In the human nervous system, dendrites reach into the synapses between nerve centers to gather and deliver information needed to perform almost every living function. When these routes of communication break down, the entire human body falters.
In a health care system, there are many such nerve centers — often called "silos" in business slang — that traditionally operate independently of one another.
Fortunately, there is a community in Whatcom County, Washington whose fortitude and commitment to patients surpasses the implanted force of silos and "what's always been." Family Care Network, North Cascade Cardiology, Center for Senior Health, SeaMar Community Health Center and St. Joseph Hospital (of the PeaceHealth health care system) are in the throes of developing a patient-centered system of care that aims to dissolve the silos with a continuous flow of information and continuity of care centered around the patient.
They are working with Regence Blue Shield, Group Health Cooperative and Community Health Plans of Washington to realign the current health care dollars to ensure this high-quality care. The objective is to increase operational efficiency, reduce cost, increase safety , and create an environment where the patient is better cared for throughout the entire system of care. St. Joseph Hospital is coordinating these efforts as a participant in the Institute for Healthcare Improvement's Pursuing Perfection
program, funded by The Robert Wood Johnson Foundation.
However, transformation of health care across an entire community is easier said than done. "If it was easy, people would have done it already," says Mary Minniti, Project Manager for Pursuing Perfection in Whatcom County. "It's not that health care professionals don't care. They do. But we're changing paradigms, and that's tough work."
To start, these pilot sites are working with a small number of patients to develop a patient-centered system.
Introducing the Shared Care Plan
One of the most positive changes Whatcom County has made is to introduce a "shared care plan" (SCP) to a small number of patients (currently 50 patients). The SCP is a document that includes the patient's personal profile, self-management goals, treatment goals, prescriptions and medications, allergies, chronic diagnoses and health care team members. The SCP is available on a secured web site, allowing patients and those to whom they give permission to download the information from anywhere there is an Internet connection. It can also be printed. Patients carry a printed copy to each appointment, and if changes are made, the health care team updates it. Having all the information available in one place:
- Increases accuracy and safety;
- Slashes administrative redundancy;
- Ensures that the doctor has all relevant decision-making information; and
- Makes life a little easier for the patient.
Says Minniti, "The shared care plan creates a conversation with a cross-functional team, even if they're not in the same location."
Another tenet of patient-centeredness is patient participation and feedback to the process, as patients' viewpoints have shown to be instrumental in creating positive and relevant change. St. Joseph and the community sites include patients in a number of ways:
- Phone interviews — patients share their opinions and respond to survey questions over the telephone.
- Focus groups — patients provide feedback in a group format with other patients.
- Committees — patients bring their and their family's perspective to care design meetings and other committees.
- Product reviews — patients give feedback on new web sites and informational materials.
- Story sharing — patients share their health experiences with care providers and other patients.
- Patient advisory councils — patients/family members participate in monthly meetings to provide advice and perspectives about hospital changes/programs.
"The recruiting and screening of patients to provide them with meaningful ways to make a difference is resource intensive," says Minniti, "You want to choose patients who will be representative and articulate. Then you need to create forums that they can actually attend, taking into consideration people's schedules and transportation issues. Additionally, including patients from diverse backgrounds is critical to meeting the needs of the entire community. However, in the end it's worth it to create a program that meets patient needs and is more effective overall."
Innovative programs have been brought to the community to encourage patient involvement in self-care. For example, St. Joseph provided a community-wide training for outreach workers on teaching classes for people with diabetes. These classes will be held in parishes, community centers and clinics throughout Whatcom County. According to Minniti, "The cooperative effort will have a much larger impact than if one organization had provided the service."
Registries and Group Visits
Like many health care agencies that are trying to provide better care for chronically ill patients, Whatcom County's participating health care groups are putting renewed focus on maintaining updated registries, which are lists of patients with similar diagnoses. Registries help clinicians manage and monitor patients' care, ensuring that they are receiving the best care possible according to best practices research. Information from the registries can be used to initiate outreach efforts with patients who could benefit from improved services.
