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Patient-Centered Care

Leadership Assignment 3: Shannon Glover, Danielle Holwager, Jessica Hull, Brooke Hummel, Brittany Baker & Carly Ruckman

Danielle Holwager

on 29 October 2012

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Transcript of Patient-Centered Care

Care 8 Dimensions of
Patient-Centered Care Focused on patient and family experiences
Places the patient at the center of care delivery
Respects patient's values, beliefs, and preferences related to health care and illness
Mutual trust and respect among professionals, patients, and significant others Definition Dignity Information
Sharing Participation Collaboration Shannon Glover, Danielle Holwager
Brittany Baker, Carly Ruckman,
Jessica Hull, Brooke Hummel Respect for patient values, preferences, and expressed needs Coordination of care and integration of services Narrating Care Communication between patient and providers; Dissemination of accurate, timely and appropriate information; and education on long-term implications of disease Deliver physical care, comfort, and pain management Emotional support and relief of fears and anxiety Inclusion of Family and Friends Patient has access to care References Respect for patient values, preferences, and expressed needs
Coordination of care and integration of services
Narrating Care
Communication between patient and providers; Dissemination of accurate, timely, and appropriate information; and education on long-term implications of disease
Deliver physical care, comfort, and pain management
Emotional support and relief of fears and anxiety
Inclusion of family and friends
Patient has access to care Implementing Patient-Centered Care Basic Principles and Expectations For
Patient-Clinician Communication According to an article by the Institute of Medicine, there are many dynamics that influence the quality and clarity of communication between patients and clinicians. Basic principles are used as a starting point for both patients and clinicians: mutual respect, harmonized goals, a supportive environment, appropriate decision partners, the right information, full disclosure, and continuous learning. This element of best practice should be used as an important assessment or evaluation tool of care. Individual and mutual expectations of patients and clinicians can
be identified by looking at the seven principles
(Paget et al., 2011). Expectations of Patients
and Clinicians 1.) Mutual Respect
a. Each patient and clinician as full decision-making partners.
b. Respect for the special insights each brings to solving the problem.
2.) Harmonized Goals
a. Common understanding of and agreement on the care plan.
3.) Supportive Environment
a. A nurturing and secure services environment and decision climate.
4.) Appropriate Decision Partners
a. Clinicians, or clinician teams, with skills appropriate to patient circumstances.
b. Assurances of competence and understanding by patient. 5.) Right Information
a. Best available evidence, choices discussed in depth.
b. Presentation by patient of perceptions, symptoms, and personal practices.
6.) Transparency and Full Disclosure
a. Candid and explicit acknowledgment to patient limits.
b. Patient openness to clinician
7.) Continuous Learning
a. Effective approach for regular feedback on progress.
b. Established periodic assessments and adjustments as needed. Continued (Paget et al., 2011) (Paget et al., 2011) Abraham, M., & Moretz, J.G. (2012) Implementing patient- and family-centered care:
Part I - understanding the challenges. Pediatric Nursing, 38(1), 44-47.
Ahmann, E., & Dokken, D. (2012). Strategies for Encouraging Patient/Family Member
Partnerships With the Health Care Team. Pediatic Nusing, 38(4), 232-235.
Holleran, K., Wilson, J., & Panik, A. (2012). A ROADMAP involves patients and families
in the plan of care. American Nurse Today, 7(9), 42-46.
Horton, S., & Johnson, R.J. (2010). Improving access to health care for uninsured
elderly patients. Public Health Nursing, 27(4), 362-370.
McClimans, L., Dunn, M., & Slowther, A. (2011). Health policy, patient-centred care
and clinical ethics. Journal of Evaluation in Clinical Practice, 17, 913-919.
Moretz, J.G., & Abraham, M. (2012) Implementing patient- and family-centered care:
Part II - strategies and resources for success. Pediatric Nursing, 38(2), 106-109.
Paget, L., Han, P., Nedza, S., Kurtz, P., Racine, E., Russell, S., Santa, J., Schumann, M.,
Simha, J., Kohorn, I. (2011). Patient-clinician communication: basic principles and
expectations. Institute of Medicine of the National Academies, 1-7.
Pi-Ling, C., & Chia-Chin, L. (2011). A pain education programme to improve patient
satisfaction with cancer pain management: a randomized control trial. Journal of Clinical Nursing, 20(13/14), 1858-1869.
Staiduhar, K. I., Thome, S. E., McGuinness, L., & Kim-Sing, C. (2010). Patient
perceptions of helpful communication in the context of advanced cancer. Journal of Clinical Nursing, 19(13/14), 2039-2047.
Stichler, J.F. (2011). Patient-centered healthcare design. Journal of Nursing
Administration, 41(12), 503-506.
Ward-Smith, P. (2012). Health Literacy. Urologic Nursing, 32(3), 167-168.
Williams, A. M., & Kristjanson, L. J. (2009). Emotional care experienced by
hospitalised patients: Development and testing of a measurement instrument. Journal Of Clinical Nursing, 18(7), 1069-1077. References The Planetree Model: A model of healthcare design aimed at providing holistic patient-centered care
9 elements of the Planetree Model
1. Human interaction
2. Patient education and information
3. Healing partnership with family and friends
4. Healing Nutrition
5. Spirituality and personal healing resources
6. Human Touch
7. Healing Arts
8. Alternative and Complementary Care
9. Healing Environment An environment conducive to Patient-Centered Care Provide space for family and friends
Provide a "home-like" atmosphere
Private rooms
Artwork in patient rooms
Centralized nursing stations
Conference rooms located on the unit for collaborative meetings, including the patient and family at times 3 Keys to Implementation 1. Educating self and team
creation of a core team; education of all team members
conduct an initial hospital assessment
Free assessment tool http://www.aha.org/aha/content/2005/pdf/assessment.pdf
Identify strengths and weaknesses
Include patient/family perspective
Attend training sessions/webinars held by patient-centered organizations

