Moving Patients to Engagement and Activation
Engaging patients and family members is an essential component of any health reform initiative in the United States, as individual health care choices and active management often profoundly affects health care utilization and outcomes. Improving patient self-management and participation, however, is given much less attention than many of the other elements of the medical home. This article focuses on lessons learned to improve patient engagement and clinical outcomes. Simply put, clinical outcomes will change when patients become activated to make the changes necessary in behavior and lifestyle. In fact, research suggests that a patient’s ability to self-manage their health accounts for 70 to 80 percent of those outcomes.
So how do we start to improve patient engagement? I suggest several steps, many of which are related to some of the fundamental aspects of the medical home and delivering “person-centered care,” below.
Step 1: Know your patients. Conducting a comprehensive health assessment is pivotal to knowing the person sitting in front of you. What are their beliefs and attitudes toward health? What barriers (health literacy, environment, financial considerations, transportation, religious beliefs, etc.) may prevent them from following a plan of care? What do they already know about the state of their health? What knowledge and skills do they have to move from being a passive participant in their health to an activated individual willing to make behavioral changes? What health care issues do they have that may lead to long-term, chronic health conditions? What support do they have from family members to make changes? What would motivate them to do so?
Step 2: Establish the health care partnership. The foundation for this partnership lies in the formation of a continuous relationship focused on maintaining wellness, managing illness and addressing the needs and concerns of the whole person (body, mind and spirit). This partnership must be based on mutual trust, be culturally sensitive and allow for the person to feel that their preferences are respected and that they are an active participant in shared decision making when it comes to their health. To set the stage for this relationship, practices should develop a brief guide for patients to set expectations when joining a practice, including: how to make appointments, financial considerations, how the practice operates and what the person and health care team members’ role will be in their care. The Center for the Advancement of Health has an informative reference article, Supporting Patient Engagement in the Patient-Centered Medical Home, to follow if you are in need of a guide.
Step 3: Assess your patient’s level of motivation. Performing a brief analysis of how motivated your patient is will significantly aid the care team as they determine next steps. Keep in mind that the focus of motivational interviewing and the corresponding reflection is not to persuade the patient to change behavior but rather to increase their motivation and personal willingness to engage in change themselves. This focus will help patients perceive and achieve more realistic outcomes. Behavior change is hardly ever an isolated event and continuous support and reinforcement are critical to adopting a long-term lifestyle change.
There are four stages of change:
- Pre-contemplation is when the patient is unwilling to change and/or denies the need for change. This stage often results from a lack of awareness, from the belief that the consequences are not serious or from a lack of hope because previous attempts to make change were unsuccessful. To try to convince a patient that change is necessary or to provide “advice” at this stage will many times result in increased resistance and denial. In this stage, the best approach is to listen, provide some education regarding personalized risk factors and establish the idea and need for a subsequent visit with the goal of going over follow-up questions.
- Contemplation is when the patient is beginning to weigh the benefits against the losses of the proposed change.
- Preparation is when the patient experiments with small tests of change. At this point it is important to help the individual assess and articulate their potential ambivalence in a supportive manner.
- Action, the final stage, is defined by a definitive lifestyle and/or behavior change.
Remember, it takes time to create new habits. It also takes time to process what these changes really mean in terms of lifestyle and there may well be times when a person reverts to old behaviors. Focus on successes and what they have learned; encourage and support letting them know this is an anticipated part of any sustained change process. In any phase of the change process it is important to remember that the person who will be making the goals should be the one establishing where they would like to begin. Our role as health care team members is to help that person set specific, measurable, actionable, realistic and time-oriented goals (SMART goals).
Step 4: Set a date for follow-up. This is especially important when managing chronic conditions. Establish with the patient how frequently and in what way they would like for follow-up to occur. Follow-up by the health care team emphasizes the importance of the change, provides the patient with a message that they and their success in this change process are important to the health care team, builds confidence and reinforces accountability. Celebrate successes, explore barriers and challenges and use the opportunity to establish additional goals or to modify current goals. This is not an activity that has to be performed solely by the provider. Patients should be made aware that other team members are going to be involved and that when they will be following up on behalf of their provider.
It is critical to understand that behavior change occurs over time. For clinical outcomes to change, people (our patients) must take an active role in managing their health. Meeting people where they are, avoiding judgment and working closely with them through their stages of change will afford them the confidence and skills to be successful in managing their health.
Elaine Skoch, PCMH-CCE is a CAFP consultant, board-certified Nurse Executive at the advanced level and recognized as a PCMH Clinical Content Expert by NCQA.
 VonKorff, M et al.; “Collaborative Management of Chronic Illness” Annals of Internal Medicine 127 (12); 1097-1102.
 Gruman, Jessie, et al. ; Supporting Patient Engagement in the Patient-Centered Medical Home; Center for the Advancement of Health, Washington, DC; 2008.
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