Interest in patient engagement among primary care practices has surged in recent years. While many clinicians agree that patient engagement is important and beneficial, practices lack clarity on what this term really means and what approaches would be most effective for helping providers and patients to achieve this goal. This lack of clarity can create variable implementation of patient engagement strategies, a perception by the patient of a lack of coordination by the health care team, and a lack of uptake of offered engagement activities.
To achieve a better understanding of what primary care practices are doing to engage patients, the Massachusetts Health Quality Partners (MHQP) (an independent, nonprofit measurement and reporting organization that brings together providers, health plans, and patients to improve the quality of patient care experiences in Massachusetts) and CRICO (the insurance program owned by and serving the Harvard medical community) surveyed 412 Massachusetts primary care practices in the spring of 2017.
Overall, 134 practices (33%) responded to this 62-item survey, which covered 10 categories: Care Planning, Care Coordination, Communication with Patients, Communicating Results, Shared Decision-Making and Education, Patient Engagement with Clinical Leadership, Patient Feedback, Access to Health/Visit Records, Mobile and Web-Based Tools, and Social Media.
By performing this first-of-its-kind survey to inventory the structural programs and innovative efforts that Massachusetts practices have in place to engage patients and families, MHQP sought to better understand the landscape in order to identify improvement strategies, and CRICO sought to incorporate patient engagement into primary care risk-reduction strategies. The principal finding was that, while most primary care practices in Massachusetts have developed structures and processes to improve their engagement with patients (particularly in the areas of care planning, care coordination, shared decision-making, and electronic communication), these programs are in the early stages of implementation and are underutilized.
There’s a Will, but the Way Isn’t Clear
The results of the survey indicated that, while clinical and office staff believe that patient engagement activities increase the quality of interactions with patients (and simultaneously improve staff satisfaction), they see many barriers to the full implementation of these programs. Respondents cited concerns related to finances, operations, emotions, and practice culture (e.g., lack of training for providers on how to better engage with patients, a long learning curve for successful implementation, not enough time in a 15-minute visit to fully engage patients, insufficient staff levels to implement new engagement ideas, the need for coordination among a variety of different specialists reimbursement structures that do not provide financial incentives for providers to better engage with patients, etc.).
Some of the specific challenges highlighted by the survey are discussed below.
Research has shown that a care plan (defined as an agreement between the patient and the health care professional, in the form of either a written document or an entry in the patient notes, designed to help the patient manage his or her health from day to day) is critical for establishing a shared patient-provider understanding of care goals, ensuring that the patient receive the care that he or she wants, and enhancing the quality of life during an illness.
Most practices (79%) responded that they are able provide plans to patients, but fewer (64%) responded that patients are involved in the creation of the plans, and fewer still (only 16%) responded that the majority of patients who need such plans actually receive them. Importantly, only 64% of practices responded that they had a process in place to ensure that patients who have such plans understand what they need to do to implement them.
Most practices (78%) responded that they employ decision aids and/or shared decision-making resources to engage patients, but only a slight majority (53%) responded that they offer programs to educate providers in how to engage patients in shared decision-making. Similarly, only about half responded that they offer chronic disease self-management programs (53%) or training in basic skills needed to manage one’s condition (51%).
Three-quarters of practices responded that they ask patients to provide feedback about their experiences with the practice, and 80% responded that they share that feedback with staff, but only 8% responded that they share the feedback with their patients. Moreover, while most practices (74%) responded that they have portals, very few (23%) responded that their patients communicate with the practice via the portal, and fewer still responded that patients communicate via email (9%) or text messaging (7%).
Some Promising Developments
Nevertheless, in follow-up interviews, individual practices reported that they have made changes designed to increase engagement and improve outcomes. Several practices noted that they are using motivational interviews to better understand patients’ goals and to encourage small steps toward changing behaviors to improve health status. Others have created Patient and Family Advisory Councils (PFACs) and have seen changes that have resulted from patient and family involvement.
For example, at one pediatric practice, a PFAC helped to create laminated information sheets designed to make parents comfortable with the transition to adolescent confidentiality, and the parents themselves helped to enhance the practice’s website. At another practice, a PFAC helped to redesign the reception area to provide better access for wheelchair-bound patients.
While decision aids remain underutilized, some clinical staff and practice administrators have stated they have begun to use decision aids to help patients decide between surgery and alternative treatments such as physical therapy, emphasizing that the use of such aids helps to ensure that patients are well informed, that they are meaningfully involved in making treatment decisions, and that treatment is tailored to what matters most to them.
Going Beyond the “Check Box”
Because patient engagement programs are seen as desirable but are not well utilized, practice administrators and leaders need to help practices go beyond a “check the box” approach and experiment with approaches that both patients and providers value, with incentives to match. To create true patient engagement, practice administrators and leaders must determine what structures and programs are useful for which segments of the patient population. Deciding what changes would be most effective is best done with input from patients and families.
Importantly, the health care industry as a whole needs to work with patients and their caregivers to clarify and provide consistent definitions for even the simplest of terms. For example, the term patient engagement, and other associated terms such as shared decision-making, should be clearly defined with explicit components and use cases.
For instance, the care plan example described above raises several questions:
- Which patients should have care plans?
- What is the purpose of a care plan?
- What information should be included in a care plan?
- Who is responsible for creating a care plan?
- Can a care plan be created without input from the patient?
- Who should benefit from a care plan?
- Who decides if a care plan is useful?
- How valuable are static care plans?
- Whose responsibility is it to train providers to create useful care plans?
- Who decides how much provider time should be devoted to care plans?
In discussions with providers, we found that there were no consistent answers to these questions. The impact and components of care plans should be examined more thoroughly, and positive outcomes that stem from specific components of care plans should be shared within the practice’s provider network and more broadly with the larger professional community. Sharing specific components of plans that have created positive outcomes would lead to much clearer guidelines for implementing effective care plans.
Where Do We Go from Here?
The results of this survey showed that patient engagement strategies are beginning to be adopted and that clinicians increasingly agree that patient engagement is important. However, it also showed that, before primary care practices can improve their patient engagement strategies, policies, and procedures — and before we are to make real progress in improving outcomes — we need to provide better guidance on definitions, better training, and a better understanding of how these approaches provide value to patients.
MHQP and CRICO propose the following important steps:
- More research needs to be done with providers, diverse patients, and health plans to better understand the link between patient engagement and health outcomes.
- Health care systems and physician practices should work with patients to elicit patient perspectives on what increases patient engagement and adopt educational policies that make it clear how to implement patient engagement strategies.
- Health plans should develop flexible reimbursement policies that would cover the cost of the time required to create, document, and evaluate the quality and cost of different patient engagement approaches.
The implementation of patient engagement programs is clearly challenging and will require the active participation of both patients and caregivers. Ultimately, however, we believe that these efforts will yield substantial rewards in terms of improved outcomes.