Patient-centered care becoming 'person-centered care'

Health systems are broadening their definition of patient-centered care, sometimes extending the concept beyond clinical care by replacing the term “patient” with a seemingly more holistic “consumer” or “person.”

Patient-centered care, a term popularized by the Institute of Medicine in 2001, initially described an approach to care that allows patients to guide their own clinical decisions. Now its definition has expanded—health systems see it as encompassing not just clinical care, but also patient experience, including how encounters stack up to patients’ expectations from other consumer-facing industries and, subsequently, whether patients view their care as worth the expensive price tag.

But even as the term’s definition changes, health systems are in general agreement about the concept’s continued importance, according to Modern Healthcare’s most recent Power Panel survey of top healthcare CEOs. Nearly 70% of CEOs said they’ve made changes to the structure of their organization to be more patient-centered, and more than half have someone formally in charge of leading those efforts.

There’s a financial component, too, as health systems are facing increased competition for patients as new entrants to the industry—such as virtual care companies and retail-clinic chains—are taking away some of the ambulatory market share.

That means patients are weighing their options when deciding where to seek ambulatory care, and they aren’t always going to big-box hospitals.

“Traditionally, our business has all been about the patients we have in beds. That’s where the revenue source was generated,” said David Entwistle, CEO of Stanford Health Care in Palo Alto, Calif. “That, however, is starting to change,” he added, noting 53% of Stanford Health’s income is now generated from outpatient settings.

Patients’ interest in nontraditional healthcare settings is driven by a few changing market dynamics. That would include rising out-of-pocket costs, as well as expectations about convenience and digital experience that they have come to take for granted in other industries, according to Dr. Kaveh Safavi, senior managing director for Accenture’s global healthcare business. “Fundamentally, what we mean (by patient-centered care) is that people want care on their own terms, where and when they want it,” he said.

While health system CEOs say the vision of patient-centered care remains central to their missions, the term itself has been swept up in the “patient” versus “consumer” debate.

“ ‘Patient-centered’ has been around for awhile,” Safavi said. “But it has taken on a little bit more of an expanded notion, as we think about not only people as patients, but also as consumers.” That shift to thinking about “patients” as “consumers” has been taking place for the past three to five years, he added.

That evolving backdrop has led health systems to redefine patient-centered care in recent years, with 65% of CEOs indicating their definition of the term has changed over time.

That was the case for ProMedica in Toledo, Ohio, which has increasingly been using the term “consumer” or “customer” to capture a more holistic view of a patient, including their needed medical care, social determinants of health and general well-being. “It’s evolved to be much more consumer-based,” Randy Oostra, ProMedica’s CEO, said of the health system’s vision.

It’s not an insignificant change. It’s really been in the last decade that the notion of being patient-centric included the idea of the patient as a consumer, he said. “If you said the word ‘customer’ 20 years ago at a medical staff meeting they would have dragged you out or somebody would have given you a lecture saying they’re not customers, they’re patients,” Oostra said.

There’s also a growing contingent of health systems transitioning to the phrase “person.” Froedtert Health in Milwaukee tends to use the phrase “person-centered care,” while Allina Health in Minneapolis has opted for the phrasing “whole-person care.”

“We’re not just treating the condition of the patient that happens to be in front of us,” said Michael Callero, Allina’s vice president of consumer insights, highlighting initiatives related to social determinants of health. Allina established Callero’s role less than a year ago to help the system better “understand the people that we deliver care to,” he said.

Still, some are standing by the traditional “patient” terminology and its long-standing history. Nearly 40% of CEOs in the survey said their organization has used the term patient-centered care for more than a decade, and an additional 30% said they’ve used the term for six to 10 years.

Despite changes in the broader healthcare industry, Entwistle said, the term “patient” still resonates best with his system’s staff.

“Consumerism and consumers are very much thought about as a business, whether it’s a retail setting or something else,” he said. “We would very overtly err on the patient side.”

The first step to redesigning care around the patient means improving access to get patients care where they want it and when they want it.

That’s been an ongoing area of focus for health systems, with the majority of system CEOs citing clinical practice and consumerism as top areas of healthcare in need of innovation, according to a separate CEO Power Panel survey conducted earlier this year. That’s in part because patients are being asked to navigate an increasingly complex and expensive healthcare system, CEOs say.

“Historically, we’ve asked the patient to be the navigator for their own care,” said Chris Van Gorder, CEO of Scripps Health in San Diego. “But many patients don’t even know how to navigate the system.”

Scripps has established a 24/7 nurse triage service for patients to call as part of its push to make it more convenient for patients to get to the appropriate care site. That includes directing patients to telemedicine options or the system’s more than a dozen Scripps HealthExpress walk-in clinics, a program the system has worked to build up during the past year.

Directing patients to the appropriate care site is becoming increasingly important, particularly for low-acuity conditions, as patients express interest in a spate of new same-day options—with one study in JAMA Internal Medicine estimating a 140% increase in use of urgent-care centers, retail clinics and telemedicine appointments between 2008 and 2015. That’s led to concerns about fragmented care—as younger patients may be using these options in lieu of traditional primary care—but there are ways to integrate these convenient services into a continuum of care.

