health Services
Featuring Yogman Pediatrics
Shared Decision-Making
Featuring Partners HealthCare
Self Management
Featuring Westwood-Mansfield Pediatrics
PRE-VISIT PLANNING
Featuring Hilltown Community Health Center
Clinicians have limited time with each patient and it should be focused on the patient, not on paperwork. By having other team members do some prep work in advance of the appointment, the practice can optimize the time clinicians spend with patients and the providers can fully focus their attention on the patient’s needs. It’s a great way to make face-to-face interactions more efficient, be respectful of the patient’s time, and help build the relationship between the provider and the patient.
At first glance, it seems counter-intuitive to spend time on a patient in advance of his or her visit. But this is time well spent. Practices report that, while the process requires entirely new workflow patterns for many staff members, they also report that it results in significant rewards for providers and patients alike.
There are many ways to implement pre-visit planning. Some practices reach out to patients 1-2 weeks before the scheduled appointment to make sure the team is up-to-date on critical issues and logistics, and then has time to follow-up on any specialty appointments the patient has had since their last visit. In other practices, the team simply reviews patient files a day or two in advance of the primary care appointment to identify and urgent issues and make sure everything is ready for the appointment.
Here are some thoughts from Eliza Lake, CEO at Hilltown Community Health Center, a network of community health centers in rural Western Massachusetts, which has successfully implemented one approach to pre-visit planning in its organization:
“We do pre-visit planning before every patient comes in. Each of our clinical teams does it in their own way, but the general idea is the medical assistant and the PCP get together to review the patient a few days before the actual appointment. They talk about the issues they believe the patient is struggling with, the topics they need to be sure to raise with the patient, and things they need to do in advance to make the visit as productive as possible. The medical assistant then gets as much of the pre-work done as they can within their scope. By the time the patient arrives, the medical assistant already has a sense of the screening tests the patient needs to have done, where they stand with their mammogram or their cervical cancer screening, etc. Everything is lined up before the patient walks in the door and the PCP can immediately get right to the heart of the matter with the patient.
We’ve been doing pre-visit planning for long enough now that it’s part of our standard process. It’s just what we do. I’m not sure people would know what a visit would look like without it. It’s a very important piece of how we ensure our patients are getting what they need and that they build relationships with their provider. As a rural community health center, we see a vulnerable patient population with very complex needs, and we try to meet all of those needs. Our patients have many social determinants of health that are contributing to their health status, including poverty, food insecurity, housing, etc. So, it’s important for us to understand the full picture because there could be a lot of things going on with somebody – and if you don’t know them well, you could potentially miss something and not address it.”
INVOLVING PATIENTS AND FAMILIES IN THE PRACTICE
Featuring Yogman Pediatrics
It has often been said that patients are the greatest untapped resource in healthcare. Patients are in the best position to give constructive feedback to a practice. By giving patients and families a platform, in the form of a patient advisory group or Patient and Family Advisory Council (PFAC), the practice can create productive partnerships with its “customers” and use their guidance to continually improve service and care.
Pediatric practices are especially ripe for parental involvement. One practice that has been particularly innovative in this area is Yogman Pediatrics in Cambridge, Massachusetts. We spoke to Dr. Michael Yogman, the founder and principal partner in the practice, and Aaron Pikcilingis, a member of the parent advisory group, to learn about how they build productive partnerships between parents and the practice:
Michael Yogman, MD:
“Our parent advisory group is our chance to get advice from some of the already-engaged parents in our practice. We have about 10-12 people in the group – mothers, fathers, people of diverse racial and ethnic groups. We meet quarterly. We follow an agenda to keep the meetings focused.
Mainly we’re looking to them for advice on challenging issues. For example, we have a lot of issues with adolescent confidentiality and how to make the transition from visits where we’re predominantly speaking with the parents to telling the parents that now your teenager runs the show. We got a lot of advice from the group about how to negotiate that and they helped us create laminated information sheets for parents about that transition. Another example is they helped us design our system for getting everyone flu vaccines. These are things that affect the patient and parent experience. We also got a lot of help from the group around the difficulties of coordinating with schools and educational assessments and IEPs. And parents were incredibly helpful when we were enhancing our website. One of them helps us put topical posts on the site and keeps the site up-to-date, which is an enormous help.
They really are partners in the true sense of the word. From the very beginning, it was clear that this is the way to go, that this would lead to important breakthroughs. They volunteer their time and talents because they care about the practice and they feel like they’re active participants in shaping something bigger than just the care of their own child.”
Aaron Pikcilingis:
“What I like best about the parent advisory group meetings is they get me thinking about kids who are different than mine. Specifically, older kids. Mine are still young – 6 and 9 – but we talk a lot about how the practice could help with transition to adolescence. Things in the practice can get sticky with that age group in terms of operations. For example, the providers were struggling with the question of when do you ask the parent to step out for the first time, so the doctor can have time with just the kid. The parents with older kids had some really helpful advice for the practice, I think, and hearing about it gave me a better sense of what is going to happen to me in the future. It’s nice to have a deeper connection to these kinds of issues.
I’m a stay-at-home dad. There are lots of places where that’s a surprise to people, which I find surprising. But the practice has done a really good job of not making me feel like it’s unusual or uncommon that I come there as a dad. Elsewhere, people always ask me if I’m baby-sitting. No, I’m parenting. But the expectation there is I know what’s happening and I know what to do, which is nice. And inviting me to be a part of the Parent Advisory Group was a further demonstration that they believe dads have an important role.
