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Patient Engagement and Coaching Models
Rebecca DurhamProject Coordinator, HealthInsight
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Incorrect Assumptions
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Incorrect Assumptions
• Patients want to change behavior
• Advising optimal health is motivator for change
• Patients are either motivated to change, or not
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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
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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
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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
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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)
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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.
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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
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Ideal PCC Approach
Tennison, J. (2012)
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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.
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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.
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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
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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.
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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
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Keep Your Glucose in Normal Range
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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.
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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
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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.
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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.
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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)
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OARS
• Open-ended questions• Affirmations• Reflections• Summaries
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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
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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
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Discussion Question #1
How will I use patient engagement techniques to improve patient outcomes?
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Discussion Question #2
Name two times during an encounter when you might engage a patient using a patient engagement or
coaching model