Physicians everywhere are challenged to keep up with the literature and apply the latest science to the care of their patients. Several studies have documented that for the evidence we know can help patients be better, only about 55% is actually delivered. There is an emerging recognition that focusing only on the prescription of care through the doctor's office or hospital is woefully inadequate to integrating real change in the lives of patients.
Medical professionals have for years used the pejorative term "noncompliance" to describe patients who do not follow medical advice. There is now a literature and experience in care delivery systems that shows that the barriers to people achieving best care are often social and environmental. These barriers can be influenced by stepping outside the medical model, embracing the environment of the patient, and truly using shared decision-making models that focus on patient goals. A recent review suggests that we rename this thinking. Moskowitz and Bodenheimer suggest we call this new perspective "evidence-based health."
I had the privilege of leading the provider component of a statewide chronic disease management initiative that used a community-based model based on the work of Wagner to improve the care of people with diabetes.
We providers learned some important lessons:
• Patients who completed a curriculum in self-management experienced a dramatic (30 to 50 percent) drop in office visits and emergency room visits.
• Patients who understand their illness and set their own goals do better, and require a paradigm shift in thinking by their physicians. Physicians found they needed to "let go" of their agenda for the office visit, and this is very difficult to do.
• Non-physician interventions often have a much bigger impact than physician interventions. These included community walking programs, support groups, home visits, and addressing social issues such as transportation and navigation through the various components of the healthcare system.
• Enhancing the public health infrastructure and truly integrating it with primary care and community-based interventions is powerful.[img_assist|nid=755|title=This graphic illustrates how organizing resource can improve chronic care.|desc=|link=none|align=left|width=640|height=418]
As Moskowitz and Bodenheimer indicate:
“While the implementation of evidence-based health poses substantial challenges, the first step needs to be the medical profession’s acceptance of the evidence-based health paradigm.”
Evidence-based health broadens our perspective, making the patient the center, surrounded by teams of medical professionals, community-based services, support systems for behavior change, and programs of navigation, transportation, and cultural change. The evidence is emerging that such systems provide much better outcomes.
Ob, Peter, and Jeff clearly resonate with these concepts. I think the energy is high for changing our approach. Doing things the same way (but faster...) is not changing outcomes.
Until now, one of the giant challenges is coordinating the multiplicity of services, so that the patient is truly the center. Public health, community-based programs, home health agencies, skilled nursing facilities, primary care offices, and hospitals all have "their own way of doing things", and despite the most altruistic intentions of each of these services, patients experience a severe lack of coordination. The Institute for Healthcare Improvement has sponsored a series of collaboratives to study communities that have been highly successful in what they call "integrating". From the patient's perspective, successful outcomes require that they experience that each service knows them, uses the same forms, keeps their medication list up-to-date, and reinforces their care plan. In the world of performance improvement, an approach is to experiment with a small group of people whose needs are high, appointing "a grand integrator" who looks across the entire continuum of care for that group of patients, standardizes the approach around the patient's choices, and identifies gaps and overlaps. Building on the learning for that small group of patients then allows spread of the improvements.
thanks for your story. Sad, but obviously still a very big issue. What I find so interesting about the recent literature on this topic is the impact not just on the satisfaction of the patient and their family, but the dramatic impact on the outcomes of the care! It shouldn't surprise us, but it is so powerful that physicians really cannot ignore it. Our goal is for patients to get better: when they understand their illness, and make their own choices about how to manage the illness, among the options available, the outcomes are far better!
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