It’s always interesting hearing the different perspectives in the group, especially hearing from others who have been through things that my kids are going to go through. For example, some of the conversations have been about talking with kids about sex. To see how the practice is thinking through that stuff and that they were asking parents about it was really great. The parents say a lot of things that the physicians and the staff hadn’t really thought about. It’s hard to put yourself in a parent’s perspective all the time. And as a parent, you think about your kids and their experience, but if you have typically-developing kids, there’s going to be a whole host of other experiences. That’s a general theme that keeps coming up: there are so many different experiences. There’s common and uncommon and it’s really hard to think of those uncommon things. For me, what I’ve gotten out of this the most is thinking about those edge cases.
I think the practice has benefitted mostly around issues of communications with patients. They recently switched their EMR to EPIC and there’s been a lot of transition in their system as a result. Changing EMRs is a big deal. And we’ve been giving them advice on issues around how to help parents access information and effective communications during the transition. There are many operational issues – and it seems to me that getting feedback from parents is a lot more efficient than waiting for something to not work and hearing parents complain on their own.
From my perspective, it works best when they come to the meetings with problems and look to us to help find solutions. There’s usually a set agenda around things they’re doing and they’re trying to address a problem. But they also give us more open-ended opportunities to identify the problems that parents are dealing with. Sometimes parents just bring things up. So, they get a good sense of what’s happening and what’s not working for people.”
MOTIVATIONAL INTERVIEWING
Featuring Valley Medical Group
Primary care practices are “in the business” of behavior change – helping patients identify goals and overcome their ambivalence to achieving them. MI is a focused and goal-directed approach, so it is ideally suited for engaging patients in primary care. By bringing MI into primary care, providers can more effectively engage the intrinsic motivation within the client to change his or her unhealthy behavior.
The techniques can be transformative in the primary care setting and are relatively easy to learn and spread throughout the practice. Generally speaking, a practice will designate an internal MI expert who becomes trained in the techniques and then trains others in the practice. The practice establishes a process for training new staff members and periodically offers a refresher course for those already trained.
One practice that has deployed Motivational Interviewing techniques extensively is Valley Medical Group, a four-site practice based in central Massachusetts. We interviewed John Novo, MEd, LMFT, CADC II, LADC I, who leads the MI training. Here are his thoughts about using MI in primary care:
Q: Can you first provide some perspective of what patient engagement means in your practice?
Patient engagement for us involves developing a collaborative relationship with patients, getting them to be active participants in their own care. We want them to be not just happy with their experience, not just treated respectfully and civilly. That’s part of it and that’s foundational, but that’s not the same as having patients actively engaged in shared decision-making and taking on an active role, recognizing that what they do at home is crucial to their health outcome. Very little of what happens in the office leads to behavior change outside the office. Most of what we do involves chronic care, chronic conditions, COPD, reducing smoking, increasing exercise, things that impact health and wellness. And so, it involves helping patients set goals for themselves, resolve their ambivalence about making changes, and it involves more than just telling patients what they should do. We have all kinds of ideas about what is health and what is healthy, and they are sound ideas, but it’s a big step to go from giving someone information to actually helping them make and sustain changes in their behavior.
Q: How does Motivational Interviewing help to create these behavior changes?
In healthcare, we need to give information. Typically, we say, now that we’ve told you what the problem is, here are the things you should do – you need to test your blood, you need to exercise, you need to take your medicine regularly, it’s helpful to get some good sleep, etc. People’s eyes glaze over and they leave and too often do none of it. The provider hasn’t really engaged with them on what they’re willing to do, what they’re able to do, and what’s most important to them. But with Motivational Interviewing, we provide information in a particular way that evokes more engagement. You ask a patient what their concerns are, what they’re worried about, you talk about their health or whatever they want to talk about, and you provide some information, but then you say, “Well, what do you make of that?” or “What do you think?” And you elicit from them their reaction, how they’re taking the information in, and then do that in cycles.
The focus of MI is helping people resolve their ambivalence about pursuing some behavior change. The behavior change might involve thinking differently or exercising more or drinking less, but it also might involve disruptive patterns, negative thoughts or cognitive sorts of things as well. It assumes the patients have the ability to make changes; it values their own opinion about what’s best for them; it respects patient autonomy; it involves compassion and a particular kind of spirit; and it’s collaborative. The basic assumption is everybody has trouble making difficult behavior changes; that there’s not a population of motivated patients and a population of unmotivated patients. Everybody’s motivated to do something, even if they’re not motivated to do the thing that’s in their best interest at the moment. MI has a focus, trying to find a way to help people search their own experience and figure out what they’re concerned about, what’s working for them, what’s not working for them, and help them take in information and make it their own and decide what it is – if anything – that they’re going to do.
Q: MI is a counseling technique. How have you used it in primary care?
We’ve trained not just the primary care providers, but also the nurses and medical assistants. It’s a major commitment of resources and time, the big expense being pulling providers out of providing care. But we thought it was important enough that if we’re going to hit our targets for quality and outcomes – not just process, but really affect health outcomes with chronic illness – then patients need to be engaged, they have to collaborate, and they have to make changes. And we recognize the importance of trying to improve the way that we talk to patients so that they’re much more likely to be active participants in their own care. Just telling people and giving them psycho-education and letting them know what they should be doing really has not worked well at all for many, many people. Sometimes it’s actually counter-productive. Everybody knows that cigarette smoking is bad for them. They know it causes cancer and all of that. But that knowledge in and of itself is not enough for most people to make a change. The people who have heard that and responded to it quit smoking a long time ago, and what we’re left with are the people for whom it’s a much more difficult behavior change. It serves a function in their life. It requires other changes to address things that they’re ambivalent about.
