The Essentials For Patient Centered Care: A United States ’ Perspective

1. The Essentials For Patient Centered Care: A United States’ Perspective Lee Hilborne, MD, MPH UCLA Center for Patient Safety & Quality

2. The Institute of Medicine Provides a Framework • Two landmark reports from the Committee of the Quality of Health Care In America • To Err Is Human: Building a Safer Health System (Sept 1999) • Crossing the QualityChasm: A New HealthSystem for the 21stCentury (Mar 2001) • www.iom.edu

3. These Reports Have Stimulated Profound Interest In Improving Quality • The first report received the most public attention • Addressed issues most important to people • Focused the agenda on safety rather than quality • The second report, however, drew more important and broader conclusions

4. The Quality Chasm Report Drew Sweeping Conclusions • “In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves.” • Addresses change needed across the health care system Health Affairs 2002;21:80-90

5. Why Is It Suddenly So Difficult To Do The Right Thing? • Science and technology are increasingly complex • New treatments and medications • Increased diagnostics and now genomics • More are living with chronic conditions • A consequence of longer life expectancy • 17-20% of Americans must limit activity • 44% have more than one chronic condition • Effective treatment must be patient centered

6. And US Systems Struggle To Put The Patient At The Center • Our systems are not really systems • Most still practice in small groups • Patients are left to navigate through the healthcare arena with little guidance • Structures limit improvement opportunities • Evidence based guidelines are inconsistently followed • Organizations are still designed for acute care, not to take time needed to address chronic conditions • Challenges and delays in seeking clinical expertise remain

7. Despite Evidence, 20-30% Of Patients Do Not Receive Therapy Patients Receiving ACE Inhibitors When Indicated For Treatment of Congestive Heart Failure JCAHO ORYX Measures

8. Nor All The Information Needed To Optimize Care At Home Patients Receiving All Discharge Instructions Following HF Admission JCAHO ORYX Measures

9. The Committee Recommends We Better Exploit Technology • Providers and patients should have better access to evidence through the web • 40% of Americans had access in 2000 • 90% are expected to have access by 2010 • Decision support tools • Promote appropriate sharing of clinical information • Reduced errors through standardization and automation • Improved communication • On line access to information and providers

10. Healthcare Professionals Are Not The First Source of Healthcare Information Sources Consumers Are Likely To Use Preliminary RAND/CHCF Report

11. The Quality Chasm Report Aims For Improvement In Six Healthcare Quality Dimensions • Safety • Free from injury by the healthcare system • Effectiveness • Care based on evidence • Patient-centeredness • Honor patient preferences for care • Timeliness • Reduced delays for patients and providers • Efficiency • Reduced waste and maximize resource use • Equity • Close racial and ethnic gaps

12. Today We Focus on Patient Centered Care • How well do we meet the patients’ (not our) needs? • Ambulatory care • Intermediate care • Hospital care • Hospice care • Transitions of care • Is the care we give consistent with what the patient values and believes? • Can and do our systems respond to patient preferences?

13. Consider Six Dimensions Of Patient Centered Care • Coordination and integration of care • Respect for patients’ values, preferences and expressed needs • Provision of appropriate information, education, and communication (transparency) • Physical comfort • Emotional support • Family and friends involvement Geretis M, Edgman-Levitan S, Daley J. (1993) Through the Patient’s Eyes. Understanding and Promoting Patient-Centered Care

14. Coordination of Care Has Been A Challenge For Fragmented Systems • Whenever there are handoffs, patients are at risk • Transition from inpatient to outpatient care • Coordination among specialists and allied health providers • Movement from one acuity level to another • When surveyed, patients were most dissatisfied with continuity and transition

15. We’ve Responded In Several Ways • Physicians partner with other caregivers • Clinical nurse specialists • Physician assistants • Social workers and other staff • Instructions with each encounter are more explicit • Standardized, web available discharge instructions • Information provided in simple languages (we have some documents in multiple languages) • Staff incentives are tied to satisfaction scores

16. Respect For Patient’s Values, Needs, and Preferences Seems So Simple • Patients become a partner through shared decision making • Preferences for aggressive care or comfort care • Patients’ right to participate in ethical decisions related to care • Culturally sensitive care • Respecting patient preferences requires listening to each patient • Yet physicians interrupt patients after 15-20 seconds • Meaningful participation also requires adequate informed consent

17. Most Elderly Patients Wanted CPR • Study of 1266 patients at least 80 years old in academic hospitals • Patient estimates of prognosis were higher than their physicians’ estimations • O'Donnell H, et al.Preferences for cardiopulmonary resuscitation among patients 80 years or older: the views of patients and their physicians.J Am Med Dir Assoc. 2003;4:139-44.

18. Accredited Hospitals In The US Are Required To Explicitly Address Patient Rights • Access tocare • Psychosocial • Cultural • Spiritual • Advance Directives • Active participation • Conflict resolution • End of Life Support • Confidentiality • Spatial • Property • Complaint resolution • Communication • Disclosure of conflicts of interest • Contracting • Marketing • Admission • Transfer • Discharge • Billing • Providers • Payers • Educational efforts • Procurement • Donation • IRB when appropriate • Addressing staff discomfort with care of a specific individual Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals (2003). Oakbrook, IL

19. Patient Centered Care Requires Active Dialogue • Individuals have certain basic information needs • Diagnosis (what is wrong) • Prognosis (what is likely to happen) • Treatment options (what can be done) • Information transfer should accommodate patients’ needs • Face to face encounters (regular, periodic) • Electronic (e-mail, web based) [a big debate now] • Should be understandable • Explain technical terms • Culturally appropriate language • Sensitive to educational levels

20. We Standardized Informed Consent Documents For Consistency • Developed byphysicians • We now have about 300 covering common procedures • Available in two languages • Copy goes to the chart and the patient • Not a substitute for a physician-patient discussion

21. Patient Centered Care Responds To Patient Discomfort • Many patients fail to receive adequate pain relief • When in older Americans, some allege this to be elder abuse • Particularly for end of life care, dependency should not be a concern • Shortness of breath and other physical discomforts • Attention to physical surroundings • Excessive light, noise, distractions

22. Care Is Complete When Sensitive to Patient Emotional Needs • Anxiety and fear often accompany illness • Outcomes are better when emotional support accompanies physical treatments • Uncertainty regarding diagnosis or prognosis • Fear of pain • Concerns about separation or isolation • Financial well being • Impact on family dynamics

23. Patients Do Best When Family And Friends Are Engaged • Appropriate at the discretion of the patient • Providers should make time to explain the course of care to family and friends • Involve family and friends as caregivers in appropriate phases of care • Understand family sensitivities during the decision making process • Acknowledge and appreciate family and friend input

24. How Many Countries Responded To SARS Suggests A Unique Patient Centered Focus

25. Our Patient Centered Approach Is Leading To Improvement