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708-How to Develop Staff Competencies that Competencies that

Support Patient Engagement

Merrily Evdokimoff RN, PhD

M & J A i tM & J Associates

Objectives

1 Assess the current status of interventions utilized in home health care related to Care Transitions1. Assess the current status of interventions utilized in home health care related to Care Transitions.

State of the research, Care Transitions; Patient Engagement

Implementation Science, home health care, 2014

2. Identify underlying competencies and eliciting staff engagement to implement these interventions.

A. Coaching

B. Motivational Interviewing

C. Teach Back

D. Use of Personal Health Record

E. Supporting patient-engagement

D l g id bl i t b d i l t ti d t th t t th i d t iDevelop an agency wide blueprint, based on implementation and systems theory, to support the required competencies.

A. Blueprint Development

B. Work Flow Analysis

C. Competency Assurance

D. Implementation barriers

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Why Competencies?

Liability

Consistency

Patient/caregiver satisfaction

Enhance Critical Thinking Skills

Critical Thinking

S f t t D k l d Surface structure vs Deep knowledge

Deep Thinking

What to do with the facts?

What are the right questions to ask

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Critical thinking questions:Reflective inventory

Wh t i ?What surprises me?

What puzzles me?

Do you see any patterns or themes emerge?

Anything you should know immediately?

What things can wait?

Does anything else come to mind?

Jim Keene, PhD

A Blueprint……….

U d l i i i lUnderlying principles

Changing paradigms

Management of data

Critical Thinking-using data for benefit of patient

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Current Concepts

P ti t lf tPatient self-managementPatient Education

Teach BackLiteracy Levely

Care TransitionsEvidenced Based Practice

Changing ParadigmsCoaching

Motivational InterviewingPatient Engagement

Access to Clinical RecordPHRWays to Measure/Increase Pt. Engagement

Staff EngagementValue based reimbursementValue based reimbursementCritical thinkingCaregiver educationDecision aids for patients

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COACHING:

A h f t i ith ti t t h lf t An approach of partnering with patients to enhance self-management strategies for the purpose of preventing exacerbations of chronic illness and supporting lifestyle change” (Huffman, 2007, p. 271).

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Coaching vs Teaching

COACHINGFacilitator

TEACHINGTeacher

Patient identified goals/timelines

Patient/care partner centered

Improved motivation

Motivational interviewing

Teacher identified goals/timelines.

“Expert centered”

Motivational interviewing

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Make Information Availableto Patients

C i f lCopies of care plans

Personal Health Record

Paper with info provided by you (see article for details)

Electronic PHR with agency downloading info into it.

Teach them to use Blue Button, patient portals

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PHR

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http://www.myphr.com/resources/choose.aspx

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Electronic Health Record-Kinergy Health

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Provide Staff with Tools to Do the Job

Access to Experts-live and on line

Medication Reconciliation Support

Time to learn what the “new world” expects and time to implement it:

Use of Motivational Interviewing

Coaching

Teach BackTeach Back

Patient Activated Learning

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Motivational Interviewing

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Motivational Interviewing: OARS

O-Open Ended Question

A-Affirmations

R-Reflection

S-SummaryS-Summary

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O d d C t b d ith

Characteristics of Open Questions

Open ended-Cannot be answered with yes or no.

Focus on patient.

Asking for guidance from patient, not telling.

Allowing patient/advocate to identify priorities.

Non-judgmental

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Examples of Open Ended ?

What is it you do not like about taking that medication?What is it you do not like about taking that medication?What is your main worry since leaving the hospital?What is one thing I can do for you that would make you feel less anxious?What can I do to help you this week?What symptom on this “Red Flag List” are you most concerned about?How important is _____to you?What is the most important part of your recovery to you?What do you want to see happen in next 30 days?What would you like our agency to help you accomplish while we are servicing you?

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Affirmations

Affi ti t t t th t i li t t thAffirmations are statements that recognize client strengths.

Key element in supporting patient self-efficacy.

Remind client of prior achievements

Tie current challenges to past successes

Identify supports in their environment

Praising for small accomplishments

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How Can Health Coaching Be Used with “Resistant Patients?”

F MI ti i t i t ti t bl b t l ti hiFrom an MI perspective, resistance is not a patient problem but a relationshipproblem.

avoid the “resistance trap”

put the choice and responsibility for change back in the hands of patients.

people have a natural tendency to resist being told what to and respond to such advice with direct or indirect resistance.

Called the “righting reflex” or the natural tendency to try to stop patients Called the righting reflex or the natural tendency to try to stop patients from doing what provider feels is wrong

Usually ineffective, exhausting and frustrating for the patient and the clinician!

