It’s pretty clear by now that the healthcare industry is pushing away from disease-centered care and toward patient-centered care. But there are some key things that need to happen before patients will really be able to sit at the center of their healthcare experiences.
On this week’s TEDMED Great Challenges live chat, panelists from various corners of care weighed in on how to shift the paradigm from one that asks, “What is this disease?” to, “Who is this person?”
The “whole patient” must be addressed, not just physical health
Diane Meier, director of the Center to Advance Palliative Care, brought up a point that’s not talked about as much. Treating the whole patient, she said, includes thinking about the patient within his social context — considering his socioeconomic status, family situation and other factors that play into how he accesses and receives care.
“If I give a patient a follow-up appointment two weeks after discharge from the hospital, but I don’t pay attention to whether they have transportation, can afford transportation or have someone who can help them get there, that was a waste of everybody’s time,” she said.
Other panelists noted that, with the way care works now, that may be outside the scope of the physician. “That really did not come up in conversations that I’ve had with clinicians and healthcare executives about how to restructure care and make it more patient-centric, and I think that’s because we really don’t know how to do it,” said Susan Hernandez, a Ph.D. student and research assistant at University of Washington.
The payment model must shift
Fee-for-service care doesn’t encourage doctors to spend time with patients. But a staple of patient-centered care revolves around the physician having enough time to address the whole patient, rather than feeling rushed to refer to a specialist unnecessarily or leaving questions unanswered.
“Once [the payment model] shifts in a fundamental way … you’re going to see team care really come of age,” said Blair Sadler, a senior fellow at the Institute for Healthcare Improvement and a faculty member at the UCSD School of Medicine.
Every piece of the system must be engaged
Dr. Jack Der-Sarkissian, a family physician at Kaiser Permanente, relayed the story of his father’s experience near the end of his life to demonstrate this point: “The healthcare system that he was engaged in was highly dependent on him to engage the healthcare system,” he said. “His physicians were not talking to each other … the pharmacy was not integrated with his physician, therefore [the physician] didn’t know whether prescriptions were getting filled.”
Part of that also means using nurse practitioners and physician assistants more effectively, allowing them to work to their highest degree or certification. Kaiser’s integrated team approach is a model for how this can be done. Der-Sarkissian said he works with care managers to help him reach out to patients with chronic diseases, a nurse practitioner who shares responsibilities and a pharmacy group that helps check for drug interactions and warns him when patients aren’t refilling medicines. “As long as patients know that we are all communicating, that we are all in agreement with the goal of treatment for that patient … I think that is what patients want and what patients expect.”
Some great ideas here. Clearly, as stated by other commenters, communication and options are important. I have experienced the transition from Medical Care to Health Care to Patient Centric health care. We still struggle with dissonant voices, some groups tied to the Electronic Medical Record while the rest are moving to the more global Electronic Health Record. Payment based on improved outcomes is a good step, but as Gayle E. stated, until we can talk about "cures" rather than better outcomes, we need to be aware of the total patient "Gestalt".
