Patient Centred Care Delivery Flashcards
Two extremes decision making model
Paternalism
Consumerism (informed choice)
Shared decision making is the middle
Shared Decision Making steps
- Choice Talk
There is exchange of information between a patient and his doctor, medical and personal information included - Option Talk
Possible options and outcomes are discussed and considered by patient and doctor - Decision talk
Doctor and patient reach consensus about what needs to be done
Paternalism
When talking to your physician about what to do in terms of treatment, the physician decides.
Consumerism/informed choice
The patient decides what treatment to follow. The physician simply has to accept the decision.
Ethicist view SDM
The right of patients to determine what happend to their bodies is self evident. SDM increases autonomy.
Economist view SDM
Increase in consumer power is a means to subject health care providers to market discipline. SDM will increase cost effectiveness.
Epidemiologist view SDM
Patients have an almost universal desire to be informed and to be involved in the treatment in one way or another.
Clinicians view SDM
More active involvement of patients in decision making process improved treatment relationship with better outcomes as a result
- enhanced patient adherence
- more satisfaction
- better clinical outcomes
Objections SDM
- Options may harm those patients who are having difficulties in decision making. Options may result in growing awareness of missed opportunities.
- Patients may find it difficult to appreciate outcomes because of their inability to foresee how they themselves will adapt to outcomes.
- Choice and having a say raise expectations. Disappointment and dissatisfaction lie ahead when clinical realities fail to meet expectations.
SDM is more appropriate for..
- relatively healthy patients
- patients with active coping skills
- patients with chronic conditions
SDM is less appropriate for..
- elderly patients
- less educated patients
- acute patients
- minor decisions
appropriate circumstances for SDM
- When there is uncertainty regarding effectiveness or outcome
- Risks and benefits are equal
- Patient is willing and able to participate
- Patient is able to comprehend and appreciate trade offs
- SDM fits perfectly within the changes of health care
SDM obstacles
Lack of resources
- Seeing less patients is unprofitable
- Implementation SDM is costly
Fear of loss of professional autonomy
- Doctors are creatures of habit
Poor communication
- Giving information about risks and possible outcomes can be extremely difficult
Patients needs and expectations
- Belief among doctors that patients do not wish to be fully informed
- Preferences among patients for participation vary
- SDM is a choice
Requirements Sdm
- underlying legislation supporting SDM
- investment in decision aids, self help, patient support groups, case management
- Attention SDM for doctors; training programs, skills
- Spread the positive influences of SDM
Role of professional Acute Care
Expert
select en conduct therapy
Role of patient Acute Care
Follow orders
passive
Role of professional Chronic Care
Teacher/Coach and partner/consultant
Supporting patients
Role of patient Chronic Care
Partner/daily manager/own caregiver
What do patients with chronic conditions need?
A continuous relationship with a care team and practice system organized to meet their needs for:
- effective treatment
- Information and support for their self management
- More intensive self management
- Coordination of care across settings and professionals
- Systematic follow up and assessment tailored to clinical severity
Three p for good chronic care
Prepared,
Proactive,
Practice team
What characterizes an informed activated patient
Patients have the motivation, information, skills and confidence necessary to effectively make decisions about their health and manage it
What characterized a prepared proactive practice team?
Teams of professional have the patient information, decision support, time and resources necessary to deliver high quality care
How can you recognize productive interactions?
- Assessment of self management skills and confidence as well as clinical status
- Tailoring of clinical management
- Collaborative goal setting and problem solving resulting in a shared care plan
- Active, sustained follow up
The Chronic Care Model
Community
- Resources and policies
Health System
Healthcare organization
- Self management support
- Delivery system design
- Decision support
- Clinical information systems
These two come together in productive interactions between informed, activated patient and prepared, proactive practice team.
This will result in functional and clinical outcomes
CCM self management support
Goal is to empower and prepare patients to manage their health and healthcare.
- emphasize patients central role in managing health
- use effective self management support strategies
- organize internal and community resources
CCM Delivery system design
The goal is to assure the delivery planned, effective and efficient care and self management support.
- define roles and distribute tasks among team members
- use planned interactions to support evidence based care
- provide case management services for complex patients
- ensure regular follow up by care team
- give care that patients understand and fits cultural background
CCM decision support
Goal is to promote clinical care that is consistent with scientific evidence and patient preferences.
- embed evidence based guidelines into daily clinical practice
- integrate specialist expertise and primary care
- use proven provider education methods
- share guidelines and information with patients
CCM clinical information systems
Goal is to organize patient and population data to facilitate efficient and effective care.
- Provide timely reminders for providers and patients
- Identify relevant subpopulations for proactive care
- Facilitate individual patient care planning
- Share information to coordinate care
- Monitor performance of practice team and care system
CCM Health System
Healthcare system
Goal is to assure that practices within the organization have the motivation, support and resources needed to redesign their care systems.
- visibly support improvement at all levels of the organization
- promote effective improvement strategies aimed at comprehensive system change
- provide incentives based in quality of care
- encourage open and systematic handling of problems
- develop agreements that facilitate care coordination within and across organizations
CCM community resources and policies
Goal is to help patients access effective and useful services and resources in their surrounding community.
