1. How to Be Patient- Centered and On Time in Clinic Chris Haymaker, PhD Adam Roise, MD, MPH NEIMEF Conference May 20, 2015

2. Special Thanks to: Larry Mauksch, M.Ed Clinical Professor Department of Family Medicine University of Washington Editor, Families, Systems, and Health

3. By the end of this session we will: Practice techniques to help improve the likelihood patients get what they want out of a visit Practice techniques that will help you be less likely to be bogged down during a visit

4. Definitions: Patient-centered: “The needs of the patient come first.” “Nothing about me without me.” “Every patient is the only patient.” On-time: Able to cover needed concerns, not appear rushed, not short-change other patients, and be home before supper (ideally with your work complete) Berwick, D. Health Affairs. 2009. 28 (4): w555-w565.

5. Activity: Starting the visit…

6. Language Structures Thought and Behavior Inarticulate The art of medicine Good bedside manner TLC Touchy-feely stuff Engagement Listening Articulate Emotional and cognitive cues Agenda setting Teachback Continuer phrases Transparent thinking Illness explanatory Model Larry Mauksch, M.Ed University of Washington Department of Family Medicine

7. Upfront Collaborative Agenda Setting Brock, Mauksch, et al. JGIM, Nov, 2011; Mauksch et al, Fam, Syst, Health, 2001 Identifies patient’s prioritiesOrganizes the visit Decreases chance that patients or providers will introduce “oh by the way” items Screens for mental disorders Facilitates shared decisions about time use between acute, chronic, and health maintenance care Does not lengthen the visit; protects time for planningDecreases clinician anxiety

8. Agenda Creation Orient the patient: “I know you are here to talk about ____. Before we get into_____ is there something else important to addresses today? Making a list will help us make the best use of time”. Ask: which of these things are the most important for you? Avoid premature diving by patient or yourself If a person lists more than three items, they are screen positive for anxiety and/or depression When needed, interrupt the patient or yourself Acknowledge, empathize, and share reasoning State the agenda out loud, and ask for agreement. Maybe write it down.

9. Rehearsal Setting an agenda

10. Larry Mauksch, M.Ed University of Washington Department of Family Medicine

11. Interrupting patients

12. EEE: Polite Interruption Excuse yourself (acknowledge and/or apologize)Empathize with the problem that is being cut offExplain why you are interrupting Planning time use Finishing an important topic (topic tracking) Stopping to explore an important cue Larry Mauksch, M.Ed University of Washington Department of Family Medicine

13. Interruption: Important cue Mr. Fredricks, forgive me for stopping you. You just said something about wondering if your thigh pain was in your bones and perhaps serious. Can we go back to that? It sounds like you have some important concerns that I want understand further.

14. Rehearsal Polite interruption for topic tracking

15. Closing the visit Questions: “What questions do you have about what we discussed today?” Teachback: “We talked about a lot today, so I’d like you to tell me the plan from your perspective.” After visit summary Combine Teachback and AVS and share the screen (do them together!)

16. Rehearsal Closing techniques

17. Commitment What can you work on to change your practice? Agenda setting Interrupting Closing

18. Agenda Creation Avoid premature diving by patient or yourself When needed interrupt the patient or yourself. Acknowledge, Empathize Share reasoning If the list is greater than three items, the patient is screen positive for depression or anxiety Ask, “what is most important” Listen (feel) for the most important concern Orient the patient: “I know you are here to talk about ____. Before we get into_____ is there something else important to addresses today? Making a list will help us make the best use of time”.