As a physician, how many times have you thought to yourself, "If only I could get that patient (I am sure someone pops into your head even as you read this) to follow my instructions, then his health would be so much better and I would feel so much more satisfied.
" Unfortunately, this lament is all too common in almost all healthcare settings.
If patients did follow their physicians' advice rigorously, then the outcomes would be much more consistent and better.
The patients would have better lives in many ways and the income and satisfaction for physicians would generally improve.
Patient self-engagement is the key to compliance and is one of the cornerstones of both the Advanced Medical Home and the Wagner Chronic Care Model.
In the Chronic Care Model self-engagement is essential.
For patients diagnosed with hypertension, for instance, a diet rich in certain nutrients (manganese and potassium) is essential; the patient, obviously, is responsible for this area of care.
The Advanced Medical Home supports the Chronic Care Model and advocates that its basic tenets be applied to all patients.
This concept is also supported in the Institute of Medicine's Crossing the Quality Chasm.
You might say, "That's all well and good.
But how do I get better compliance?" Fortunately there are a number of approaches which can be very effective.
For instance, many studies have shown that a mere 15 minute intervention by a physician with a patient who has an alcohol use disorder can cut the amount of drinking significantly.
The brief intervention is effective in bringing alcohol consumption to acceptable levels in 20% to 50% of patients and the results are effective for at least six months to two years.
Thus, engaging the patient correctly in a discussion about what you the physician expect from the patient is effective.
When I say "correctly", I don't mean just a general lecture.
Correct engagement includes listening.
I like using the Socratic method in many of these verbal engagements.
Give the patient a few instructions and then ask them to describe how she would specifically apply the instructions to her life.
Instructions, of course, should be based upon best medical practices.
As shown above, discussions are an important part of the initial steps of all patient engagement.
As outlined in Organizing Care for Patients with Chronic Illness (Wagner, Austin and Van Korff) one of the most important steps is patient education (discussion) about the nature of their disease or condition and what the patient must do to help improve his condition.
Unless a patient clearly understands, the chronic condition is less likely to improve.
Of course, the patient must clearly understand his role in self-care situations with acute conditions.
For instance, a patient should clearly understand that he should take all the antibiotics prescribed.
In many cases patients with chronic diseases go to educational classes outside the primary care setting.
Diabetics often are instructed to take lessons from outsourced providers in managing their glucose levels with diet and exercise.
Often a self-management program is prescribed at these educational settings.
I believe that in order to achieve lasting results from these outsourced educational instructions, the primary care physician needs to be involved in seeing that the patient remains engaged.
Even if instructions in self-management are done in-house, the primary care provider needs to remain engaged.
Effective physician engagement is more than just having the patient come in sporadically to check up on how he is doing.
Regular contact is necessary.
What, then, are some more good tools of self-engagement that foster regular contact? Journaling is one.
This tool is often used by diabetics to keep daily records of their glucose levels.
Weight Watcher dieters use it to count points and lose weight.
If used consistently, journaling helps a patient adopt new patterns of behavior which lead to the desired outcomes.
By merely writing a description of one's behavior or by recording certain facts (as glucose level) correct behaviors become more consistent.
Journaling is even more effective if it supported by the primary care office.
For instance, having a patient with hypertension email his dietary intake over a 3 or 4 day period to his primary care physician and having the physician reply with comments will help improve the patient's general diet.
Emailing is a good approach to this task as it allows both parties to address the issue at their convenience.
A speedy reply from the physician's office will greatly enhance the results.
An occasional spot check of patients who need some help in maintaining their diets will greatly improve the results.
Registries can help your office in using this approach.
Another tool that can help the patient remain engaged is to include in the education of the patient those with whom he lives.
This education can be done by having relatives or home companions come to an office visit with the patient.
Educational literature can be sent home to be read by those who live with the patient.
Relatives and home companions who understand the patient's condition are much more likely to be supportive.
Again, we see patient engagement and office engagement.
Another tool is the support group or mentor.
Some patients are very willing to attend regular meetings with others who have the same condition.
This tool is very effective for some who have a chronic condition.
It is not useful for all, though.
This tool is very effective in treating alcoholism, for instance.
Sometimes insurers will provide such support groups.
Other groups meet virtually online.
Physician groups with large enough practices may even form and maintain such groups.
Doing so requires that the practice provide a health coach to run and support the meetings.
Mentors for patients new to the group will lend additional support.
These are just a few of the successful approaches that I have encountered in helping patients become engaged in the management of their condition.
I don't recommend that a physician's office try all of them at once; rather, experiment with a couple and fine tune each.
Other approaches can be added if necessary.
The results will be beneficial to both patient and physician.
Many if not most patients will see an improvement in their condition.
The positive results will be self-reinforcing as the patient will be able to do more as the condition improves.
However, there will be patients who will not take on responsibility to manage their condition no matter what approach is taken.
Such patients can be very frustrating.
I urge you to consider the improvement in the majority who do a better job when given the right tools.
See how full the glass is, not how empty.
Physicians will also benefit financially.
For those who participate with insurers with pay for performance plans income should generally improve from this source.
Too, as those with chronic conditions improve, there will be fewer visits to the physician office.
A study (article by Truls Ostbye in the May/June 2005 edition of the Annals of Family Medicine)showed that a patient whose chronic condition is not under control comes about once a month to the physician's office.
Such a patient whose condition is under control comes in about once every six months.
This may seem like a loss of income, but for physicians with a large patient load there will be more time for patient visits which provide a better return on investment of time.
Brief dialogues, journaling, education of those with whom the patient lives and support groups are just a few approaches to enabling a patient to self-manage her condition.
Others are described in literature centering on the Advanced Medical Home and the Chronic Care Model.
Good places to start are The Advanced Medical Home: A Patient-Centered, Physician Guided Model of Health Care by the American College of Physicians and Organizing Care for Patients with Chronic Illness (authors listed above).
Adopt and refine a few and see if the benefits I indicated don't occur.