I'm sorry, but sadly--this discussion makes me want to laugh as I leap to my soapbox. Social workers have been saying this for YEARS--shouting it from the rooftops, in fact. And now because physician's and nurses are finally noticing the phenomena--after shoving social work to the side, calling us "allied health professionals" or some such nonsense--they finally "get" what OUR discipline invented--patient-centered care as a way of getting away from the paternalistic medical model of the Freudian medicine/mind disconnect. But now you're seeing medical professionals WAVING THIS BANNER LIKE THEY INVENTED THE NOTION! Not only are clinically-prepared master-level social workers in hospitals attuned to these psychosocial needs (setting up discharges/resources for patients) they are BEHAVIORAL CLINICIANS licensed to perform psychotherapy. And people are really asking the question "We just don't know what to do about this?" Hello! Ask a social worker--they know--boy do they know. And treat social workers with the respect they deserve for their expertise in this area instead of the "soft-science" profession you perceive them to be. Learn more about the multi-faceted PROFESSION of social work at www.nasw-dc.org
I think to get to patient centered care physicians, providers, etc must change to become engaged healers with the accompanying appropriate change in approach, attitude and communication. Andrew Baron, MD
We tried patient centered care years ago and abandoned it not for quality of care issues but cost. Too much time and there too much money was expended by healthcare providers for items that the patient should be responsible for taking care of. Our hospital terminated the program. Why would you send a patient to medical school or nursing school so they could call transportation services for a patient. Our cheaper alternative was to hire 4 social workers to deal with those issues in the ER. This is what our evidenced showed. Social workers help patients with their issues that will help them heal. Patient centered care is irrelevant if we do not empower the patient and mke them responsible for their care. It is affter all it is to their benefit. As in money, there is nobody as good to watch your money as yourself so really there is no one better to take care of patients than the patient themselves. Let us empower them and make the patients deal with their smoking, morbid obesity, poor diet, dangerous behavior etc. As my kids will never mature unless I allow them understand the consequences of their actions. If I tell the kids what to eat all the time they will also eat what I tell them. If they go to a restaurant they may not be able to order from the menu. If we constantly always tell patients what to do and only if they listen, will only do what we tell them. Don't eat fatty high calorie fast food, you'll get diabetes morbidly obese and heart disease. Who listens? Until we empower patients to the healthcare system, it will continually cost more and always considered to be imperfect.
I also work in a nursing home and try to practice this, As one nurse to 30 residents (and for the most part they will spend the rest of their lives there) it is impossible in time to complete the job in the 8 hours allotted. The company is cutting staff, buying cheaper supplies or cutting supplies. These residents have dementia are often uncooperative and I have two nurses' aides to do the hands on care while I pass medications and do treatments and paperwork. If it's not on paper it isn't done! I feel as though where I have worked for 35 years has taken from me the ability to do the best job to cutting corners and doing what looks good on paper. It's pathetic and I go home feeling disgusted. For years I have been trying to get time and therefore money saving practices in play... I keep trying but it falls on deaf ears!
The preventative dental model works fairly well to accomplish patient centered care. Patients receive their cleaning and oral exam/check-up at least once per year, and usually twice. If we could help patients understand prevention vs simply seeing their MD when they are sick, it at least provides an opportunity as we have in the dental community. However, we still bill for services and receive reimbursement for procedures, not patient education... Which we all know can vary significantly from patient to patient. I also believe the patient must have some skin in the game so to speak. By not following up with care, meds, recommendations, or at the very least communication back to their providers, their has to be some consequences. All of the responsibility cannot rest on health care providers alone. We can educate and then hope some personal responsibility will be achieved as we understand their circumstances and can help in a variety of ways. I can keep pulling their teeth, but if I do not understand why they are getting decay, and help them own their disease, I am only doing half my job. But, I cannot hold their hand at the grocery store when they choose to buy another case of pop, but many are addicted to sugar and caffeine. It's a balancing act that is so complex.
The dental health model differs from the medical model because dentistry by design focuses on disease prevention. When the medical model changes to make it profitable for physicians to actively promote their practices as prevention oriented rather than disease oriented, then patient oriented healthcare will be a reality...@Lisa DDS
There are many obstacles to providing this approach. Integrating care and communication among practitioners is very important, unfortunately, some obstacles have inhibited this approach. The discussion was excellent. The concept of person centered care has been embraced within my Skilled Nursing Setting for quite some time. We battle some of the Physicians "buying in" or participating in the approach. In addition, we struggle with the financial component of the model. This is definitely benefits for the patient to have an integrated approach to healthcare. It is my hope we can overcome the complexity and serve our communities.
