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Committee on the Learning Health Care System in America; Institute of Medicine; Smith M, Saunders R, Stuckhardt L, et al., editors. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington (DC): National Academies Press (US); 2013 May 10.

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Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.

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7Engaging Patients, Families, and Communities

In June 2011, Alvin, a terminally ill patient with end-stage pulmonary fibrosis, was hospitalized for pneumonia. His doctor, a specialist in lung disease at a top academic medical center, gave Alvin 100 percent oxygen and powerful antibiotics and steroids, but his condition quickly deteriorated. Faced with the choice of intubation and a mechanical ventilator or palliative care, Alvin chose to forgo life support and spend his last days at home with his family. His family was given a prescription for morphine with little instruction on how to use it appropriately; when they tried to fill the prescription, several pharmacies refused. Despite the hospital's orders for oxygen to be sent home, Alvin's family found that the oxygen supplied was insufficient for his needs. The emergency medical technicians who took Alvin home offered only one solution—to bring him back to the hospital. Trying to honor his wishes, the family refused. Five hours after leaving the hospital, Alvin was in pain and struggling for breath. Since it was a Saturday evening, hospice personnel were off duty; Alvin's family had to arrange for a private-duty nurse to help them care for him in his final hours. After he passed away, a hospice nurse finally arrived, apologized, and instructed his family on how to dispose of the remaining vial of morphine correctly. Alvin's case highlights the critical importance of all members of the care team—family members, clinicians, and other health care providers—working together to overcome system complexity and poorly aligned incentives to ensure patient-centered care, as well as the ways in which the health care system falls short on this critical dimension (Winakur, 2012).

Clinicians and health care staff work tirelessly to care for their patients in an increasingly complex, inefficient, and stressful environment. However, the structure, incentives, and culture of the system in which they work are often—perhaps usually—poorly aligned to support their efforts to respond to patients' needs as their core priority. Recognizing the imperative to center on the patient, a learning health care system is one in which patients and their families are key drivers of the design and operation of the learning process. When patients, their families, other caregivers, and the public are full, active participants in care, health, the experience of care, and economic outcomes can be substantially improved.

Crossing the Quality Chasm underscores patient-centeredness as a core aim of the health care system, yet care often fails to meet this aim (IOM, 2001). Despite the Quality Chasm's call to action more than a decade ago, patient-centered care still is not the norm, and users continue to find the health care system uncoordinated and stressful to navigate. As the complexity of the system continues to grow with advances in science (Chapter 2), patient engagement takes on increased importance as a means of ensuring that patients can find the right care for their individual characteristics, needs, preferences, and circumstances.

In these complex situations, patients and clinicians both need to be involved for optimal care. Clinicians supply information and advice based on their scientific expertise in treatment and intervention options, along with potential outcomes. Patients, their families, and other caregivers bring personal knowledge on the suitability—or lack thereof—of different treatments for the patient's circumstances and preferences. Information from both sources is needed to select the right care option. It is important to note that patient-centered care does not mean simply agreeing to every patient request. Rather, it entails meaningful engagement on the options available in order to understand the patient and establish a dialogue between patient and clinician on the evidence and the decisions in play (Epstein et al., 2010; Fowler et al., 2011). The provision of patient-centered care can be complex and time-consuming, and requires broad involvement of the patient, the family, and the care team to consider all of the issues affecting the patient's care.

This chapter explores the ways in which a learning health care system can fill some of the gaps in orienting and coordinating the U.S. health care system around people's needs. First, the chapter considers what is currently known about focusing the health care system on people's needs and preferences, sets forth a vision for how the system could be improved in this regard, and summarizes the benefits of moving toward that vision. The chapter then investigates how this knowledge can be applied at different levels of the health care system, from the patient care experience to the broader system. Next is a discussion of communities of care and how they can incorporate those stakeholders not normally included in the health care system. The chapter concludes with recommendations for realizing the vision of a health care system that engages patients, families, and communities. Throughout, the discussion highlights ways in which a learning health care system can better incorporate patients, families, and the public in managing health and health care.

CENTERING CARE ON PEOPLE'S NEEDS AND PREFERENCES

Informed and engaged patients, invested in their own health care as well as in the improvement of the broader health care system, are crucial to a learning system. Patients bring unique and important perspectives on their own care, on the experience in health care organizations, and on the coordination and cooperation among various elements of their care. Unfortunately, patients, their families and other caregivers, and the public all too often are not meaningfully engaged in care or as partners in its improvement. Moving to the vision of a system centered on people's needs and preferences has the potential to bring multiple benefits for patients, the health care system, and the nation.

A Focus on the Patient

As noted, more than 10 years after Crossing the Quality Chasm highlighted the crucial role of patient-centered care, such care still is not the norm, and patients continue to find the health care system uncoordinated and stressful to navigate. A 2011 survey of public views of the health care system found that patients have difficulty accessing care, experience poor care coordination, and want a system that is more integrated and patient-centered. Seven of 10 adults surveyed reported difficulty in making doctor's appointments when they needed them, getting advice over the phone, or receiving care after hours. Nearly half of adults reported problems with care coordination, notification of test results, and communications between primary care providers and specialists, and one-third said the health care system was poorly organized (Stremikis et al., 2011).

The lack of patient focus is particularly evident in patient communications, especially about care options. Surveys of patients who have recently made a medical decision have found that those patients often did not receive critical information about the risks and benefits of the treatment and intervention choices under consideration (Fagerlin et al., 2010; Lee et al., 2011, 2012; Sepucha et al., 2010). These patients also reported that their clinicians stressed the benefits of interventions more than they discussed the risks, and asked patients about their preferences only half of the time (Zikmund-Fisher et al., 2010). Because modern health care often offers multiple interventions for a given condition, each with its own benefits, side effects, and costs, identifying the most valuable intervention for each patient requires both that patients be well informed about the options and that clinicians be aware of their patients' individual circumstances, preferences, and needs.

The lack of patient focus in the health care system also is evident in patient transitions between care settings. Patients often report that care transitions, such as being discharged from the hospital, are abrupt. Patients often receive little information about what the next steps are in their care, when they can resume activities, what side effects or complications they should monitor, or whom they can approach with questions about their recovery. In other cases, patients receive too much information at the time of discharge, stressing their ability to remember and apply this information over the transition period. As a result of poor transitions, almost one-fifth of hospitalized Medicare patients are rehospitalized within 30 days, often without seeing their primary care provider in the interim (Jencks et al., 2009). Communications between primary care practitioners and specialists often lack critical information, and hospitals often either do not notify primary care practitioners when their patients are discharged or relay insufficient information (Bodenheimer, 2008). Transitions may be even less effective and more complex when patients' needs extend beyond traditional health care to include a broader array of health and human services, such as long-term care; mental health and substance use care; and social, economic, and community services related to wellness and healthy lifestyles.

Foundational Elements of Patient-Centered Care

Part of the challenge is that the notion of patient-centeredness simply is not embedded in the care culture and often feels foreign, even disruptive, to clinicians unfamiliar with the concept (Berwick, 2009). Because investments in moving toward patient-centered care currently are being made on a large scale, developing a working definition of patient- or person-centered care is a matter of some urgency, especially given that patient perspectives will soon be factored into Medicare value-based payments to hospitals.1 Absent this framework, it will be impossible to assess the progress of initiatives toward the goal of improving patient focus. The difficulty is that multiple definitions of patient- or person-centered care exist, each capturing important aspects of this type of care. Moreover, the concept itself has multiple names, ranging from “patient-centered care,” to “patient- and family-centered care,” to “patient activation,” to “patient engagement,” to “public engagement.”

Another challenge is determining who needs to be involved. Almost every person is a past, present, or future patient of the health care system. Moreover, each person often receives care from family caregivers, relatives, friends, and neighbors who support and assist those coping with both acute and chronic health problems, and who are vital to the patient throughout the care experience. While the term “patients” is used here for brevity, it always refers to patients, family and other caregivers, and the public. Similarly, the term “communities” includes all forms of community, such as those defined by geography, culture, disease or condition, occupation, and workplace.

Recognizing the complexity of the terms involved, several individuals and organizations have developed definitions for patient-centered care. One advocate for promoting patient-centered care defines it as “the experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one's person, circumstances, and relationships in health care” (Berwick, 2009). The Institute for Patient- and Family-Centered Care outlines four concepts that underlie patient-centered care: respect and dignity, information sharing, participation, and collaboration (Institute for Patient- and Family-Centered Care, 2011). The National Quality Forum's National Priorities Partnership characterizes patient-centered care as health care that “honors each individual patient and family, offering voice, control, choice, skills in self-care, and total transparency, and that can and does adapt readily to individual and family circumstances, and to differing cultures, languages, and social backgrounds” (NPP, 2010).

This chapter builds on the definition of patient-centered care outlined in Crossing the Quality Chasm: “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (IOM, 2001, p. 40). The concept encompasses multiple dimensions, including respect for patients' values, preferences, and needs; coordination and integration of care; information, communication, and education; physical comfort; emotional support; and involvement of family and friends. Crossing the Quality Chasm outlines several principles to help the system provide this kind of care: care should be based on continuous healing relationships, care should be customized according to patient needs and values, the patient should be the source of control, knowledge should be shared and information should flow freely, information should be provided to patients transparently, and the patient's needs should be anticipated (IOM, 2001). In short, the patient should be considered in all aspects of care and care delivery.

Benefits of Patient-Centered Care

A growing body of evidence highlights the potential benefits of patient-centered care for clinical outcomes, health, satisfaction among health care workers, and providers' financial performance. For example, several hospitals that encourage patient-centered care by paying greater attention to patient needs and preferences, as well as care coordination, have found that adverse events decrease, employee retention increases, operating costs decrease, malpractice claims decline, lengths of stay are shorter, and the hospital's costs per case decrease (Charmel and Frampton, 2008; Epstein et al., 2010).

Patient and family involvement in decision making has been associated in primary care settings with reduced pain and discomfort, faster recovery in physical health, and improvements in emotional health (Stewart et al., 2000). Similarly, heart attack patients who did not receive patient-centered care were found to have worse long-term outcomes, such as overall health and likelihood of experiencing chest pains, than patients who received such care (Fremont et al., 2001). A study of patient-centered nursing interventions for cancer patients found that the interventions were correlated with improved patient self-representation, optimism, and sense of well-being (Radwin et al., 2009).

Patient-centered care also has been found to correlate with a patient's ability to undertake personal health maintenance and adhere to complex treatment regimens. An observational study of Commonwealth of Massachusetts employees found that physicians' knowledge of their patients and patients' trust in their physicians strongly influenced whether patients completed the recommended treatment regimen (Safran et al., 1998). Similarly, HIV patients who reported that their clinician knew them “as a person” had higher odds of receiving and completing highly active antiretroviral therapy, as well as better health outcomes, relative to other HIV patients (Beach et al., 2006). These studies underscore the potential role of patient-centered care in improving the health outcomes from a therapy or intervention that relies on patient self-management, including many therapies for chronic diseases.