2. Educate Others
share information with other healthcare team members
Core team members as peer mentors
Work to integrate patient-centered care into nursing and medical education
Involve organizational leadership; provide evidence via a presentation including patient/family advisors to gain support of organization's leadership in the implementation of patient-centered care
Provide a discussion panel of patients and family members to discuss patient centered care for nurse education
http://ipfcc.org/advance/Presentation_By_Patients.pdf 3 Keys to Implementation (Continued) 3. Infrastructure Development: create and sustain improvement
Appoint a staff liaison in charge of working with patients and families to assist in developing and sustaining policies conducive of patient-centered care
Form an action plan: goals, projects, and tasks
Form partnerships with patients, clinicians, staff members, and administration to ensure continued commitment (Moretz & Abraham, 2012) (Stichler, 2011) (Stichler, 2011) (Moretz & Abraham, 2012) Successful Implementation Education must be provided for all staff members
Staff must have access to appropriate resources
Leadership must be accepting of patient-centered care as a core mission of the facility
Collaboration between physicians, leaders, nurses, patients, and families to develop policies of patient-centered care Role of the Nurse Catalyst for change
Be a role model and mentor
Encourage organizational leadership to become involved (Abraham & Moretz, 2012) Challenges to Implementation Resistance at an organization level
Restrictive organizational policies
Staff attitudes
family will hinder safe patient care
Patient-centered care will take up too much time
patient/family will make unreasonable requests
families with question caregiving skills
patient/family will misunderstand information
Patient/family advisors may hear negative things about the unit/organization
Challenges at an organizational level
Organizational leaders don't recognize patients and families as partners
Patient-centered care isn't included in the organizations mission statement
Patient-centered care is thought of as customer service only
Leaders aren't committed
No incentives for patient-centered practice (Abraham & Moretz, 2012)
When an individual experiences a physical
health concern the person usually experiences
psychological and social consequences as well and in
some cases, emotional distress. Physical symptoms
associated with illness or injury may be exacerbated by
emotional distress, thus decreasing healing and
rehabilitation (pg 1070). The World Health Organization’s
definition of health includes the emotional well-being of patients as an component of care provided during hospitalization. (Kristjanson & Williams 2009) The connection between
the mind and the body: Barriers to Accessing Health Care #1: Lack of Transportation

20million U.S. drivers are age 65
To use public transportation you need to have:
physical fitness
understanding of bus routes
ability to take long rides and transfer from bus to bus
These can become difficult as increased age brings risk of increased deficits

Possible Solution
Mobile units that go out into the community
Not a new concept
Lillian Ward was the first public health nurse
specialized in preventative care
traveled door to door
Some communities have similar outreaches for children immunizations
Could be adopted to also provide preventative and primary care for adults who cannot travel The importance of time
Patients appreciate providers who were able to make time to discuss their concerns.
Time in minutes was not as important to how time was utilized.
Direct eye contact, active listening techniques, and sitting down rather than standing were ways clinicians demonstrated they had "time."
Stajduhar, Thorne, McGuinness, Kim-Sing, 2010 Patient Perceptions of helpful communication
The importance of time
Demonstrations of caring
Acknowledging fear
Balancing honesty ad hope in information provision. Demonstrations of caring
Providers should be respectful and sensitive during communication.
Expressions of empathy and physical contact were interpreted as evidence of caring and support.
Communication efforts that increased this relational connection left participants feeling cared for, prioritized, and reassured that someone is looking out for them.
Stajduhar, Thorne, McGuinness, Kim-Sing, 2010 Acknowledging fear when communicating
This validates the patient's experience and allows them to talk about their concerns.
Reassurance was an important strategy for patients when narrating their care.
Stajduhar, Thorne, McGuinness, Kim-Sing, 2010 Balancing honesty in information provision
Providing as much relevant information as possible in a variety of formats (diagrams, pictures, etc.)
Patients were appreciative when their provider referred them to appropriate sources.
Patients are appreciative when providers admit their knowledge deficit.
Stajduhar, Thorne, McGuinness, Kim-Sing, 2010 Health Literacy
Effective communication has been identified as a major element in improving health literacy.
This needs to be utilized in any plan of care for patients.
Use the repeat back method for comprehension.
Educational materials need to be written at no more than a fifth grade reading level, accompanied by pictures, and allowed to take home.

