- Delivering meaningful patient engagement requires that patients play a key and active role in their own healthcare. As a part of that effort, healthcare professionals are increasingly looking to integrate shared decision-making into patient engagement strategies.
“Shared decision making is a key component of patient-centered health care,” according to the ONC. “It is a process in which clinicians and patients work together to make decisions and select tests, treatments and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values.”
Shared decision-making has received praise across the industry for its clinical benefits and positive impact on patient engagement. Baylor College of Medicine researcher J.S. Blumenthal-Barby has lauded shared decision-making as a driver of positive patient experience.
“Researchers and clinicians should be motivated to find ways to engage patients on the ethical imperative that many patients prefer to be more engaged in some way, shape, or form; patients have better experiences when they are engaged, and engagement improves health outcomes,” Blumenthal-Barby said in a March 2017 paper. “Reminding ourselves of those goals can help further the work of patient engagement.”
A research team led by Ming Tai-Seale, PhD, MPH, also acknowledged those clinical benefits, while adding that shared decision-making has a moral component.
“Shared decision making is not only conducive to reducing information asymmetry but also is ethically the right thing to do,” Tai-Seale and colleagues previously wrote in Health Affairs. “Systematic reviews of the preconditions for improving health care delivery have emphasized the importance of shared decision making as a mediator and moderator of health care quality.”
Implementing a valuable and patient-centered shared decision-making strategy will hinge on strong patient outreach. Clinicians working to improve shared decision-making should leverage patient education techniques, assess patient cultural and personal preferences, and involve patient family members and caregivers into treatment decisions.
Strong patient education, decision aids
Patients cannot effectively participate in shared decision-making if they do not fully understand their current health condition, all of the treatment options, and the potential side effects of each treatment option.
Healthcare professionals should foremost rely on their patient-provider communication skills to drive better patient education. Clinicians who clearly communicate key health and disease concepts are more apt to inform the patient of key topics.
Patient teach back, for example, helps the provider deliver health information and ensure the patient has retained that information. The technique calls for providers to first teach the patient about various pertinent health concepts. From there, clinicians should ask patients to repeat that information back to them in the patients’ own words.
Patient teach back accomplishes two goals.
First, it requires the patient to synthesize information so that she can describe it in a way that makes sense to her, promoting information retention.
Second, it allows the provider to assess where there are lapses in understanding. If the patient recalls information incorrectly, the provider knows to go back and review that fact with her.
Healthcare professionals also leverage specific tools for shared decision-making, such as decision aids.
Decision aids offer an understandable, comprehensive review of the patient’s condition and treatment options, and prompts her to think about how all of this will fit into her lifestyle needs and preferences, according to Peter Goldbach, MD, Chief Medical Officer at decision aid company Health Dialog.
“The patient is the expert on the patient, so the provider needs that information. The provider is the expert on the disease, so the patient needs that information,” Goldbach said in an interview with PatientEngagementHIT.com. “Together, they can do the best job in terms of finding an approach to a clinical problem.”
Research has confirmed the efficacy for decision aids as hosted on the patient portal. However, limited adoption has made these positive effects less pronounced than anticipated. Decision aid efficacy may be felt on a wider scale as more clinicians recognize the importance of shared decision-making and the need for tools to support their efforts.
Understanding patient cultural and personal preferences
Clinicians must also understand what the patient wants out of her care and interactions with providers. Assessing personal preferences should begin with how big of a role the patient wants to play in her care.
“Patients should be asked what role they want to play or what model they prefer,” Baylor’s Blumenthal-Barby advised. “More research is needed to identify patients whose preference for low involvement is authentic—in other words, on when to ‘nudge’ patients towards more involvement.”
Cultural differences can have a significant impact on patient preferences for care. Some cultures might value the clinician has the primary decision-maker. These patients may be less likely to want to engage in shared decision-making.
Clinicians should assess these values at the start of the care process, Blumenthal-Barby explained.
“Expressing values can be primed by having patients complete values clarification exercises. Creating a social norm that this is acceptable (‘normative messaging’) is imperative,” Blumenthal-Barby said. “All of these initiatives work to create a ‘2-way street’ between patients and providers. Cultural influences are an important consideration in the expression of values and questions.”
Providers should also reframe their idea of making treatment decisions. Making a healthcare decision is not always about what the provider wants to do, but about what will complement a patient’s life circumstances.
Providers need to uncover the motivating factors that drive a patient care decision rather than make assumptions.
“We really need to understand what patients are most fearful of and most concerned about and what they want to talk about because otherwise it becomes a very provider-centric program as opposed to a patient-centric program,” explained Corey Siegel, MD, a gastroenterologist at Dartmouth Hitchcock Medical Center.
Siegel conducted a 2016 study on his ulcerative colitis patients who faced two treatment options with significant, life-altering side effects. Siegel hypothesized that patients were conflicted about the side effects of the treatments, but a patient preference analysis revealed otherwise. Patients were fundamentally concerned with adverse side effects of their ulcerative colitis.
These results showed that doctors do not always know what is running through a patient’s head, and should not presume to know. Providers must always ask patients what their concerns are to determine how to best engage in shared decision-making, Siegel concluded.
Engaging family and caregivers
As with many aspects of patient care, involving family members and caregivers is important. Patients lean on their loved ones during times of uncertainty and when their health is ailing. Involving family members in the care decision-making process is a key strategy to supporting patient care and driving a positive experience.
“When patients and families are partners in planning and making decisions about their care, health outcomes are better, patient experience and satisfaction improves, and often, costs are lower,” said a group of experts from the Patient-Centered Primary Care Collaborative, the Institute for Patient- and Family-Centered Care, and Planetree.
The path to better family engagement in shared decision-making looks much like shared decision-making with individual patients. Providers need to offer ample education on the matter at hand and support a patient- and family-centered approach.
Clinicians also need to understand patient preferences for family involvement. In some cases, patients may not want high levels of family engagement.
Providers may also encounter families and patients with contrasting wishes. In these cases, clinicians must recognize that the patient is fundamentally in charge.
In a nursing home, an adult child may want her mother to regularly attend Bingo to make sure she is socializing and engaging in the community, Planetree’s Jill Harrison, PhD, offered as an example. However, the mother may have different priorities that Harrison says must be respected.
“While there are good intentions, there must be a balance between honoring what the patient wants and what the family wants,” said Harrison, who is Director of Research at Planetree. “We have to make sure, especially in long-term care, that we don’t disempower the patient from making her own decisions and charting her own life and rhythm. It needs to be a partnership.”
Shared decision-making is key to driving patient-centered care. Clinicians can ensure treatment adheres to patient wishes and ideally encourages better patient engagement by allowing patients a place at the decision-making table.
Healthcare professionals must use strong communication and education skills, incorporate patient preferences, and support family members and caregivers in care choices to drive effective shared decision-making.