After a traumatic experience as a hospital patient, Angelica Thieriot founded Planetree in 1978. Her vision was to help hospitals become healing havens, places where patients have an equal voice in their health care experience. Since then, the voices and experiences of patients, families, professional caregivers and physicians have guided the ongoing development of Planetree's patient-centered care philosophy.
A number of focus groups uncovered consistent themes about how patients define a high-quality health care experience. Today, those themes are the 10 core tenets of the Planetree philosophy. Among them are compassionate human interactions; family, friends and social support; and patient/resident education and community access to information. These components of patient-centered care work in elegant harmony to ensure that patients' needs and preferences are listened to and acted upon.
Taking Steps toward Shared Decision-Making
Engaging patients as integral members of their health care team by sharing their real-time medical records with them, welcoming loved ones as official care partners, lifting rigid restrictions on visitation to promote the healing presence of the patient's support system, and providing access to health resource librarians are just a few of the necessary steps to achieving a two-way dialogue with a physician about evidence-based treatment plans.
The impact of these practices is substantially weakened when they occur in isolation from each other — or worse yet, sporadically, dependent on particular caregivers' comfort level. However, when they occur routinely and systematically as part of a comprehensive culture of patient-centered care, their impact — on patient engagement and satisfaction, quality of care and health care costs — can be profound. These patientcentric engagement principles pave the way for shared decision-making. Due to its potential impact with value-based contracting, shared decision-making has again become an industry hot topic for its cost-saving potential and for boosting patient satisfaction.
Shared decision-making is a collaborative process during which patients and providers make health care decisions together, taking into account the evidence-based medical options and the patients' preferences, values and beliefs. The method is frequently used when a patient has a condition — such as low back pain or early-stage prostate or breast cancer — that has one to three viable treatment options. It also helps patients to manage chronic conditions such as diabetes, asthma and hypertension. To support patients in the evaluation of their options, clinicians using shared decision-making employ decision aids in written or video form to help patients weigh the pros and cons of each option.
Improving Satisfaction and the Bottom Line
Including patients in their health care decisions is at the heart of patient-centered care. Planetree has been espousing the benefits of active patient engagement for 35 years. But talking about patient engagement is one thing; doing it is quite another. Planetree partners with hospitals and other health care settings to improve communication and create a two-way dialogue. These efforts have resulted in substantially improved patient satisfaction scores.
Now, more and more data are emerging that demonstrates involving patients in decision-making not only leads to increased patient satisfaction, but also positively impacts the bottom line. The New England Journal of Medicine reports that 20 percent of patients involved in shared decision-making choose less invasive, more conservative treatments; therefore, hospitals seeking to thrive in a value-based environment (which would be all of them) would be well-advised to support shared decision-making, to insist that clinicians buy into it, and to provide them the training and tools to make it happen.
Further evidence of the efficacy of shared decision-making comes from a large-scale systematic review by the evidence-based Cochrane Collaboration finding that shared decision-making:
- improves patients' understanding of their health care choices, including the benefits and harms of each choice;
- increases patients' active engagement;
- improves patients' adherence to their treatment plans;
- facilitates patient-provider communication;
- lessens patients' uncertainty about their choices;
- lowers health care costs.
Despite these numerous benefits, shared decision-making is used only sporadically in the United States. But it is gaining greater scrutiny as a strategy to support health care reform and the three primary objectives of the National Quality Strategy: improved health outcomes, enhanced community health and reduced health care costs.
Improving Outcomes for Asthma Patients
A study at six asthma clinics in the Carolinas Healthcare System is a case in point. Carolinas researchers hypothesized that engaging asthma patients in shared decision-making would promote treatment plan adherence and, thereby, improve patients' outcomes, including reductions in their emergency department visits and hospitalizations. The study involves a network of 88 practices located within Carolinas in Charlotte, N.C. Specialized asthma shared decision-making clinics were implemented at six of its primary care practices that serve a predominantly Medicaid, Medicare and indigent population, encompassing the majority of the community's poorly controlled asthma patients.
Using a cooperative approach, core members from each practice, including a physician champion, health coach, clinic staff and researchers, met regularly to adapt and then implement a shared decision-making toolkit. A staggered rollout of the toolkit intervention took place throughout the participating sites beginning in April 2011 and proceeding through May 2012. Caregiver teams were trained in how to use the toolkit; the resulting asthma shared decision-making half-day clinics were individualized to capture each clinic's unique culture, focusing on sustainability as well as provider productivity.
These same clinics were revisited by the research team 12 months after implementation to share study results, address any operational issues and provide ongoing support. They also evaluated patients' perceptions of the extent of shared decision-making during their asthma clinic visit.
Initial results show significant and marked improvements in patient adherence to medications, decreases in asthma exacerbations, and fewer emergency visits and hospitalizations for asthma. In particular, preliminary results show that, of the 241 shared decision-making visits between June 2011 and December 2012, 87 percent of the visits involved a shared decision concerning patients' asthma treatment plan. Comparative data (6 months) on ED visits before and after the shared decision-making visit show ED visits dropped from 14.2 to 8.1 percent (a 43.6 percent decrease), and inpatient hospitalizations declined from 4.1 to 1.4 percent (a 65.9 percent decrease). Additionally, there was a notable decrease in the use of oral steroids for asthma exacerbations: from 27 to 19 percent.
Coaching Organizations to Go the Distance
Encouraged by the growing evidence base for shared decision-making, as well as the importance patients in focus groups place on dialogue and partnership with their health care providers, Planetree is committed to encouraging hospitals to commit to the implementation of shared decision-making.
For organizations with established patient-centered cultures, the finish line may be within reach, but for many, it's miles away. Specialized training has been developed to bring caregiver teams together to re-engineer workflow and find the time for health coaching. By bringing the entire care team together, focusing on a priority patient population, and committing to seeing the experience through the patient lens, the daily work process can, in fact, be rewired for the successful implementation and subsequent tracking and measurement to ensure sustainability.
Yes, there are obstacles in this course, but it's a team relay race. Planetree believes it is well worth running the race and celebrating the rewards of healthier, happier patients.
Susan B. Frampton, Ph.D., is the president of Planetree in Derby, Conn.