In addition, patient-oriented care has been associated with decreased utilization of resources. Studies have found that patient-centered communication in primary care visits correlates with fewer diagnostic tests and referrals (Epstein et al., 2005; Stewart et al., 2000). A similar study found that patients who received less patient-centered care incurred 51 percent higher annual charges relative to patients who received more patient-centered care (Bertakis and Azari, 2011). Further, well-informed patients often choose less aggressive and costly therapies; one study found that informed patients were up to 20 percent less likely than other patients to choose elective surgery (O'Connor et al., 2009; Stacey et al., 2011).

Yet not all care delivered in the name of patient-centeredness reduces costs or improves outcomes. For example, one study found that patient-centeredness was associated with better outcomes but also higher costs (Bechel et al., 2000). Other studies have yielded mixed results with respect to cost, quality, and value for care models that aim to implement different aspects of patient-centeredness, such as disease management and care coordination programs (Nelson, 2012; Peikes et al., 2009). This inconsistency of results stems in part from the difficulty of identifying what truly constitutes patient-centered care (Epstein and Street, 2011; Hudon et al., 2011). Confusion about the implications of patient-centered care can stymie the efforts of well-meaning individuals and organizations, producing changes that are superficial, fail to address underlying challenges, and add little value to the experience. In the name of patient-centeredness, for example, some health care organizations have adopted luxury, hotel-like amenities; added new technology; or renovated their facilities. Although some of these initiatives may enhance the patient's experience, they do not achieve the true goals of patient-centered care and may increase costs while not improving care quality or outcomes. Patient-centered care must be implemented in a way that directly addresses the patient's needs and preferences and supports those goals most important to improving quality, health, and value.

Moreover, establishing a causal link between different aspects of patient engagement and ultimate outcomes can be difficult. For example, several studies have shown a link between patient-centered care and measures of patient experience, which in turn have been linked to better health outcomes (Beach et al., 2006; Browne et al., 2010; Mead and Bower, 2002; Stewart, 1995). Yet researchers are only beginning to understand the chain of causality through which patient-centered care techniques, such as communication, contribute to better health outcomes (Epstein and Street, 2011; Street et al., 2009). Additional research is needed to understand how different patient-centered techniques produce direct and indirect outcomes—from physical and emotional health, to the ability to manage one's care, to improved decision-making ability.

Conclusion 7-1: Improved patient engagement is associated with better patient experience, health, and quality of life and better economic outcomes, yet patient and family participation in care decisions remains limited.

Related findings:

  • Patients often are insufficiently involved in care decisions. Fewer than half of patients receive clear information on the benefits and trade-offs of the treatments for their condition, and fewer than half are satisfied with their level of control in medical decision making (see also Chapter 2).
  • Patient-centered care has been correlated with better health care outcomes and quality of life, as well as other benefits. The use of patient-centered care in a primary care setting has been associated with reduced pain and discomfort, faster recovery in physical health, and improvements in emotional health.
  • If implemented properly, meaningful engagement of patients in their own care has the potential to reduce costs. For example, it has been reported that informed patients are up to 20 percent less likely than other patients to choose elective surgery.

ENGAGING PATIENTS AS ACTIVE PARTICIPANTS IN THEIR CARE

Patients and the public across many diverse demographic groups have shown a desire to become more involved in their care and more informed about their health (Frosch et al., 2012; President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1982). For example, 80 percent of Internet users now seek health information online, making this the third most popular Internet activity (Fox, 2011). After a doctor's appointment, individuals seek out information on diagnoses, tests, and prescriptions to learn more (Diaz et al., 2002). While this online information is variable in quality and should be viewed with caution, this growing interest in health represents an opportunity to increase patients' involvement in their own care, in the care of their loved ones, and in the improvement of the overall system. It further highlights new roles for health professionals in partnering with patients to share reliable online sources of health information (Alston and Paget, 2012). Moreover, the development of new models of care delivery, such as patient-centered medical homes, health homes, and accountable care organizations (ACOs), offers opportunities to incorporate patient engagement. This section explores patient engagement at multiple levels—from the personal relationship of patients with their health care providers, to patients' experience while being treated in a health care organization, to the interaction of patients with the broader system, to patients' management of their own care.

Engaging Patients at the Care Delivery Level

Increased patient engagement in individual interactions with practitioners is needed. Some studies have found that patients and clinicians have differing views on the importance of different health goals and health care risks (Lee et al., 2010a,b). Other studies have found that physicians have inaccurate perceptions of their patients' health beliefs, assuming that their patients' beliefs are more aligned with their own than is actually the case. This misperception improves when patients are able to participate actively in the consultation (Johnson et al., 2010; Street and Haidet, 2011). However, studies have found that physicians tend to interrupt patients within 15 seconds of their beginning to speak at the outset of a visit, while uninterrupted patients tend to conclude their remarks in under a minute (Beckman and Frankel, 1984). These studies highlight the need to prepare health care professionals with communication skills and techniques that optimize opportunities for patient engagement.

Metrics have been developed for quantifying a patient's activation, defined as the capability to participate in the care process (Hibbard, 2004; Hibbard et al., 2004). These metrics make it possible both to assess whether interventions improve activation and to customize care based on a patient's activation level. Evidence demonstrates that increasing a patient's activation correlates with improvement in a variety of self-management behaviors (Hibbard et al., 2007; Mosen et al., 2007) and that tailoring interventions to a patient's level of activation can improve the interventions' impact (Hibbard et al., 2009). Evidence also suggests that patient activation and self-management can be enhanced through such strategies as improved communication, motivational interviewing, shared decision making, ready access to personal health information and providers, and increased focus on goals that matter to patients and their families.

Communication

Patients, their families, and other caregivers can bring useful and often critically important knowledge to bear on care if they are invited to do so. Patients often are unable to discuss all of their concerns in a single visit. Some interventions to remedy this limitation are straightforward; one study found that simply asking patients whether there was “something else” to discuss instead of “anything else” reduced the number of unmet concerns by almost 80 percent (Heritage et al., 2007). Moreover, patients bring a different perspective to the encounter than clinicians and will introduce different information. For example, patients on statin drugs were far more likely than their clinician to initiate the discussion of symptoms potentially related to the prescription (Golomb et al., 2007).

A variety of interventions are aimed at improving the state of patient-clinician communication (Maurer et al., 2012). Opportunities to improve patient-centered communication skills exist throughout all levels of health professions education, from degree to continuing education (Levinson et al., 2010). Other tools include patient coaching and question checklists, which are designed to assist patients in communicating with their clinicians. In one study, coaching and the use of checklists were shown to increase the number of questions patients asked and were associated with a modest improvement in patient health outcomes (Kinnersley et al., 2007). The implementation of these tools has yielded some success in improving clinician communication behaviors, as well as patient knowledge and satisfaction, although evidence is mixed on the ultimate impact on patient health outcomes (Coulter and Ellins, 2006).

Communication tools need to be customized to patients' circumstances, especially their health literacy. Health literacy refers to an individual's ability to obtain, understand, and apply health information to make appropriate health decisions. Given the complexity of the field, even highly educated people may have difficulty finding and understanding health information and applying it to their own care or that of their loved ones (IOM, 2004). Ensuring that patients have the tools they need to manage health information is critical, as lower levels of health literacy have been associated with increased hospitalizations, greater use of emergency rooms, lower use of preventive services, and limited ability to manage complex treatment regimens (Berkman et al., 2011). Given that effective communication requires effort from two parties, those who produce health care information for patients must consider how that information will be received and used by patients (Eckman et al., 2012). Several useful communication techniques, such as motivational interviewing, can promote certain health behaviors and adherence to treatment regimens by drawing out the patient's motivation for change (Rollnick et al., 2008). There is also a need for research on interventions that can improve a patient's ability to manage health information (Berkman et al., 2011).

Shared Decision Making

While informing patients about options is important, true patient-centered care requires a new model of decision making in which responsibility is shared between patient and clinician. Implementing this model will require a shift toward health care in which clinicians and patients work together to manage complex conditions, and make decisions on the basis of not only the best scientific evidence but also the patient's biological characteristics, preferences, values, and life circumstances. Such a decision-making model is increasingly important for the growing number of clinical situations in which there are multiple care options, each with different benefits and potential harms. In these situations, where trade-offs will have to be considered, clinicians will need to discuss the risks and benefits of competing diagnostic and treatment options with patients and their caregivers (Collins et al., 2009).

In addition to enhanced communication techniques, tools for promoting shared decision making include decision aids. Decision aids provide balanced information on diagnostic and treatment options, including risks and potential outcomes, and help patients consider what factors are most important to their decision. The goal is to help patients identify the diagnostic technology or treatment that best meets their needs, goals, and circumstances. Studies of such tools have found that they increase patients' knowledge and understanding of benefits and risks and encourage them to participate in decisions (Arterburn et al., 2011; Belkora et al., 2012; O'Connor et al., 2004, 2007a,b; Solberg et al., 2010; Stacey et al., 2011). Several organizations, including the International Patient Decision Aids Standards Collaboration, have developed standards against which to validate the quality of decision aids and ensure that they are accurate, unbiased, and understandable.

The concept of patient-centered care entails customizing care according to patient preferences along all dimensions, including the level of involvement in decision making. Some patients will be interested in playing a strong role in care decisions, while others may want to play a less active role. Evidence suggests that the system currently does not allow patients to realize their desired level of participation; in one study, fewer than half of patients reported they had achieved their preferred level of control in decision making (Degner et al., 1997). Several studies confirm that while most patients wish to be asked their opinions and be offered choices in their care, patients differ in how they would like to be involved in final care decisions (Chung et al., 2011; Deber et al., 2007; Fineberg, 2012; Levinson et al., 2005; Solberg et al., 2009). These studies illustrate the complex role of patient autonomy in the provision of patient-centered care and confirm the variability in the preferences of individual patients and patient populations in this aspect of care. They also signal that patient satisfaction requires patient-clinician communication that not only shares the appropriate clinical information for each patient, but also provides the appropriate amount of information and degree of autonomy in acting on the information. These findings suggest as well that it is important for clinicians to be working in an environment where they can function as careful listeners and coaches, as well as experts in their field.

The implementation of new communication and decision-making paradigms will need to be customized for different patient populations. For vulnerable populations, including low-income individuals, racial and ethnic minorities, and the elderly, there are multiple obstacles to achieving this type of care. For example, patients whose primary point of contact with the health care system is a hospital emergency department are unlikely to develop long-term partnerships with a clinician for making care decisions (Silow-Carroll et al., 2006). In addition, decision-making initiatives will need to be measured and rewarded routinely to ensure their regular use in clinical practice (Sepucha et al., 2004). Challenges will be faced, then, in applying shared decision-making principles to a diverse patient population. However, patient-centered care, delivered through a team approach, can be effective for patients at a range of socioeconomic levels and at a variety of health care organizations, including safety-net systems. For example, several programs have shown success in introducing patient-centered care in urban settings with populations of low socioeconomic status and in achieving long-term engagement in preventive care and improved control of chronic conditions (Jones et al., 2007; Scott et al., 2011).