One of the key concepts in MI is that readiness to change is made up of importance plus confidence. If someone doesn’t think something’s important enough, they’re not going to pursue it. And if they also feel it’s hopeless and they’re not going to be successful or it’s too much of a change, then they’re not going to pursue it. For most people there’s a mix of both. One of the differences in MI is we pay attention to those kinds of things. We have some ways to help people recognize if this is a problem of importance or if it’s a problem of confidence. If you’ve got somebody who you’re talking to about a health issue and they just don’t feel it’s as important as you do, having a conversation about all those things they ought to do and how they ought to pursue it, it’s really not going to be very helpful. But if you’ve got someone who recognizes that they need to make a change and maybe even feels desperate about it, but they don’t know where to start and they don’t feel confidence, that’s a different conversation. MI pays attention to those kinds of things and tries to meet people where they’re at.
Q: Has this led to some sort of a culture change within the practice?
I think it did help providers think differently about how their patients get stuck – why they don’t make changes. Instead of being judgmental, it made people more empathic and they could realize we all have difficulty making behavior changes. Every one of us has something that we would like to change that we don’t change. Part of the culture change, I think, is talking and thinking about how we relate to patients and how we motivate them to make changes, rather than just lamenting the patients who don’t do the things that we think they should do.
Q: How does this relate to goal-setting?
The way MI approaches goal setting is that the goals should come from within the patient. They are hopefully influenced by the medical knowledge and the interaction with the provider, but the goal has to be one that patients think is important enough and they have some confidence in pursuing. And then the focusing part helps determine what those goals will be.
You’re trying to get people to a place where they can take some action, sometimes just a small action. For example, just getting someone to park their car further away from the door when they go to the mall is a way to increase a little bit of exercise. Part of the approach is you build on small changes, if that’s where people are at. Some people are ready to make a bigger leap and you go with that, but it’s determined by the patient. Just getting people unstuck and if they find they can do a few things then their confidence goes up and they become more willing and able to make other more significant lifestyle changes.
Q: Could you talk about the nuts and bolts about how you rolled this out across the practice?
We’ve actually done this several times, the first time was way back in 2006. And there were a few years when we didn’t do much with it and then we had another big effort last year. I divided the training into four 3-hour segments and spread those out so there were a few weeks between sessions. It’s very active training. We try to minimize the didactic talking part and we do roll-playing and exercises that break down some of the skills and practice. The idea is people would take whatever piece of it they thought they could into their practice and work on it between the sessions. For example, somebody might just work on asking open questions to elicit from patients their own perspective – I’m going to give a little bit of information and then I’m going to pause and ask the patient what they make of what I’ve just said. So those kinds of small things.
Q: How has the feedback been from your providers?
The feedback from providers has been very positive. People tell me they struggle much less with their patients and it helps with burnout because they no longer feel the responsibility for making people change. In healthcare, we have taken a lot of responsibility for outcomes – getting people to do things – and much less responsibility for our own behavior in the process. In MI, we don’t take responsibility for the outcome. What we take responsibility for and pay attention to is how we interact with our patients in a way that moves them toward change or farther away from change. Being overly directive, being confrontational, being judgmental, being overly educational, those are behaviors on a provider’s part that are less likely to lead patients to make changes and in fact may push them farther away from making changes. You’re not taking on the responsibility of getting somebody to lower their A1c or whatever, but you are fully taking responsibility for interacting with them in the way that is most likely to be helpful. Plus, it’s collaborative, so if you can engage somebody, then there’s two people working on it, there’s not just one person taking responsibility for the change.”
TEAM APPROACH/CARE COORDINATION
Featuring North Shore Physicians Group
In recent years, pressures have mounted on primary care providers to deliver high-quality care in less time to an ever-growing panel of patients. As one strategy to end this unsustainable cycle, many primary care practices have sought to spread the primary care provider’s traditional work load among a team of providers, each of whom is encouraged and empowered to “work to the top of their license.”
Distributing the workload reduces the burden on the PCP and elevates other members of the team. In this way, practices can get today’s work done today and staff and providers are able to achieve better work-life balance.
One organization that has achieved great success through a team approach is North Shore Physicians Group, a multi-specialty group practice affiliated with North Shore Medical Center and Partners HealthCare, with 320+ providers and 23 locations throughout Boston’s North Shore. Lindsay Gainer, RN, MSN, Senior Executive Director of Innovation, discusses their transformation in this area:
“Over the past several years, we’ve focused intensely on reducing the burden of work for the providers. In 2007, when we were just beginning our journey around lean transformation and thinking about patient-centered medical home, our providers were drowning. There was a study in JAMA in 2009 that said that if one PCP were to manage an average panel of patients and provide every bit of care that every one of those patients needed, it would take something like 21-22 hours per day, which is obviously unsustainable. That felt like our experience at the time. Our goal over the last 5-7 years has been to level-load that work across the whole practice team and to engage and allow each member of the team to work to the top of their license or their scope of practice – and make sure everyone feels like an empowered and valued member of the team. If you spread out the work, you can get all of today’s work done today, patients are going to have their needs met, and our staff and providers are able to have work-life balance, which helps address provider burnout issues.
One key to patient engagement for us is leveraging each of our different team members. We have certain guiding principles for what care teams look like, but each practice team looks a little bit different. We try to be flexible to make the team the most appropriate skill mix for the unique patient population in that practice.
Alongside the physicians and NPs, we rely heavily on medical assistants – they are the backbone of our practices. They are fundamental to our whole care model and elevating their role has been a huge part of our transformation. One of the roles they play is as a flow manager. Our MAs work in a one-to-one ratio each day with our providers and they sit side-by-side in what we call a flow station. For the most part, we don’t have separate provider office spaces anymore; it’s pretty much all shared, communal workspace. We’ve created a strong dyad between the medical assistant and the provider. A big part of the medical assistant’s job is set up for the providers and a lot of that is done through standard work. In this model, medical assistants are able work to the top of their scope and nothing should go to the provider unless the MA has touched it first and done everything they possibly can do to try to solve a patient issue or to complete a form as much as possible. Then, the provider can come out from seeing a patient, do their notes, do their billing, and do a few simple tasks – sign a form, complete a refill, perhaps read a consult note – before they move on to the next patient. That is how we have accomplished getting away from batching huge piles of work at the end of the day and get our providers and staff home on time.
