1. Providing Patient Centered Communication Sue Butts-Dion Improvement Advisor Institute for Healthcare Improvement This project was supported by grant number R18HS019508 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official view of the AHRQ.

2. Learning Objectives By the end of this module you will be able to: Demonstrate the connection between improved communication with patients and improved patient safety, efficiency, and patient satisfaction. Utilize a Model of Successful Communication Practices in your practice. Identify steps for a personal action plan Apply principles of patient-centered communication 2

3. “Nobody cares how much you know, until they know how much you care.” -- Theodore Roosevelt Rx: Communicate Caring Also 3

4. Source: The Permanente Journal/ Winter 2007/ Volume 11 No. 1 4 Successful Methodology

5. And the research says… Between 30-80 % of patients' expectations are not met in routine primary care visits Providers often give patients less than 30 seconds to express their concerns Providers tend not to involve patients in decision making and, in general, rarely express empathy Patients forget ≥50% of providers‘ recommendations Differences in agendas and expectations are often not reconciled 5 Source : Epstein et al.

6. Collaborative Agenda Setting 1. Orient patient: “I know you’re here to discuss the next steps related to your recent hospitalization. I’m sorry this happened to you; it must be scary. Are there other concerns to address while we’re here today.” 2. Mindfulness cue: Remind yourself that you may not be able to cover all in one visit. 3. Make a list: “What concerns do you have today? Is there something else? Sure?” (Pause. Allow the patient to tell pieces of their story without interruption.) 6

7. Collaborative Agenda Setting 4. Mindfulness cue : Can I address all concerns today? When else might we address them? 5. Confirm what is most important to the patient: “We may not have time to discuss all your concerns today. Is talking about your meds the most important thing to you? ” 6. Express concerns about what must be covered. “We need to discuss your Florida trip next week— and also your treatment and meds for the next few months. If we can’t get to all of the items today, we’ll set up another time.” 7

8. And the research says… 1984, Beckman and Frankel Patients interrupted after 18 seconds 1999, Marvel (used Beckman methodology) Patients interrupted after 23 seconds 2001, Rhoades Patients interrupted after 12 seconds 2002, Langewitz 78% of complete story in ≤2 minutes if uninterrupted 2005, Dyche (used Beckman methodology) Patients interrupted after 16.5 seconds 2013, Solvoll Patients also interrupted by physician’s mobile devices! 8

9. And the research says… 1984, Beckman and Frankel Patients interrupted after 18 seconds 1999, Marvel (used Beckman methodology) Patients interrupted after 23 seconds 2001, Rhoades Patients interrupted after 12 seconds 2002, Langewitz 78% complete story in ≤2 min if uninterrupted 2005, Dyche (used Beckman methodology) Patients interrupted after 16.5 seconds 2013, Solvoll Patients now also interrupted by physician’s cell phone! 9

10. Some Reactions Is this process an invitation for a long list? No! Patient doesn’t expect to cover every concern raised Technique helps uncover patient's real agenda Expectations can be kindly and gently re-oriented “In our time allotted today, I’d like to cover the most important items. That way, I’ll be confident that we’ve dealt with them completely and that you understand them fully. I’m concerned about these other items. Would you consider another appointment in the near future to cover them?” 10 Olson, 2002

11. Personal Action Plan Change I want to make happen is… Goal for the next month is… Specific steps I will take to achieve my goal are… Challenges in achieving my goal are… Plans to overcome these challenges are… Support I need to achieve my goals are… Confidence I can achieve my goal is… Source: http://www.swselfmanagement.ca/smtoolkit/SMTK-manual/ 11

12. Teach Back, Show Back, Inquiry 40-80% of the medical information patients receive is forgotten immediately. Kessels RP. Patients’ Memory for Medical Information. J R Soc Med. May 2003; 6(5):219-22 12

13. Teach Back or Show Back “I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine?” 13

14. Teach Back or Show Back “I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine?” “Can you show me how you will keep track of your medications when you get home?” 14

15. Teach Back or Show Back “We covered a lot today about your INR, and I want to make sure that I explained things clearly. So let’s review what we discussed. What are three foods you will want to be careful of when taking warfarin?” 15

16. Inquire Often! Developing a collaborative action plan On a scale of 1 - 10, 10 being the most important, how important is this to you? On a scale of 1 - 10, 10 being the most likely, how likely are you going to do this? What do you want to do now? 16

17. Lastly...Assume Good Intent Note found in my medical record: <Gave instructions to patient’s husband, he will have her comply (name) 12/14/2011 8:03:46 AM> 17

18. Challenging Common Assumptions Noncompliance Not valid construct for understanding patient behavior Patient is not always the source of the problem! Solution to noncompliance Changing behavior Changing systems 18 Source: Anderson, Robert; Patient empowerment: reflections on the challenge of fostering the adoption of a new paradigm. Patient Education and Counseling 57(2005) 153-157

19. 19 Source: The Permanente Journal/ Winter 2007/ Volume 11 No. 1 Successful Methodology

20. What Could You Do Today? Approach a visit with 1 patient Use Successful Communication Practice Model (See if it takes any longer ) Develop an agenda with 1 patient Try teach back or show back with 1 patient What else? 20

21. Thank You! Thank you for your time and attention today 21

22. A Few References Epstein R, Mauksch L, Carroll, Jaén C. Have You Really Addressed Your Patient’s Concerns. Family Practice Management. March 2008. www.ihi.org www.deming.org 22