Engaging Patients at the Organizational Level

Patient-centered care goes beyond direct patient-clinician interactions to the clinic, unit, and health care organization level. At this level, patient-centeredness means different things, such as creating patient and family councils, establishing portals that allow patients to access their health information, and developing policies that ensure timely access to care (Balik et al., 2011; Maurer et al., 2012). Given that patients, their families, and other caregivers are the people who actually experience care, their perspectives can contribute substantially to effective and efficient health care organizations. Leveraging their knowledge can improve the experience of care through the application of their insights to the design and delivery of care in health care organizations—from hospital design, to visiting hours, to care delivery (Bergeson and Dean, 2006; Groene, 2011; Johnson et al., 2008; Scholle et al., 2010). Thus involving patients in improvement initiatives ensures that patients' values and perspectives guide system design, in addition to keeping the teams working on these projects focused on patient priorities.

There are several successful approaches for improving the patient experience, such as those focused on reducing waiting times (Litvak and Bisognano, 2011; Litvak et al., 2005), which also can improve quality and reduce costs (see Chapter 9 for further discussion of these initiatives). To further center care on patient needs and preferences, health care organizations and systems can act on lessons learned about what patients value by engaging patients, their families, and other caregivers. For example, systems can ensure the inclusion of patient perspectives in an institution's operations by promoting patient and family participation on advisory councils, giving patients and their families direct access to the institution's decision-making structures. Case studies have shown that by working on such councils, patients may participate in institutional quality improvement projects, help redesign service delivery processes, serve on search committees for new executives, and help develop educational programs for hospital staff. They also may aid the hospital in making its procedures more efficient and patient-centered and may participate in rounds, which can lead to new suggestions for improvement (Balik et al., 2011; Conway et al., 2006; Ponte et al., 2003). Other programs have shown the potential benefits—including reduction of medical errors and increased hand hygiene—of including patients in safety initiatives, although various institutional factors may limit this potential (Davis et al., 2007; Longtin et al., 2010; Weingart et al., 2005, 2011). Using a different approach, initiatives at one health care organization, using value stream analysis and production system methods, improved care by incorporating patients in continuous improvement projects and measuring value from the patient perspective (Toussaint, 2009).

In one example, leaders at Dana-Farber Cancer Institute invited patients and family members to populate all decision-making structures and processes in the organization. Patients provided input on organizational policies, were placed on continuous improvement teams, and were invited to join search committees and develop educational programming for staff (Ponte et al., 2003). Leaders at the organizational level made the commitment to patient-centered care and communicated that vision to the organization (Shaller and The Commonwealth Fund, 2007) (see Chapter 9 for detail on the leadership and other commitments necessary to achieve a patient-centered learning health care organization). Box 7-1 presents another example of such patient and family involvement.

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BOX 7-1

Medical College of Georgia Health System. In 1993, in response to an internal assessment revealing that care focused more on the needs of clinicians than on those of patients and family members, the Medical College of Georgia (MCG) Health System in Augusta, (more...)

Another strategy for engaging patients in organizational change is routine measurement. The use of valid and reliable instruments can document the gaps between what routinely occurs and the ideal, thereby stimulating behavioral change among clinicians and patients. These tools include patient experience surveys, mechanisms for submitting complaints, and other feedback opportunities for patients. Beyond the information received, these tools convey the message that the voices of patients, families, and other caregivers are important (Shaller and The Commonwealth Fund, 2007).

Patient portals, dashboards, and other information technology-enabled devices are another avenue for bridging the gap between clinician visits and patients' ongoing information and health monitoring needs. By simplifying communication, e-mail and telephone care allow patients to reach their clinicians easily and receive information when they need it. In one organization, office visits fell by 9 percent after the implementation of electronic health records that facilitated effective patient-clinician communication via telephone (Garrido et al., 2005). Similarly, patient portals allow patients to communicate with their clinicians, access their health information, and monitor their own health, thereby facilitating their active participation in their care (Halamka et al., 2008; Shaller and The Commonwealth Fund, 2007). One example of the use of a patient portal in chronic care management is the Palo Alto Medical Foundation's diabetes management system, which allows patients and their clinicians to monitor key measures for the condition and highlights how the measures relate to overall health goals. Early focus group results indicate that while patients initially used the portal because they knew clinicians reviewed the results, over time they started using the system on their own to understand how different behaviors affected their health (IOM, 2011d). Likewise, Partners HealthCare's Center for Connected Health provides health information technology for patients with cardiac conditions, diabetes, and hypertension that allows them to share information with their clinicians and receive feedback. While some patients stop participating early on, 90 percent of those who remain active through the first 2 months continue to participate (IOM, 2011d). These examples demonstrate the potential of health information technologies, as well as highlight the need for these technologies to be easy for patients to use and access.

Engaging Patients at the System Level

Routine assessment of patient experience can be used to support patient-centered care across a continuum of health care settings while also providing the opportunity to promote better integration, transitions, and coordination of services. To support financial reforms and payment strategies that reward patient-centered care, it is important to develop methods for accurately measuring such care. One instrument for assessing patient experience, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) suite of surveys, was developed as a nationally standardized tool for eliciting reports from patients on their experiences in interacting with the health care system (Browne et al., 2010; Charmel and Frampton, 2008). The hospital version of the survey, called Hospital CAHPS or HCAHPS, is used by hospitals to assess indicators of patient experience, including interactions with staff, information provided, overall satisfaction with the care experience, and the patient's willingness to recommend the hospital to others (Charmel and Frampton, 2008). HCAHPS results also are being used by the Centers for Medicare & Medicaid Services (CMS) to forge a link between patient experience and reimbursement. As of July 2007, hospitals had to report HCAHPS data to CMS or absorb a 2 percent reduction in reimbursement for inpatient services (Charmel and Frampton, 2008). Moreover, under recent policy initiatives, CMS will expand the use of HCAHPS when it uses the survey data as one measure in calculating value-based purchasing payments to hospitals.2 The same focus on patient experience and patient-centered care can be applied to outpatient and non-hospital-based settings.

Despite the importance of assessing patient experience and rewarding institutions that perform well on measures of patient-centeredness, some uncertainty exists as to which aspects of the patient experience are most important to measure and best correlate with improved outcomes. Multiple terms exist for defining this aspect of the patient-centeredness of an institution, including “patient satisfaction,” “patient experience,” “patient perception,” and “patient ratings of quality.” Additionally, multiple factors affect patients' rating of their care experience, ranging from accordance with evidence-based processes, to staff care, to information availability (Gao et al., 2012; Sofaer and Firminger, 2005). Another challenge in measurement is ensuring that patient experience data are collected frequently, thereby enabling the organization to assess its improvement in patient-centeredness.

One study of patients' perceptions of hospital care, including inpatient care and discharge planning, suggests that higher patient satisfaction may be associated with lower 30-day readmission rates (Boulding et al., 2011). In terms of correlation with an institution's technical expertise, one study compared a hospital's overall patient satisfaction score with its clinical quality and mortality rates for heart attack patients, finding that higher satisfaction correlated with improved adherence to guidelines and lower mortality rates. Yet, high overall patient satisfaction scores showed no correlation with questions about the patient's room, meals, or wait time for tests and treatment or with the speed of the discharge process (Glickman et al., 2010). Another study of patient-centered medical homes found an association between practices rated by patients as high-quality and improved patient blood pressure control (Gray et al., 2011). Still another study found that measures of patient experience correlated with process measures of clinical quality, although they did not correlate with health outcomes (Sequist et al., 2008). Showing the relationship between patient experience and other aspects of care, another study found that patients' satisfaction with hospitals' nursing staff and with staff care influenced the patients' perceptions on overall quality of care, willingness to recommend, and willingness to return (Otani et al., 2010). On the other hand, one recent study cast doubt on the correlation between high levels of patient-centeredness and improved outcomes, finding that greater patient satisfaction was associated with higher inpatient use, higher health care costs, and increased mortality (Fenton et al., 2012). These examples highlight the range of factors that affect a patient's experience and illustrate the potential knowledge gained from these assessments, but also underscore the need for further study regarding the conclusions that can be drawn from patient satisfaction data.

Engaging Patients, Families, and Caregivers in Health Management

Refocusing the health care system on the people it serves will require renewed attention to the ways in which patients, their families, and other caregivers access health information and manage the patient's health. In some cases, patient self-management is a realistic expectation, while in other cases, family and other caregivers will be the primary managers of care. Regardless, patient engagement and support for self-management require education and interventions that enhance patients' ability to monitor and manage their own health problems (IOM, 2003). To this end, it is necessary to provide information and teach people disease-specific skills so they will understand what behavior changes they must make to improve their health prospects and will have the problem-solving skills to cope with changes in their condition. It is also necessary to recognize and assist with the reality of living with a chronic condition, provide patients with support and follow-up opportunities, and encourage patients to actively manage their disease. The horizon for these approaches is promising. Initiatives such as the Empowered Patient Coalition highlight the potential of online mechanisms to provide information and support for patients, their family and other caregivers, and their clinicians in encouraging self-management. Moreover, reviews of patient education and reminder interventions for chronic disease management have found that such interventions are associated with improved health outcomes (Deakin et al., 2005; Guevara et al., 2003; Weingarten et al., 2002). Ultimately, given the complexity of chronic disease management, engaging patients as active participants in their care is quickly becoming an imperative for the health care system.

Technology offers opportunities for clinicians to engage patients by meeting with them where they are. The use of mobile devices both to help clinicians reach out to patients and to enable people to monitor their own health holds promise for promoting patient-centered care. The advent of smartphones has led to the creation of numerous applications that enable people to become engaged more completely in their own health through greater access to health information and tracking tools such as built-in pedometers, diet management aids, and weight and blood pressure logs. A recent review of the use of mobile phones for chronic disease management found 23 articles describing interventions involving use of a mobile phone for disease prevention, diagnosis, management, and monitoring, as well as patient education. The interventions spanned a broad range of chronic illnesses, including diabetes, asthma, dementia, and hypertension. Across all interventions, high rates of user compliance and satisfaction were reported (Skinner and Finkelstein, 2008).

Early trials reveal the potential of this approach. In a trial of txt2stop, a text messaging service that sends motivational and behavioral change support messages to smokers attempting to quit, smokers who received the text messages showed significantly better cessation rates at 6 months relative to the control group (Free et al., 2011). Another study focused on IDEALL (Improving Diabetes Efforts Across Language and Literacy), an automated telephone support service for diabetics that offers targeted health education messages based on people's responses to questions about exercise, blood glucose monitoring, and other indicators. The study found that, while the service did not lead to differences in blood glucose level for participants, it did lead to increased patient participation, engagement, and self-efficacy compared with patients undergoing typical care (Schillinger et al., 2009). These trials suggest that mobile technologies represent a new avenue for engaging, educating, and activating people in their own care and that of their loved ones.