Ward-Smith, 2012 Barriers to Accessing Health Care #2: Lack of Insurance

Often prevents individuals from seeking medical care
Higher risk for social isolation
Lack of access to health care
Underinsured (private or government sponsored insurance)
Out-of-pocket expenditures and deductibles exceed their means to pay

Possible Solution
Outreach services such as FBOs (faith-based organizations)
Ensure that all patients have access to health care services and serve to diminish the barriers to healthcare
Perform outreach and health promotion services
Assign case managers to underinsured
Help navigate system
Less expensive than ED visits due to uncertainty of how to use the system #3: Complexity of the Health Care System Barriers to Accessing Health Care Difficulty accessing and navigating the health care system
Especially government health care plans
Often confusing
Customers feel
concerned of health care system in general
impersonal service
loss of control
Health care system and different insurance plans are constantly changing
Paperwork and multiple rules of insurance plans are complicated and confusing
Education levels, mental capabilities, and language all present barriers

Possible Solution
Assign case managers for a certain time after entering the system
Help successfully navigate system
Community programs
Help complete the massive paperwork required to qualify for insurance coverage
Teach how to navigate the system #4: Poverty Barriers to Accessing Health Care Poverty prevents individuals from seeking health care for financial reasons
Low income populations are at high risk for adverse health conditions
Low income populations have little or no access to regular health care services
Not all persons are eligible for Medicare and Medicaid
Age 65 and older, those under age 65 with certain disabilities, or any age with end-stage renal disease
State-administered; each state holds individual guidelines and eligibility rules
For persons with low-income
Some practices will not accept new Medicaid patients
Some practices will not accept new privately insured patients

Possible Solution
Outreach services and FBOs
Help navigate system
Help understand and complete paperwork of complex insurance and health care system
Provide outreach and health promotion services regardless of socioeconomic status, race/ethnicity, or cultural background #5: Lack of Family Support

Lack of support (emotional, physical, financial) places individuals at higher risk for social isolation and inadequate access to health care
Lack of family and/or friend support causes elderly adults to arrange appointments, manage their health care, organize transportation on their own
Activity level tends to decrease with increase in age
limiting ability to socially interact with other in community

Possible Solution
Community outreach programs
Mobile health care services Barriers to Accessing Health Care According to William & Kristjanson (2009), the absence of emotional care during emotionally stressful times for patients may lead to the development of more serious,debilitating psychological disorder. 1) Level of security: One study found that nurses who attempt to make a relationship with patient’s tend to decrease emotional discomfort such as fear, powerlessness, anxiety, isolation and distress and in return patients feel more secure which increases their coping ability. Overall supported
Overall secure
Staff respond
Staff competent
Nurse contact
Nurses help (Kristjanson & Williams 2009) While giving patient centered care it is crucial to meet the emotional needs of the patient. Ways to emotionally support patients to lower fear and anxiety include 4 levels.
1)Lever of security
2)Level of connection
3)Level of knowing
4)Level of personal value. #7: Communication
Lack of communication between health care providers and patients
leaves patients without information about services
develops mistrust toward health care system (can result in patients not seeking care when needed)
Effective communication may...
enhance patient and family education, adherence to treatment, patient outcomes
promote participation and healthy lifestyle behaviors
reduce health disparities
increase trust in the health care system

Possible Solution
Effective communication
Community outreach programs Barriers to Accessing Health Care #6: Culture
May indirectly affect access to health care
Cultural beliefs may influence decisions to seek medical care and treatment

Possible Solution
Health care providers need to be culturally sensitive and respectful of diverse cultures
Community outreach programs #8: Race/Ethnicity
Perceived discrimination creates a barrier to seeking/receiving preventative care
BIG problem. Why?
Minorities are at greater risk for illness and disease
Health care providers need to acknowledge special health care needs of different minority populations
Lack of knowledge and specialized care can lead to increased problems as well as mistrust in the health care system

Possible Solution:
Cultural sensitivity programs
Outreach programs
FBOs (Horton, S. & Johnson, R., 2010) (Horton, S. & Johnson, R., 2010) (Horton, S. & Johnson, R., 2010) (Horton, S. & Johnson, R., 2010) (Horton, S. & Johnson, R., (2010) (Horton, S. & Johnson, R., 2010) Physical Care In delivery of Care
Patients value:
effective communication
sit down with patients
active listening
As clarified by the IOM, the 7 principles of quality communication facilitate a working relationship and in turn, satisfaction with the care received
The 7 Principles
mutual respect
harmonized goals
supportive environment
appropriate decision making partners
right information
full disclosure
continuous learning A study examining the effects of a pain education program on improving patient satisfaction with cancer pain management, researchers found that the program significantly increased patient satisfaction with nurses and physicians.

