Meeting the Challenge of Patient Engagement

Healthcare systems are using high-tech and high-touch approaches to reach patients where they are and with what they need, but an actively engaged patient remains an elusive partner in care.

This article appears in the July/August 2015 issue of HealthLeaders magazine.

Providing a patient with clinical care that is safe, effective, and costs less all are high-priority issues competing for the attention of leadership at hospitals, health systems, and physician groups. Top organizations are developing new models of care with the patient at the center of this new paradigm, but it is the patient who is a key variable that can sink a system's efforts.

In the April 2014 HealthLeaders Media Intelligence Report, The New Primary Care Model: A Patient-Centered Approach to Care Coordination, 59% of respondents cited patient engagement as one of the most challenging clinical components of primary care redesign. But it can be argued that patient engagement is a sticking point no matter the setting.

At face value, the term patient engagement seems straightforward. For example, patients who come in for their annual wellness exams on time, or patients with a chronic disease like diabetes who are faithfully taking their medication, monitoring their blood sugar, and coming in for regular checkups would be considered engaged patients.

But providers are finding that there is a lot of nuance to defining a truly engaged patient, one who is an active partner in his or her own healthcare. Settling on a definition is difficult, and measuring it is even harder. Those who have successfully engaged patients in their care have done so with a combination of human touch and technology, as well as an understanding that patience is essential when looking for long-term success.

Patient engagement requires a culture of compassion
In 2009, Brenda Jones was 57 years old, weighed nearly 400 pounds, and suspected she had type 2 diabetes. With no insurance, a temporary job in Dallas, and a sick father to take care of, she first turned to the Internet for help because she didn't have a regular primary care doctor—nor the money to see one.

"My urine started smelling sweet," she recalls. "At first it was faint, but then it increasingly got more noticeable, and it was like, 'What is that?' So, I Googled it, and every hit that came up said type 2 diabetes. I went and bought a glucose tester, and my sugar tested 320 mg/dL. I knew a trip to the ER wasn't what I needed. I knew this was going to be long-term care. I needed medicine and guidance."

Jones was like 17% of adults in the United States and 33% of adults living in Dallas at that time: employed without health insurance. But lack of insurance was just one barrier Jones faced. She says her access to affordable and healthy food was limited, she didn't know how to start eating healthier, and making a lifestyle change seemed too hard to do on her own. "It was too much for me to figure out," she says.

Such situations present a challenge for physicians, too, as they try to figure out how to get patients more involved in taking care of their disease outside of a hospital or exam room.

Last year, Jones recounted her struggle with barriers to care in front of a group of physicians who had gathered for the AMA interim meeting in Dallas. But she was a different person than she was in 2009. At 150 pounds and free of diabetes, Jones gave the room full of doctors advice on engaging patients: "Don't overwhelm a patient with information," she told them. "Patients are in crisis mode and can't handle very much."

Jones, who did not have any type of weight-loss surgery, and did not even take action to diet or exercise until 2012, says what kept her engaged and got her motivated to lose weight was the relationship she formed with Christopher Berry, MD, a family practitioner who has worked at three area nonprofit health clinics that care for low-income and uninsured patients. This is the patient population that Berry says he is passionate about working with.

The pair first met at Worth Street Clinic, a facility run by Baylor Scott & White Health, the Dallas-based healthcare system that includes 46 hospitals and 500 outpatient care sites. But, when Berry moved to become to be chief medical officer at a similar clinic, Mission East Dallas, Jones followed him.

"I come from a background of abuse," says Jones. "It's hard for me to trust anybody, and I'd come to trust Dr. Berry. I felt like he knew me. I wanted to go where he went."

Berry says Jones is the kind of engaged patient all physicians want—but rarely get.

"I have less than five 'Brenda' stories," says Berry. "Lifestyle is hard to change. What I've learned is that diabetes, depression, and obesity is a lot like treating addiction, in terms of hitting rock bottom. Doctors treat addiction in a certain way—to be compassionate. That's helped me think differently."