From an MI perspective, patient autonomy is always reinforced. 21

Don’t lecture

Rolling with Resistance

Don t lectureAcknowledge & validate how difficult it is to change life long behaviors“Back off”-ask open ended questions, don’t pressure or preachClarify decision is the patient’sClarify decision is the patient sMaking the effort to understand the causes of each patient's non-adherent behavior helps tailor an approach to removing obstacles

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Reflective Listening

Reflective listening is a way of checking what is meant rather than assuming that you know

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Reflective Listening to Express Empathy

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Summarizing

Summaries communicate interest and understanding and call attention to Summaries communicate interest and understanding and call attention to important elements of the discussion.

Allows clinician to assist patient in setting goals.

Organizes information

Confirms mutual understanding

Presents both pros and cons patient has identified

Helps patient identify desired goals, how to proceed

Additional information on MI may be found at: http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

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Barriers to MI Implementation

Lit ILiteracy Issues

Loss of Control/Role Changes (Independence)

Time to Master

Need for Practice

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Patient Engagement

Patient Expectations of Self-Management

A t i f ti Access to information

Involved in decision making

Identify own goals

Dialogue care plans

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Decision aids for patients

Statin Decision Aide

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A Patient-Centric Definition of Participatory Medicine:

P ti i t M di i i t i hi h t k d ti t hift f Participatory Medicine is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners

The Society for Participatory Medicine is a 501(c) 3 The Society for Participatory Medicine is a 501(c) 3 devoted to promoting the concept of participatory medicine, a movement in which networked patients shift from being mere passengers to responsible drivers oftheir health, and in which providers encourage and value them as full partners.

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Minimally Disruptive Medicine

Sh d d i i ki bl ti t d li i i t h th b t Shared decision making enables patients and clinicians to share the best available research evidence and make decisions that better reflect the patient's values and preferences. Minimally disruptive medicine focuses on pursuing the patient's goals (preventing premature death, feeling better, and living without hindrance from complications of disease or treatment) while reducing the treatment burden.

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SBAR

Access to Clinical Record

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Aetna

Affinity Networks, Inc

CareTrio

Centers for Medicare and Medicaid Services

CNSI

Department of Defense

Department of Veterans Affairs

EastRidges Medical Software

Gorge Health Connect, Inc.

Humana Inc and certain of its operating subsidiaries

Current Participants:

Humana Inc. and certain of its operating subsidiaries

Iatric Systems

Intuit Health

InXite Data Systems

KRM Associates, Inc.

LifeMed ID, Inc.

McKesson

MediKeeper, Inc.

MedRed LLC

mHealthCoach

MIMedicalHealth

NaviNet, Inc.

NextGen Healthcare

The door is wide open, the room is filled, and we’re ready to design new ways to give consumers/patients their own health information in the most

Ne tGe ealt ca e

NoMoreClipboard.com

OneCare

Patagonia Health Inc.

PatientClick EHR

PatientsLikeMe

RelayHealth

SAMBA Health Benefit Plan

SOAPware

United Healthcare

Vermont Blueprint for Health, Department of Vermont Health Access

Walgreens

meaningful way.Susan Woods, 2013

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Patients who had access to their medical records reported:

Positives:

Better communication with providers

enhanced knowledge of health and improved self care

greater participation in and improved decision making

improved quality such as f/u on abnormal tests

Identified errors or inconsistencies and had corrected

Negatives:

seeing previously undisclosed information

Mi t i bb i tiMisconstruing abbreviations

(Woods et al, 2013)

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Ways to Measure/Increase Pt. Engagement

Hibbard, J. (2005) Use with permission only. cswanson@insigniahealth.com(612) 998 6216

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Hibbard,J.

Writing Short-term Achievable Goals

How to write a Smart Goal How to write a Smart Goal SpecificMeasureableAttainableRelevantRelevantTime based

Source: CDC40M & J Associates

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Importance/Confidence ruler

Aft l ttiAfter goal setting:

Allows assessment of probability of success.

Aides in setting realistic goals

Refocuses on patient, not provider goals

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Teach Back:Chunk and Check

Chunk – small piece of information example: daily weights

Check – to see if the patient understands this small concept – “chunk”

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Value based reimbursement

MMeasure

Chart

Share

Guide Practice

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Healthcare Transformation

= data + transparency + engagement

Vivian Lee from University of Utah at MedX Conference stated that

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Caregivers: Who Are They?

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Caregivers: Who Are They?

90% f th h d d b ld i th U it d St t h b 90% of the home care needed by elders in the United States has been provided for free by more 65 million family and friends.

Caregivers provide care an average of 20.5 hours a week.

If were paid for, would amount to $56,000 per year per patient.

Caregivers are typically female, socially isolated, financially stressed and feel trapped.

Caregiver education-Tips for CaregiversFill the well.

