| As a physician, how many times have you | | | | correct behaviors become more consistent. |
| thought to yourself, "If only I could get that | | | | Journaling is even more effective if it supported |
| patient (I am sure someone pops into your head | | | | by the primary care office. For instance, having a |
| even as you read this) to follow my instructions, | | | | patient with hypertension email his dietary intake |
| then his health would be so much better and I | | | | over a 3 or 4 day period to his primary care |
| would feel so much more satisfied." Unfortunately, | | | | physician and having the physician reply with |
| this lament is all too common in almost all | | | | comments will help improve the patient's general |
| healthcare settings. If patients did follow their | | | | diet. Emailing is a good approach to this task as it |
| physicians' advice rigorously, then the outcomes | | | | allows both parties to address the issue at their |
| would be much more consistent and better. The | | | | convenience. A speedy reply from the physician's |
| patients would have better lives in many ways | | | | office will greatly enhance the results. An |
| and the income and satisfaction for physicians | | | | occasional spot check of patients who need some |
| would generally improve. | | | | help in maintaining their diets will greatly improve |
| Patient self-engagement is the key to compliance | | | | the results. Registries can help your office in using |
| and is one of the cornerstones of both the | | | | this approach. |
| Advanced Medical Home and the Wagner Chronic | | | | Another tool that can help the patient remain |
| Care Model. In the Chronic Care Model | | | | engaged is to include in the education of the |
| self-engagement is essential. For patients | | | | patient those with whom he lives. This education |
| diagnosed with hypertension, for instance, a diet | | | | can be done by having relatives or home |
| rich in certain nutrients (manganese and | | | | companions come to an office visit with the |
| potassium) is essential; the patient, obviously, is | | | | patient. Educational literature can be sent home to |
| responsible for this area of care. The Advanced | | | | be read by those who live with the patient. |
| Medical Home supports the Chronic Care Model | | | | Relatives and home companions who understand |
| and advocates that its basic tenets be applied to | | | | the patient's condition are much more likely to be |
| all patients. This concept is also supported in the | | | | supportive. Again, we see patient engagement |
| Institute of Medicine's Crossing the Quality Chasm. | | | | and office engagement. |
| You might say, "That's all well and good. But how | | | | Another tool is the support group or mentor. |
| do I get better compliance?" Fortunately there | | | | Some patients are very willing to attend regular |
| are a number of approaches which can be very | | | | meetings with others who have the same |
| effective. For instance, many studies have shown | | | | condition. This tool is very effective for some |
| that a mere 15 minute intervention by a physician | | | | who have a chronic condition. It is not useful for |
| with a patient who has an alcohol use disorder can | | | | all, though. This tool is very effective in treating |
| cut the amount of drinking significantly. The brief | | | | alcoholism, for instance. Sometimes insurers will |
| intervention is effective in bringing alcohol | | | | provide such support groups. Other groups meet |
| consumption to acceptable levels in 20% to 50% | | | | virtually online. Physician groups with large enough |
| of patients and the results are effective for at | | | | practices may even form and maintain such |
| least six months to two years. Thus, engaging the | | | | groups. Doing so requires that the practice |
| patient correctly in a discussion about what you | | | | provide a health coach to run and support the |
| the physician expect from the patient is effective. | | | | meetings. Mentors for patients new to the group |
| When I say "correctly", I don't mean just a | | | | will lend additional support. |
| general lecture. Correct engagement includes | | | | These are just a few of the successful |
| listening. I like using the Socratic method in many | | | | approaches that I have encountered in helping |
| of these verbal engagements. Give the patient a | | | | patients become engaged in the management of |
| few instructions and then ask them to describe | | | | their condition. I don't recommend that a |
| how she would specifically apply the instructions | | | | physician's office try all of them at once; rather, |
| to her life. Instructions, of course, should be based | | | | experiment with a couple and fine tune each. |
| upon best medical practices. | | | | Other approaches can be added if necessary. |
| As shown above, discussions are an important | | | | The results will be beneficial to both patient and |
| part of the initial steps of all patient engagement. | | | | physician. Many if not most patients will see an |
| As outlined in Organizing Care for Patients with | | | | improvement in their condition. The positive |
| Chronic Illness (Wagner, Austin and Van Korff) | | | | results will be self-reinforcing as the patient will be |
| one of the most important steps is patient | | | | able to do more as the condition improves. |
| education (discussion) about the nature of their | | | | However, there will be patients who will not take |
| disease or condition and what the patient must do | | | | on responsibility to manage their condition no |
| to help improve his condition. Unless a patient | | | | matter what approach is taken. Such patients can |
| clearly understands, the chronic condition is less | | | | be very frustrating. I urge you to consider the |
| likely to improve. Of course, the patient must | | | | improvement in the majority who do a better job |
| clearly understand his role in self-care situations | | | | when given the right tools. See how full the glass |
| with acute conditions. For instance, a patient | | | | is, not how empty. |
| should clearly understand that he should take all | | | | Physicians will also benefit financially. For those |
| the antibiotics prescribed. | | | | who participate with insurers with pay for |
| In many cases patients with chronic diseases go | | | | performance plans income should generally |
| to educational classes outside the primary care | | | | improve from this source. Too, as those with |
| setting. Diabetics often are instructed to take | | | | chronic conditions improve, there will be fewer |
| lessons from outsourced providers in managing | | | | visits to the physician office. A study (article by |
| their glucose levels with diet and exercise. Often a | | | | Truls Ostbye in the May/June 2005 edition of the |
| self-management program is prescribed at these | | | | Annals of Family Medicine)showed that a patient |
| educational settings. I believe that in order to | | | | whose chronic condition is not under control |
| achieve lasting results from these outsourced | | | | comes about once a month to the physician's |
| educational instructions, the primary care physician | | | | office. Such a patient whose condition is under |
| needs to be involved in seeing that the patient | | | | control comes in about once every six months. |
| remains engaged. Even if instructions in | | | | This may seem like a loss of income, but for |
| self-management are done in-house, the primary | | | | physicians with a large patient load there will be |
| care provider needs to remain engaged. Effective | | | | more time for patient visits which provide a |
| physician engagement is more than just having | | | | better return on investment of time. |
| the patient come in sporadically to check up on | | | | Brief dialogues, journaling, education of those with |
| how he is doing. Regular contact is necessary. | | | | whom the patient lives and support groups are |
| What, then, are some more good tools of | | | | just a few approaches to enabling a patient to |
| self-engagement that foster regular contact? | | | | self-manage her condition. Others are described in |
| Journaling is one. This tool is often used by | | | | literature centering on the Advanced Medical |
| diabetics to keep daily records of their glucose | | | | Home and the Chronic Care Model. Good places to |
| levels. Weight Watcher dieters use it to count | | | | start are The Advanced Medical Home: A |
| points and lose weight. If used consistently, | | | | Patient-Centered, Physician Guided Model of Health |
| journaling helps a patient adopt new patterns of | | | | Care by the American College of Physicians and |
| behavior which lead to the desired outcomes. By | | | | Organizing Care for Patients with Chronic Illness |
| merely writing a description of one's behavior or | | | | (authors listed above). Adopt and refine a few |
| by recording certain facts (as glucose level) | | | | and see if the benefits I indicated don't occur. |