Guest Column | June 14, 2017

Dancing With The Patients: Patient Engagement Edition

HITO Nan Hou, Zynx Health

By Nan Hou, PhD, RN, Managing Editor, Zynx Health

Anyone who is familiar with Dancing with the Stars understands the importance of having a great partner. On the TV show, experienced professional dancers are often paired with celebrities who have little-to-no dancing background. Yet within a few weeks most look like they’ve been dancing all their lives, at least at a high amateur level.

The amazing thing is the professionals don’t force the celebrities to improve. Instead, they use their experience to determine what will help the celebrities get the feel of each weekly dance routine and guide them to find what they’re capable of doing well — and sometimes surprisingly elegantly. This same process of guiding and collaborating instead of forcing (or dancing instead of wrestling, as described in motivational interviewing) can make a huge difference in whether patients will become engaged in following their plans of care.

Most adults don’t like to feel they’re being forced to do something. Your goals for a patient are not nearly as important as your patient’s own self-defined goals. However, if you collaborate with your patients on setting goals and decide upon how to achieve them, they will be much more willing to follow whatever is agreed to because they have ownership.

First start with a standardized, evidence-based plan of care. The standard approach can help ensure consistency in treating conditions, reduce errors, and decrease adverse events; the shared plan of care can also be a powerful communication tool to ensure that every member of the care team is on the same page.

Finding The Motivation

“That’s all well and good,” you say, “but where do I begin?” You begin by discovering what the patients want, what their priorities are, and what’s important to them. You do this by talking to them. The objective is to attain patient activation, which refers to a patient's knowledge, skills, ability, and willingness to manage his or her own health and care.

For example, a 75-year-old woman who is overweight may not be interested in losing weight for her own sake. But she may be motivated by the thought of looking better in photos of her granddaughter’s upcoming wedding, or feeling good enough to dance at the reception. She may want to be able to garden for more than 20 minutes without feeling lightheaded or breathless, or take her dog on longer walks.

Whatever the motivation, once you understand it you can work together using the evidence and the evidence-based standard plan of care to create an individualized version with goals that you not only know will work but will also facilitate patient engagement.

Overcoming The Barriers

Of course you must also understand the potential barriers. These can be categorized as intrinsic and extrinsic.

Intrinsic barriers are factors such as age, cultural background, gender, education, and income level. These are factors about that patient that cannot be changed, and therefore must be taken into consideration when building the plan of care. Expecting an elderly patient to begin running three miles every day, or a low-income patient to purchase an expensive piece of exercise equipment is beyond unrealistic. There is a greater likelihood the objectives will be carried out if the plan of care supports the beliefs of the patients and family, incorporates a holistic approach, places the patient and their family at the center, and takes into consideration the patient’s family and social roles.

Extrinsic barriers are factors that come from outside the individual, such as the cost of treatment, whether the patient lives alone, whether family/caregiver/community support is available, insurance coverage, and so forth. Patients who require 24/7 care with limited self-care ability and without a caregiver at home will not be candidates for returning to their homes unaided. The desire to go back home and resume independence may, however, be a good motivator for following a plan of care that could lead to that preferred outcome.

Whatever barriers exist must be taken into consideration when designing and individualizing the plan of care. Adjusting for those barriers will enable both sides to work together in developing a plan that is realistic and achievable rather than one built upon wishful thinking.

Simplifying The Language

Plans of care tend to be filled with technical terms and medical jargon that require a high degree of healthcare literacy — much higher than the average patient possesses. If the patient plan of care simply transfers what was in the nurse plan of care, then there is a high likelihood the patient won’t understand it and, thus, won’t follow it, even if he or she agreed to it earlier.

It is important to present all of the health information from all disciplines in simple terms. The old rule of thumb about presenting information at a fifth- to sixth-grade reading level definitely applies in order to support self-management.

Also keep in mind different people learn in different ways. Some may prefer text or illustrated step-by-step instructions that can be posted on the refrigerator, in their bedroom, or in another handy location. Others may do better with information presented in audio or video form, or a combination of those formats, depending on the type of information.

Making It Sharable

Two levels of sharing are required. One, of course, is with the patient. Here again, it’s important to present the information to the patients in the way they prefer to consume it to achieve the best outcomes. Patients are far more likely to engage information that is interesting, understandable, and well presented.

This is where having patient-focused content available in the electronic medical records (EMR) system and in online patient portals can be very helpful. You can present patients with different options as you collaborate on the program development, then ensure they have access to it in the most appropriate format(s).

The second level is sharing the plan of care with other clinicians, such as primary care physicians, specialists, home health workers, skilled nursing facility or assisted living personnel, physical therapists, and anyone else in the care continuum who works with that patient. This is another good reason that the plan of care, and any support materials, should be included in the patient’s record in the EMR. The shared plan of care (based on the best evidence available, patient preferences, and clinical judgment) can also facilitate the decision-making process.

Including the patient plan of care in the EMR provides the best opportunity to improve consistency and avoid confusion, such as one provider instructing the patient to call if he or she has a five-pound weight gain in one week and a second provider advising to call if the patient gains two pounds in two days.

If the patient and everyone in all care settings work off the same plan, providers can avoid tripping over each other and patients can feel confident they’re doing the right thing, which makes engaging in the plan of care much easier for them.

Follow-up is also essential. During follow-up, ask focused questions, identify problems and barriers as early as possible, and adjust the care plan as needed. Regular, early follow-up is highly correlated with the patient's likelihood to complete the plan.

Dancing For The Win

When two well-honed partners dance together, the result is a thing of beauty. The same can be said when clinicians dance with their patients rather than wrestling with them.

Does getting patients engaged in your plans of care feel more like a dance or a wrestling match? How much involvement do patients have? Is patient-oriented information easily available both to you and your patients? What else have you done to spur engagement? Developing comprehensive solutions to these issues is the first step toward making positive changes at the organization level.

By including patients in the goal-setting and intervention-tailoring process for their unique goals and situations and the interim steps to get there (via a well-constructed, workable, and evidence-based plan of care), the healthcare provider and patient can land on a mutually agreed upon plan of care, making it easier for the patient to do the right thing at the right time. Healthcare organizations can enhance patient engagement, improving outcomes while driving down costs and increasing satisfaction. That’s something worth dancing about.

About The Author

Nan Hou, PhD, RN Nan Hou, PhD, RN, is a managing editor at Zynx Health, where she is responsible for the development and maintenance of the interdisciplinary content. In her free time, she loves to travel with her family of four and shuttles two kids to music and swimming practices. Nan also loves reading and actively participates in a reading club with neighborhood moms.