- Encourage patients to participate in effective communication programs
- Form partnerships with community organizations to support and develop interventions that fill gaps in needed services
- Advocate for policies to improve patient care
Theory of relational coordination
Coordinating work through relationships of shared goals, shared knowledge and mutual respect.
Relational dimensions reinforce and are reinforced by dimensions of communication:
- Frequency
- Timeliness
- Accuracy
- Problem Solving
definition of relational coordination
a mutually reinforcing process of communication and relating for the purpose of task integration
impact of relational coordination
- Improvements in patient related outcomes, such as care quality, well being, satisfaction with care
- Improvements in professional related outcomes, including job satisfaction
- Mixed outcomes on the organizational level
Characteristics patients with multimorbidity
- Two or more co-existing chronic conditions
- Complex care needs
- Single disease-oriented guidelines
- Uncertainty
- Time constraints
- Fragmented care
- Multiple healthcare providers involved
A typology of actions to reduce health inequalities
- Strengthening individuals
- Strengthening communities
- Improving living and working conditions
- Promoting healthy macro policies
WHO definition of health
From health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity
Dimensions of well being
Overall well being
Physical and social well being
Comfort/stimulation and Affection/behaviour confirmation/status
Activities. resources, healthcare services
eg self management abilities
Taking initiative
Self efficacy beliefs
Investment behavior
Positive frame of mind
multifunctionality
Variety
Domains of functioning
Social functioning
Cognitive functioning
Physical functioning
Whitehead The logic of health inequalities interventions categories
- Observed problem of health inequality
- Perceived causes of problem
- Policy goals to address causes
- Theories about how and why interventions might work to bring change in cause
- Design of intervention programme
- Outcome of programme
Shortcomings CCM
- Focused mainly on clinically oriented systems and outcomes
- Difficult to use for prevention and health promotion practitioners
- Does not encompass the complexity and interplay of social, cultural and economic factors that affect health
- The capacity of communities in addressing these conditions
Expanded Chronic Care Model
- Self-management/ Develop personal skills
- Delivery system design/ re-orient health services
- Decision support
- Information systems
- Build healthy public policy
- Create supportive environments
- Strengthen community action
- Outcomes
Outcomes
- Productive interactions and relationships among community members/groups, healthcare professionals and organizations
- Functional outcomes
- Clinical outcomes
- Population health outcomes
Strengthen community action
- Empowerment of communities
- Partnering with communities to promote community health and healthy environments
Create supportive environments
Realizing living and employment conditions that are safe, stimulating, satisfying and enjoyable
Build healthy public policy
- Policy and legislation aimed at improving population health
- Safe and healthier goods, services and environments
Information systems
- Community data beyond the healthcare system
- Support information about demographics, population health and trends
Decision support 2
- Decision support not only related to disease and treatment
- Also, evidence on strategies for well being and healthy living
- Community based best practice
Delivery system design/ re orient health services
- Holistic way of providing support to individuals and communities
- Connections between health and broader social, political economic and physical environmental conditions
Self management/ develop personal skills
- Support of self management in coping with disease
- Also developing skills for health and well being
Innovative Care for Chronic Conditions framework (ICCC)
- When health problems are chronic, the acute care practice model doesn’t work
- ICCC is an adaptions of the CCM for a global perspective
What are the current problems on different levels?
- Micro level: Patient interaction problems
- Meso level: Problems with healthcare organization and links to community
- Macro level: policy problems
The micro level
- Patient interaction problem
- Patients and families partnering with community partners and healthcare teams
- Informed, motivated and prepared
The meso level
- Healthcare organization elements reframed
- Community is strongly emphasized
- Community services should complement organized healthcare
The macro level
- Positive policy environment to support care for chronic conditions
- Leadership, policy integration, financing, allocation of human resources, legislation, partnerships
Innovative approached and strategies for managing chronic conditions can successfully:
- Improve disease outcomes
- Save money and healthcare resources
- Change patients lifestyle and self-management abilities
- Improve functioning, productivity and QaL
- Improve the processes of care
Active aging
Is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age
Active aging examples
- Recognizing capacities & resources among older people
- Anticipate flexibly to aging related needs and preferences
- Respect their decisions and lifestyle choices
- Protect the most vulnerable
- Promote their inclusion and contribution to all areas of community
Development of the WHO framework
Outdoor space & buildings
Transportation
Communication & information
Housing
Respect & social inclusion
Social participation
Civic participation & employment
Community support & health services
Lacy & Backer
either or model
Integrated Model
Continuum Model
Cyclical Model
Either or model
Evidence based and patient centred care are distinct from one another
Integrated model
group members conceptualized overlapping spheres, creating a band of practice where the pratitioner applies both spheres
Continuum model
When reviewed as a continuum, EBPCC ranged from purely evidence based to purely patient centred. When viewed as a balance, this model suggests a point at which a clinician incorporates both.
Cyclical
EBPCC is process that moves from patient centred care through evidence based care and then back to patient centred care. It is more dynamic.
eight dimensions of PCC
1 respect for patient preferences
2 information education and communication
3 coordination and integration of care
4 emotional support
5 physical comfort
6 involvement of family and close others
7 continuity and transition from hospital to home
8 access to care and services