The study also found that patient satisfaction with pain management was a mediator between the barriers to using analgesics and adherence to the analgesic treatment plan.

3 Factors influencing patient satisfaction with pain management:
(1) Previous experience with pain
affects beliefs, attitudes, expectations
(2) Patient appraisals of health care providers
manage with empathy, care, sufficient knowledge builds confidence and trust
(3) Personal experience with managing pain
involvement of family with treatment plan
development of effective strategies
patient involvement in own plan Delivery of Pain Management & Comfort (Paget, et. al., 2011) (Pi-Ling, C., & Chia-Chin, L. (2011) 4 Main Factors Influencing Satisfaction with Pain Management
Administer treatment in respectful manner
Provision of a safety net
Efficacy of pain management
Involvement of patient as a partner
Collaborative relationship between patients and health care providers is the most important factor. Continued... Facilitate a Comfortable Environment
Smiles go a long way
Keep work space tidy
Use comfort measures to help ease pain
pillows & blankets
hot/cold packs
music/TV Pi-Ling, C., & Chia-Chin, L. (2011) 2) Level of connection: Patient viewed more as a person than a patient.
Patient feels valued and comfortable with the nurse.
Staff available 24 hours.
Doctor contract. 3) Level of knowing: Overall informed
Nurses explain
Doctors explain (Kristjanson & Williams 2009) 4) Level of personal value: (From staff to patient) Caring
Facial expression
Eye contact
Conversation (Kristjanson & Williams 2009) Encouraging Family and Friends by: Using "we" language: shows respect and gives expectation to get family involved. (p. 233)
Inviting active participation: this can be done by asking family/friends for help on specific aspects which encourages partnership. (p.233) Encourage Family and Friends
Continued: Teach family/friends signals to indicate misunderstanding or confusion. (p.233)
"Teach Back" method: this allows for everyone to get involved and it lets nursing staff know they have the information needed by the nurse and the family and patient understand.
(p.233) Ideas how to Encourage Family and Friends: Use a white board in patients room. This allows patient, family, and friends to see:
name of the nurse and the variety of doctors taking care of the patient. This allows for family not to feel like an outsider
Write the patient's schedule on the board to give everyone a sense of control and awareness of what is happening
Having an area for questions so health care staff knows what is going through everyone's mind. (p.233) Giving the patient and family a journal to keep during their stay encourages involvement by:
Allowing an area to write vital signs or labs down so they can be compared day to day to see the change.
Allowing a space to write feelings and thoughts down.
Using it as a reference to where they write their questions or comments so they can interact and not be put on the spot. (p.233) "Ask Me 3" This is a program that was created by the Partnership for Clear Health Communication at the National Patient Safety Foundation. This program encourages patient, family and friends to get actively involved in the care of their loved one by asking the following three questions every time you see the doctor:

"What is my (or my loved one's) main problem?"
"What do I (or we) need to do?"
"Why is it important for me (us) to do this?"
(p.233-234) How should we respect our patient's? There is no "right" answer for this question because it is often unclear on what an individual considers respect. As nurses we need to apply the moral concepts into concrete answers and this is done by using our practical reasoning. According to McClimans, Dunn & Slowther if we use our practical reasoning this will allow for legitimate questions on whether some actions does or does not respect patients values, preferences and needs. "Treating persons with respect and dignity is not a matter of acting on informed individual decisions, but rather a matter of acting on principles that express the worth of humanity." (p. 915) Action & Choices! By providing our patient's with more information, control and choices does not give respect or dignity towards our patients. We need to act! Like using principles that show and express our patients with self worth or with choices that have been used in the past and have gone against substantial scrutiny We must show our patient's good choices and actions to give our respect and the best care possible because just treating them with respect and dignity is not always enough! (Ahmann & Dokken, 2012) (Ahmann & Dokken, 2012) (Ahmann & Dokken, 2012) (McClimans, Dunn & Slowther, 2011) (McClimans, Dunn & Slowther, 2011) (McClimans, Dunn & Slowther, 2011) (Ahmann & Dokken, 2012) (Stichler, 2011) (Holleran, Wilson, & Panik, 2012)
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