It’s not uncommon for a patient to be confused or overwhelmed by a diagnosis or treatment plan.  Complicated medical procedures or decisions can overwhelm patients to the point that they feel that they cannot, or should not, ask questions of their providers.   However, this lack of patient involvement in decision making can lead to decreased patient compliance, higher costs, and less than favorable care outcomes.  Poor patient engagement is further compounded by provider-centric care delivery that still dominates so much of medical care.

As healthcare provider organizations search for ways to improve care outcomes while simultaneously lowering costs, the concept of patient engagement has gained considerable traction.  Patient engagement entails involving and informing the patient in choosing treatment options, encouraging the patient to develop healthy habits, and educating and empowering the patient so that they feel confident making health related decisions.  It’s integral to patient-centered care, particularly medical homes.

Patient engagement can take many forms.  It can include doctors discussing options directly with patients, genuine shared decision making, educational initiatives, comparative information on provider quality and safety, information on the out-of-pocket costs of different treatment options, consumer-friendly guides on comparative effectiveness research findings, eHealth tools, and systems to support patient feedback.  Patient involvement can and should also take place at different levels, including the provider level, the organizational leadership level, and at the public policy level.

Patient Engagement Features, Obstacles, and Savings:

A helpful Health Policy Brief by Health Affairs explores many issues and opportunities providers and organizations face in improving patient engagement, including:

  • Lack of Health Literacy:  Patients may not feel they have enough information to be active participants in decision making.
  • Diverse Backgrounds:  The extent to which patients desire to be involved in decision making may be dependent upon several factors including age, religion, education level, cultural differences, etc.
  • Cognitive Differences Among Patients.
  • Lack of Consideration for Cost:  Patients may be unable or unwilling to take costs and tradeoffs into account when making decisions.
  • Provider Resources:  Healthcare organizations often lack staff, training, health information technology, and incentives in order to fully address patient engagement.
Ultimately, the three biggest obstacles to patient engagement are all at the provider level:
  1. Overworked physicians.
  2. Insufficient provider training.
  3. Clinical information systems that fail to adequately track patients.

Increasing patient engagement is an excellent opportunity to reduce costs while improving quality and safety:

Patients with the lowest activation scores—having the least skills and confidence to actively engage in their own health care—incurred costs up to 21 percent higher than patients with the highest activation levels.

Evidence shows that strong patient engagement programs can improve outcomes while significantly reducing hospital admissions and other costs.

Patient engagement has been on the radar of policy makers too.  In addition to being an essential ingredient to patient-centered medical homes, patient engagement will likely become a major aspect of Accountable Care Organizations (ACOs) and is programmatic goal in the Affordable Care Act.  There has been a push for greater patient engagement at the state level too, including Medicaid reform efforts in Massachusetts and Washington State.

Learn More About Patient Engagement:

In addition to the excellent issue brief, the journal Health Affairs has a series of new studies on patient engagement, including best practices and savings opportunities.  Examples include:

Patients, Providers, And Systems Need To Acquire A Specific Set Of Competencies To Achieve Truly Patient-Centered Care.  By Elizabeth Bernabeo and Eric S. Holmboe.

Abstract:  Studies show that patients want to be more involved in their own health care. Yet insufficient attention has been paid to the specific competencies of both patients and providers that are needed to optimize such patient engagement and shared decision making. In this article we address the knowledge, skills, and attitudes that patients, physicians, and health care systems require to effectively engage patients in their health care. For example, many patient-physician interactions still follow the traditional office visit format, in which the patient is passive, trusting, and compliant. We recommend imaginative models for redesigned office care, restructured reimbursement schemes, and increased support services for patients and professionals. We present three clinical scenarios to illustrate how these competencies must work together. We conclude that effective shared decision making takes time to deliver proficiently and that among other measures, policy makers must change payment models to focus on value and support education and discussion of competencies for a modern health care system.

Patient And Family Engagement: A Framework For Understanding The Elements And Developing Interventions And Policies.  By Kristin L. Carman, Pam Dardess, Maureen Maurer, Shoshanna Sofaer, Karen Adams, Christine Bechtel, and Jennifer Sweeney.

Abstract:  Patient and family engagement offers a promising pathway toward better-quality health care, more-efficient care, and improved population health. Since definitions of patient engagement and conceptions of how it works vary, we propose a framework. We first present the forms engagement can take, ranging from consultation to partnership. We discuss the levels at which patient engagement can occur across the health care system, from the direct care setting to incorporating patient engagement into organizational design, governance, and policy making. We also discuss the factors that influence whether and to what extent engagement occurs. We explore the implications of our multi-dimensional framework for the development of interventions and policies that support patient and family engagement, and we offer a research agenda to investigate how such engagement leads to improved outcomes.

A Demonstration Of Shared Decision Making In Primary Care Highlights Barriers To Adoption And Potential Remedies.  By Mark W. Friedberg, Kristin Van Busum, Richard Wexler, Megan Bowen, and Eric C. Schneider.

Abstract:  Recent developments in health reform related to the passage of the Affordable Care Act and ensuing regulations encourage delivery systems to engage in shared decision making, in which patients and providers together make health care decisions that are informed by medical evidence and tailored to the specific characteristics and values of the patient. To better understand how delivery systems can implement shared decision making, we interviewed representatives of eight primary care sites participating in a demonstration funded and coordinated by the Informed Medical Decisions Foundation. Barriers to shared decision making included overworked physicians, insufficient provider training, and clinical information systems incapable of prompting or tracking patients through the decision-making process. Methods to improve shared decision making included using automatic triggers for the distribution of decision aids and engaging team members other than physicians in the process. We conclude that substantial investments in provider training, information systems, and process reengineering may be necessary to implement shared decision making successfully.