Berry's medical training was also slightly different. He completed the In His Image Family Medicine Residency Program, a Tulsa, Oklahoma–based program that is accredited by the Accreditation Council for Graduate Medical Education. The Christian-based program trains physicians to be compassionate and unafraid to tap into their spiritual side with patients.

Berry is not out to convert patients to Christianity, but he does pray with them, if they want. He did pray with Jones and says that spiritual dimension of care is a big part of their story.

"Addressing things like diabetes and weight was not going to touch what was going on with Brenda," he says. "It transcended into shame, fear, guilt, and judgment. How do you doctor in that space?" When patients learn that he will pray with them, patients' eyes "light up; sometimes they cry," says Berry.

"It's common in this population [low-income and uninsured]," he says. "At the end of a visit, I say, 'Do you have a religious preference? I'm a doctor who will pray with you.' When you work with people who are really in need more than the average person, you exercise elements of your personality that you may not have to exercise in other settings." Berry says the training he received helps him connect with patients in a more human way, which earns their trust and helps engage them in their care.

Establishing a solid relationship with patients is not the only factor that can improve patient engagement, but it helps, says Charles Wiltraut, CEO at Mission East Dallas, where Jones followed Berry in 2012. Wiltraut says Mission East Dallas, a federally qualified health center (FQHC), measures patient engagement through satisfaction surveys it administers to patients when they are in the waiting room.

The clinic designed its own survey to find out what its patients wanted. The patients are asked about how well the staff listens and whether the staff is giving advice on how to stay healthy. Patients drop off their completed—and anonymous—surveys in a secure box at the clinic. The number of patients who participate in the survey is relatively low, but that is likely because their health issue has reached an acute stage and their focus is on feeling better. Still, the surveys are an important tool for Mission East Dallas staff to see how they are treating patients, says Wiltraut.

"We have a mission to create exceptional patient experiences," says Wiltraut. "We're not a Medicaid mill. The culture we have here is we listen to our patients. We do warm transfers out of the room. We make eye contact."

Wiltraut says the clinic's most recent monthly survey of 60 patients shows that 92% report that the staff listens, and 80% report that staff members give advice on staying healthy. Another way he says Mission East Dallas tries to keep patients engaged is by having them on the board of directors. "Fifty-one percent of the board must be users of our facility," he says, referring to rules governing FQHCs. "There is no better way to engage patients than to give them a seat on our board."

The biggest cheerleader Mission East Dallas has is Jones, who was elected president of the clinic's board in January. Berry encouraged her to be on the board in April 2014 because of her dramatic story of engagement and improvement.

"I like being in involved with Mission East Dallas because I know how it served me and I am happy to give back," says Jones. "The community needs that center for people like me. Without it, they're wandering around hopeless, trying to get somebody to help them."

FQHCs play an important role in caring for socioeconomically challenged and underserved populations. In 2013, the California Primary Care Association studied claims data from 134,797 adults who received Medi-Cal benefits. Researchers compared two groups of patients within that population: those who used a FQHC to receive healthcare and those who did not. The patients who used services at an FQHC had an 8.2% 30-day readmission rate while non-FQHC users had readmission rate of 13.1%. A non-FQHC patient was also more expensive, costing $656. Patients who were FQHC users cost $414.

Do these metrics point to a more engaged patient population? Yes, says Wiltraut. "It means we are managing care and seeking to be a medical home for individuals and families."

Mission East Dallas also is improving patient outcomes with key populations. For example, in 2012 the clinic was not screening adolescents for obesity; now the screening rate is at least 56%. Its rate of appropriate treatment for asthma increased from 60% in 2012 to 85% in 2013.

Patient engagement requires time and trust
Another organization trying to improve patient engagement through its culture is Yakima-based Community Health of Central Washington, a network of four medical clinics, one dental clinic, a family residency program, and providers who care for seniors in residential facilities as well as hospitalized pediatric patients. Each medical clinic is an FQHC and recognized as a patient-centered medical home by the National Committee for Quality Assurance.