The MAs also do a lot around population management. In the rooming process, part of their standard work is to look at overdue tests. If the patient is due for a colonoscopy, for example, it’s up to the MA to start that conversation. They don’t go into all the details about the risks – that would be up to the provider – but they’re starting the conversation and that elevates them in the patient’s eyes as an important member of the care team. The MA is also doing health coaching, both during the rooming process and between visits. Another part of their standard work for rooming is to ask the patient what their health goals are – every visit, every time, including sick visits. They typically follow-up on that goal at the next visit. If they saw a diabetic patient three months ago and that patient said, “I want to start walking three times per week,” then the MA will ask them next time, “How’s the walking going?” By starting the conversation, they are teeing things up before the provider comes in the room.
Elevating the MA’s role and giving them confidence in that role didn’t happen overnight. We do a lot of training with our medical assistants. We’ve developed a four-day intensive clinical training that builds on their post-secondary training. The training is mostly about the “Why” – why do we do things and it builds their critical thinking and helps them be a more valuable member of the team. It’s been very well received by our staff and our providers.
We’ve also completely changed the role of nursing in our practices, from a very traditional office nurse – where we believe many nurses were working far below their scope of practice and doing things that well-trained medical assistants can do – to an elevated role of nurse care managers to help with complex patients that have multiple needs, often more than can be addressed in a 20-40 minute visit every 3 months.
Social work and embedded behavioral health are also hugely important additions to our practices. We used to rely exclusively on our wonderful community mental health resources for behavioral health needs, but there was limited access and there was a lot of stigma. By having those services embedded in our practices as part of our team, we’ve really been able to move the needle and help those patients.
With nursing and social work, we’ve really tried to focus on matching the right patient with the right primary care manager. The PCP is always the leader of the team, but there are a lot of complex issues at play. So, what we’ve tried to do is what we call skill-task alignment. If it’s primarily a mental health issue, a social worker is usually going to be their primary care manager, working shoulder-to-shoulder with the PCP to come up with a care plan for the patient and doing a lot of the between-visit touches with that patient. If it’s medical frailty or complexity, it’s usually going to be a nurse case manager. And if it’s social instability or lack of social support, it’s going to be a social worker or maybe a community resource specialist. We’re very collaborative in our practices, but we do try to have someone on point, depending on the patient’s needs.
And then there’s the newest role on our team, Population Health Coordinators, which is something centrally funded through Partners. They sit offline, and do a lot of virtual work with our registries in EPIC. They do a lot of cleaning of the data, but they’re also doing automated reminders for patients that have care gaps. By doing this, we’re able to sort down to the patients that we need to escalate back to the care team – those patients that have numerous care gaps or have gone a very long time without care or have an A1c that’s wildly out of control. They feed that information to the care team – because if they’re not coming in to see us, we may not know that they have these care gaps. It’s a very new program for us. It’s something that’s been tested at the very large academic medical centers downtown, but we’re one of the first community groups to try this with Partners, so we’re very excited about it. It’s another way of trying to relieve the burden of work from the people in the office, not having to comb through manual lists or dig through those registries. That’s not really a value-added task for physicians and MAs and being able to take that offline is a huge benefit.
The keys to our success are about not just asking people to do more as a team, but trying to remove the waste and the burden of work in what they’re doing – so every person on the team is doing a manageable amount of work every day. Our people are happier, which has led to many positive outcomes. We’ve had a huge increase in our professional engagement and teamwork. We’ve maximized operational efficiency. We’ve had reduced turnover and increased provider satisfaction. And all of that dovetails with our overall patient experience scores, which have gone up year-after-year, particularly on experience with adult behavioral health and patient engagement.”
COMMUNITY OUTREACH
Featuring Hilltown Community Health Center
“If the mountain will not come to Muhammad, then Muhammad must go to the mountain,” so the saying goes. In healthcare, this is perhaps most true with chronically ill patients, especially in under-served populations and in rural settings. Many practices have discovered the best way to engage patients and motivate them to be active in their own care is through dedicated resources engaging with patients in the community. These are workers whose job description is “whatever it takes.”
One exemplar of this strategy is Hilltown Community Health Center, a network of community health centers in rural Western Massachusetts. We spoke with Eliza Lake, Hilltown’s CEO, and Kim Savery, the practice’s Community Programs Director, about their efforts in this area.
Eliza Lake:
Q: Can you tell us about the role of patient engagement in your health center?
The community health centers in general use a model that is all about patient engagement. FQHCs are required by federal regulation to be patient-focused. In fact, our boards are required to be comprised of 51% patients. We are private non-profits, and our mission is to serve everyone regardless of ability to pay, with a particular focus on unmet needs in the community and low-income populations, populations of different ethnic groups who, for one reason or another, do not have reliable access to care. So that means that we already will do relatively well on patient engagement issues.
As a community health center, we are able to spend more time with individual patients talking about their specific situation, potentially beyond the clinical issue that is the reason for the visit. Since we are a small community and a small health center, we have strong connections to the patients and focus on the patient’s whole health. To do so, you have to engage with the patient and know what else is going on in their lives – transportation issues, domestic violence, all of the family navigation, etc. Our Community Programs can address all of those issues here; our providers know we have those resources in-house, and they know the questions to ask.
Q: Can you tell us about the nuts and bolts of how the community health workers engage with patients?
We’ve had community health workers (CHWs) for many years, funded by various grants. One of the challenges has been that they are all grant-funded and there’s currently no direct reimbursement in the health care system for that role. Sometimes the CHWs are focused on specific populations, such as elders or people with diabetes, but in general, our CHWs are available for providers to turn to when they see that somebody needs more support in achieving or maintaining their health goals, or coping with a chronic condition.
