March 2012 - Patient-centered CareI have noticed the growing frequency of the term “patient-centered care” in the aging literature, and increasingly in marketing materials as well. But what do these terms mean and how will they affect you?
The concept behind patient-centered care (“patient-directed” or “consumer-directed care”) is to put you, the patient, back at the center of your medical care. Patient-centered care is a paradigm shift, moving decision making back to the patient, creating a partnership between patient and primary care doctor, that moves away from the day when one could not question a physician’s authority. The healthcare environment today includes increasing specialization, little time for patient-doctor communication (and no reimbursement), a bewildering array of options, and a growing number of ethical dilemmas as our ability to sustain life often comes at great economic and emotional cost. Too often physicians will talk with family members across a frail older adult as if he or she does not exist.
Christine Bechtel of the National Partnership for Women & Families, identifies four key features in patient centered care: “whole-person care, coordination and communication, patient support and empowerment, and ready access.”1
To achieve true patient-centered care, there needs to be a primary physician who will coordinate care from all providers and serve as a guide to the patient. Patients and families need to play an active role in medical decision making, but they need reliable unbiased information about options, benefits and risks. Doctors need to know what matters most to each patient and what motivates and helps them to get and stay well. They need to consider a person’s cultural traditions, personal preferences and values, family situation, social circumstances and lifestyles.2
Patient-centered care focuses on helping patients make the best decision for each individual, by helping them be fully informed and involved in the process. Don Berwick, formerly of Institute for Healthcare Improvement, defined patient-centered care as: “the experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.” 3
One example of implementing this new thinking is the POLST (Physicians Orders for Life Sustaining Treatment). This past week I attended a press conference at the University Medical Center at Princeton, which is a pilot site for implementing POLST in NJ. The presentation pointed out that NJ ranks highest in costs, doctor visits and tests in the last weeks of life, without improved patient outcomes. Ageism can also cause some physicians to withhold treatment without talking to the patients about options. The POLST paradigm involves physicians having frank discussions with their patients about their end-of-life wishes and writing a physician’s order based on the patient’s goals, to be honored by all providers across all treatment settings. As Dr. Barile has explained in his presentations at PSRC, designing a treatment plan to support a patient’s desire to finish writing their book is different from using every available test and treatment to sustain life as long as possible without consideration for quality of that life and the patient’s goals. (For more information, go to www.POLST.org or www.goalsofcare.org).
Another model following the patient-centered philosophy is the “medical home” which involves creating a practice team coordinating care across episodes and specialties. It was initiated by the American Academy of Pediatrics to provide “accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care to all children…” 4 It emphasizes prevention, primary care and integration; returning control to the patient; and is touted as more cost-effective than current care models.
So what can you do to experience patient-centered care? First, find a physician who is able and willing to
be your partner, who will coordinate the care you receive from any number of physicians, and who will see you as a whole person. Educate yourself about your health and your options for care, and learn how to find reliable information on the internet. Begin talking now to your family and physician about your wishes and philosophy of life, providing the background and context for future decision making. Personally, I worry that physicians will not make the necessary time available without insurance reimbursement, which creates a critical role for social workers, nurses and care managers, as we often have more time to listen and ask questions that can help you clarify your thoughts before you go to the physician to have this conversation. These professionals have focused on empowerment, supporting independence and individualized client-centered care for a long time. Using a tool like the Five Wishes document (agingwithdignity.org) can help you clarify your thinking and start the discussion with family and professionals. Having some idea of your thinking will help your family keep you at the center of your care decisions.
Susan W. Hoskins, LCSW, Executive Director