The Essentials For Patient Centered Care: A United States

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Perspective

Lee Hilborne, MD, MPH UCLA Center for Patient Safety & Quality

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 Quality Chasm: A New Health System for the 21 st Century (Mar 2001) www.iom.edu

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

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

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

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

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

100% Academics All Participants 80% 60% 40% 20% 0% Oct 02 Nov 02 Dec 02 Jan 03 Feb 03 Mar 03 Apr 03 May 03 Jun 03

JCAHO ORYX Measures

Nor All The Information Needed To Optimize Care At Home Patients Receiving All Discharge Instructions Following HF Admission

80% 70% 60% UCLA Academics National 50% 40% 30% 20% 10% 0% Oct-02 Nov-02 Dec-02 Jan-03 Feb-03 Mar-03 Apr-03 May-03 Jun-03

JCAHO ORYX Measures

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

Healthcare Professionals Are Not The First Source of Healthcare Information Sources Consumers Are Likely To Use Similar Patients Family & Friends Nurses Co-Workers Toll Free Live Church/Community Doctor's Office Info Quality Ratings Newspapers Web Site Radio or TV Video At Home Toll Free Recordings

0% 10% 20% 30% Likely To Use 40% 50% 60%

Preliminary RAND/CHCF Report

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

Today We Focus on Patient Centered Care • • • How well do we meet the patients ’ needs?

– Ambulatory care – – – – Intermediate care Hospital care Hospice care Transitions of care (not our) Is the care we give consistent with what the patient values and believes?

Can and do our systems respond to patient preferences?

Consider Six Dimensions Of Patient Centered Care • • • • • • Coordination and integration of care Respect for patients expressed needs ’ values, preferences and 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

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

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

• • • 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

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

100% 80% 60% 40% 20% 0% Do Not Want CPR Desire CPR Patients Physicians For Their Patients 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.

Accredited Hospitals In The US Are Required To Explicitly Address Patient Rights

Access

•Access to care

Patient Rights & Organizational Ethics Patient Rights Organizational Ethics Treatment Respect Conduct & Conflict Code of Eithics Organs Research Manging Staff Requests

•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

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

We Standardized Informed Consent Documents For Consistency • • • • • Developed by physicians 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

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

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

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

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

Our Patient Centered Approach Is Leading To Improvement