We’ve had incredible success with diabetes prevention programs in the community, in which patients get together and talk about disease self-management. The groups have been successful while they’re meeting, and then patients have created their own list-serves, keeping in touch with each other, continuing to meet after the classes. We also received a grant focused on mammogram outreach, which was extremely successful, supporting hundreds of women who needed to be screened. The CHWs reached out to women at risk individually and with community events, and were able to offer them support in the form of gas cards or caregiving respite while they went to their mammogram. We also had staff dedicated to contacting hospitals to learn who had gotten a mammogram and who hadn’t.
Q: How have the CHWs been received by the other providers?
The CHWs have been very well received by all of our providers. Everybody appreciates having them here and understands the work that they do and how crucial it is to ensure the patients are engaged between visits. That’s the big thing – when a patient leaves an appointment, the providers don’t necessarily know what they will do to support their health until the next appointment. With CHWs, there can be continued contact with and support of patients outside the clinical encounter.
Kim Savery:
Q: What’s unique about your community outreach program?
“Hilltown is a very rural health center. We cover thirteen towns. We serviced people from, I think, 121 zip codes last year in one way or another. We have social service workers here on site that help people access food stamps, fuel assistance, employment training, that kind of thing. We have two Domestic Violence Advocates on staff, we have two Health Access Navigators, three Community Health Workers, (including a CHW who specializes in doing Outreach and Engagement work for a consortium of Councils on Aging,) and two Family Support workers. They’re all health center employees. We also have a family center on site and offer groups for families with young children here and at other sites across the hilltowns.
It’s a very isolated area with a high incidence of domestic violence. There is no public transportation and resources are virtually non-existent. So, there are all sorts of barriers, left and right. We started our community health worker program about 10 years ago. The family center has been here a little bit longer and social services about the same time. We went from those basic services to community health workers and we started working at the time helping people with self-management of chronic disease and we’ve just kept expanding those programs to help meet patients’ needs. And I think we’re a little bit ahead of the curve. It’s sexy now to look at social determinants of health, but I don’t think it was 10 years ago. For us, it was a necessary step in looking at the health of our patients and our community.
This is a large geographic area, but in terms of community and number of people, it’s small. People know our programs now, they have the expectation that, if they are in need, we will do our best to find a way to help them. Whether it is a social or concrete need, or even if they need help understanding or navigating medical or other issues, we are here. We are also out in the community, listening and talking with people. Patients know that they can stop by our offices at any time. For example, the day before Christmas is always a big day here. People run out of fuel or what-not. We have that ability right here on site to help them with these kinds of things.
How would you get them fuel the day before Christmas?
We have a Salvation Army Service unit that is comprised of three staff members on site. We have the ability to make decisions to write checks without tracking down some distant unit. We also have connections with the local community to provide fuel, a local guy who has an oil company right in Chester. And he will gladly, if we guarantee it, he will get them 50 gallons of fuel – he’ll be there that day.
Is there anything that’s off limits? Any needs where you won’t or can’t respond?
The hardest thing for us, well, there’s so much that’s hard, but housing and transportation are huge here and there’s not much we can do about that. To be perfectly honest with you, our CHWs and everybody else who works here are driving patients to medical appointments or appointments at DTA or Social Security. Housing stock is limited here, and for the economically disadvantaged, it is incredibly difficult to find local housing. Homelessness also looks a little different here. In the summer, people camp out. At this time of year, they are “couch surfing.” We find a way to help people in some way or another in most situations. It’s not ever ideal, but we figure out how to mitigate the barriers to health.
How many CHWs do you have on staff?
Right now, we have three amazing CHWs on staff. All have at least a Master’s level education (one has a PhD) and are highly skilled at what they do. But, it’s not enough. The providers will say the ideal model would be for every provider to have one on their care team, but that’s not going to happen in the current climate. We have had up to six at one time and that seemed to work pretty well. But, the numbers fluctuate with the funding. It still would have been nice to have more. Years ago, when we’re writing proposals and looking for funding for them, people were just starting to look at quality measures and we had trouble justifying the impact. Now it’s out there. People recognize these interventions do work and we can now measure it in ways that clearly show the impact on outcomes and dollars.
INTEGRATED BEHAVIORAL HEALTH SERVICES
Featuring Yogman Pediatrics
Many medical conditions are greatly affected by patients’ behavioral choices and mental health issues and primary care teams must often address common mental health disorders, such as depression, anxiety and substance abuse. In addition, behavioral and lifestyle issues, such as smoking or lack of exercise and poor sleep, affect many aspects of health.
By bringing medical and behavioral health services together within primary care and practicing “warm hand-offs,” the clinical team is able to ensure appropriate engagement on both the mental and general health needs of the patient – and integrate the two.
One practice that has successfully integrated mental health services is Yogman Pediatrics in Cambridge, Massachusetts. We spoke with Susan Betjemann, the social worker embedded in the practice, to learn more about their successful program:
Q: What are the nuts and bolts of the work that you do and why is it unique to be doing it in this setting?
I am a clinical social worker, trained in behavioral health as a therapist for kids and families. Being integrated into the practice essentially means I am fully part of the practice. The warm hand-off is critical because, when primary care doctors are talking with patients about seeking behavioral healthcare or making a referral or a recommendation, the rate of follow-up is low. It’s also really hard for people to track because finding the right therapist is really challenging. So, by handing them off to me, whether it’s going to be me who will see the patient in an ongoing way, or even if I’m just working with the family to make a referral and help them figure out who is going to be the right fit for them, it gives the doctor more of an opportunity to follow-up in that process.
Q: Is it literally that the doctor sees a patient and walks them down the hall and you speak with them right then and there if you’re available?