"We have to engage everyone on our staff—nursing, providers, front desk, reception, medical assistants—to look for opportunities where we can improve the interaction with our patients," says Michael Schaffrinna, MD, chief medical officer of CHCW. "The patient engagement challenge is about time. Healthcare teams need enough time to focus on patients and their needs in order to have credibility. It has been shown that when patients know you care, they are more likely to follow care plans."

He says CHCW took last year to define what type of culture the organization wanted to have. Employees were placed into six groups and asked to come up with ideas. From those sessions, four key words emerged that Schaffrinna says are getting pushed out into the organization continuously: helpfulness, encourage, team, and accountable. Staff members receive a coin to acknowledge their demonstration of those attributes with patients. The coin says "roundtuit," referring to the phrase "You got around to it."

"It's acknowledging staff for taking the extra time," says Schaffrinna, who says the coins are a first step to getting nurses, physicians, and other staff engaged in the extra effort it can take to make a patient aware that they are an equal partner in their care. "Mental health issues, overweight patients, chronic disease—these are opportunities we'remissing because we haven't engaged early enough."

CHCW has only just begun handing out the coins, which can be exchanged for a vacation day. Schaffrinna says he is determined to change the culture at the organization, not because its providers aren't doing a good job, but because he thinks they can do better.

"Every one of our locations is a patient-centered medical home," he says. "When an organization gets to that level, they're better than they were, but it's too low of a bar. Engaging a patient is more than giving them information. They have to trust you. If we don't take control of this ourselves and make it better, our patients are going to suffer."

CHCW has made small improvements in its care of the 30,000 patients its providers see annually. The rate of women receiving prenatal care has improved from 78.5% in 2011 to 80.5% in 2013, and the rate of childhood immunizations increased from 72.9% to 84.2% over the same time period.

Patient engagement is activation
Healthcare organizations have a variety of ways to measure patient engagement. They may look at health outcomes over a period of time, or measure patient satisfaction, or encourage and monitor interaction with the organization's online tools. But a researcher at the University of Oregon put a finer point on the definition of engagement and developed a statistically validated and peer-accepted method to measure a patient's activation level.

Judith Hibbard, DrPH, is professor emerita in the department of planning, public policy, and management at the University of Oregon, and serves on the leadership team of Insignia Health as the lead researcher and developer of the Patient Activation Measure. PAM is a 10- or 13-question survey a patient takes to assess his or her knowledge, skills, and confidence in managing his or her health. The results of the questionnaire assess patients on a 0–100 scale and can be used to categorize them as a 1, 2, 3, or 4, with 1 representing the lowest activation level and 4 representing the highest.

According to the description of what PAM 1 means, a patient at this level is likely to feel "disengaged and overwhelmed." As the levels increase, so does a patient's confidence. At a PAM level 2, patients are "becoming aware, but still struggling." At a PAM level 3, patients are actively taking a role in the management of their health, and a PAM level 4 patient has made and kept healthier habits. Hibbard has been studying patient activation for 10 years, and has published many peer-reviewed studies that repeatedly show a patient's activation level is related to health outcomes.

"Patients who are less activated are twice as likely to have a 30-day readmission," says Hibbard. "If you look at a commercially insured population, about 30% are in the bottom two levels of PAM; in the Medicare population, 40% are in the bottom two activation levels; and in the Medicaid population, 50% are in the bottom two categories. Becoming activated is possible for everyone."

Time is a critical element to engaging patients. Whether it is encouraging staff to spend more time with patients to get them engaged, as Schaffrinna suggests, or giving patients more time to become active in their own care, Hibbard says that model of care for which most physicians have been educated and trained does not encourage true patient engagement.

