In the Literature
In his preface to the July–September 2006 issue of the Journal of Ambulatory Care Management, Donald Berwick, M.D., writes that health care in the United States is "neither patient-centered nor collaborative."
Berwick, president and CEO of the Institute for Healthcare Improvement, maintains that the "quality chasm" famously noted by the Institute of Medicine will not be closed without wholesale restructuring of the U.S. health system. To make care more patient-centered, it must be more proactive, inclusive, and customized to individual patients. To make it more collaborative, it must utilize teams of practitioners that share information among members and patients alike. In this special issue of the Journal, articles supported by The Commonwealth Fund discuss key issues central to achieving such fundamental changes.
Good Collaborative Care Associated with Improved Outcomes
In the article, "Patients Report Positive Impacts of Collaborative Care," Dartmouth Medical School's John H. Wasson, M.D., surveyed with colleagues approximately 25,000 adults with common chronic diseases (like hypertension or diabetes) or dysfunction (like pain or emotional problems) about the collaborative nature of the care they receive. Respondents were considered to have "good" collaborative care if they received useful information about their condition from clinicians and if they reported being very confident about their ability to control and manage their condition. Patients who reported one of these criteria were described as having "fair" collaborative care, and those who reported neither as having "poor" care.
Only 21 percent of all respondents participated in good collaborative care, 36 percent attained fair collaborative care, and 43 percent experienced poor collaborative care. Those who experienced good collaborative care, say the researchers, are more likely to enjoy higher levels of provider continuity, easier access to care, and greater efficiency of care.
Good collaborative care was also strongly associated with better treatment outcomes, such as control of blood pressure, blood glucose, serum cholesterol, and pain management. It was also associated with greater use of preventive services, like bowel cancer screening, and with less lost time at work and fewer sick days at home. "Good collaborative care," the researchers concluded, "is very likely to increase quality care and lower its costs."
Planning for Patients' Care Needs
Planned-care management—disease management that includes preventive care as well as elements of self-care—is a cornerstone of patient-centered, collaborative care. Such care requires knowing both "what is the matter?" and "what matters" to patients, says John Wasson, lead author of the article, "Resource Planning for Patient-Centered, Collaborative Care." To construct a planned-care management strategy that serves patients on multiple levels, Wasson and colleagues examined data from HowsYourHealth.org, a free online survey that helps people assess their health status and then tailors information to their particular needs. The researchers reviewed information from 13,271 older adults (aged 50 or older) who had at least one chronic disease or "bothersome" condition.
Wasson's team determined that many patients would do well with a low-intensity, self-care strategy consisting of a standard assessment, feedback to the physician, and tailored information for the patient. "As long as patients reliably receive information tailored to their needs and their clinician takes the feedback seriously, the patient should benefit," Wasson says.
A second, smaller group of patients would require telephone reinforcement and problem-solving from a member of the clinical team. Finally, patients with low confidence or poor financial status may require additional support, possibly through one-on-one or group visits.
While the researchers admit that it is not possible to provide all things to all patients, it is possible to "plan the delivery of the most effective management strategies to the most appropriate group of patients."
Business Coalitions Encourage Patient-Centered, Collaborative Care
In "Patient-Centered Collaborative Care: Employer-Led Business Coalition Vision for Action," Andrew Webber, of the National Business Coalition on Health, and Suzanne Mercure, of Barrington and Chappell, a health care consulting firm in Fredericksburg, Va., outline the ways in which employers and employer-led coalitions can build on the momentum for patient-centered care. Individual employers can provide employees and retirees with decision-support tools, coaching in preparation for physician visits, and worksite health programs. Employer coalitions, meanwhile, can inform and educate members about available tools for promoting patient-centered care—including pay-for-performance incentives, benefit plan design, and value-based purchasing—and provide leadership and support for community-based initiatives focused on patient-centered care.