Yes, so what will happen is they’ll have a well visit, or even a sick visit with a kid. Part of my position is meant for non-clinical time, so I’m often available to meet with the patient on the spot. If that’s the case, they will truly just walk them into my office, give me a brief introduction, and I’ll either have the patient come back at the end of their visit or we’ll meet briefly and plan to have a phone call or a follow-up visit.
Q: You don’t launch into a therapy session at that moment, do you?
It does depend. A simple introduction is usually the intention. But as a therapist, it’s quite interesting because people feel so comfortable in the office and comfortable with their PCP that they’ll launch right into talking about what’s going on for their child or themselves. There are times when you have to kind of pump the brakes a little bit and say, OK, let’s make a time to follow-up on this. But it’s really helpful because it immediately gives me a sense of what’s going on for the patient and how I can be most useful and helpful. And sometimes there are things where the parent is looking for kind of quick, simple advice on something and we talk for maybe 10 or 15 minutes and that’s it, that’s the whole intervention.
Q: What are some examples of the kinds of things people come to you for?
The most common for individual therapeutic services are anxiety and depression. That’s typically what’s coming in. I do see a lot of parents around parenting issues. I like to focus on preventative work, if possible. Challenging behaviors in early childhood is a specialty area that fits with my background and my previous work and I really enjoy meeting with families around that. I’m trained in a specific intervention called “Triple P” that focuses on working with children with challenging behaviors. That stands for “Positive Parenting Program.” It’s evidence-based brief intervention for parents of kids who have challenging behaviors. We also try to apply Dr. Berry Brazelton’s approach of taking a strength perspective in working with families. We’re also working toward de-stigmatizing behavioral health. So, having folks come to me right here in the practice and the pediatrician is just handing them off, we can explain that this is no different than coming to see your doctor, that this is a different part of care, but just as important.
Q: Do you get any more extreme cases?
Certainly, but those are the ones where we might hand off to external resources. Most of the kids I see for therapy or families I work with more intensively, it’s on a short-term basis. If it feels like it’s going to be a more long-term issue or if it’s something that’s going to need more attention, then we’ll refer out. There are providers that we know in the community who we have good relationships with that I can refer them on to. For example, eating disorders, ADHD, oppositional defiance disorder in some cases, these are things I will typically refer out.
Q: And is another one of the benefits of being integrated that you can more easily loop back to the primary care doctor?
Yes, the PCPs here are very attached to the families, and vice versa, and they like to be kept in the loop, of course, on their patients. That communication varies. If I’m not going to have a chance to see one of the pediatricians, I can send them a message through our medical record system. But oftentimes, the updates take place in person – we just find time and chat. And I really benefit from their knowledge of the family, what they know of the family dynamics, the history, the documentation that they have, it’s critical to my work.
Q: Can you give us some perspective on this term “patient engagement”? What does that mean to you?
It’s a tough term to get an operational definition. I’ve always thought of it as the patient being an active participant in their healthcare. That’s our model within the practice as well – that we’re all kind of partners in this and that the family is, of course, a critical part of that. So, it’s really the work we do together to figure out where we go from here. If the child is having a well visit and has been walked over to me because they’ve been experiencing some increases in anxiety or something like that, then it’s a collaborative decision between myself, the family or the patient, and the doctor as to where we go now.
SHARED DECISION-MAKING
Featuring Partners HealthCare
Patients do not always have adequate input into the decisions that clinicians make about their health and their lives. In particular, they often do not know enough about their treatment options – especially the underlying evidence base – to make informed decisions. Even when providers are supportive of patient involvement in decision-making, they may not have the tools or capability to make it happen.
Shared decision-making is a model of patient-centered care that enables and encourages people to play a role in the medical decisions that affect their health. It assumes that consumers armed with good information can and will participate in the medical decision-making process and that clinicians will respect patients’ goals and preferences and use them to guide recommendations and treatments.
We spoke with Soren Capawanna, Program Manager for the patient engagement group in the Center for Population Health at Partners HealthCare, and Karen Sepucha, PhD, Director of the Health Decision Sciences Center in the Division of General Internal Medicine at Massachusetts General Hospital, to learn about their decision aid program:
Soren Capawanna:
“One of our key patient engagement strategies is to provide decision aids to the patient in order to improve their satisfaction and experience outside of the conversation that occurs in the clinic with the provider. We encourage patient self-management and strive to increase patient confidence levels by providing patients with tools that not only improve their understanding of their disease, but equip them to manage their disease. Once a patient gets a new diagnosis, the doctor has an introductory conversation, but the patient has a long road of treatment ahead of them. The provider provides the decision aid to the patient and our hope is that they are reviewing it at home with their family. When they come back in for their follow-up appointment, they feel more empowered to make a decision with their provider that is in line with their goals and their family’s goals. It’s not just the doctor telling the patient what they should or should not do. For example, before we jump right to recommending back surgery, we want to engage the patient in conversations about their treatment options, what is important to them and to their family, all the pros and the cons of physical therapy, of pain management through medication or surgery. The decision aid helps the patient along this journey of determining what is important in their treatment choices.
We have about 40 decision aids that are available online or in print that cover common decisions for adults. Some of the decision aids include videos of patients talking about their experience with the treatments and doctors explaining the diagnosis and treatment. Providers across the Partners network are able to order decision aids for their patients via the patient’s electronic medical record. Once an aid has been ordered, it is sent directly to the patient through regular mail or e-mail. These orders are tracked internally and data is provided to practices to show which decision aids are being ordered most frequently and by which providers.”
