By: Nameeta Dookeran, MD National Medical Director of Behavioral Health Care Solutions
For too long, we have focused on taking a disease-centered approach, bombarding patients with directives such as, “Eat more fruits and veggies,” or “Increase your physical activity.” We’ve tried to manage adherence to care plans or prescriptions. We’ve tried to push patients toward evidence-based standards of care for the conditions they are managing. These efforts have largely fallen short for one simple reason. We are not connecting with patients where they are at and learning what issues are most important to them. We know that patients who are engaged in the goal setting process and invested in outcomes are more likely to adhere to their plan of care and treatment. What patients are willing (and able) to do to accomplish a goal is critical to its achievement, which means that collaborative goal setting is crucial.
The more effective approach is to partner with patients. Spend time better understanding patients’ viewpoints and what’s important to them at any given time and then find ways to incorporate our clinical objectives in a way that aligns with their personal objectives. This is a paradigm shift for most health management programs, which traditionally have attempted to coach patients into compliance.
Partnering with patients to hear what’s important to them, and what’s holding them back, is a very effective way to get them engaged and involved in their own care. It also helps uncover the obstacles preventing them from doing what they need to for a healthier life. There are many barriers that prevent patients from actively participating in their care. Life experiences, health literacy, behavioral health, social factors, it’s an extensive list. And for the most part, these barriers are not clinical in nature and not typically taken into consideration when interacting with patients.
This approach requires us as healthcare professionals to align our goals with the goals of the patient. Their priorities must be our priorities. Just as importantly, it requires more coordination among all the various clinical resources who are supporting a specific patient. If we are adjusting a care plan for a patient based on personal goals or non-clinical concerns, it’s critical that everyone on the care team understands the strategy and how it is being deployed. This obviously means we have to be intentional to defragment care and commit to communication that currently is uncommon in our system.
In many cases, this also requires meeting patients where they are, which for older and sicker patients means in their home. The home setting also offers opportunities for more comprehensive assessment and collaborative goal setting. The provider in the home can help patients identify and articulate priorities and develop goals based not just on medical diagnoses but on the patient’s individual, complex reality. That is, the provider can consider and evaluate all aspects of the patient’s medical, physical, cognitive, psycho-social, emotional, and spiritual needs and values. Deploying resources to make house calls, whether that is a physician, nurse or community health worker, can help gain a more complete picture of each patient and what non-clinical barriers might exist. For many of the most complex and costly patients in a population, investing in a team that engages patients in the home can deliver significant value across the quadruple aim in health care delivery.
Let’s start with a dramatic example of what we’re talking about here. You can’t focus on adherence to medication when the patient you’re helping is currently experiencing homelessness. They need a stable home situation before they can effectively focus on medications they are supposed to be taking. Our team encountered this very scenario recently, and we had to adjust our approach dramatically in order to really help this patient.
Here's a more common example. Our team was supporting a medically complex patient who had been seen in the ER four times in less than a year. This patient was obese, had recurrent urinary tract infections and was also managing diabetes, arthritis and kidney disease. Every time he spiked a fever, it was another trip to the hospital, and he was suffering. He was tired of what he saw as a significant drain on his quality of life.
We worked closely with his urologist to come up with a different plan. Our team could help this patient with a urine culture, antibiotics and follow up, all in his home, instead of spending multiple days in the hospital when symptoms presented. With this extra dose of care coordination, we were able to craft a plan that was more convenient for the patient and less costly for the system.
Another patient was healing from an ulcer and not doing well at all. He was losing weight and not following through with scheduled appointments with his vascular doctor, even when transportation had been arranged for him. Despite the importance of healing this wound, this patient was struggling with grief and depression. His son had just been murdered months before, and he was being asked to participate in ongoing court cases. He needed closure, and he needed to spend his limited mobility on being there for the case. Everything else was secondary. We worked to switch as many of his appointments to telehealth as possible and provided resources and support to help him with his grief and depression. All these things helped him remain in care, while also addressing his primary concerns.
Here's yet another example. This patient had been hospitalized for congestive heart failure, and his condition was getting worse. He needed physical therapy, but the nearest provider was a long drive from his residence. To make matters more complicated, he lived in a trailer in a junkyard, and it was determined that his living environment was too dangerous for in-home services. Our team worked with him to understand why his home was so important for him to maintain. We discovered his wife had passed a few years earlier, and this was their home. So, we worked around the limitations of his environment to provide the help he needed, which included providing him exercises he could complete and staying in touch via a nurse. We continued to work with him on his prolonged grieving process that was impacting different aspects of his life and functioning.
There are many reasons patients are not able to comply with our medical recommendations. Trying to force compliance on any of these patients would have been futile at best. Yet by working with each of these patients on the underlying issues and personal priorities, none of which were directly related to clinical needs, we were able to help all of them transition to a healthier path. This is the model we must follow moving forward, particularly for patients who have complex medical, behavioral, and social needs. We must refocus and take patient-centered approach to collaborate with patients on developing treatment goals and ways to work on accomplishing them in small increments, instead of maintaining a diseased-centered or provider-centered approach focused on whether the patient is compliant or not compliant with our recommendations to meet our larger end goals. We must see patients as people and consider the context of their lives at any point in time and their holistic needs. And, we have to balance directives with dialogue so that individuals are set up for success in their healthcare journey.