Self-care has become increasingly crucial as patients today are discharged from health care organizations more quickly and in poorer health. As a result, postdischarge care now requires more advanced management by patients, their families, other caregivers, and the community. What used to be the purview of the health care professional now has been delegated to the patient, too often with inadequate handoff. Meeting this challenge will require new methods of education and communication; new technologies for management; and additional community supports, explored in the next section.

INTEGRATING HEALTH CARE AND THE HEALTH OF THE COMMUNITY

While patient engagement can help drive the U.S. health care system toward continuous learning and improvement, the value, quality, and care coordination challenges faced by the system cannot be met by any single platform, organization, or entity acting alone. Rather, communities and coalitions are needed to drive improvement.

Broadening the Definition of Communities

The typical definition of a community is a group located in a particular geographic area. However, communities that promote continuous learning and improvement in health care go beyond geographic boundaries to include groups linked through culture, occupation, conditions based on a common workplace, prognosis, stage in the care process, intensity of care needed, and more.

One natural community comprises people who share a particular condition or disease. The disease-specific organizations that represent these patients are a form of top-down community structure. They play a crucial role in gathering, reaching, and motivating patient constituents; funding research; advocating on behalf of patients; and conducting campaigns focused on quality improvement and patient-centered care (Conway et al., 2006). Their efforts aid patients in becoming more educated and informed consumers, and aid clinicians in staying abreast of clinical advances by disseminating clinical guidelines and decision support tools. Disease-specific affinity groups may also form organically as communities with which patients can share their experiences. Box 7-2 presents an example of how a community of patients formed around a common health care need—in this case, the need for prenatal care—can lead to improved health outcomes.

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BOX 7-2

A Community of Patient Peers Helps Reduce Premature Births. For many patients, a community of similar patients can offer useful supports for health management. One such patient, Ruth Lopez, was referred by her physician to a CenteringPregnancy program (more...)

The Internet has proven key in facilitating the development and rapid growth of these communities. Examples include the New Health Partnerships, C3N, and PatientsLikeMe. Websites, blogs, and social networking platforms such as Facebook and Twitter also give patients the tools to interact with others who share their diagnosis, gain access to new expertise and information, query members of their network, share updates about their health status, and receive support from friends and family. For example, a group of diabetic patients at the Fargo Family Health Center decided to create a blog and listserv where they could share their diabetes treatment experiences at the center, as well as support each other in managing and living with diabetes (IOM, 2011d). In another example, a frustrated mother whose son was getting sicker and sicker despite visits to the pediatrician posted pictures of her son on Facebook, and members of her extended social network were able to relate experiences that led to a correct diagnosis of Kawasaki disease—a rare autoimmune disorder (Kogan, 2011). These examples illustrate how patients and families can utilize existing communities or create new ones to seek out information, manage their care, and gain support from others.

Another natural focal point for patient engagement is the workplace. Workplaces have several attributes that make them conducive to community-oriented health and wellness programs: they host a group of employees who share a common goal; they have social, organizational, policy, and financial supports for employee behavior change; they have open and straightforward communication channels; and they have the ability to incentivize and monitor employee participation in sponsored health programs. Over the past 40 years, increasing numbers of employers have taken advantage of these characteristics to create worksite health promotion programs designed to improve employee performance and productivity and mitigate rising health care costs associated with preventable, lifestyle, and behavior-based chronic diseases. According to some studies, well-designed workplace health programs have the potential to produce strong returns on investment, although there are outstanding questions on the returns generated and the generalizability of the results (Chapman, 2005; Goetzel et al., 1999; IOM, 2010). According to a 2008 study, however, only 6.9 percent of health promotion programs offered by employers are evidence-based and include five essential elements: health education, employee screenings, supportive physical and social environments, integration of health promotion into the organizational culture, and links to employee services (Linnan et al., 2008). Recent policy support for evidence-based workplace health programs includes technical assistance and assessment, federal grants to small businesses, and policy changes that allow employers to offer financial incentives to encourage employee participation in wellness programs (Kaiser Family Foundation, 2011).

Such workplace communities do face challenges. One of these challenges lies in the tension between the goals of employers and employees, some of which will differ. Another is the need to build trust, as well as to operate transparently (Berry et al., 2010; Goetzel et al., 2007).

Recognition of the potential of communities to achieve better outcomes at lower cost has led to a number of initiatives aimed at bringing coalitions together to improve health care. One example is the Aligning Forces for Quality project, which has brought together coalitions of clinicians, patients, employers, insurers, and others in 16 communities to focus on improving health care quality, reducing disparities, and developing new models with the potential to be diffused nationally (Aligning Forces for Quality, 2012; Hurley et al., 2009).

Coordinating Patient Care Throughout the Health Care System and Community

Opportunities exist for bridging the gaps between patients, their care, and the broader community. One example is care transitions—changes in the set of clinicians delivering care or in the setting of care that patients must navigate. In the current health care system, both the incentives that encourage health care spending and the increasing specialization of clinicians have led to a situation in which a growing number of patients are seeing an array of clinicians in a variety of care settings. This increase in the number of clinicians and settings involved in a patient's care has led to a corresponding increase in hospitalizations, adverse events, errors, and breakdowns in communication across the care team, and has left patients in the precarious position of coordinating their own care without the knowledge or resources to do so. Further, the rising prevalence of chronic conditions in the United States, with 27 percent of Americans having multiple such conditions, necessitates coordinated care interventions, because chronically ill people experience frequent changes in their health status that require transitions between multiple care providers. Such transitions require successful interactions among the multiple clinicians, organizations, and community-based resources involved in the patient's care and support (HHS, 2010; Naylor et al., 2011).

New innovations in care delivery, such as the patient-centered medical home, are aimed at coordinating a patient's care across specialists, hospitals, home health agencies, nursing homes, the patient's family and other caregivers, and community-based services (AAFP et al., 2007; Fields et al., 2010). Multiple initiatives have been developed to increase opportunities to engage patients and their families in care processes, practice improvement, and the design of medical homes (Scholle et al., 2010). Another example is the Patient Protection and Affordable Care Act's creation of ACOs—collaboratives of health care professionals and institutions that provide coordinated health care services to a defined panel of Medicare patients in exchange for a share of the resultant cost savings (Merlis, 2010). Because they will share primary care, hospital, and other organizational resources, ACOs have the potential to develop into integrated, de facto communities of clinicians and patients. Although it remains to be seen whether ACOs will deliver on their promise of better-coordinated care at lower cost, their formation represents a key opportunity for community engagement. Involving patients in the design, formation, and evaluation of ACOs would help ensure that these organizations will adhere to the principles of patient-centered care (Springgate and Brook, 2011).

Achieving the elements of effective care transitions represents a crucial challenge—and opportunity—that can be met only in an environment of collaborative patient-centeredness where patients, families, clinicians, and health and social institutions work together to accomplish quality care transitions. Still, successful models demonstrate that effective care transitions are indeed possible. For example, the Care Transitions Model has been shown to reduce hospital admissions by 17 percent and costs by 50 percent (Naylor et al., 1999). A review of 21 randomized controlled trials focused on improving care transitions for chronically ill adults found that, despite substantial heterogeneity among the populations and care transition interventions studied, all but one of the trials yielded positive findings with respect to health outcomes, quality of life, patient satisfaction, resource use, and costs. Nine of the trials showed reductions in readmissions, and eight of those showed reductions in all-cause readmissions in the 30 days after discharge (Naylor et al., 2011). These findings suggest that effective care transition models hold great potential for bridging gaps between care settings and community-based organizations.

Several more recent initiatives have been undertaken to improve care coordination and transitions. One is the Department of Health and Human Services' strategic framework for multiple chronic conditions, initiated in 2010, which is designed to facilitate home- and community-based services (HHS, 2010). Similarly, Massachusetts has established a strategic plan for improving care transitions in the state. In developing this plan, it was found that seven principles of effective care transitions were necessary: transfer of clinical information, a communication infrastructure that supports care transitions, patient and family engagement, clinical responsibility for the patient and accountability on the part of clinicians with no lapses in care, clinician and practice engagement, assessment of transitions using standardized process and outcome measures, and payment incentives that promote effective transitions and minimize adverse events (Bonner et al., 2010). Many other initiatives are under way nationally to improve the coordination of patients' care. Although initiatives on care coordination are important for improving patient health, however, achieving cost savings from these programs can be difficult in many cases (Nelson, 2012; Peikes et al., 2009).

Leveraging Resources Beyond the Traditional Health Care Enterprise

Although historical commonalities exist between the health care system and public health, the two have evolved into distinct sectors, with the health care system focusing on care of individual patients and the public health sector concentrating on populations, prevention, and social determinants of health. Both perspectives are needed to improve the health of Americans and to confront the problems of increased prevalence of chronic diseases, which is often due to biological and social factors, and rising health care costs (IOM, 2011b,c, 2012a). Moreover, synergies can be realized in improving the quality and value of care by applying a population perspective to traditional medical practice, using clinical practice to identify and address community health problems, strengthening health promotion and health protection by mobilizing community campaigns, and improving health care by coordinating services for individuals (Lasker and Committee on Medicine and Public Health, 1997). Indeed, these sectors have important potential overlap in health surveillance, health promotion, and prevention (Rowan et al., 2007).

Several initiatives have been aimed at increasing coordination on this front in the United States and in an international context. Most reported outcomes from these initiatives have been positive, including improved population health, health care delivery processes, and partnership and team functioning. However, evidence on how best to accomplish this integration, as well as how to sustain such initiatives, is limited (Martin-Misener et al., 2009). An Institute of Medicine (IOM) committee recently explored in depth the opportunities for integrating the primary care and public health sectors (IOM, 2012b).

Important examples exist of leveraging resources beyond the traditional health care system to promote the provision of services to people whose health and social needs are intertwined (Craig et al., 2011). New initiatives have linked community health centers and community development financial institutions to support community improvements, such as addressing food deserts,3 reducing childhood exposure to allergens and irritants, and increasing the supply of affordable housing and community supports to allow older adults to age in the community (Braunstein and Lavizzo-Mourey, 2011; Erickson and Andrews, 2011; Kotelchuck et al., 2011). These initiatives reflect a recognition of the many determinants of health that can be harnessed to promote patients' health and well-being (IOM, 1997, 2011a; Madden et al., 2007; McGinnis and Foege, 1993; McGinnis et al., 2002). Most determinants of the health status of individuals and populations lie not in health care—medical care accounts for only 10 to 20 percent of overall health prospects—but in such factors as behavior, social circumstances, and environment. Thus, protecting and improving health requires close clinical-community coordination (McGinnis et al., 2002). Such initiatives also reflect a recognition that health is not merely a biological descriptor; rather, it represents patients' and populations' ability to detect and respond to their illnesses; improve their current and future functional capacity; and achieve physical, emotional, and social well-being (IOM, 1997). Further, these initiatives address the increasing burden of chronic disease on the health care and public health systems, on health care expenditures, and on the U.S. population as a whole (Lasker and Committee on Medicine and Public Health, 1997).