Karen Sepucha:
“I’m an engineer by training, with a focus on decision sciences. I’ve always been fascinated with how people make decisions, particularly situations that require collaborative decision-making –when you have to work with other people – and in situations where there’s uncertainty. In many medical decisions, physicians and patients need to work together to figure out the best choice, while managing a lot of uncertainty. Our work in shared decision-making focuses on training physicians to have good conversations with patients, and providing tools, called decision aids, to patients to help inform and engage them in decisions.
Decision aids are educational tools and there’s a large evidence base, more than one hundred randomized controlled trials that have tested these tools. They’re different from traditional pamphlets patients might get from their doctor that talk about, “How to get ready for surgery.” They focus on describing different options, the potential outcomes of each option and probabilities of those outcomes, and then help patients focus on what’s most important to them. The studies of these tools across a range of different conditions have found that they are very good at communicating information to patients and that patient knowledge is much higher when we use them. Decision aids also help patients who might have been unsure about what they want to reach a treatment preference. And that’s really important. Patients who might otherwise defer to the doctor, are more likely to share their goals and preferences and play a role in making decisions after reviewing a decision aid. That helps our doctors tailor their recommendations to the outcomes the patient values most.
We have distributed more than 50,000 decision aids since the project first started back in 2005. The most popular topics are treatment of insomnia, anxiety, chronic low back pain, knee osteoarthritis and prostate cancer screening. More than 1,000 unique clinicians and staff have ordered programs for our patients, so this is something that has spread across the entire system. Having the ability to order decision aids integrated into the electronic medical record helps, as does the centralized distribution of the decision aids. We work with different practices and centers across Partners, often engaging staff as well as clinicians, to design workflows that integrate the decision aids into routine care. Strong support from the Center for Population Health, as well as strong support from the clinicians across the sites has been critical for the success of the program.
When we think about what it means to make a good decision, there are three things we’re looking for (1) evidence that the patient is well-informed, in other words, did we do a good job communicating the important information so that the patient understands it; (2) evidence that patients were meaningfully involved, that there was a really good conversation; and (3) evidence of what we call concordance, that we’ve tailored the treatment to what matters most to the patient – so match the right patient to the right treatment. If they say they really want surgery, that’s what they would end up getting. Or if they say they want non-surgical options, is that what they ended up getting? We have done some studies within our patient population to see whether using the decision aids helps achieve these things when used in routine care—and they do help improve the quality of medical decisions. Looking ahead, we are always trying to improve on the available tools and training, so that we can ensure high quality decisions for all patients.”
SELF-MANAGEMENT
Featuring Westwood-Mansfield Pediatrics
Patients with chronic conditions are frequently in the best position to manage their own care. Effective practices provide the support and encouragement to help people with chronic conditions and their families understand their central role in managing their illness, make informed decisions about care, and engage in healthy behaviors.
Enabling patients to make good choices and sustain healthy behaviors requires a collaborative and trusting relationship between healthcare providers and patients and their families. This partnership supports patients in building the skills and confidence they need to lead active and fulfilling lives.
One practice that shines in this area is Westwood-Mansfield Pediatrics in Westwood, Massachusetts. Lester Hartman, MD, describes his breakthrough thinking and innovative approaches to self-management with asthmatics and home strep tests:
Asthmatic Patients:
“Early in my practice, I had a mother of an asthmatic child come to me and say, ‘Look, I’m tired of going to the ER. They give three nebulizer treatments and oral steroids and send us home. Why can’t I do that myself at home?’ And that’s how the whole asthma program began – by listening to the patient. One of my favorite teachers, Dr. Warner Slack, said, “The greatest untapped resource in healthcare is the patient.” And in pediatrics, you’d have to say the family as well.
So, I started looking at data and I discovered that asthma is an incredibly predictable disorder. You know the fall and the spring are going to be worst. So, because of the predictability, you develop tools to teach parents how to self-manage their kids, get them prepared in advance, and explain the disease process to them. And more important is making the initial diagnosis when they’re young, rather than letting them have recurrent pneumonias or recurrent ER visits before you finally say, hey, they have asthma. That’s not an uncommon thing – half of all admissions to hospitals in asthmatics are under age 5, although, I think that dynamic is changing right now.
Back in 1997, we developed an asthma plan that included steroids in the Red Zone (when the patient is really sick), which pediatricians at the time were totally averse to. We developed the plan over the years. It’s gone through 6 or 7 new editions and there’s still information in there about steroids in the Red Zone. Plus, we give a nighttime asthma attack plan, so they can manage it at home initially. In addition, twice a year, we put out reminders – because again, it’s a predictable disease. In August, we ask, ‘Do you have your asthma plan? Do you have your medications?’ And then in late February or early March, we do it again for the springtime. We do this for all asthmatics in the practice. Sometimes we send these reminders to everyone. And then we put out videos that we’ve made. The beauty of these videos is we get a little poetic license – we don’t have to have perfect dialogue, we can stumble a little bit, we don’t have to have perfect lighting. We just need to get the information out – like, how to use an asthma plan or how to use your holding chamber or what can you do in your environment to prevent asthma attacks in the future? So, we put these videos out in the fall and spring to remind people. We go out on social media with it as well – we put it on Facebook, reminding people.
The next thing we do is we have a disease-specific nurse, close to what people call a community healthcare worker. For example, when we have a patient that has an exacerbation, and went to an ER or is hospitalized, the nurse will put a reminder in her calendar to call the family next year two weeks short of the time the kid was seen in the ER – and she’ll ask, do you have your meds (including oral steroids), do you have your plan and the nighttime asthma attack plan, are you clear, are you ready?
Then the other step we do is I review every week all the kids in the practice who came in with an asthma exacerbation or have a nebulizer and I make suggestions to the other providers, which is a very difficult thing in a lot of practices because providers silo themselves. Our practice has always had an attitude that that’s fine, whatever’s best for the patient.
