“Patient engagement” is a buzz word that, in some ways, reveals how far away much of the health care system has strayed from truly serving patients. Most doctors are used to thinking about things like “compliance” and “adherence.” For example, are patients taking their medication as prescribed? But think of how much more powerful this question is: What would motivate my patient to take this prescription?
Patients are not used to being asked what they want to accomplish for their own health. Yet, a new movement is changing things. Health care systems large and small are trying to get patients involved, not only in their own self-care, but also in the way health care systems, clinics, and doctors provide care. For individuals seeing a doctor, a partnership looks something like the doctor and patient determining the best treatment together. Health systems and clinics could involve patients as advisers, or even have them co-leading quality improvement efforts with staff members.
One Health Affairs article describes “Patients, families, their representatives, and health professionals working in active partnership at various levels across the health care system – direct care, organizational design and governance, and policy making – to improve health and health care.” The patient engagement movement is really rethinking the way health systems provide care.
Some organizations have already turned the care model on its head, such as Central City Concern, an organization providing solutions for homelessness. Because its clinic serves a homeless population, it has rethought how to interact with its patients from the ground up compared to a traditional medical center. While not every approach they use is possible in other clinics (or for that matter applicable to every population), looking at such a specialized populace is a great illustration of how the typical clinic set-up has many inherent barriers to connecting with patients.
Rachel Solotaroff is the Chief Medical Officer at Central City Concern, and at the last Alternative Payment & Care Model learning collaborative, she described their approach. To make people feel more at home, the clinic has a fluid physical layout in which patients are free to move and the walls are filled with art. The staff reflect the served community so they can recognize them from time on the streets. Because of Central City’s population, they provide “trauma-informed” care. A critical piece of this approach is to always let the patient feel they have a choice. When people with a history of trauma are put in a position of having no choice, even about something simple like an appointment time, it can retrigger the trauma. So everyone, including the front desk staff, is trained to give choices at each interaction. Now, take a step a step back. Wouldn’t all patients want choices in their care, clinical staff that reflect themselves, and a physical environment that makes them feel welcome?
Rachel also talked about some techniques they use to humanize the providers and the medical appointment experience. In the inner-city clinic, they don’t wear white coats and doctors use their first names only. When a doctor wants to address a medical issue, he or she asks for permission to talk about it. They ask to touch or physically examine a patient. When a patient first comes into the clinic, they are not required to fill out a long medical history. (There are several intake forms required out of necessity.) Rachel starts the first appointment by asking, “What do you want from the clinic?” Then the medical history unfolds over the course of many visits to the clinic. Rachel has patients recap the visit and any instructions, and then uses their own words in the after visit summary.
Compare this to the typical medical setting, which often gathers an individual’s social and medical history through 2-3 rounds of questioning at the first visit (i.e., pre-visit paperwork, a questionnaire in the lobby, and an interview with the provider). In community clinics, doctors describe being worried that a patient will not return, citing transportation issues or work conflicts as barriers to seeking medical care. Because of this risk, they often want to get a patient’s whole medical history at the first visit. The patient engagement perspective, however, suggests that people should be motivated to come back by being allowed and encouraged to take part in their own care. An arsenal of information is not an end in itself; the goal is good health. Clinicians get at good health by building trust. Rachel’s approach of asking as few questions as possible during the first visit might help people feel more engaged, and ultimately give a clinic information that is more reliable.
Of course, some of the Central City techniques would not work well in other places. For example, some immigrant communities would find the lack of white coats insulting because it is considered too casual. But the bigger picture is that space, staffing, and communication style all work together to set people up for an empowered, low-barrier encounter. A patient encounter really comes down to what information and self-care motivation someone walks away with.
Many clinics and health systems think of patient engagement as a nice-to-have thing rather than central to their success. They are focused on important health outcomes and quality measures. If you flip around the perspective, however, it is easy to see how things like access, communication, and partnership could completely change health outcomes. By using a health care visit to solidify a sense of partnership, rather than gather information and dispense advice, health care providers might just inspire patients towards better health.
 Carman, Kristin; Dardess, Pam; Maurer, Maureen; Sofaer, Shoshanna, Adams Karen; Bechtel, Christine; Sweeney, Jennifer. “Patient and Family Engagement: A Framework for Understanding The Elements And Developing Interventions and Policies.” Health Affairs 32 No.2 (2013 223-231).