Other new initiatives encourage coordination among health care services and community resources. Successful care coordination initiatives identify community needs and assets and system-level stakeholders and institutions that define parameters for community action (Craig et al., 2011; McKnight, 1978). They utilize patient stratification techniques to target patients whose needs are not being met by the primary care system—patients who visit emergency rooms more frequently than others, whose illnesses require inpatient care, and whose health care costs are among the highest in the community. Using these criteria, such initiatives develop panels of patients for whom they assume responsibility and harness resources—family religious groups, and others—as partners in those patients' care. These initiatives also have skilled leaders who can coordinate the interests of stakeholders, including hospital administrators and state and local health, housing, and mental health departments, at the system level (Craig et al., 2011). Box 7-3 describes an example of a community initiative aimed at improving care delivery and health outcomes through better care coordination.

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BOX 7-3

Vermont Blueprint for Health. Communities of integrated health services, spanning organizations and clinicians, are an example of the evolving definition of communities—in this case focused on care coordination. Community-based teams support patient-centered (more...)

Successful care coordination models also utilize care coordinators to work with identified patients in formulating care plans that advance the patients' life and health goals and to coordinate services, including social services and health provider services, to meet those goals. Care coordinators may be nurses, social workers, other health workers, or lay people as long as they have the skills to communicate with and motivate their patients, coordinate a broad range of services, and do all that is necessary to prevent negative outcomes (Bradway et al., 2011). New types of health care professionals also have been introduced to coordinate care in many health care settings; an example is the increasing use of hospitalists to coordinate care in inpatient visits (Meltzer and Chung, 2010; Meltzer et al., 2002).

Conclusion 7-2: Coordination and integration of patient services currently are poor. Improvement in this area will require strong and sustained avenues of communication and cooperation between and among clinical and community stewards of services.

Related findings:

  • Care often is poorly coordinated across different settings and providers. In one survey, roughly 25 percent of patients noted that a test had to be repeated because the results from another provider had not been shared (see also Chapter 3).
  • Inadequate, sometimes absent, continuity of care endangers patients. Almost one-fifth of hospitalized Medicare patients are rehospitalized within 30 days, often without seeing their primary care provider in the interim (see also Chapter 3).
  • Although results for care coordination programs are mixed, there are effective interventions for improving care transitions. For example, the Care Transitions Model has been shown to reduce readmissions by 17 percent and costs by 50 percent.
  • Comprehensive health care requires accounting for factors typically outside of the traditional health care system. Most determinants of health lie outside of health care, with health care accounting for only 10 to 20 percent of health prospects. Thus there is a clear need for close clinical-community coordination.

FRAMEWORK FOR ACHIEVING THE VISION4

As discussed in this chapter, neither patients nor clinicians can perform their tasks alone. While clinicians supply their scientific expertise on the benefits and risks of different options, patients contribute their knowledge about the suitability of different options for their needs, goals, and circumstances. Both are necessary to providing the right care. Given that patient-centered care is not simply agreeing to every patient request, many tools are needed to communicate information, create partnerships, and improve decision-making models (Maurer et al., 2012). Further, involving patients meaningfully at the organizational and system levels requires changes in organizational structures and measurement tools and an expanded focus on the patient in all aspects of care. Recommendation 4 highlights the broad aims that different stakeholder groups need to pursue if health care's focus on patients is to increase.

Recommendation 4: Patient-Centered Care

Involve patients and families in decisions regarding health and health care, tailored to fit their preferences. Patients and families should be given the opportunity to be fully engaged participants at all levels, including individual care decisions, health system learning and improvement activities, and community-based interventions to promote health.

Strategies for progress toward this goal:

  • Patients and families should expect to be offered full participation in their own care and health and encouraged to partner, according to their preference, with clinicians in fulfilling those expectations.
  • Clinicians should employ high-quality, reliable tools and skills for informed shared decision making with patients and families, tailored to clinical needs, patient goals, social circumstances, and the degree of control patients prefer.
  • Health care delivery organizations, including programs operated by the Department of Defense, the Veterans Health Administration, and Health Resources and Services Administration, should monitor and assess patient perspectives and use the insights thus gained to improve care processes; establish patient portals to facilitate data sharing and communication among clinicians, patients, and families; and make high-quality, reliable tools available for shared decision making with patients at different levels of health literacy.
  • The Agency for Healthcare Research and Quality, partnering with the Centers for Medicare & Medicaid Services, other payers, and stakeholder organizations, should support the development and testing of an accurate and reliable core set of measures of patient-centeredness for consistent use across the health care system.
  • The Centers for Medicare & Medicaid Services and other public and private payers should promote and measure patient-centered care through payment models, contracting policies, and public reporting programs.
  • Digital technology developers and health product innovators should develop tools to assist individuals in managing their health and health care, in addition to providing patient supports in new forms of communities.

Beyond patient-centered care, this chapter has described how integrating services among and across health care organizations and community-based organizations can improve health and address complex care needs. Further, partnerships between health care organizations and public health systems can advance community health goals. Recommendation 5 describes the broad actions that different stakeholders need to take to improve coordination and partnerships between and among the health care system, community resources, and public health bodies. Further, the recommendation introduces two specific actions that can be taken to produce change immediately by rewarding care that improves population health and by increasing the accuracy of metrics that measure population health.

Recommendation 5: Community Links

Promote community-clinical partnerships and services aimed at managing and improving health at the community level. Care delivery and community-based organizations and agencies should partner with each other to develop cooperative strategies for the design, implementation, and accountability of services aimed at improving individual and population health.

Strategies for progress toward this goal:

  • Health care delivery organizations and clinicians should partner with community-based organizations and public health agencies to leverage and coordinate prevention, health promotion, and community-based interventions to improve health outcomes, including strategies related to the assessment and use of web-based tools.
  • Public and private payers should incorporate population health improvement into their health care payment and contracting policies and accountability measures.
  • Health economists, health service researchers, professional specialty societies, and measure development organizations should continue to improve measures that can readily be applied to assess performance on both individual and population health.

For many patients, care can be fragmented and uncoordinated, whether they are transitioning from the hospital to a community setting or between two different clinicians. As patient needs have grown more complex, focusing on coordination and communication across all of a patient's health care providers has become increasingly crucial. These coordination and communication needs may be more acute when patients require services beyond the traditional health care system, such as social and community services, for managing their condition. Recommendation 6 outlines actions that need to be taken to improve care transitions and coordination to provide seamless care for patients.

Recommendation 6: Care Continuity

Improve coordination and communication within and across organizations. Payers should structure payment and contracting to reward effective communication and coordination between and among members of a patient's care team.

Strategies for progress toward this goal:

  • Health care delivery organizations and clinicians, partnering with patients, families, and community organizations, should develop coordination and transition processes, data sharing capabilities, and communication tools to ensure safe, seamless patient care.
  • Health economists, health service researchers, professional specialty societies, and measure development organizations should develop and test metrics with which to monitor and evaluate the effectiveness of care transitions in improving patient health outcomes.
  • Public and private payers should promote effective care transitions that improve patient health through their payment and contracting policies.

Given the advantages that accrue from involving patients and communities in health care, their inclusion is a goal for a learning health care system. Challenges are entailed in promoting this involvement, from changing the existing culture of medicine to creating metrics that accurately measure involvement. As noted in this chapter, there are differences between patient involvement in care and measures such as patient satisfaction. However, these challenges do not prevent a focus on patients in care, and each can be overcome to allow for a health care system that continually improves patient care.

