Friday, December 15, 2017

Part 1- Helping Patients Take Charge of Their Chronic Illnesses

Helping Patients Take Charge of Their Chronic Illnesses
The best thing you can do for your patients with chronic diseases is to let them run with the ball.
Martha M. Funnell, MS, RN
Fam Pract Manag. 2000 Mar;7(3):47-51.
Noncompliance has always been a significant challenge in chronic disease care, and it's one of the issues Family Care Network has had to confront as part of its diabetes quality improvement project, which FPM is following (see “Series overview”). This article is derived from a presentation the author made to the physicians and staff members of Family Care Network as part of that project. As you'll see, the author's solution to noncompliance is simply to render it obsolete.
It's been said that, as health care professionals, we take credit for our patients' successes and blame them for our failures. How often have you heard a colleague say something like, “I got Mrs. Smith's HbA1c down to 7 percent, but Mr. Jones was noncompliant.” The truth is that, in both cases, the responsibility is shared, but ultimately the patient has more control of the outcome than we do.
Think about two of your patients who have, say, type-2 diabetes. Focus on one patient whose condition is well managed and another whose condition is not well managed. What would you say are the differences between those two? Why is one more successful at controlling the disease than the other? Very often, if you examine it closely, the key difference is the patient's level of involvement and responsibility for his or her own condition.
·       The old models of care, where physicians tell patients what to do and try to motivate them to change, do not work.
·       Because patients' day-to-day decisions have a tremendous impact on their health, they must be active, informed participants in the health care process.
·       Physicians can help patients take charge of their conditions by encouraging them to set self-management goals.
The old models
Our health care systems are not always designed with the patient in mind and do little to empower patients to take charge of their conditions. Instead, they are based on an old acute-care model, where the patient presents to his or her physician and the physician tells the patient what to do to get better. It is a “do as I say” model of care, and the patient's role is fairly passive.
That model works fine for a good deal of acute care and in some other circumstances, but it doesn't work well for chronic illness. Having recognized this, many health care systems have tried a different model in which the focus is compliance, or adherence. This model does a better job of recognizing that the patient needs to do something, but it doesn't give the patient any more power. The health care professional is still very much the authority trying to get the patient to do what is needed; the patient's job is simply to be obedient. What we've found, however, is that you can't get patients to do anything. The motivation to change one's behavior — even to take one's medication — is largely internal. The patient is responsible and must take an active role in his or her own care.
Of course the idea of an active patient can be taken to the extreme. Some patients, in response to the old models of care that haven't been working for them, have become not just active patients but activists. They come to their visits with (mis)information from the Internet and other sources; and, although they are involved in their care, they are involved in an adversarial way. This doesn't create better outcomes, and it can result in an unproductive doctor-patient relationship.
The failure of the traditional models has led the health care community to ask, what kind of approach can we use to deal with chronic illness, recognizing that our influence over patients' behavior is limited and fairly temporary? In other words, how can we change chronic illness care so that it better fits with chronic illness?
The patient is the solution
We have learned over the years at our center that effective chronic illness care requires two things. First, it requires a team with the patient at the center. Second, it requires active, involved participants — especially an active, involved patient. This model of care can be described using various terms — empowerment, informed choice, patient centered — but they all have the same underlying concept: The patient is at the center and is actively involved in his or her own health care.
The old model vs. the new
“I hate this exercise plan.”
“Then try walking after dinner every night with your husband for 10 minutes.”
“What do you hate about it? What would help you do better at it?
“I don't think I can quit smoking.”
“Smoking is the leading cause of preventable death...”
“Why do you think that? What has happened in the past when you tried to quit? What concerns you most when you think about trying to quit?
“I haven't been able to test my blood sugar four times a day.”
“It's hard at first, but just keep trying. You really need to keep track of it.”
“What is preventing you from doing that? Do you know what the numbers mean?”
But why can't we stick with the old models? Why does the patient need to be so involved? There are several reasons.
First, most chronic illness care does not even involve physicians and other health care professionals. Instead, it's estimated that between 95 percent and 99 percent of chronic illness care is given by the person who has the illness. On a day-to-day basis, the patient is in charge of his or her own health, and the daily decisions people make have a huge impact on patient outcomes and quality of life.
Second, as a family physician, you may know what's best for treating diabetes or asthma or congestive heart failure, but that does not mean you necessarily know what's best for an individual patient. Even in close doctor-patient relationships, you can't always know the details of your patient's lives: what's most important to them, what their other priorities are, what motivates them, what their financial situation is, and so on. Each patient is the expert in his or her own life.
Finally, we know from several studies that when patients are encouraged to be more involved and when their physicians are less prescriptive, patients do have better outcomes. We also know that this approach does not take any more time but, in fact, can be more efficient because the health care team is addressing the patient's agenda first — and the patient's agenda is, after all, the real reason for the visit.1

In addition to being a more effective approach, it can also be a relief. As a physician, you may feel less frustrated because it is no longer your responsibility to make change happen. It is a joint process. When you create that partnership and get out of the role of simply telling patients what to do, you pave the way for the patient to make significant, lasting change.

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