What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs.  By Judith H. Hibbard and Jessica Greene.

Abstract:  Patient engagement is an increasingly important component of strategies to reform health care. In this article we review the available evidence of the contribution that patient activation—the skills and confidence that equip patients to become actively engaged in their health care—makes to health outcomes, costs, and patient experience. There is a growing body of evidence showing that patients who are more activated have better health outcomes and care experiences, but there is limited evidence to date about the impact on costs. Emerging evidence indicates that interventions that tailor support to the individual’s level of activation, and that build skills and confidence, are effective in increasing patient activation. Furthermore, patients who start at the lowest activation levels tend to increase the most. We conclude that policies and interventions aimed at strengthening patients’ role in managing their health care can contribute to improved outcomes and that patient activation can—and should—be measured as an intermediate outcome of care that is linked to improved outcomes.

Patients With Lower Activation Associated With Higher Costs; Delivery Systems Should Know Their Patients’ Scores.  By Judith H. Hibbard, Jessica Greene, and Valerie Overton.

Abstract:  Patient activation is a term that describes the skills and confidence that equip patients to become actively engaged in their health care. Health care delivery systems are turning to patient activation as yet another tool to help them and their patients improve outcomes and influence costs. In this article we examine the relationship between patient activation levels and billed care costs. In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences. What’s more, patient activation was a significant predictor of cost even after adjustment for a commonly used “risk score” specifically designed to predict future costs. As health care delivery systems move toward assuming greater accountability for costs and outcomes for defined patient populations, knowing patients’ ability and willingness to manage their health will be a relevant piece of information integral to health care providers’ ability to improve outcomes and lower costs.

A Proposed ‘Health Literate Care Model’ Would Constitute A Systems Approach To Improving Patients’ Engagement In Care.  By Howard K. Koh, Cindy Brach, Linda M. Harris, and Michael L. Parchman.

Abstract:  Improving health outcomes relies on patients’ full engagement in prevention, decision-making, and self-management activities. Health literacy, or people’s ability to obtain, process, communicate, and understand basic health information and services, is essential to those actions. Yet relatively few Americans are proficient in understanding and acting on available health information. We propose a Health Literate Care Model that would weave health literacy strategies into the widely adopted Care Model (formerly known as the Chronic Care Model). Our model calls for first approaching all patients with the assumption that they are at risk of not understanding their health conditions or how to deal with them, and then subsequently confirming and ensuring patients’ understanding. For health care organizations adopting our model, health literacy would then become an organizational value infused into all aspects of planning and operations, including self-management support, delivery system design, shared decision-making support, clinical information systems to track and plan patient care, and helping patients access community resources. We also propose a measurement framework to track the impact of the new Health Literate Care Model on patient outcomes and quality of care.

Shared Decision Making: Examining Key Elements And Barriers To Adoption Into Routine Clinical Practice.  By France Légaré and Holly O. Witteman.

Abstract:  For many patients, the time spent meeting with their physician—the clinical encounter—is the most opportune moment for them to become engaged in their own health through the process of shared decision making. In the United States shared decision making is being promoted for its potential to improve the health of populations and individual patients, while also helping control care costs. In this overview we describe the three essential elements of shared decision making: recognizing and acknowledging that a decision is required; knowing and understanding the best available evidence; and incorporating the patient’s values and preferences into the decision. To achieve the promise of shared decision making, more physicians need training in the approach, and more practices need to be reorganized around the principles of patient engagement. Additional research is also needed to identify the interventions that are most effective.

Enhanced Support For Shared Decision Making Reduced Costs Of Care For Patients With Preference-Sensitive Conditions.  By David Veroff, Amy Marr, and David E. Wennberg.

Abstract:  Shared decision making is an approach to care that seeks to fully inform patients about the risks and benefits of available treatments and engage them as participants in decisions about the treatments. Although recent federal and state policies pursue the expanded use of shared decision making as a way to improve care quality and patient experience, payers and providers want evidence that this emerging model of care is cost-effective. We examined data obtained from a yearlong randomized investigation. The study compared the effects on patients of receiving a usual level of support in making a medical treatment decision with the effects of receiving enhanced support, which included more contact with trained health coaches through telephone, mail, e-mail, and the Internet. We found that patients who received enhanced support had 5.3 percent lower overall medical costs than patients who received the usual level of support. The enhanced-support group had 12.5 percent fewer hospital admissions than the usual-support group, and 9.9 percent fewer preference-sensitive surgeries, including 20.9 percent fewer preference-sensitive heart surgeries. These findings indicate that support for shared decision making can generate savings. They also suggest that a “remote” model of support—combining telephonic coaching with decision aids, for example—may constitute a relatively low-cost and effective intervention that could reach broader populations without the need for the direct involvement of regular medical care team members.

Engaged Patients Will Need Comparative Physician-Level Quality Data And Information About Their Out-Of-Pocket Costs.  By Jill Mathews Yegian, Pam Dardess, Maribeth Shannon, and Kristin L. Carman.

Abstract:  For patients to be engaged, they will need meaningful and comparable information about the quality and cost of health care. We conducted a literature review and key-informant interviews, reviewed selected online reporting tools, and found that quality and cost reporting fell into two categories. One emphasizes public reporting of information, supported by philanthropic or government institutions that aim to improve provider quality and efficiency. The other is characterized by proprietary websites that aim to provide personalized, integrated information on cost and quality to support consumers’ decision making on providers and services. What consumers seem to want is quality data at the physician level and cost data that reflect their personal out-of-pocket exposure. These needs will be acute under the coverage expansions inherent in the Affordable Care Act. State and federal policy thus should support all-payer claims databases, standards for electronic health records to facilitate sharing of quality data, and a unified approach to presenting information that prioritizes consumers’ needs.