Patients reeling from multiple medical maladies can't simply be given care plans to follow. They have to understand, embrace and be motivated to incorporate clinical advice in ways that make sense in their lives. That requires a concerted effort to "meet the patients right where they are in their health challenges," says Lisa Horne, a health navigator with the HealthWorks program of Genesys Health System in Michigan.
Part of "where they are" is literal: the neighborhood around them, with its social and economic barriers to complying with physicians' orders. But it's also a state of mind, both in comprehending the information given to them and in readiness to accept what they have to change as a result, Horne says.
With a background in social work, Horne says social challenges and their impact on patient care have not been at the forefront of improving overall health. She's met many physicians and other staff who are caring and compassionate, but unable to do more than give patients a lead or two toward improving their situations outside the office setting. "Traditionally it's been, 'Go to the doctor, get medication, take medication' — that's it, when there's a lot more involved."
Concerns Delay Compliance
Another part is reaching the patient in certain situations, such as after an acute episode in the hospital, where time is of the essence, says Frederick Bloom Jr., M.D., of Geisinger Health System, Danville, Pa. Patients can do a lot of ill-advised things in the interim between hospital and first follow-up visit, for example. "A patient would show up in my office a week later with the prescriptions still in hand, and say, 'Dr. Bloom, I just want to check with you before I got any of these medications filled.' And some very critical medicines — antibiotics or anticoagulants — that should have been started Day 1, haven't been," he says.
But caution over meds is "a very natural reaction for patients; it's something that [requires] an educational effort," Bloom notes. "We need to make sure patients understand the need for their medications, understand completely their concerns about side effects of their medications, and have the cost of their medication addressed, to make sure that they can afford to take the medications that have been prescribed."
Bloom says 20 percent of hospitalized Medicare patients end up being readmitted within 30 days. "We're finding that a significant percentage of that, maybe a third, is within the first week. So making sure we have close contact with patients early on, and close follow-up in the primary-care physician office, we think is critical."
New Responsibilities for Providers
The barriers to overall compliance with health care regimens are legion, Horne says. "It can be anything from a newly diagnosed patient who doesn't understand anything about their condition, to a patient who has had a health challenge for years, but because of so many different barriers, a lot of social challenges, they just have not been able to bring things together to where it improves their overall health and wellness."
A navigating or coaching role is particularly important when dealing with patients who are less-educated in communities with fewer resources, says Mary Witt of the Camden Group. Those patients may have more stress and social problems in their environment. Care coordinators are seen often in community clinics and federally qualified health centers for these reasons, she says.
Traditionally the onus has been on patients to figure out the routine, the vernacular and everything else about getting around a health care environment. But responsibility for proactive care management puts the responsibility on providers to understand the routine and vernacular of their patients, Witt says. "You want to make sure patients are going to have the knowledge and skill set to be compliant and be able to do what they have to do to stay healthy; you have to be able to talk to them in a language — it may still be English — but talking to them in terms they can understand."
Horne's training helps patients to understand their role. Usually they know something about their illness and their test results, and they've been told what they need to do. The key is to get them to say what they will do now to make things better, and to listen to what they say. "I don't tell them what they're doing wrong, I let them tell me what they know they're doing wrong, and then begin to ask them, 'What do you think you can change about that?' 'How important is it for you to change?'" she says.
Letting patients think of their own goals has been pivotal in the success of HealthWorks, Horne says. "Because we can say all day long, 'You need to get your a1c under 6 [to a safe blood-sugar level]' … but if they don't know what 'under 6' means, and they don't know how taking their sugar levels daily impacts that number, that doesn't mean anything to them."
Horne remembers one patient who was angry with her doctors, complaining that "they're not helping me." All health results and diagnoses were laid out, meds prescribed and education delivered on long-term effects of her condition. "What was missing is that the patient did not see how her weight impacted her health. She just really didn't see it; she saw everything else but that." So Horne had her think about a time she felt really good; how much did she weigh then?
"A little tear came down [her face] and she realized, 'I was smaller then.'" Then Horne gently explained to the patient that her legs can only hold so much weight, and related it to her knee pain. "Doctors don't have time to get into that kind of detail with patients," she says.
"Each patient is different, I've learned, and they're all at different levels based on who they are, what they've been exposed to, their family dynamics. Economics plays a role," says Horne. "With this lady, it honestly took over a year for her to really even give me that much time." Because even health navigators, like other health care representatives, initially may look like "another person talking to me about what I need to do, as opposed to a person talking to me about where I am and where I want to go."
For more on health navigators and other new roles in primary care, read our April cover story, "Filling the Gaps in Primary Care."
John Morrissey is a writer in Mount Prospect, Ill.