Remind yourself of you.

Give yourself a soundtrack.

Take care of your back.

Find the funny.

https://caregiver.org/taking-care-you-self-care-family-caregivers

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So Where are you in the Process?Medications

Reconciliation Tools

Pharmacy Supporty pp

CommunicationSBAR-Staff and Patients

Motivational Interviewing

Teach Back

Patient EngagementPersonal Health Record

SMART Goals

PAM Assessment

Confidence Ruler

MeasurementEvery patient, every time

SOP-every readmission

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Blueprint Development

A. Work Flow AnalysisB. Competency AssuranceC. Implementation barriers

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Staff Engagement

P i i l f Ch Th (I l t ti S i )Principles of Change Theory (Implementation Science)

Inclusion

what matters

attention to detail

Test, Revise, Test, Revise

Questions to Ask:Questions to Ask Before Starting Implementation

• Does it have a clear purpose for all relevant participants?

• Do participants have a shared sense of purpose?

• Are the benefits likely to be valued/advantageous by potential participants?

• Does it fit with overall goals and activities of the organization?

• Will the participants see the point of the intervention easily?

• Will they be prepared to invest time, energy and work into it?

• How will the intervention affect their work?

• Will it promote or impede ability to meet agency expectations?

• Will staff require extensive training and how will it be provided?

• How compatible is it with existing work practices?

• What impact will it have on division of labor, resources, power and responsibility among professional groups?

• How are users likely to perceive the intervention once it has been used for a while?

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Questions to Ask:

D i I l t tiDuring Implementation:

• Is it clear what effect the intervention has had?

• Can staff contribute feedback about intervention and will the information be considered in evaluating intervention?

• Can the intervention be adapted or improved once it has been implemented?

Barriers to Implementation

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Competency Assurance

H d d it ?How do you do it now?

What works, what doesn't?

Teach back

Staff Engagement

MI for Managers

Job Description

Inclusion in evaluation

Devil is in the details

Measure,Measure,Measure

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(IHI, 2012, p. 57-61)

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Reference ListBradley, E., Curry, L., Horwitz, L., Sapsma, H., Elma, J., Walsh, M. & Krumholz, H. (2012). Contemporary evidence about hospital strategies for reducing 30-day readmission rates. Journal of the American College of Cardiology, 60(7). 607-614

Coleman, E. & Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatric Society, 51(4), 556-557

Coleman, E., Parry, C., Chalmers, S. & Min, S. (2006). The Care Transitions Intervention: Results of a randomized controlledtrial. Archives of Internal Medicine, 166(25), 1822-1828

Evdokimoff, M. (2011). One home health agency’s quality improvement project to decrease rehospitalizations: Utilizing a care transitions model. Home Healthcare Nurse, 29(3), 180-196.

Evdokimoff, M. (2012). Testing the efficacy of a nurse-led, patient self-management intervention to decrease rehospitalization in older adults. Doctoral Dissertation. Boston College: Chestnut Hill, MA

Hibbard, J., Stockard, J., Mahoney, E. & Tusler, M. (2004) Development of the patient activation measure (pam): conceptualizing and measuring activation in patients and consumers. Health Services Research, 39(4), 1005–1026

2May, C. (2013). Towards a theory of implementation. Journal of Implementation Science, 8(18). Accessed on line at www.implemetantionscience.com/content/6/1/18

May, C., Sibley, A. & Hunt, K. (2013). The Nursing work of hospital-based clinical practice guideline implementation: An Explanatory systemic review using Normalization Process Theory. The International Journal of Nursing Studies. Accessed at http://dx.doi.org/10.1016/j.ijnurstu.2013.06.019

Newport, C. (2012). So Good They Can’t Ignore You. New York: Business Plus

Sevin C, Evdokimoff M, Sobolewski S, Taylor J, Rutherford P, Coleman EA. How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations. Cambridge,MA: Institute for Healthcare Hospital to Home Health Care to Reduce Avoidable Rehospitalizations. Cambridge,MA: Institute for Healthcare

Improvement; June 2012. Available at www.IHI.org.

Silver, M.P., Ferry, R. J. & Edmonds, C. (2010). Causes of unplanned hospital admissions: Implications for practice and policy.Home Healthcare Nurse, 28(2), 71-81

Woods, S., Schwartz, E. Tuepker, T., Press, N., Nazi, K., Turvey, C. & Nichol, P. (2013). Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record pilot: Qualitative

study. Journal of Medical Internet Research, 15(3). Accessed at http://www.jmir.org/2013/3/e65/

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708-How to Develop Staff Competencies that Competencies that

Support Patient Engagement

Merrily Evdokimoff RN, PhD

M & J Associates

merrilyevd@gmail.com

Mjhomehealthassociates.com