Patient-Centered Care

216 Patient-Centered Care



Kevin Klauer, Kirsten G. Engel



image      Key Points




• Patient-centered care is an approach to patient-provider interactions in which providers work together with patients and their families in an effort to ensure that the patient’s personal experience and preferences are an integral part of the care process.


• A patient-centered approach to care confers many benefits in the acute care setting and can be critical in overcoming barriers to the communication process in the emergency department.


• The practice of patient-centered care involves both personal elements that individual providers can integrate into their daily interactions, as well as system-level elements that can be implemented and supported on the departmental and institutional level.



Introduction


Patient-centered care (PCC) is an approach to patient-provider interactions that promotes a collaborative partnership among health care providers, patients, and their families. In clinical practice, emphasis is placed on understanding patients and their clinical presentation within the larger context that includes their family, personal views, preferences, values, past experiences, and cultural factors. By embracing each patient as an individual, a patient-centered approach seeks to ensure high-quality care that consistently meets the needs and preferences of patients and their families.



Goals


The goals of this chapter are as follows:



1. To review the evolution and core features of PCC and its importance to clinical practice in emergency medicine


2. To discuss practical, realistic approaches and strategies in the following three domains of daily clinical practice, which can facilitate the delivery of PCC:


a. Personal issues—practice considerations for the individual provider that can promote PCC

b. Systems issues—practice considerations on a departmental level and from a systems perspective that can promote PCC

c. Critical issues—practice considerations for special circumstances when PCC can be particularly important


Background


The concept of PCC gained attention with the influential Institute of Medicine reports in 1999 (“To Err Is Human”) and 2001 (“Crossing the Quality Chasm”). The first report outlined mechanisms to improve patient safety, including efforts to engage patients in their care and enhance their understanding of their treatment.1 Two years later, “Crossing the Quality Chasm” identified PCC as one of the six aims intended to improve the quality of health care in our country.2


In 2006, the American College of Emergency Physicians (ACEP) and the American Academy of Pediatrics issued a joint policy statement supporting patient and family-centered care as an important means of improving satisfaction, safety, and quality of care for patients and their families.3


The emergency department (ED) environment is inherently challenging to the communication process between patients and providers, and a patient-centered approach to care can be particularly valuable in this setting. ED providers routinely confront significant time constraints, unpredicted interruptions, and overcrowding while caring for patients with life-threatening illness and injury.4–7 Given these circumstances, it is essential that ED providers possess skill in rapidly establishing rapport and engaging patients in critical decision making. A patient-centered approach to care is vital in overcoming barriers to the communication process through an understanding of the many situational and personal factors that characterize a patient’s visit to the ED. In many cases, fear, anxiety, and uncertainty, as well as preconceived and often unrealistic expectations, play an important role, and these factors must be recognized and appropriately managed to effectively communicate with patients.3


A patient-centered approach to care provides clear benefits to the immediate patient-provider interaction, but it also appears to have a positive impact on important outcomes for the patient and provider. Although research in this area is challenging, early work indicates that PCC improves patient satisfaction and may also enhance adherence and health outcomes.8–12



Personal Issues


As individual providers, there are many simple things that we can do every day in the ED during our patient interactions that facilitate the provision of PCC. The following sections highlight practical approaches and strategies that can be realistically incorporated into clinical practice on a daily basis. Our discussion will consider three areas: communication, operational considerations, and humanistic considerations.



Communication


Communication is the process of information exchange and is a central and critical aspect of our care of patients in the ED. As providers, we must solicit and receive information, establish the diagnosis, understand the social situation, and make an appropriate plan for care. In addition, we must provide our patients with information to facilitate understanding of their treatment and diagnosis, improve adherence to instructions, and ensure good outcomes.


Communication has two major components: verbal and nonverbal. These components work together and complement one another, with both having an impact on information exchange.


Verbal communication in our interactions with patients includes several key elements:



1. Introduce yourself, including your name and role.


2. Allow patients to speak and complete their thoughts while avoiding interruptions whenever possible. Be sure that you address all the patient’s medical concerns.


3. Use clear, nontechnical language.


4. Give patients the opportunity to ask questions.


5. Review information to confirm patient understanding (i.e., treatment, diagnostics, follow-up, discharge instructions).


Nonverbal communication is just as powerful as verbal communication with respect to its impact on patient-provider interactions. Facial expressions, body language, and physical space or touch are several aspects of nonverbal communication. Although nonverbal communication is more subtle and may seem less vital than verbal communication, it is essential to recognize the importance of nonverbal elements and their role in supporting or undermining the words that we use. This component is particularly critical in our efforts to convey courtesy, compassion, and respect.