REFERENCES

  • AAFP (American Academy of Family Physicians, AAP (American Academy of Pediatrics), ACP (American College of Physicians), and (AOA) American Osteopathic Association. Joint principles of the patient-centered medical home. 2007. [August 31, 2012]. http://www​.pcpcc.net​/content/joint-principles-patient-centered-medical-home.
  • Aligning Forces for Quality. AF4Q alliance overview. 2012. [May 15, 2012]. http:​//forces4quality​.org/af4q-alliances-overview.
  • Alston C, Paget L. Communicating evidence in health care: Engaging patients for improved health care decisions. 2012. [August 31, 2012]. http://iom​.edu/∼​/media/Files/Activity%20Files​/Quality​/VSRT/IC%20Meeting%20Docs​/ECIC%2006-07-12​/Lyn%20Paget%20and%20Chuck%20Alston​.pdf.
  • Arterburn DE, Westbrook EO, Bogart TA, Sepucha KR, Bock SN, Weppner WG. Obesity (Silver Spring). 8. Vol. 19. 2011. Randomized trial of a video-based patient decision aid for bariatric surgery; pp. 1669–1675. [PubMed: 21475138]
  • Balik B, Conway J, Zipperer L, Watson J. Achieving an exceptional patient and family experience of inpatient hospital care. Cambridge, MA: Institute for Healthcare Improvement; 2011.
  • Beach MC, Keruly J, Moore RD. Journal of General Internal Medicine. 6. Vol. 21. 2006. Is the quality of the patient provider relationship associated with better adherence and health outcomes for patients with HIV; pp. 661–665. [PMC free article: PMC1924639] [PubMed: 16808754]
  • Bechel DL, Myers WA, Smith DG. Joint Commission Journal on Quality Improvement. 7. Vol. 26. 2000. Does patient-centered care pay off; pp. 400–409. [PubMed: 10897457]
  • Beckman HB, Frankel RM. Annals of Internal Medicine. 5. Vol. 101. 1984. The effect of physician behavior on the collection of data; pp. 692–696. [PubMed: 6486600]
  • Belkora JK, Volz S, Teng AE, Moore DH, Loth MK, Sepucha KR. Patient Education and Counseling. 2. Vol. 86. 2012. Impact of decision aids in a sustained implementation at a breast care center; pp. 195–204. [PubMed: 21665420]
  • Bergeson SC, Dean JD. Journal of the American Medical Association. 23. Vol. 296. 2006. A systems approach to patient-centered care; pp. 2848–2851. [PubMed: 17179462]
  • Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A, Brasure M, Lohr KN, Harden E, Tant E, Wallace I, Viswanathan M. Health literacy interventions and outcomes: An updated systematic review. Rockville, MD: RTI International/University of North Carolina Evidence-based Practice Center; 2011. [PMC free article: PMC4781058] [PubMed: 23126607]
  • Berry LL, Mirabito AM, Baun WB. Harvard Business Review. 12. Vol. 88. 2010. What's the hard return on employee wellness programs. [PubMed: 21188899]
  • Bertakis KD, Azari R. Journal of the American Board of Family Medicine. 3. Vol. 24. 2011. Patient-centered care is associated with decreased health care utilization; pp. 229–239. [PubMed: 21551394]
  • Berwick DM. Health Affairs (Millwood). 4. Vol. 28. 2009. What “patient-centered” should mean: Confessions of an extremist; pp. w555–w565. [PubMed: 19454528]
  • Bielaszka-DuVernay C. Health Affairs (Millwood). 3. Vol. 30. 2011. Vermont's blueprint for medical homes, community health teams, and better health at lower cost; pp. 383–386. [PubMed: 21383346]
  • Bodenheimer T. New England Journal of Medicine. 10. Vol. 358. 2008. Coordinating care—a perilous journey through the health care system; pp. 1064–1071. [PubMed: 18322289]
  • Bonner A, Schneider C, Weissman JS. Massachusetts strategic plan for care transitions. Boston, MA: Massachusetts State Quality Improvement Institute; 2010.
  • Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. The American Journal of Managed Care. 1. Vol. 17. 2011. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days; pp. 41–48. [PubMed: 21348567]
  • Bradway C, Trotta R, Bixby MB, McPartland E, Wollman MC, Kapustka H, McCauley K, Naylor MD. Gerontologist. 3. Vol. 52. 2011. A qualitative analysis of an advanced practice nurse-directed transitional care model intervention; pp. 394–407. [PMC free article: PMC3342512] [PubMed: 21908805]
  • Braunstein S, Lavizzo-Mourey R. Health Affairs (Millwood). 11. Vol. 30. 2011. How the health and community development sectors are combining forces to improve health and well-being; pp. 2042–2051. [PubMed: 22068394]
  • Browne K, Roseman D, Shaller D, Edgman-Levitan S. Health Affairs (Project Hope). 5. Vol. 29. 2010. Analysis & commentary. Measuring patient experience as a strategy for improving primary care; pp. 921–925. [PubMed: 20439881]
  • Chapman LS. Meta-evaluation of worksite health promotion economic return studies: 2005 update. 2005. [August 31, 2012]. http://www​.inspirationaljourneys​.org/wp-content​/uploads/2010​/04/Meta-evaluation-of-worksite-health-promotion-economic-return-studies-2005-update.pdf. [PubMed: 16022209]
  • Charmel PA, Frampton SB. Healthcare Financial Management. 3. Vol. 62. 2008. Building the business case for patient-centered care; pp. 80–85. [PubMed: 19097611]
  • Chung GS, Lawrence RE, Curlin FA, Arora V, Meltzer DO. Journal of Medical Ethics. 2. Vol. 38. 2011. Predictors of hospitalised patients' preferences for physician-directed medical decision-making; pp. 77–82. [PubMed: 21697296]
  • Collins ED, Moore CP, Clay KF, Kearing SA, O'Connor AM, Llewellyn-Thomas HA, Barth RJ Jr, Sepucha KR. Journal of Clinical Oncology. 4. Vol. 27. 2009. Can women with early-stage breast cancer make an informed decision for mastectomy; pp. 519–525. [PubMed: 19114703]
  • Conway J, Johnson B, Edgman-Levitan S, Schlucter J, Ford D, Sodomka P, Simmons L. Partnering with patients and families to design a patient- and family-centered health care system. Bethesda, MD: Institute for Family-Centered Care with Institute for Healthcare Improvement; 2006.
  • Coulter A, Ellins J. Patient-focused interventions: A review of the evidence. 2006. [June 11, 2010]. http://www​.health.org​.uk/publications/research_reports​/patientfocused.html.
  • Craig C, Eby D, Whittington J. Care coordination model: Better care at lower cost for people with multiple health and social needs. Cambridge, MA: Institute for Healthcare Improvement; 2011.
  • Davis RE, Jacklin R, Sevdalis N, Vincent CA. Health Expectations. 3. Vol. 10. 2007. Patient involvement in patient safety: What factors influence patient participation and engagement; pp. 259–267. [PMC free article: PMC5060404] [PubMed: 17678514]
  • Deakin T, McShane C, Cade J, Williams R. Cochrane Database of Systematic Reviews. Vol. 2. 2005. Group based training for self-management strategies in people with type 2 diabetes mellitus; p. CD003417. [PubMed: 15846663]
  • Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Health Expectations. 3. Vol. 10. 2007. Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations; pp. 248–258. [PMC free article: PMC5060407] [PubMed: 17678513]
  • Degner LF, Kristjanson LJ, Bowman D, Sloan JA, Carriere KC, O'Neil J, Bilodeau B, Watson P, Mueller B. Journal of the American Medical Association. 18. Vol. 277. 1997. Information needs and decisional preferences in women with breast cancer; pp. 1485–1492. [PubMed: 9145723]
  • Diaz JA, Griffith RA, Ng JJ, Reinert SE, Friedmann PD, Moulton AW. Journal of General Internal Medicine. 3. Vol. 17. 2002. Patients' use of the Internet for medical information; pp. 180–185. [PMC free article: PMC1495021] [PubMed: 11929503]
  • Eckman MH, Wise R, Leonard AC, Dixon E, Burrows C, Khan F, Warm E. Patient Education and Counseling. 2. Vol. 87. 2012. Impact of health literacy on outcomes and effectiveness of an educational intervention in patients with chronic diseases; pp. 143–151. [PubMed: 21925823]
  • Epstein RM, Street RL Jr. Annals of Family Medicine. 2. Vol. 9. 2011. The values and value of patient-centered care; pp. 100–103. [PMC free article: PMC3056855] [PubMed: 21403134]
  • Epstein RM, Franks P, Shields CG, Meldrum SC, Miller KN, Campbell TL, Fiscella K. Annals of Family Medicine. 5. Vol. 3. 2005. Patient-centered communication and diagnostic testing; pp. 415–421. [PMC free article: PMC1466928] [PubMed: 16189057]
  • Epstein RM, Fiscella K, Lesser CS, Stange KC. Health Affairs (Millwood). 8. Vol. 29. 2010. Why the nation needs a policy push on patient-centered health care; pp. 1489–1495. [PubMed: 20679652]
  • Erickson D, Andrews N. Health Affairs (Millwood). 11. Vol. 30. 2011. Partnerships among community development, public health, and health care could improve the well-being of low-income people; pp. 2056–2063. [PubMed: 22068396]
  • Fagerlin A, Sepucha KR, Couper MP, Levin CA, Singer E, Zikmund-Fisher BJ. Medical Decision Making. Suppl. 5. Vol. 30. 2010. Patients' knowledge about 9 common health conditions: The decisions survey; pp. S35–S52. [PubMed: 20881153]
  • Fenton JJ, Jerant AF, Bertakis KD, Franks P. Archives of Internal Medicine. 5. Vol. 172. 2012. The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality; pp. 405–411. [PubMed: 22331982]
  • Fields D, Leshen E, Patel K. Health Affairs (Millwood). 5. Vol. 29. 2010. Analysis & commentary. Driving quality gains and cost savings through adoption of medical homes; pp. 819–826. [PubMed: 20439867]
  • Fineberg H. Israel Journal of Health Policy Research. 1. Vol. 1. 2012. From shared decision making to patient-centered decision making; p. 6. [PMC free article: PMC3424821] [PubMed: 22913639]
  • Fowler FJ Jr, Levin CA, Sepucha KR. Health Affairs (Millwood). 4. Vol. 30. 2011. Informing and involving patients to improve the quality of medical decisions; pp. 699–706. [PubMed: 21471491]
  • Fox S. Health topics: 80% of Internet users look for health information online. Washington, DC: Pew Research Center; 2011.
  • Free C, Knight R, Robertson S, Whittaker R, Edwards P, Zhou W, Rodgers A, Cairns J, Kenward MG, Roberts I. Lancet. 9785. Vol. 378. 2011. Smoking cessation support delivered via mobile phone text messaging (txt2stop): A single-blind, randomised trial; pp. 49–55. [PMC free article: PMC3143315] [PubMed: 21722952]
  • Fremont AM, Cleary PD, LeeHargraves J, Rowe RM, Jacobson NB, Ayanian JZ. Journal of General Internal Medicine. 12. Vol. 16. 2001. Patient centered processes of care and long term outcomes of myocardial infarction; pp. 800–808. [PMC free article: PMC1495308] [PubMed: 11903758]
  • Frosch DL, May SG, Rendle KA, Tietbohl C, Elwyn G. Health Affairs (Millwood). 5. Vol. 31. 2012. Authoritarian physicians and patients' fear of being labeled ‘difficult’ among key obstacles to shared decision making; pp. 1030–1038. [PubMed: 22566443]
  • Gao GG, McCullough JS, Agarwal R, Jha AK. Journal of Medical Internet Research. 1. Vol. 14. 2012. A changing landscape of physician quality reporting: Analysis of patients' online ratings of their physicians over a 5-year period; p. e38. [PMC free article: PMC3374528] [PubMed: 22366336]
  • Garrido T, Jamieson L, Zhou Y, Wiesenthal A, Liang L. British Medical Journal. 7491. Vol. 330. 2005. Effect of electronic health records in ambulatory care: Retrospective, serial, cross sectional study; p. 581. [PMC free article: PMC554034] [PubMed: 15760999]