The other thing we’re doing is we’re giving oximeters, the little thing you put on your finger to measure oxygen. If somebody goes to the ER or has a bad exacerbation in the office, we give them an oximeter to go home with. We explain to them how to use it and when it’s good to do it and when it isn’t. And I’ve posted a video on how to use it.
Asthma is a disease that’s ideally suited for self-management because it’s predictable and it’s easy to treat. It’s sometimes hard to diagnose – because the criteria are so unclear for kids under 6 – and sometimes people may not be aggressive enough about diagnosing it. So, that’s the biggest problem. But it’s so easy to teach parents. As long as you have a system in your office of nurses teaching things. It’s that personal touch. So those are the things in the asthma program – the plan, proactively alerting people, making sure people follow-up for visits.”
Home Strep Testing:
“Again, this was parent-driven. In 2006 on a Sunday, I got a phone call from a mother who said to me, ‘My kid’s strep test is positive. Can you call in an antibiotic?’ I said, ‘Oh, that’s interesting. How did you get that?’ She said, ‘It’s easy, it’s on Amazon.’ Sure enough, I click on Amazon and you can get a home strep kit in boxes of 25. This mother tells me her sister is a medical technologist, so she tested the kid. So, I said, ‘Well, I really need you to come in, but I’m intrigued with the story.’ At this point, I was risk averse and just not comfortable with the idea. So, I made three phone calls. Number one, what is the biggest fear about strep? Rheumatic fever, which causes heart damage. So, I called a cardiologist at Children’s Hospital, the largest cardiac program in the world and he told me they see only two cases per year – and we’re talking about a group that sees thousands and thousands and thousands of visits per year. So, then I called rheumatology because rheumatic fever also causes swollen joints, like arthritis. They see two cases per year also – and I’m saying to myself that it must be the same two that cardiology sees. Then I called infectious disease and asked how long it takes from the time someone gets strep to somebody getting rheumatic fever and what does the fever usually have to be? He said they have to have fever and sore throat for at least 7-10 days. I said to myself, no parent in this area is going to wait 7-10 days.
So, I said, what the heck, let me give this a shot and see what happens. I started piloting it with a few kids, giving them home strep tests, just to see how it would work. We laid out how to do the swab, how to assess the test, and gave some tips.
Like asthma, strep is a predictable disease. We don’t think of it like that, but it is. It begins roughly November and ends roughly April or by mid-May. It’s roughly running along the same time as flu. And it starts usually at age 5 and ends usually by age 12. You get much fewer kids under 5 and much fewer over 12 who get strep. So, it’s a very predictable group – the 5-12 year olds. And you have well check-ups every year with them. So, I asked my partners if I could mail out 2,000 strep tests with instruction kits that we designed – what strep is, what the concerns are. The kits also explained when not to use it. That’s just as important because one of the worries was that we’d have all these kids who carry strep, but don’t really have it, come in and we would over-treat them. That has not turned out to be the case.
So, we sent out 2,000 kits. And when we look at the total number of visits for sore throats, compared to other practices and compared to us the year before, we had a 27% reduction in office visits for sore throats. Sore throats by volume were the number one visit in our practice back then. It’s now dropped to like number four in our practice now. And so that was a big success.
The primary purpose of this effort was to reduce acute, non-urgent visits, so we could spend more time on the important things with kids. 75% of the time, this test is negative. So, most people won’t need to come in. Now that we’ve done this for 9 or 10 years and have had no harm, we now will give people an antibiotic prescription if they call. Parents don’t like giving antibiotics to their kids any more. When I first started, people wanted their kids to be on antibiotics for colds all the time, but that attitude has changed. As a result, we will call in an antibiotic if a parent tells us they have a positive strep test at home, and the nurse reviewed it closely to make sure they did the test properly. We have a short video online that I did about how to properly swab a kid’s throat. It has had about 80,000 hits. And I did one on when a sore throat isn’t just a sore throat, where it could be dangerous, because that’s the thing that scares people. So, the purpose is to reduce the acute, non-urgent visits, to focus on the medical home and practice at the top of your license with higher, complex needs in your patient. When people look at managing patient care in the medical home, they focus on the complex kid. They don’t focus on how can I reduce the volume, make a good living, and have more time with the patient. The big problem is the time. They’re not taking the 10,000 foot view – if I cut back on these acute, non-urgent visits, I can spend more time with the patients who can most benefit from the time.
Now, a pediatric group still could think that we’re crazy. That’s money. I don’t mean to be cynical, but those are visits and that’s how we make our living. And the reality of it is we have to figure out a business case for doing these kinds of things. So, we started focusing more on chronic diseases – obesity, ADHD, learning style issues, depression, etc. And my partners are all happy about it. They could have stopped me a long time ago on this. But they’ve seen the wisdom of it. They’re happy to offload these acute, non-urgent visits to spend time on other issues. So, then you have to learn how to code properly to be able to make a living.
Now we do it on every well check-up between 5 and 9, they get a free home strep test in a packet explaining it and sending them to the video. Parents can also come by and buy a packet for $8. I’ve heard from front desk people that parents come in, buy a packet, go down to their car and swab the kid’s throat. If it’s negative, they take off. But now-a-days, if it’s positive, we’ll call the prescription in without seeing them. Because we’ve had so many years of no harm – so we felt we could take it to the next level.
Of course, the risk is someone will lie with their results. Other pediatricians tell me they’re going to call in for an antibiotic even if their kid doesn’t have strep. The old days, I might have seen that. But not now. Most young families don’t like giving antibiotics. So, the benefit outweighs the risk. This all goes back to trust. Do you trust families and their judgment?
So, that’s what we’re trying to do – help parents to manage these things. These are two self-management programs that we think are key. Sore throats and asthma were such a large chunk of visit volume that can be significantly reduced with parents involved. It’s good for the patients and for the practice.”