"Most physicians are trained to give patients information, and if the patient doesn't follow through, that's not the doctor's problem," she says. "That model doesn't work. In healthcare, we often ask people to do things that are way beyond their capabilities. People want to have good health, but for some, their motivation is muted because they are overwhelmed and discouraged."

Hibbard developed PAM to give physicians a starting point for determining how motivated, confident, and knowledgeable their patients are. The tool is gaining traction with healthcare providers. According to Insignia Health, the Portland, Oregon–based company that licenses PAM, there are 140 health systems, hospitals, and physicians who use the tool in the Unites States and United Kingdom.

Minneapolis-based Fairview Health Services, a nonprofit health system that includes seven hospitals and more than 40 primary care and specialty clinics, has been collecting PAM scores on patients who visit the system's primary care clinics since 2010.

Valerie Overton, DNP, FNP-BC, vice president of quality and innovation at Fairview Medical Group, which is part of Fairview Health Services, says the medical group began measuring patient activation because leaders believed it would help capture the value of patients' health.

"We believe that one of the most important moves of the future for primary care is not only an emphasis on the measurement of disease-related outcomes but the measurement of health outcomes," Overton says. "As we move forward as an accountable care organization, we will be able to talk about how much health we produce for dollars spent."

A study of PAM scores collected from 33,163 Fairview Medical Group patients in 2010 found that patients with a PAM level of 1, the lowest, incurred a higher cost ($966) than patients who were PAM level 4, which is the highest level of activation. These patients' healthcare costs were $799. The results proved to Overton that PAM is a valuable tool, but clinicians were reticent to use PAM actively, she says, because it wasn't clear that if patients' PAM levels changed, their clinical outcomes would, too.

"Clinicians are evidenced-based," says Overton. "There's a time investment that it takes for clinicians to interact with patients, and clinicians really want to understand, 'If I'm going to change my approach, it really is going to make a difference.' "

What has not been clear is what a physician can do to improve a patient's activation measure. First, Overton says she had to gain physicians' trust about using PAM with patients. Now, even though definitive clinical outcomes are not yet available, the results of the most recent PAM study have allayed physicians' concerns, says Overton, because researchers found that when PAM levels improve, so does patient health.

Published in March in Health Affairs, a longitudinal study of patients who had their PAM levels taken twice, once in 2010 and again in 2012, showed that 58% of patients did not move between PAM levels, but of the 42% of patients who did either increase or decrease their activation level, their outcomes and costs moved with them. For example, 9% of patients with a baseline of PAM level of 3 or 4 moved to a PAM level of 1 or 2. Those patients' incidence of having higher A1c levels, going to the emergency department, and being obese also increased, as opposed to those who improved their PAM levels.

Fairview Medical Group is engaging with its clinicians now to figure out what interventions are most effective at improving a patient's PAM score. "This study is a turning point for us," says Overton. "We're trying to understand how to help our clinicians embrace certain ways of interacting with patients that are engaging to patients and are likely to improve their engagement. What does it really take to change activation levels? We're looking at patient-facing technologies, patient monitoring, websites related to their disease management, and improving provider interpersonal communication skills and coaching skills."

Overton says the medical group has taken a step in determining how it can improve patients' PAM scores by differentiating how patients are managed. For example, Fairview Medical Group experimented with using health coaches to help depressed patients. She says the group added a health coach to the care management of mildly to moderately depressed patients with a low PAM score. The additional resource was supposed to improve patients' depression, but what the group found was that the combination of depression and low activation was too much for a health coach to handle. Overton says they learned that patients needed more targeted resources.

"We're going back to the drawing board," says Overton. "We're pursuing using more behavioral health counselors for patients with depression and a low activation score, but using health coaches for patients with high activation scores. Our behavioral health resources are scarce, and we want to make sure we get the right patients to the right resources."

The lesson learned, says Overton, is that PAM isn't only useful for physicians and patients, but also for the system. "You can't care manage or case manage everybody. If you're going to deploy scarce resources, PAM can help you figure out which subpopulations to deploy your resources to."