  • Glickman SW, Boulding W, Manary M, Staelin R, Roe MT, Wolosin RJ, Ohman EM, Peterson ED, Schulman KA. Circulation: Cardiovascular Quality and Outcomes. 2. Vol. 3. 2010. Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction; pp. 188–195. [PubMed: 20179265]
  • Goetzel RZ, Juday TR, Ozminkowski RJ. AWHP's Worksite Health. 3. Vol. 6. 1999. What's the ROI? A systematic review of return on investment (ROI) studies of corporate health and productivity management initiatives; pp. 12–21.
  • Goetzel RZ, Shechter D, Ozminkowski RJ, Marmet PF, Tabrizi MJ, Roemer EC. Journal of Occupational and Environmental Medicine. 2. Vol. 49. 2007. Promising practices in employer health and productivity management efforts: Findings from a benchmarking study; pp. 111–130. [PubMed: 17293753]
  • Golomb BA, McGraw JJ, Evans MA, Dimsdale JE. Drug Safety. 8. Vol. 30. 2007. Physician response to patient reports of adverse drug effects: Implications for patient-targeted adverse effect surveillance; pp. 669–675. [PubMed: 17696579]
  • Gray BM, Weng W, Holmboe ES. Health Services Research. 1, Pt. 1. Vol. 47. 2011. An assessment of patient-based and practice infrastructure-based measures of the patient-centered medical home: Do we need to ask the patient; pp. 4–21. [PMC free article: PMC3447253] [PubMed: 22092245]
  • Groene O. International Journal for Quality in Health Care. 5. Vol. 23. 2011. Patient centeredness and quality improvement efforts in hospitals: Rationale, measurement, implementation; pp. 531–537. [PubMed: 21862449]
  • Guevara JP, Wolf FM, Grum CM, Clark NM. British Medical Journal. 7402. Vol. 326. 2003. Effects of educational interventions for self management of asthma in children and adolescents: Systematic review and meta-analysis; p. 1308. [PMC free article: PMC161636] [PubMed: 12805167]
  • Halamka JD, Mandl KD, Tang PC. Journal of the American Medical Informatics Association. 1. Vol. 15. 2008. Early experiences with personal health records; pp. 1–7. [PMC free article: PMC2274878] [PubMed: 17947615]
  • Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Journal of General Internal Medicine. 10. Vol. 22. 2007. Reducing patients' unmet concerns in primary care: The difference one word can make; pp. 1429–1433. [PMC free article: PMC2305862] [PubMed: 17674111]
  • HHS (U.S. Department of Health and Human Services). Multiple chronic conditions—a strategic framework: Optimum health and quality of life for individuals with multiple chronic conditions. Washington, DC: HHS; 2010.
  • Hibbard JH. Health Affairs (Millwood). Suppl. Variation. 2004. Moving toward a more patient-centered health care delivery system; pp. VAR133–135. [PubMed: 15471780]
  • Hibbard JH, Stockard J, Mahoney ER, Tusler M. Health Services Research. 4, Pt. 1. Vol. 39. 2004. Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers; pp. 1005–1026. [PMC free article: PMC1361049] [PubMed: 15230939]
  • Hibbard JH, Mahoney ER, Stock R, Tusler M. Health Services Research. 4. Vol. 42. 2007. Do increases in patient activation result in improved self-management behaviors; pp. 1443–1463. [PMC free article: PMC1955271] [PubMed: 17610432]
  • Hibbard JH, Greene J, Tusler M. American Journal of Managed Care. 6. Vol. 15. 2009. Improving the outcomes of disease management by tailoring care to the patient's level of activation; pp. 353–360. [PubMed: 19514801]
  • Hudon C, Fortin M, Haggerty JL, Lambert M, Poitras ME. Annals of Family Medicine. 2. Vol. 9. 2011. Measuring patients' perceptions of patient-centered care: A systematic review of tools for family medicine; pp. 155–164. [PMC free article: PMC3056864] [PubMed: 21403143]
  • Hurley RE, Keenan PS, Martsolf GR, Maeng DD, Scanlon DP. Health Affairs (Millwood). 1. Vol. 28. 2009. Early experiences with consumer engagement initiatives to improve chronic care; pp. 277–283. [PubMed: 19124880]
  • Institute for Patient- and Family-Centered Care. Frequently asked questions. 2011. [November 11, 2011]. http://www​.ipfcc.org/faq.html.
  • IOM (Institute of Medicine). Improving health in the community: A role for performance monitoring. Washington, DC: National Academy Press; 1997.
  • IOM. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; 2001.
  • IOM. Priority areas for national action: Transforming health care quality. Washington, DC: The National Academies Press; 2003. [PubMed: 25057643]
  • IOM. Health literacy: A prescription to end confusion. Washington, DC: The National Academies Press; 2004.
  • IOM. The public health effects of food deserts: Workshop summary. Washington, DC: The National Academies Press; 2009.
  • IOM. Value in health care: Accounting for cost, quality, safety, outcomes, and innovation: Workshop summary. Washington, DC: The National Academies Press; 2010.
  • IOM. Clinical data as the basic staple of health learning: Workshop summary. Washington, DC: The National Academies Press; 2011a.
  • IOM. For the public's health: The role of measurement in action and accountability. Washington, DC: The National Academies Press; 2011b.
  • IOM. For the public's health: Revitalizing law and policy to meet new challenges. Washington, DC: The National Academies Press; 2011c.
  • IOM. Patients charting the course: Citizen engagement in the learning health system: Workshop summary. Washington, DC: The National Academies Press; 2011d.
  • IOM. For the public's health: Investing in a healthier future. Washington, DC: The National Academies Press; 2012a.
  • IOM. Primary care and public health: Exploring integration to improve population health. Washington, DC: The National Academies Press; 2012b.
  • Jencks SF, Williams MV, Coleman EA. New England Journal of Medicine. 14. Vol. 360. 2009. Rehospitalizations among patients in the Medicare fee-for-service program; pp. 1418–1428. [PubMed: 19339721]
  • Johnson B, Abraham M, Conway J, Simmons L, Edgman-Levitan S, Sodomka P, Schlucter J, Ford D. Partnering with patients and families to design a patient- and family-centered health care system: Recommendations and promising practices. Bethesda, MD: Institute for Family-Centered Care and Institute for Healthcare Improvement; 2008.
  • Johnson FR, Hauber B, Ozdemir S, Siegel CA, Hass S, Sands BE. Journal of Managed Care Pharmacy. 8. Vol. 16. 2010. Are gastroenterologists less tolerant of treatment risks than patients? Benefit-risk preferences in Crohn's disease management; pp. 616–628. [PubMed: 20866166]
  • Jones CA, Clement LT, Morphew T, Kwong KY, Hanley-Lopez J, Lifson F, Opas L, Guterman JJ. Journal of Allergy and Clinical Immunology. 6. Vol. 119. 2007. Achieving and maintaining asthma control in an urban pediatric disease management program: The breathmobile program; pp. 1445–1453. [PubMed: 17416407]
  • Kaiser Family Foundation. Summary of new health reform law. 2011. Menlo Park, CA: Kaiser Family Foundation; 2011.
  • Kinnersley P, Edwards A, Hood K, Cadbury N, Ryan R, Prout H, Owen D, MacBeth F, Butow P, Butler C. Cochrane Database Systematic Reviews. 3. Vol. 3. 2007. Interventions before consultations for helping patients address their information needs. [PubMed: 17636767]
  • Kogan DC. Slate. 2011. [May 15, 2012]. How Facebook saved my son's life. http://www​.slate.com​/articles/double_x/doublex​/2011/07/how_facebook​_saved_my_sons_life.html.
  • Kotelchuck R, Lowenstein D, Tobin JN. Health Affairs (Millwood). 11. Vol. 30. 2011. Community health centers and community development financial institutions: Joining forces to address determinants of health; pp. 2090–2097. [PubMed: 22068401]
  • Lasker RD., Committee on Medicine and Public Health. Medicine & public health: The power of collaboration. New York: The New York Academy of Medicine; 1997.
  • Lee CN, Dominik R, Levin CA, Barry MJ, Cosenza C, O'Connor AM, Mulley AG Jr, Sepucha KR. Health Expectations. 3. Vol. 13. 2010a. Development of instruments to measure the quality of breast cancer treatment decisions; pp. 258–272. [PMC free article: PMC2919601] [PubMed: 20550591]
  • Lee CN, Hultman CS, Sepucha K. Annals of Plastic Surgery. 5. Vol. 64. 2010b. Do patients and providers agree about the most important facts and goals for breast reconstruction decisions; pp. 563–566. [PubMed: 20395809]
  • Lee CN, Belkora J, Chang Y, Moy B, Partridge A, Sepucha K. Plastic and Reconstructive Surgery. 1. Vol. 127. 2011. Are patients making high-quality decisions about breast reconstruction after mastectomy; pp. 18–26. [PMC free article: PMC4100583] [PubMed: 21200195]
  • Lee CN, Chang Y, Adimorah N, Belkora JK, Moy B, Partridge AH, Ollila DW, Sepucha KR. Journal of the American College of Surgeons. 1. Vol. 214. 2012. Decision making about surgery for early-stage breast cancer; pp. 1–10. [PMC free article: PMC3256735] [PubMed: 22056355]
  • Levinson W, Kao A, Kuby A, Thisted RA. Journal of General Internal Medicine. 6. Vol. 20. 2005. Not all patients want to participate in decision making. A national study of public preferences; pp. 531–535. [PMC free article: PMC1490136] [PubMed: 15987329]
  • Levinson W, Lesser CS, Epstein RM. Health Affairs (Millwood). 7. Vol. 29. 2010. Developing physician communication skills for patient-centered care; pp. 1310–1318. [PubMed: 20606179]
  • Linnan L, Bowling M, Childress J, Lindsay G, Blakey C, Pronk S, Wieker S, Royall P. American Journal of Public Health. 8. Vol. 98. 2008. Results of the 2004 National Worksite Health Promotion Survey; pp. 1503–1509. [PMC free article: PMC2446449] [PubMed: 18048790]
  • Litvak E, Bisognano M. Health Affairs (Millwood). 1. Vol. 30. 2011. More patients, less payment: Increasing hospital efficiency in the aftermath of health reform; pp. 76–80. [PubMed: 21209441]
  • Litvak E, Buerhaus PI, Davidoff F, Long MC, McManus ML, Berwick DM. Joint Commission Journal on Quality and Patient Safety. 6. Vol. 31. 2005. Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety; pp. 330–338. [PubMed: 15999963]
  • Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Mayo Clinic Proceedings. 1. Vol. 85. 2010. Patient participation: Current knowledge and applicability to patient safety; pp. 53–62. [PMC free article: PMC2800278] [PubMed: 20042562]
  • Madden R, Sykes C, Ustun TB. World Health Organization family of international classifications: Definition, scope and purpose. Geneva, Switzerland: World Health Organization; 2007.
  • March of Dimes Perinatal Center. Peristats. 2012. [May 15, 2012]. http://www​.marchofdimes​.com/peristats/default.aspx.
  • Martin-Misener R, Valaitis R., Strengthening Primary Health Care through Primary Care and Public Health Collaboration Research Team. A scoping literature review of collaboration between primary care and public health. Hamilton, ON: McMaster University; 2009. [PubMed: 22336106]
  • Maurer M, Dardess P, Carman KL, Frazier K, Smeeding L. Guide to patient and family engagement: Environmental scan report. Rockville, MD: Agency for Healthcare Research and Quality; 2012.
  • McGinnis JM, Foege WH. Journal of the American Medical Association. 18. Vol. 270. 1993. Actual causes of death in the United States; pp. 2207–2212. [PubMed: 8411605]
  • McGinnis JM, Williams-Russo P, Knickman JR. Health Affairs (Millwood). 2. Vol. 21. 2002. The case for more active policy attention to health promotion; pp. 78–93. [PubMed: 11900188]
