Patient Engagement and Coaching Models

Rebecca DurhamProject Coordinator, HealthInsight

Incorrect Assumptions

Incorrect Assumptions

• Patients want to change behavior

• Advising optimal health is motivator for change

• Patients are either motivated to change, or not

Change Our Thinking

From • Patients are

Non-Compliant

To • Patients are

unsuccessful at managing their own care

• Patients are not yet engaged in their own care

Consider…

• Chronically ill patients make many daily health decisions

• Sometimes make unwise decisions • Don’t fully understand implications

of particular health decisions• Lack support to make better choice• 9/10 patients lack skills to manage

their health/prevent disease1

1. Advocate for Health Literacy in your organization (n. d.). Quick

Guide to Health Literacy. Retrieved from http://HHS.com

How to Not Engage Patients

• Tell patients what to do (give advice)• Misjudge sense of importance

regarding behavior change• Use scare tactics, argue, blame them

for no willpower and self-concern• Overestimate readiness to change

and degree of confidence • Take away control, generating

resistance

How To Engage Patients

• Listen: Don’t jump on first things patients say

• Understand behavior change and motivation

• Change clinical visits from “to-do” lists to helping patients identify and establish care priorities

• Help patients develop a care plan to improve outcomes (Shared Care Plan)

Can We Be Engaged?• 23% adopted new health

behaviors (but unsure could maintain if stressed)

• Remaining 77%: -- Remain passive recipients (12%) -- Lack basic facts to follow treatment recommendations (29%) -- Have facts, no skills/confidence (36%)

Hibbard, J. H., Mahoney, E. R., Stock, R., & Tusler, M. (2007). Do increases in patient activation

result in improved self-management behaviors? Health Services Research, 42, 1443-1463.

Polling Question

What is the most important determinant to advance patients’ with diabetes healthy behaviors?

1. Increasing patient education

2. Spending more time with patients

3. Developing a shared relationship between patient and provider

Norris, S. L., Engelgau, M. M., & Narayan, K. M. V. (2001). Effectiveness of self-management training in Type 2 diabetes. Diabetes Care, 24, 561-587

Ideal PCC Approach

Tennison, J. (2012)

Education +

• Information, technical skills

• Problems due to poor disease control

• Disease-specific knowledge

• Goal is behavior compliance to improve outcomes

Self-Management

• Skills to act on problems

• Patients ID problems in self-management

• Improving patient confidence to change

• Goal is increased self-efficacy to improve outcomes

Bodenheimer, T., & Abramowitz, S. (2010). Helping patients help themselves: How to implement self-management support. Oakland, CA: California HealthCare Foundation.

The Facts

• 40-80% medical information given forgotten immediately; half retained is incorrect1

• Physicians thought 89% of patients understood medication side effects, only 57% of patients understood2

1. Kessels, R. P. (2003). Patients' memory for medical information. Journal of Social Medicine, 96(5), 219-222. 2.Training to Advance Physicians‘ Communication Skills. (n. d). Retrieved from AHRQ Website.

Medication Adherence?

Take 3 tablets by mouth 2 times per day, with food for 14 days, then take 2 tablets 2 times per day with food for 14 days, then take 1 tablet every morning, 30 minutes before meal for 14 days, then take ½ tablet every morning, 30 minutes before meal for 14 days

Teach-Back Method• Method to confirm patients understand

their medication/treatment: – “Tell me why you need this medication”– “Tell me how you take this medication”

• Teach Back not a test of patients’ knowledge

• Is a test of how well we explain something Kessels, R. P. (2003). Patients' memory for medical information. Journal of Social Medicine, 96(5), 219-222.

Health Literacy

• The capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Healthy People. (2010). Cited in What is Health Literacy? Retrieved from www.chcs.org

• Only 12% of adults have proficient health literacy

• Lower literacy = more admissions, ER visits, costs, higher risk of poor health

Advocate for Health Literacy in your organization (n.. d.) Quick Guide to Health Literacy. Retrieved from http://HHS.com

Keep Your Glucose in Normal Range

Watch Your WordsProblem Word Consider UsingAilment Sickness, illnessAdverse BadBenign Won’t cause harm, isn’t

cancer

Condition How you feel; health problem

Lesion Wound, soreOral By mouthVertigo Dizziness

Ask Me 3. Retrieved from www.npsf.org.

What is Coaching?

• Managing: Making sure people do what they know how to do

• Training: Teaching people to do what they don’t know how to do

• Mentoring: Showing how those who are good at doing things do them

• Coaching: Helping identify skills and capabilities, and empowering people to use them as best they can

Motivational Interviewing

A collaborative, patient-centered form of guiding to elicit and

strengthen motivation for change

Miller, W. R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural and Cognitive Psychotherapy, 37, 129- 140.

Motivational Interviewing

• Non-judgmental, non-confrontational, non-adversarial

• Explore and resolve ambivalence• Help patients envision a better future,

and become increasingly motivated to achieve it

Miller, W. R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not.. Behavioural and Cognitive Psychotherapy, 37, 129- 140.

Four Principles of MI1.Express empathy (not pity) - Put yourself in patients’ shoes 2. Develop discrepancy (ambivalence) - Explore how they want their life to be and how it is now3. Roll with resistance (expect it)4. Support self-efficacy (empower)

OARS

• Open-ended questions• Affirmations• Reflections• Summaries

Care Transitions Coaching Model

• Improve transitions of care• Transitions Coaches encourage

patients and caregivers to take a more active role in their own self-care

• Not doing for, but empowering patients to do for themselves

• Involves pre-discharge and then follow-up, in-home visits

Transitions Coaching in Your Practice

• A tool everyone can use• Patients engaged in coaching have better outcomes• Effective to avoid downward trends, or

keep patients at new “normal”• Program consistently reduced 30-day

hospital readmissions and costs, and 180-day hospital readmissions

Discussion Question #1

How will I use patient engagement techniques to improve patient outcomes?

Discussion Question #2

Name two times during an encounter when you might engage a patient using a patient engagement or

coaching model