Patient engagement is high-tech and high-touch
Technology and patient engagement go hand in hand at Geisinger Health System, the Danville, Pennsylvania–based integrated health system with nine hospital campuses, a multispecialty group practice, and a health plan. With one of the industry's most mature electronic health record systems, GHS has been able to leverage patient data and technology to help get and keep patients engaged.

Interestingly, the patient engagement strategy at GHS was largely informed by Hibbard's research into patient activation, says Albert Bothe, MD, FACS, executive vice president and chief medical officer for GHS. "Dr. Hibbard's work was a demonstration that effective care wasn't just the skill of the provider," says Bothe. "It correlated the engagement of the patient with the recommended treatment."

Bothe says Geisinger doesn't use the PAM questionnaire, but it did use the concept of helping patients get activated earlier in their treatment by providing them access to websites that explain upcoming procedures. The strategy that began seven years ago has developed into what is now a robust approach to engage patients with a combination of high-tech tools and high-touch providers.

"An engaged patient is a healthier patient for us," says Gregory Moore, MD, PhD, chief emerging technology and informatics officer, and director for the Geisinger Institute for Advanced Application. "If you're a Geisinger patient, you've become used to multiple individuals reaching out to you and in different ways. It's not unusual for a nurse navigator to call and say, 'Hey, I notice you have a couple of open care gaps. You haven't gotten to that eye exam we've scheduled for you. Can we assist in getting you a ride there, or can I make that appointment at a more convenient time for you?' "

Closing those gaps in care is a key way that Geisinger measures patient engagement, and it's also used as provider incentive. Moore says physicians have 20% of their salary "on the line" for meeting quality metrics, one of which is closing care gaps. "You only get credit for closing your patients' care gaps if it is 100%," says Moore. "The metric that matters is not the number of care gaps, but how many times we get to 100% of care gaps closed."

Moore describes the GIAA as think tank and research lab for patient engagement, big data, and big concepts like population health. "We're the ideation part," he says.

The GIAA is made up of three centers: the Center for Clinical Innovation, the Center for Reengineering Healthcare, and the Center for Emerging Technology. The Center for Clinical Innovation is the laboratory for patient engagement pilots that—if they are able to demonstrate better care, cost, and patient satisfaction—are rolled out to GHS.

The Center for Clinical Innovation is where the care gap program was piloted. It gets patients with chronic diseases up to date on their immunizations, routine checkups, and lab tests. That keeps them engaged with the system, both with technology tools that GHS is constantly testing and with providers (because patients have to come into GHS clinics). The data from the pilot showed that from 2010 to 2013 there were not only fewer gaps in patient care, but there was also a $30 million increase in revenue because patients were getting more and necessary care. "That was an unexpected by-product of doing the right thing for the patient," says Moore. "We were focusing on patients with diabetes, hypertension, chronic obstructive pulmonary disease, and figuring out a reliable way to close those gaps in care."

Moore says a care gap is typically identified in the patient's EHR before the patient comes in for the appointment. Depending on the patient's preference, either a phone call, text, or email will outline what to expect, including whether it is time for a foot exam or a vaccine, for example. If it's a foot exam, the patient will be asked to remove shoes in the exam room. It's a small action that reminds the doctor a foot exam is due, though GHS' technology makes the care gap nearly impossible to miss. It is noted in the EHR so that the front desk sees it when the patient checks in, the nurse sees it when rooming the patient, and the physician sees it on the EHR screen in the exam room.

"We've found that the patients themselves are reminding the nurse and alerting their care team," says Moore. "It's about those communications. Everyone is getting information before the visit." The number of gaps that GHS closed during 2010–2013 was 250,000.

Another patient engagement initiative recently rolled out at GHS is the use of OpenNotes, which gives patients and their caregivers access to providers' notes about their care through a secure patient portal. GHS has had a patient portal since 2001. It now has 300,000 registered patients, with a daily log-in rate of 15,000–20,000. The large patient population using the portal made it a natural fit to be one of the first pilot sites for OpenNotes in 2010.