Nonverbal communication in our interactions with patients has several key elements:



1. Greet patients and family members with a handshake when appropriate.


2. Make consistent eye contact and commit your complete attention to the interaction.


3. Use calm, compassionate body language.


4. Consider appropriate use of physical touch to provide comfort while being sensitive to cultural issues.


5. Avoid nonverbal cues of discontent.



Operational Considerations


Interactions between providers and patients progress through several important stages of the ED visit. Provision of PCC relies on effective engagement of patients during each of these critical junctures. Although a systems approach to PCC is discussed later in this chapter, some practical considerations for incorporating patient-centered care into daily practice are reviewed here and include examples of appropriate phrases and statements for each stage of the ED visit.



Intake


When a patient first enters the ED, it is critical to engage the patient quickly with effort to minimize time between arrival and the first interaction. Patients often feel anxious or frightened by the ED environment and typically experience distress and frustration because of the event or abrupt change that has prompted the need for their visit. Providers should be sensitive to these feelings by immediately delivering expressions of caring and concern, acknowledging the patient’s discomfort and circumstances, and providing reassurance.


“I am sorry to hear about your injury (or that you are not feeling well). We are happy that you are here and will work as quickly as possible to help you feel better.”



Assessment


During the initial assessment phase, it is important that patients be given the opportunity to express their concerns and symptoms and to feel that they have been heard. Repeating a brief summary and highlighting patients’ key issues can help assure them that their concerns are being given appropriate consideration.


“So, let me make sure that I’ve heard everything you said about your symptoms. As I understand it, you have had …”


As the diagnostic and treatment plan is developed, it is also important that this plan be shared with the patient and that there be clarity and agreement about the intended testing strategy, its anticipated duration, and overall expectations for the visit and ultimate disposition. This approach facilitates a collaborative relationship between the provider and patient, which is a key element of patient-centered care.


“In order to better understand what might be causing your symptoms, we are going do a series of tests, including … This is expected to take … I will come back and talk to you about the results when I receive them.”



Waiting and Delays


In any situation, when a patient needs to wait or experiences a delay in care, it is vital that providers reconnect with the patient and provide explanations and reassurance. Previous research has demonstrated that patients have greater tolerance for these circumstances if they are well informed about the causes and the anticipated duration.13


“I know you are waiting, and I want to make sure you know that we have not forgotten about you. We expect that …”



Disposition


When the evaluation has been completed, and patients are ready for discharge or admission, it is critical that the treatment and management plan be reviewed with them in detail and that they be given the opportunity to ask questions. Using an open-ended statement to elicit questions may help set an expectation that questions are welcome and anticipated.


“What questions do you have?” may be preferable to a more closed approach such as “Do you have any questions?”



Humanistic Considerations


An additional core element of PCC is the consideration of a patient’s illness and signs and symptoms in the larger context of the patient’s personal experiences and background. As providers, we are well aware that similar illnesses or conditions can yield diverse reactions and responses in different patients or populations. These differences reflect variation in patients’ personal views, cultural beliefs, preferences, values, past experiences, and fears. Provision of PCC means simply that we do not disregard these differences but, instead, actively seek to understand them, embrace them, and incorporate them into our clinical practice and plan of care. We should view each patient as an individual (not a disease process or diagnosis) and recognize that each brings a unique story and circumstance to the ED.


In the real world, these humanistic elements of PCC are often met by important challenges. We discuss these issues here and consider how one can begin to recognize and minimize such barriers to the practice of PCC in a busy ED.



Time: Making the Most of What We Have


All too often, ED providers face time constraints and significant clinical demands that are perceived as obstacles to providing care with a humanistic approach. It seems impossible for us to have the time to explore individual patients’ personal experiences, values, or beliefs.


Although it is not easy to create more time during a busy shift, we can make sure to take advantage of the opportunities that we do have and optimize our available resources. During assessment and evaluation in the ED, patients often share thoughts and give small clues that are important to understanding their social situation, motivation, and values. We need to be sure to explore these avenues because this additional information can help us connect with our patients and create a plan that better incorporates their perspectives and needs. This extra effort may prevent the conflict or frustration that will lead to larger, more time-consuming obstacles and challenges. Each of us can surely think of a situation in which we disregarded a patient’s expression of anxiety or uncertainty about a plan (e.g., admission to the hospital) that later resulted in a difficult and prolonged interaction (e.g., trying to convince the patient to go upstairs when the bed was ready).


In addition, ED providers need to enlist the support of all available resources, including social workers, nursing staff, and consulting services, to evaluate and support each patient’s needs. These interactions can help us better understand our patients and their personal circumstances, even when we are unable to pursue this level of detailed information independently.

Related posts:

Pediatric Traumatic Brain Injury Neonatal Cardiopulmonary Resuscitation Pediatric Orthopedic Emergencies Venous Thrombosis Altered Mental Status and Coma Mesenteric Ischemia

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Jun 14, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Patient-Centered Care

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