In addition, they are exploring improved service through group visits. In one instance, a group of Family Care Network patients with diabetes was scheduled to have a 90-minute visit with a medical team, including their primary care doctor. They had their vital signs taken, medication reviewed, a comprehensive foot exam, learned about online resources for self-management, asked questions of the team and talked with one another. Three months later, all of the patients' HgA1c counts were reduced — an indication that they were taking control of their diabetes. One patient, who had not been seen in the previous 18 months, not only improved his blood sugars, but also was encouraging others in the next group to use the online resources and talking about the impact of the group in glowing terms.
According to Minniti, the group visits "create positive relationships between the care team and the patient instead of an experience where visiting the doctor feels like reporting to the principal's office." A longer, more interactive encounter, the group visits allow patients to connect with their care team and others who share similar challenges in managing chronic conditions.
Moving Through Barriers
Changing paradigms and behaviors in a climate of busy, overworked people is no easy task. There are many barriers that must be overcome.
As Donald M. Berwick, MD, MPP, former President and CEO, Institute for Healthcare Improvement, states in his paper, A User's Manual for the IOM's 'Quality Chasm' Report, "the hoped-for culture of openness and learning is in direct conflict to the current culture of fear and secrecy caused by increasing litigation." Patients and medical professionals are being asked to change. Physicians who have enjoyed a high level of autonomy are now asked to become a member of a larger decision-making team - that includes the patient. The change from patient-focused to patient-centered requires doctors to not just focus on the symptoms relevant to his/her own medical specialty, but also to consider the person in the context of a continuum of care. Similarly, patients who are used to giving their power over to the doctor and the health care system are being asked to become more involved in their care.
In some cases, staff shy away from the idea of opening a feedback loop with patients or including them in care design meetings. They are worried that patients will ask for more than they can possibly give — and they are already overworked. "Instead, our patients said they don't have expectations of big or immediate changes. Their questions were basic, like 'how do I get from one place to another?' They just wanted to be heard, and for us to follow through on changes that show we care about them as people," says Minniti.
Still, opening the feedback loop can be very intimidating to clinical staff as they may feel they are not able to make the changes their patients are requesting. They may take patient feedback personally, instead of realizing it is a systems issue. "We need to support staff as we support patients," says Minniti, "and communicate to them that it isn't their fault." Providing support includes orienting both staff and patients differently, laying the groundwork for positive communication. Promoting transformation includes asking staff to recount stories of success through changes. Questions such as, "When have you used patient feedback to promote positive change in your unit? How did it make a difference to the outcomes of safety, respect and cooperation?" build momentum toward a patient-centered system.
Last but not least, technology is a barrier that continues to plague the health care industry. In Whatcom County, as in every community, different organizations use different informational technology systems — from scheduling systems to electronic medical records. This makes it difficult to access needed information across the care continuum. Connecting these systems will require interfaces that work together, which is not always possible or cost effective.
Meanwhile, Minniti urges people to consider investing in developing tools that are patient-centered instead of clinic-centered first, and to test it on paper before rushing to a technical solution. "We learned a lot about the usefulness of the shared care plan on paper with patients first," says Minniti, "It informed the design of the web-based tool. Now we are building bridges to that document instead of trying to get everyone to use the exact same electronic medical record."
Advice from the Front Line
"Making this transition [to patient-centered care] initially takes more time and more resources," admits Minniti. "However, if you realize this and have a committed organization behind you, it can be a wonderful experience." She recounts a time when they were worried about getting the backlog of patients registered for the shared care plan. They mentioned their dilemma to a class of medical assistants they were visiting. "They volunteered to input all the patient information themselves," remembers Minniti. "It will take a community to make this transformation possible."
The success stories are inspiring, however. Minniti told of a patient's wife who, after calling 911 for her husband's medical emergency, grabbed his SCP off the refrigerator and showed it to the Emergency Medical Technicians (EMTs). The EMTs had instant information about the patient's medications, diagnoses and allergies and were able to transport the patient to the hospital right away. Upon entering the hospital, the SCP was provided to the doctor who had the information to begin effective treatment. "Every person she encountered looked at it and thanked her for making their job easier," says Minniti.
Slowly but surely, people have started to think differently in Whatcom County. Asked for advice for others who would like to do the same, Minniti says, "Start small. Have faith. Trust the process. There is no magic wand; it's just hard work." She emphasizes that they have only just begun, and have more questions than answers. To outsiders, however, Whatcom County is a clear leader in the movement to patient-centered care.