Engaging the Patient's Experience

Carolinas HealthCare System leaders have developed a team-based approach to effectively address patient experience through shared decision-making.

This article appears in the June 2014 issue of HealthLeaders magazine.

The term patient-centered care has had an unfortunate misinterpretation for many in healthcare. Some providers end up building teams and processes around the patient at the expense of those who work with the patient. The team at Carolinas Medical Center-Mercy understood the relationship between doctor and patient historically has been paternalistic, with the physician as expert directing care based on his or her view of what is best for the patient. Providers have generally moved past that model, but few have embraced a true collaborative model in which the physician and patient each bring their knowledge, says Hazel Tapp, PhD, associate director of research for the Department of Family Medicine at Carolinas Medical Center-Mercy.

"Shared decision-making is a meeting of two experts," Tapp says. "The patient is the 100% expert on what's important to them and their preferences. And the provider brings expertise around disease knowledge and psychosocial situations."

Dael Waxman, MD, interim chair of the Department of Family Medicine at Carolinas Medical Center-Mercy, says this approach is really about helping the patient make decisions about what is best for him or her.

"Shared decision-making says the physician is the expert on the disease and about what needs to happen to treat the disease," Waxman says. "The patient is the expert [on] what they're willing to do, what they can afford to do, what makes them happy, what's distasteful to them. In the middle, we're going to have a conversation about what the patient is going to do. The physician may have some suggestions, but the patient is the one that's going to walk away with it."

The team at CMC-Mercy decided to test the hypothesis that shared decision-making could result in better outcomes using an evidence-based toolkit, Tapp was awarded a $2 million, three-year grant from the Patient-Centered Outcomes Research Institute to test a shared decision-making toolkit for asthma care in the primary care setting. The sample size is 30 practices statewide, randomized to three arms of 10 practices per arm. The project started in August 2013 and will finish August 2016.

The first set of patients who were identified for intervention were asthmatics who had ended up in the emergency department or inpatient admission following an attack. Those patients were invited to come to the primary care office for a "specialized asthma visit," which started with the nurse taking vital signs and performing a spirometry test to measure pulmonary flow. Then the patient met with a designated asthma health coach, who "can be anyone in the practice," Tapp says. "It can be a PharmD or an educator or a nurse or someone who has a little passion around asthma." The health coach worked through a script that first explained the shared decision-making approach, and then asked a series of pointed questions about the patient's understanding of his or her asthma and medications. The goal was to come up with a treatment plan that worked with the patient's life, Tapp says.

"For example, we had a 16-year-old boy who was really struggling and coughing every day," Tapp says. "His mom was real worried about him. He was supposed to take his medication twice a day, morning and night. So we worked through the profile with him and he just said, 'I hate taking it at night.' We said, 'That's fine. You can take a higher dose in the morning. Forget the nighttime.' They came back and everyone was really crying. He was feeling so much better. The mother was feeling so much better. He just needed to be listened to and to be able to do it his way."

This approach to shared decision-making includes discussion that guides patients beyond just stating what their problem is, but what their goals are.

"Our patients all have barriers. We serve an underserved population. But when we can get a patient to state a goal, they do so much better than equivalent patients with the same number of barriers," Tapp says. "From a motivational standpoint, you're much more likely to do it by stating a goal rather than if you are just listening passively to paternalistic advice. So I repeat that to physicians all the time. Try to get them to state a goal. Trick them into stating a goal if you have to, because it's very effective."

The approach works well beyond asthma, and Waxman says he has used the shared decision-making model for patients with other chronic issues.

"I just used this yesterday with a patient who has pretty bad peripheral vascular disease, and he's smoking, which is really bad," Waxman says. "He had said it was his goal to quit smoking. We had a whole conversation about what the different options were. He had tried several of them before that didn't work. I put the options out there that other patients have told me worked for them. He selected one of those, and then we had a conversation about when he would be ready to start."

In the former physician model, says Waxman, he may have "ordered" the patient to start immediately, but instead suggested he start in a couple of months. The patient said he could start in two weeks.

"And then he was there. So it wasn't me saying, 'I think you need to do this two weeks from now.' It was him saying, 'I think two weeks is about when I'm going to be ready.' So he actually set a date and he set a plan for how he's going to do that. And the research would say that he's more likely to actually do that and more likely to reduce or stop smoking than if I had said, 'You need to stop smoking.' "

The asthma study continues, but preliminary findings showed that patients in the study saw their ED visits drop from 14.4% to 9.1%, and inpatient hospitalizations dropped from 4% to 1.7%. Use of oral steroids also dropped, from 27% to 20%.

The primary care physicians have seen the data that supports shared decision-making, and now they are seeing firsthand how much better their patients are doing, says Tapp.

"ED visits are dropping. Patients are adhering to their medication. Providers already kind of sensed that anecdotally. They just weren't seeing the same patients popping up again and again. So that really was hitting home for them."

Reprint HLR0614-11

HealthLeaders Media LIVE From Carolinas HealthCare System: Patient Experience, will be held on Thusday, July 29, 2014, from 12:00 to 3:00 p.m. ET. Participants will discover how a shared decision-making toolkit for asthma care can significantly reduce ED visits and inpatient hospitalizations among other helpful tips.

This article appears in the June 2014 issue of HealthLeaders magazine.