Thursday, October 1, 2009

The Patient at the Center

The Planetree of Hippocrates in Kos, Greece

October is Patient Centered Awareness Month. The Tree of Hippocrates has become a symbol of patient centered care. This is the planetree under which, according to the legend, Hippocrates of Kos (considered the father of medicine) taught his pupils the art of medicine. The tree's association with Hippocrates is the source of the name of the Planetree, an organization of hospitals dedicated to personalizing, humanizing, and demystifying the healthcare experience. The Planetree philosophy is patient centered committed to improving medical care from the patient's perspective. Patients are encouraged to read their own medical records. Their pets are allowed to visit. Families are encouraged to participate in the patient's care, and can even prepare the patient's favorite dishes in special kitchens on each floor. In addition to the most modern and technologically advanced Western medical treatments, alternative options such as acupuncture and massage are offered.

At Planetree We Believe...
  • That we are human beings, caring for other human beings.
  • We are all caregivers.
  • Care giving is best achieved through kindness and compassion.
  • Safe, accessible, high quality care is fundamental to patient-centered care.
  • In a holistic approach to meeting people's needs of body, mind and spirit.
  • Families, friends and loved ones are vital to the healing process.
  • Access to understandable health information can empower individuals to participate in their health care.
  • The opportunity for individuals to make personal choices related to their care is essential.
  • Physical environments can enhance healing, health and wellbeing.
  • Illness can be a transformational experience for patients, families and caregivers.
In the past, physicians commonly withheld diagnostic information from patients with patients' tacit consent. Even Hippocrates advocated “concealing most things from the patient while you are attending to him ... revealing nothing of the patient's future or present condition.” In an 1871 Bellevue Medical School graduation address, Oliver Wendell Holmes said:
"Your patient has no more right to all the truth you know than he has to all the medicine in your saddlebags.... He should get only just so much as is good for him.... It is a terrible thing to take away hope, every earthly hope, from a fellow creature... Some shrewd old physicians have a few phrases always on hand for patients who insist on knowing the pathology of their complaints without the slightest capacity of under standing the scientific explanation. I have known the term 'spinal irritation' to serve well on such occasions."
The attitude of Holmes is obviously unacceptable today. Patients increasingly expect to know not only their diagnoses, but also details of pathophysiology, treatment options, and prognosis. These days patients often even challenge their physicians' diagnoses. Patients expect and often demand information that used to be only within the physicians' reach, and physicians increasingly expect that they will share information with patients.

The change in attitude surrounding disclosure of diagnoses stands out when discussing cancer. Not surprisingly, Holmes advocated that physicians avoid the term "carcinoma" when speaking with patients. He would be very uncomfortable at the Celilo Cancer Center where the Planetree philosophy of patient centered care is practiced. Of course there is a delicate balance of keeping hope alive and brutal honesty.

Beyond simply being honest, one argument for informing patients is that information enables patients to participate in medical decisions. In less patient centered days, physicians decided what was best for their patients, and patient participation was limited to compliance with physicians' orders. As the art of medicine becomes more patient centered, participation begins with the patient helping to make medical decisions, and the emphasis will shift from compliance to participation. Including the patient and the entire family in the decision making and care of the patient is important.

Of course, individual patients are different with respect to the amount of detail they want, and the degree to which they wish to participate in decision making. Therefore, the art of patient centered care involves determining the appropriate amount of information and participation from the individual patient's perspective. For some patients, the "right not to know" is a crucial element of patient centered care. For some patients it is not necessarily information that dtermines for them whether they are at the center of their care. The provider must not assume that certain types of patients, based on age, history, or other factors, will favor or disfavor information. This is a part of patient centered care that is very intuitive for the provider.

There is a great deal of interest now in the Patient Centered Medical Home (PCMH). This is a new approach to providing comprehensive primary care. The AAP, AAFP, ACP, and AOA, representing approximately 333,000 physicians, have developed the following joint principles to describe the characteristics of the PCMH:

Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Quality and safety are hallmarks of the medical home:
  • Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.
  • Evidence-based medicine and clinical decision-support tools guide decision making
    Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
  • Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
  • Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication
  • Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
  • Patients and families participate in quality improvement activities at the practice level.
Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:
  • It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.
  • It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
  • It should support adoption and use of health information technology for quality improvement;
  • It should support provision of enhanced communication access such as secure e-mail and telephone consultation;
  • It should recognize the value of physician work associated with remote monitoring of clinical data using technology.
  • It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
  • It should recognize case mix differences in the patient population being treated within the practice.
  • It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
  • It should allow for additional payments for achieving measurable and continuous quality improvements.
As David Harlow said in his intro to his excellent interview with Paul Grundy, MD:
"The Patient-Centered Medical Home model - described more fully in materials from the Patient-Centered Primary Care Collaborative, and TransforMED, an affiliate of the American Academy of Family Physicians - relies on a shift in physician compensation from a fee-for-service focus to a patient management focus; from an episodic focus to comprehensive, relationship-based care. It’s been implemented in over 100 pilots around the country. Denmark learned about the model here in the U.S. decades ago and have implemented it fully across the country’s health care system, shuttering most of the acute care hospitals in the country in the process. Pilots in the U.S. include Geisinger’s, which Grundy says has been remarkably successful, yielding an ROI of over 250%, including a 12% reduction in ER utilization, a 20% reduction in hospitalization, ans a 48% reduction in rehospitalization.
Technology is an important part of these efforts and savings. Even given the potential high cost of technological solutions and Health 2.0 tools, the costs pale in comparison to the $1 million-a-bed cost of hospital construction, let alone hospital staffing and other operating costs."
I agree completely and recommend that you check out the entire interview. We are moving into a new paradigm in the art of medicine. It includes a technologically advanced, patient centered approach that will transform the way we care for each other.


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