  • McKnight JL. Social Policy. 3. Vol. 9. 1978. Politicizing health care; pp. 36–39. [PubMed: 10239907]
  • Mead N, Bower P. Patient Education and Counseling. 1. Vol. 48. 2002. Patient-centered consultations and outcomes in primary care: A review of the literature; pp. 51–61. [PubMed: 12220750]
  • Meltzer DO, Chung JW. Journal of General Internal Medicine. 5. Vol. 25. 2010. U.S. trends in hospitalization and generalist physician workforce and the emergence of hospitalists; pp. 453–459. [PMC free article: PMC2855010] [PubMed: 20352367]
  • Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Annals of Internal Medicine. 11. Vol. 137. 2002. Effects of physician experience on costs and outcomes on an academic general medicine service: Results of a trial of hospitalists; pp. 866–874. [PubMed: 12458986]
  • Merlis M. Accountable care organizations. 2010. [August 31, 2012]. http:​//healthaffairs​.org/healthpolicybriefs​/brief_pdfs/healthpolicybrief_23.pdf.
  • Mosen DM, Schmittdiel J, Hibbard J, Sobel D, Remmers C, Bellows J. Journal of Ambulatory Care Management. 1. Vol. 30. 2007. Is patient activation associated with outcomes of care for adults with chronic conditions; pp. 21–29. [PubMed: 17170635]
  • Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, Schwartz JS. Journal of the American Medical Association. 7. Vol. 281. 1999. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial; pp. 613–620. [PubMed: 10029122]
  • Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. Health Affairs (Project Hope). 4. Vol. 30. 2011. The care span: The importance of transitional care in achieving health reform; pp. 746–754. [PubMed: 21471497]
  • Nelson L. Lessons from Medicare's demonstration projects on disease management and care coordination. Washington, DC: Congressional Budget Office; 2012.
  • Norris M. National Public Radio. Jul 13, 2011. Group prenatal care: Finding strength in numbers.
  • NPP (National Priorities Partnership). Patient and family engagement. 2010. [February 18, 2011]. http://www​.nationalprioritiespartnership​.org/PriorityDetails.aspx?id=596.
  • O'Connor AM, Llewellyn-Thomas HA, Flood AB. Health Affairs (Millwood). Suppl. Variation. 2004. Modifying unwarranted variations in health care: Shared decision making using patient decision aids; pp. VAR63–72. [PubMed: 15471770]
  • O'Connor AM, Stacey D, Barry MJ, Col NF, Eden KB, Entwistle V, Fiset V, Holmes-Rovner M, Khangura S, Llewellyn-Thomas H, Rovner DR. Medical Decision Making. 5. Vol. 27. 2007a. Do patient decision aids meet effectiveness criteria of the international patient decision aid standards collaboration? A systematic review and meta-analysis; pp. 554–574. [PubMed: 17873255]
  • O'Connor AM, Wennberg JE, Legare F, Llewellyn-Thomas HA, Moulton BW, Sepucha KR, Sodano AG, King JS. Health Affairs. 3. Vol. 26. 2007b. Toward the “tipping point”: Decision aids and informed patient choice; pp. 716–725. [PubMed: 17485749]
  • O'Connor AM, Bennett CL, Stacey D, Barry M, Col NF, Eden KB, Entwistle VA, Fiset V, Holmes-Rovner M, Khangura S, Llewellyn-Thomas H, Rovner D. Cochrane Database of Systematic Reviews. 3. 2009. Decision aids for people facing health treatment or screening decisions; p. CD001431. [PubMed: 19588325]
  • Otani K, Waterman B, Faulkner KM, Boslaugh S, Dunagan WC. Journal of Healthcare Management American College of Healthcare Executives. 1. Vol. 55. 2010. How patient reactions to hospital care attributes affect the evaluation of overall quality of care, willingness to recommend, and willingness to return. [PubMed: 20210071]
  • Peikes D, Chen A, Schore J, Brown R. Journal of the American Medical Association. 6. Vol. 301. 2009. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials; pp. 603–618. [PubMed: 19211468]
  • Ponte PR, Conlin G, Conway JB, Grant S, Medeiros C, Nies J, Shulman L, Branowicki P, Conley K. Journal of Nursing Administration. 2. Vol. 33. 2003. Making patient-centered care come alive: Achieving full integration of the patient's perspective; pp. 82–90. [PubMed: 12584460]
  • President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making healthcare decisions. 6 vols. Vol. 1. Buffalo, NY: W.S. Hein; 1982.
  • Radwin LE, Cabral HJ, Wilkes G. Research in Nursing & Health. 1. Vol. 32. 2009. Relationships between patient-centered cancer nursing interventions and desired health outcomes in the context of the health care system; pp. 4–17. [PubMed: 18814304]
  • Rollnick S, Miller WR, Butler C. Motivational interviewing in health care: Helping patients change behavior (applications of motivational interviewing). New York: Guilford Press; 2008.
  • Rowan MS, Hogg W, Huston P. Healthcare Policy. 1. Vol. 3. 2007. Integrating public health and primary care; p. e160. [PMC free article: PMC2645118] [PubMed: 19305749]
  • Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE Jr, Tarlov AR. Journal of Family Practice. 3. Vol. 47. 1998. Linking primary care performance to outcomes of care; pp. 213–220. [PubMed: 9752374]
  • Schillinger D, Handley M, Wang F, Hammer H. Diabetes Care. 4. Vol. 32. 2009. Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes; p. 559. [PMC free article: PMC2660485] [PubMed: 19131469]
  • Scholle SH, Torda P, Peikes D, Han E, Genevro J. Engaging patients and families in the medical home; Rockville, MD: Agency for Healthcare Research and Quality; 2010.
  • Scott L, Morphew T, Bollinger ME, Samuelson S, Galant S, Clement L, O'Cull K, Jones F, Jones CA. Journal of Allergy and Clinical Immunology. 1. Vol. 128. 2011. Achieving and maintaining asthma control in inner-city children; pp. 56–63. [PubMed: 21531451]
  • Sepucha KR, Fowler FJ, Mulley AG. Health Affairs (Millwood). Suppl. Variation. 2004. Policy support for patient-centered care: The need for measurable improvements in decision quality; pp. VAR54–62. [PubMed: 15471772]
  • Sepucha KR, Fagerlin A, Couper MP, Levin CA, Singer E, Zikmund-Fisher BJ. Medical Decision Making. Suppl. 5. Vol. 30. 2010. How does feeling informed relate to being informed? The decisions survey; pp. S77–S84. [PubMed: 20881156]
  • Sequist TD, Schneider EC, Anastario M, Odigie EG, Marshall R, Rogers WH, Safran DG. Journal of General Internal Medicine. 11. Vol. 23. 2008. Quality monitoring of physicians: Linking patients' experiences of care to clinical quality and outcomes; pp. 1784–1790. [PMC free article: PMC2585686] [PubMed: 18752026]
  • Shaller D., The Commonwealth Fund. Patient-centered care What does it take. New York: The Commonwealth Fund; 2007.
  • Silow-Carroll S, Alteras T, Stepnick L. Patient-centered care for underserved populations: Definition and best practices. Washington, DC: Economic and Social Research Institute; 2006.
  • Skinner C, Finkelstein J. Review of mobile phone use in preventive medicine and disease management. Anaheim, CA: ACTA Press; 2008.
  • Sofaer S, Firminger K. Annual Review of Public Health. Vol. 26. 2005. Patient perceptions of the quality of health services; pp. 513–559. [PubMed: 15760300]
  • Solberg LI, Asche SE, Anderson LH, Sepucha K, Thygeson NM, Madden JE, Morrissey L, Kraemer KK. Journal of Women's Health. 7. Vol. 18. 2009. Evaluating preference-sensitive care for uterine fibroids: It's not so simple; pp. 1071–1079. [PubMed: 19580366]
  • Solberg LI, Asche SE, Sepucha K, Thygeson NM, Madden JE, Morrissey L, Kraemer KK, Anderson LH. Medical Decision Making. 4. Vol. 30. 2010. Informed choice assistance for women making uterine fibroid treatment decisions: A practical clinical trial; pp. 444–452. [PubMed: 19949063]
  • Springgate BF, Brook RH. Journal of the American Medical Association. 17. Vol. 305. 2011. Accountable care organizations and community empowerment; pp. 1800–1801. [PubMed: 21505120]
  • Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Legare F, Thomson R. Cochrane Database of Systematic Reviews. 10. 2011. Decision aids for people facing health treatment or screening decisions; p. CD001431. [PubMed: 21975733]
  • Stewart MA. Canadian Medical Association Journal. 9. Vol. 152. 1995. Effective physician-patient communication and health outcomes: A review; p. 1423. [PMC free article: PMC1337906] [PubMed: 7728691]
  • Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. Journal of Family Practice. 9. Vol. 49. 2000. The impact of patient-centered care on outcomes; pp. 796–804. [PubMed: 11032203]
  • Street RL Jr, Haidet P. Journal of General Internal Medicine. 1. Vol. 26. 2011. How well do doctors know their patients? Factors affecting physician understanding of patients' health beliefs; pp. 21–27. [PMC free article: PMC3024116] [PubMed: 20652759]
  • Street RL Jr, Makoul G, Arora NK, Epstein RM. Patient Education and Counseling. 3. Vol. 74. 2009. How does communication heal? Pathways linking clinician-patient communication to health outcomes; pp. 295–301. [PubMed: 19150199]
  • Stremikis K, Schoen C, Fryer A-K. A call for change: The 2011 Commonwealth Fund survey of public views of the U.S. healthcare system. Washington, DC: The Commonwealth Fund; 2011. [PubMed: 21476323]
  • Toussaint J. Health Affairs (Millwood). 5. Vol. 28. 2009. Writing the new playbook for U.S. health care: Lessons from Wisconsin; pp. 1343–1350. [PubMed: 19738250]
  • Weingart SN, Pagovich O, Sands DZ, Li JM, Aronson MD, Davis RB, Bates DW, Phillips RS. Journal of General Internal Medicine. 9. Vol. 20. 2005. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents; pp. 830–836. [PMC free article: PMC1490203] [PubMed: 16117751]
  • Weingart SN, Zhu J, Chiappetta L, Stuver SO, Schneider EC, Epstein AM, David-Kasdan JA, Annas CL, Fowler FJ Jr, Weissman JS. International Journal for Quality in Health Care. 3. Vol. 23. 2011. Hospitalized patients' participation and its impact on quality of care and patient safety; pp. 269–277. [PMC free article: PMC3140261] [PubMed: 21307118]
  • Weingarten SR, Henning JM, Badamgarav E, Knight K, Hasselblad V. British Medical Journal. 7370. Vol. 325. 2002. Interventions used in disease management programmes for patients with chronic illness which ones work? Meta-analysis of published reports; p. 925. [PMC free article: PMC130055] [PubMed: 12399340]
  • Winakur J. Health Affairs Blog. Jun 18, 2012. [August 31, 2012]. The transition abyss. http:​//healthaffairs​.org/blog/2012/01/18​/the-transition-abyss/
  • Zikmund-Fisher BJ, Couper MP, Singer E, Ubel PA, Ziniel S, Fowler FJ Jr, Levin CA, Fagerlin A. Medical Decision Making. Suppl. 5. Vol. 30. 2010. Deficits and variations in patients' experience with making 9 common medical decisions: The decisions survey; pp. S85–S95. [PubMed: 20881157]

Footnotes

1

Patient Protection and Affordable Care Act, Public Law 111–148, 111th Congress (March 23, 2010).

2

Patient Protection and Affordable Care Act, Public Law 111–148, 111th Congress (March 23, 2010).

3

The term food desert refers to neighborhoods and communities where access to affordable and nutritious foods is limited (IOM, 2009).

4

Note that in Chapters 6-9, the committee's recommendations are numbered according to their sequence in the taxonomy in Chapter 10.

Copyright 2013 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK207234

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