Reform Update: Patient engagement key to better chronic-disease care, providers say

Achieving better health and more efficient care for any patient requires more than access to doctors, medications or hospitals. Success also will hinge on the degree of support, confidence, knowledge and skills that patients have to follow treatment regimens or make changes to diet or exercise that can improve their health, said healthcare providers and researchers at an industry meeting Wednesday in New York City.

“The patient role is really important in determining these outcomes,” said Judith Hibbard, a health policy professor at the University of Oregon who spoke to public health and health system officials at the symposium. “We need to pay attention to it.”

Hibbard's research is the foundation of a measure used by some health systems to identity how actively patients will participate in their care. The instrument seeks to measure patients' skills, knowledge and confidence in their ability to take healthy actions and manage their disease.

“I think as we move into an era where payments are more closely linked with outcomes, we can't afford to not pay attention to it,” Hibbard said. “It is going to become a priority.”

Indeed, helping hospitals and doctors self-manage their chronic diseases is an area of increased attention as Medicare and private insurers have introduced financial incentives to control cost growth and prevent avoidable hospital stays.

Providers that do not address issues of patients' understanding of their disease and ability to follow through—for lack of money, time, confidence or other reasons—are setting patients up to fail, said health researchers and officials who addressed the symposium.

“Patients stop listening,” said Mary Jo Muscolino, manager of case management for the Monroe Plan for Medical Care, which provides case management and social work support for Medicaid beneficiaries in New York. “They argue with us.”

Monroe uses Hibbard's activation measure to tailor information and intervention to patients' needs, Muscolino said. Those with little understanding of their disease and no confidence receive more support and education than those who are well informed about their condition, manage well and perhaps need help only during extraordinary or stressful circumstances.

Patients likely won't follow treatment goals that cannot be attained or those that compromise other priorities, such as medications that could interfere with job performance or exercise recommendations that patients working two jobs don't have time for, said Dr. Shreya Kangovi, an assistant professor of medicine at the University of Pennsylvania.

Many accountable care organizations have overlooked the role of pharmacists, but they could benefit from chronic disease medication management and better coordination of prescriptions as patients move from home to hospital to nursing home, according to a new essay in Health Affairs.

“Pharmacists can help meet the demand for some aspects of primary care and can contribute to the efficient and effective delivery of care,” said Dr. Thomas Bodenheimer, Dr. David Bates and Marie Smith, dean of the University of Connecticut's pharmacy school. “A pharmacist's expertise in medication reconciliation, pharmacotherapy management and monitoring and care coordination across multiple prescribers and care settings is complementary to the skills of other healthcare professionals.”

Their current exclusion from teams may be a result of payment policies that fail to directly pay pharmacists to manage medication. It may also be complacence, the authors said. They called it “the toleration of the status quo, including the acceptance of preventable medication errors as mere accidents.”

Pharmacists working within a team could concentrate on medications. One survey found doctors spend less than a minute during patient visits discussing new prescriptions. The authors also called for quality measures that would identify and track gaps in medication use and safety.

The authors also urged ACOs and other alternative payment and delivery models to include medication management and to pay pharmacists from global budgets.

“Medical homes, ACOs and integrated networks should be motivated to refer patients with complex drug regimens, high-cost healthcare, failure to achieve desired clinical outcomes, high risk of adverse events, poor adherence, or drug-related health literacy issues to a pharmacist for comprehensive medication management services. The pharmacist would be compensated from the practice's per member, per month payments.”

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