"The other day one of my clients told me Rakesh what you are teaching is going to make me self sufficient. I will have no reason to see you again. It seems as if you are working yourself out of business." Isn't that what a health practitioner should do- to make you self sufficient? But our current payment model goes against it. Physicians will see loss in their revenue as people participate more in their wellness. 1. Yes we must change the payment model. 2. We must change health attitudes of people to participate in health "practice" before they become sick. Read more in the article I wrote a couple of years ago. http://www.promotehealthwellness.com/health-care-reform-and-preventive-care/
I don't see this concept- patient center care/healthcare, will be properly practiced until every medical person involved with one particular patient has to understand the word Part of a Team and that put into & always consider that the patient is the number 1 member of a team. When one or two members of a team put reimbursements, money, personal gains, on top of their priority and leave the single most important member( the patient) on the bottom, this patient centered care has no where to go but just another discussion or another forgotten live chat..
I understand that everyone deserves care, but what if the patient has no payor source? I work at a nursing home that is trying to make this happen and it's very tough when all you have are budget cuts. The patient has to stay in the nursing home for 60 days or so in order to get them on some sort of Medicaid and they have to stay even longer to find them housing that they can afford with their Medicaid. It's a tough call on our end...
-maf - fnp-bc A well written article and also inclusive. My perspective is a little different in that as a nurse practitioner of 27 years, patient centered care is not new, it is not innovative, but its time has come. Administrations and organizations now recognize how much money we lose with no show appointments and patients who are not invested in care. How many times do we hear patients say. I came to the doctor about my leg pain, only to have her/him preach to me about my high blood pressure and my diet. I would have low blood pressure and exercise more if I could figure out why my leg hurts. True story, not a drug seeking patient, she had vasculitis. This was 17 years ago. My work in primary care has always been a balance of seeing patients every 10 min versus taking an extra 5 min to be sure to understand a person's milieu. Read Pam Shuler's framework for nurse practitioners. This was written in the early to late '80's. I do bristol a bit when I hear about NP's and Pa's helping to provide this care. Although I agree team work is essential. We must accept the fact that NP's have been navigating patient centered care in primary care for years. The issue is that the medical model of care has never allowed us to perform the full scope of practice as envisioned my Nursing theory. My capstone work for my Doctor of Nursing Practice will hopefully help to shed light on this fact. Historically NP's have been in the forefront of providing direct care, education, counseling, leadership and research in providing patient centered care. However, because of the Medical Home discovery ( not yet proven to be cost effective, but an important concept), it seems like a new discovery.
This is such a timely topic. I am a MSN student taking a class in Health Policy. We have to write a paper on some health policy topic and how we would get the policy adopted at a local, state or Federal level. My group chose to look at implementing the patient-centered medical home. It is true that the payment model must change and there are a lot of groups who have to buy in to this. But the research shows this can be a cost-effective way to provide quality care and help manage chronic diseases and conditions. The Affordable Care Act supports using systems like patient centered care. Our health care system is in serious need of renovation and innovation! Let's hope it happens soon!
Patient centered healthcare is often at odds with the economic reality of our healthcare system. Until the economic model on which healthcare is based is fundamentally changed our patient centered models will flounder and be largely ineffective.
I hope around the states this wIll become more prevalent. I have one doctor who believes this should be the norm and is only able to do it because she is independent. Until Hospital employed physicians begin reflecting their attention to the patient and not the reimbursement I'm afraid the patients will continue to suffer from "half care."
A good example of how team care can help deliver patient centred care has been operating in Brisbane, Australia, for around 10 years. It has been held up as a model by the Federal Government, which is now rolling out similar programs around the country. For more about Metro North Brisbane Medicare Local's Team Care Coordination program, visit: http://www.mnbml.com.au/page/support/programs/teamcare/
It's easy to trumpet patient-centered care as a means of providing better medical care and savings some money. The reality is that the patients who consume the most in a patient centered system will be both poorer and sicker than most. What we are really talking about is a better public social work/welfare system. I am not sure that the medical system is the most efficient way to deal with issues centered around poverty.
Patient centred care is essential the patient is a person with needs, questions etc not just a problem, disease, injury that needs adressing and treating. Its good to work with patients collaboratively when addressing their care which means involving them in their care plan and what they want/need as well.
I love delivering patient centered care. To me it isn't anything new - it's how I was taught and how I've always practiced. Patient centered care is the standard in my medical institution, and it's exciting to have all providers working together as a team.