"There was concern among the physicians in allowing patients to read their own notes," says Bothe. "But after the pilot study was done, all the patients who were surveyed and all but one of the physicians wanted to continue allowing access to the notes."

The study Bothe references is from the Annals of Internal Medicine in 2012, which showed that patients appreciated the ability to see their doctors' notes and to add to them to give a more complete picture of their medical history. According to the study, 77%–87% of patients said they felt more in control of their medical care, and they also reported better medication adherence. Bothe says OpenNotes is now in every department, except for mental health (psychiatry/psychology), interventional pain management, and otolaryngology.

GHS patients may be used to technology—touch screens are in every primary care exam room, some waiting rooms have iPads, and the MyGeisinger portal is also a patient app—but Chanin Wendling, director of eHealth for the division of applied research and clinical informatics at GHS, says the technology tools exist to support the patient and provider relationship, not replace it.

"We're not looking to not talk to the patient," she says. "That face-to-face time or time on the phone is still important. I'm not giving anybody a complex cancer diagnosis over a mobile app or secure message through a patient portal, but what I can do is once that doctor has had that conversation, I can reinforce care plans and give patients tools to deal with a life situation where they're going to have to think about their diet or medications."

Wendling says she studies consumer technology trends to find out how GHS can become part of a patient's routine so that it is easier for patients to be engaged with their health. A small weight management study that utilized text messaging showed positive results that Wendling says may provide a clue to patient preferences.

From November 2012 through April 2013, 700 gastroenterology patients who were trying to lose weight enrolled in a program that delivered a text message to them three days a week over 12 weeks. The text messages were motivational tips and reminders to keep weight management "front and center."

"When providers have the patient in the office, they talk about all of these strategies and get the patient pumped up, but then the patient doesn't come back for three months or six months and maybe didn't remember all the things that were said, or had trouble keeping their motivation up," says Wendling. "These text messages would come and be a little kick in the butt."

The pilot program results showed that patients who participated in the text messaging pilot lost 0.5 body mass index more than patients who didn't participate. "Going from a 50 to a 49.5 BMI may not be a huge difference, but you have to start somewhere, and the text messaging program is cheap," says Wendling. "It's not a huge cost to the system, and it's good for people who are obese, have diabetes, and high blood pressure. There are a lot of people you can touch with this program."

The text messaging program for weight management was made available across the system in 2013. That coincides with another text messaging program that has had a high adoption rate among patients. Wendling says GHS began enrolling patients in its appointment reminder via text program in October 2013 as patients came into clinics. She estimates it took a year and a half for all patients to receive information about the program because some patients only come in once a year.

"We have over 200,000 that have signed up," she says. "We consider our active patient population to be about 550,000, so that adoption is tremendous. That clearly states people want a text message reminder."

Wendling says paying attention to how patients want to be communicated with is an important step in understanding how to engage them in their care. She wants to figure out how to work healthcare into patients' normal, daily routine.

"Patient engagement is all about the patient taking action," says Wendling. "In order for the patient to take action, in my view, you have to work with them in a space they're comfortable with. I'm not trying to get the patient to do something they wouldn't normally do. I'm trying to weave our health system into how they live their life."

Patient engagement is personal care coordination
The dynamic technology solutions at GHS are not only for large integrated health systems. North Atlanta Primary Care, a patient-centered medical home with seven locations in the metro Atlanta area, also uses technology to close gaps in care, but its real secret to patient engagement, says founder Thomas Bat, MD, is physician assistants.

"We would not be here without PAs," says Bat, who initially used a PA in 1989 to fill in temporarily during a busy flu season. The PA he hired had 25 years of experience and proved to be invaluable, so Bat kept him and has since hired
14 others.