At ProMedica, Oostra said the system has begun linking patients who present to urgent-care sites without a primary-care physician to an appropriate provider before they leave the visit. “We’ve now gotten (urgent care) to be a very effective primary-care strategy,” he said. “It’s actually increasing access for patients who did not have physicians before.”

Health systems have also rolled out digital services to tackle issues with patient access.

Nearly all CEOs said they’ve made investments in technology to improve patient care, much of which has centered on electronic health records (100%) and patient-facing apps (91%).

For many systems, that includes implementing technologies that allow patients to schedule their own appointments online or patient-portal apps that let patients reach out to their care team with questions. Those software systems are some of the “low-hanging fruit” to improve patient access, said Marna Borgstrom, CEO of Yale New Haven (Conn.) Health.

Froedtert last year deployed a symptom-checker chatbot that asks patients a series of questions about their illness or condition to help them determine the right site of care. Froedtert is one of just one-quarter of health systems that said they’ve deployed chatbots to help improve patient care, putting them among early adopters of the technology, according to this quarter’s Power Panel survey.

The chatbot is part of an effort to decrease “friction” in a patient’s care experience, said Mike Anderes, Froedtert’s chief innovation and digital health officer. “The premise of person-centered care is really to understand what (the person) is trying to solve for,” he said.

That focus on consumerism doesn’t stop once a patient walks through the hospital doors—and it can involve such things as helping patients find their physician’s office, ensuring there’s enough internet bandwidth to keep systems running smoothly and keeping noise in hallways limited, Stanford Health’s Entwistle offered as examples.

“It’s just trying to create a better environment” for patients, he said.

Wayfinding apps, which essentially work like indoor GPS or navigation systems, have proved a popular way for health systems to help patients find their way around a facility or campus, cutting down on the possibility of patients getting lost or frustrated on the way to an appointment.

These systems walk patients through turn-by-turn instructions, often beginning as early as the parking lot. “Finding your way around 4 million, or however much, square feet of our academic campus is not easy,” Froedtert’s Anderes said. More than 12,000 patients have downloaded Froedtert’s app since it launched in 2017.

To improve patient experience for those who are admitted to the hospital, Scripps is taking a page from the hospitality industry: room service. The health system is working to deploy tablets at the bedside so patients can request meals when they want them. That will save money by cutting down on food that’s currently wasted when it’s delivered to a patient who doesn’t want it, according to an analysis conducted by Scripps and cited by Van Gorder.

“By doing room service, the reduction in food wastage alone (will save us money), and the patient will end up getting the appropriate diet and the food that they want,” Van Gorder said. The tablets also offer ways for patients to request items, such as blankets, or services, such as a room cleanings, as well as to view patient education materials.

Van Gorder, like 91% of the CEOs included in the Power Panel survey, also said his organization formally trains employees—including physicians, nurses and front-line staff—to be more patient-centered. And Dr. Ghazala Sharieff, who was named Scripps’ first chief experience officer last year, makes herself available to coach physicians on techniques to present as more “patient-oriented.”

“Basically, what we tell our people is that: You’re always on stage,” Van Gorder said. Even when a physician is walking down the hallway, “they’re still interacting with patients.”

While health systems aren’t ready to make the plunge quite yet, many agree that the future of patient-centered care involves a shift toward healthcare at home.

Before it was, “You come to us, and you walk through our doors,” ProMedica’s Oostra said. “Now it’s a balance of, ‘We’re going to bring a whole variety of things to you, beginning at the home.’ ” Healthcare at home, also referred to as hospital at home, is an approach that would allow patients to access acute-care services remotely through a mix of at-home visits, telemedicine and remote monitoring.

But despite interest, healthcare at home has proved challenging as the industry slowly transitions from fee-for-service. Increased virtual visits can mean decreased utilization at brick-and-mortar facilities, often creating problems with reimbursement.

Movement toward healthcare at home has been limited in part by those reimbursement issues, as well as a needed cultural shift as patients and clinical staff adjust to the idea of getting more intensive care in the home. “The technical capability to do (hospital at home) has already existed,” Accenture’s Safavi said.

There have been some successful cases. Marshfield (Wis.) Clinic Health System offers a home recovery care program that allows patients to receive care for conditions like pneumonia and congestive heart failure at home via telemedicine and home visits. “Instead of the patient being cared for in the hospital, they’re admitted to their home,” said Dr. Susan Turney, Marshfield’s CEO.

It’s helped to reduce cost of care by 17% to 30%, and readmissions are down 44%, Turney said.

Outside of traditional clinical care, health systems are also moving outside the walls of their facilities to address social determinants of health—a topic almost all CEOs participating in the Power Panel survey said they’re working on.

While healthcare leaders often refer to social determinants as a new buzzword, Safavi noted health systems have been tackling these factors for awhile, often as part of programs to reduce readmissions. “Hospitals discovered that some of the most important factors that resulted in readmissions were not the illness … but things like transportation needs,” he said.

Screening for these risk factors during physician appointments has proved useful for ProMedica, which screens patients for 10 social determinants during visits, and subsequently refers patients in need to relevant resources. For a patient suffering from food insecurity, for example, a physician will write a prescription to one the health system’s “food pharmacies.”

Food-insecure patients who go to the food pharmacy experience 15% lower healthcare costs per month compared with those who don’t fill their food prescription, Oostra said, adding that the time for addressing social determinants of health has arrived.

“That has to be a routine part of care.”