Bill Knutson, MBA, CEO of CareChoice Cooperative, which serves 22 major long-term care organizations in the St. Paul-Minneapolis metro area, says improving patient engagement, is “really examining the gaps in care.” He is working on a task force to create a new role for community paramedics to address at-risk patients. The idea is “to have the paramedics come into the nursing home and meet with the patient for the purpose of medication reconciliation. After the patient leaves our facility, the paramedics will visit them two to three times.”
During the visit, the paramedics can look for potential safety concerns, such as fall hazards or a collection of conflicting medications. “It’s not home care — but what we’ve found is the patients, when surveyed, absolutely enjoy the relationship with the paramedic,” Knutson says. “We are creating a stronger level of patient engagement,” as well as supporting the EMS department and the ACOs that are looking to reduce readmissions.
Knutson is among the respondents to NEJM Catalyst’s latest Insights Council survey, “Patient Engagement: What Creates Behavior Change May Not Sustain It,” which reveals that in-person social support and virtual social support are the top two means for sustaining behavior change, cited by 64% and 48% of respondents, respectively.
Kate Cronan, MD, a pediatric emergency medicine physician for Nemours Children’s Health System in Wilmington, Delaware, says that by nature of the specialty, there is less opportunity to build an ongoing relationship with a patient, but an important first step in patient engagement is to facilitate health literacy by making the information — written or spoken — more understandable. Beyond that, Cronan says, “A little bit of motivational speaking is not really going to change the patient. You have to stay on top of it, keep in touch, use reminders — they can be human reminders or electronic reminders.” A home visit would be the best method, but short of that, the key is contact: “continued and consistent contact.”
A pediatric hematology physician colleague has found success in engaging his hemophiliac patients through the Nemours patient portal, Cronan says. The patients, or their parents, can write a note in the system at any time, and they get a notice when there is a response. “Once they actually know the doctor and the nurses in the department who care for them, they feel like they are talking to them,” with the digital tool reinforcing the human relationship.
Cronan says she believes that home-based technology can support patient engagement, but also says clinicians must talk with patients, too, to provide a human touch and encouragement.
The fee-for-service reimbursement system can discourage patient engagement, says Nancy Klotz, MD, MBA, FACP, Chief Clinical Officer for Garden City, New York–based HealthCare Partners, a managed care organization, and Heritage New York Medical, PC, which provides direct care as an adjunct to the primary care provider through pharmacists, nurse practitioners, and social workers.
“We have an aging population that has social and behavioral health issues that are not being addressed by provider networks. Right now, the patient shows up and you do your best.” In addition to creating multidisciplinary provider teams that can assess the patient holistically, Klotz says, “I think we need to slow it down a bit. I understand the financial pressure to see more patients in less time to make money. And until there is reform in that area, obviously it’s going to be difficult for a PCP to keep their head above water.”
To support prevention and wellness, “we need to value physician-patient interaction, because that will help us prevent future costs,” Klotz says. “What we’re doing is reimbursing risk; so, a riskier procedure, which has a greater risk of litigation, gets more reimbursement.”
Spencer Kubo, MD, is a practicing cardiologist with Allina Health in Minneapolis and serves as Chief Medical Officer for both HLT Inc., a clinical-stage medical device company, and Care Cognitics, an early-stage digital health company dealing with chronic care management and patient engagement. He is among the 28% of survey respondents who include providers among the top two barriers to patient behavior change. “What provider is ever going to say that patient engagement is bad?” he asks. “But you also really have to want to push it when there’s resistance or inertia to do things. And I think that most providers give up.”
For example, many providers see obese patients. The patients “haven’t gotten it, year after year after year,” Kubo says. “We joke about it sometimes. Some patients will say, ‘I want to come back to see you, but I just don’t want you to talk about my weight.’ And your time is limited, and you say, ‘What can I do?’ That’s why provider buy-in is low. It’s so disheartening [clinicians] just give up.”
Kubo suggests that patients generally know about health and wellness matters but won’t put in the effort without incentives. The extreme motivator is the near-death experience, such as a myocardial infarction. Short of such a severe event to spark and sustain change, he also sees value in a health care equivalent to airline rewards systems. “So what is analogous to frequent flier points in the medical system? The person who figures that out will have a big advantage.”
Kubo also points to the so-called Prius effect: the instant feedback that drivers get on their car’s mileage based their real-time driving habits. “So, if there is something we can do like that for patients on whatever they are working on, whether that be weight gain or diabetes control, I think that would have an accelerating effect.”