Bat sees PAs as an integral part of providing team-based care to the 550 patients NAPC providers see daily. "Every patient has a care plan," he says. "My office managers have a spreadsheet of every patient seen, and every day they use it to look for gaps in patients with chronic disease, then they develop a daily call sheet."

Though NAPC has a portal with 100,000 patients who could get their information about a missing exam or checkup through a secure message, Bat says the PAs get a list of 10–20 people to call per day. The patients respond better, he says.

"We find that when a PA calls to follow up with a patient, 85% will make an appointment within the next week," says Bat. "Patients like it when they talk to someone who is educated."

The education track for PAs is often cited as one of the reasons they work well as midlevel providers, or physician extenders, the term Dawn Morton-Rias, EdD, PA-C, CEO of the National Commission on the Certification of Physician Assistants, prefers.

"While PAs have a very scientific approach, we have formal education on interviewing and patient engagement—how to gather medical history, ask open-ended questions, how to make eye contact, body language," she says. "You have classroom instruction long before you get out to the clinical practice."

The use of PAs in family medicine, specialty practices, and emergency medicine has grown considerably since 1975, when the NCCPA certified the first PAs. Since 2009 alone, PAs have increased in from 74,777 to 101,977 in 2014.

PAs, along with nurse practitioners, are providers who can free up time for a physician to see more complicated cases. PAs practice under the supervision of a doctor and can examine, diagnose, treat, order tests, and develop treatment plans. Bat says using PAs to their full extent allows his practice to give patients the time they need to understand their health condition, which can be complicated because 70% of NAPC patients have a chronic disease.

"We shoot for a 1:1 ratio of PA to doctor because they can exchange patients," says Bat. "If they're unsure about a next step, they can say, 'Hey doc, can you jump in on this patient while I do your refills?' It keeps the flow going."

Technology is also a part of NAPC's patient engagement strategy. Its patient portal has 100,000 registered users, which Bat says encourages compliance with patients who use it. Despite being an early adopter of electronic health records—NAPC won the Nicholas Davies Award from HIMSS in 2004—Bat says portals have their limitations, and are not the primary answer to the question of how to better engage patients.

"Portals are good and bad," he says. "Some patients love it. The technology allows patients to go more in depth with education and articles I can put out on the portal for them, and that's where it's positive. But the above-60 crowd, who has much of the chronic disease, does not use it as much as younger patients. They want one-on-one time. My goal is to have an app that fits in with patients' lives."

The tug-of-war between giving a patient more time or more technology is a struggle that most healthcare providers continue to have; however, as some organizations have found, it is a combination of both that has the best chance of getting a patient to be an active healthcare partner.

As hospitals and health systems continue to grapple with patients who have significant health issues but little motivation, Bothe says it is important to remember that health literacy is a significant challenge.

"How readily patients can have a conversation with their provider is a two-way street," he says. "If a provider recognizes a patient has limited fluency with medical terms, the provider needs to change the vocabulary and the pacing of explanations."

It is also the tone a provider strikes with a patient. Empathy is what Jones valued with Berry so much that she followed him from one clinic to another. That five-year relationship led to an extreme turnaround in her health. Remarkably, Berry did not ever ask Jones about her weight. Should he have? Jones says yes, probably, but she was relieved he didn't because it was embarrassing. Berry says more doctors need to recognize the delicate balance of knowing when to talk to a patient and when to listen.

"It gets back to that need for us doctors to be sensitive, to not be seen as accusers or judges to people who may already feel ashamed," says Berry.

And though Jones is no longer under Berry's care because she doesn't have diabetes and because he's also moved on to help another Dallas clinic become a FQHC, they still keep in touch.

"I miss him terribly as my doctor," says Jones. "I miss him praying with me. I had been able to talk to Dr. Berry about not just physical stuff, but hurts in my heart. He always took his time with me. I still feel that the doctors at Mission East treat all of me—the physical, emotional, and spiritual."

Reprint HLR0815-2

This article appears in the July/August 2015 issue of HealthLeaders magazine.