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Patient Goals, Priorities Key for Chronic Disease Management

Chronic disease management hinges on patients making lifestyle changes, not hitting a certain metric.

chronic disease management

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By Sara Heath

- Taking a holistic, patient-centric approach to wellness is crucial to chronic disease management, according to recent research from the Christensen Institute. The paper argues that goal-setting outside of health outcomes will support a path toward better health.

Tackling chronic disease management is a major goal across the healthcare spectrum, primarily because it is such a widespread and costly issue, the researchers said.

“There can be no solution to the healthcare crisis that does not address America’s unchecked epidemic of chronic disease, which afflicts more than half our citizens and consumes 86 percent of the exorbitant $3.2 trillion spent each year on care,” wrote study authors Clayton Christensen, Rebecca Fogg, and Andrew Waldeck.

However, traditional approaches are proving ineffective, the trio said. Healthcare organizations are excellent at acute clinical interventions and treating patients when they fall ill. Acute interventions, coupled with a clinically prescriptive care management plan, are not creating the results the industry wants.

“To prevent and reduce the cost of managing chronic disease, the system must learn to facilitate change in individual behavior, which has the greatest impact on health status of any contributing factor, including healthcare, by a long shot,” the team asserted.

READ MORE: Top 4 Patient Motivation Techniques for Health Improvement

Integrating the “Theory of Jobs to be Done” will help change healthcare organization mindsets to tackle holistic healthcare and lifestyle needs, both of which are far more likely to create patient behavior change than clinical strategies.

The Theory of Jobs states that people only do things (or do nothing) to further their own goals, which individuals set based on their own personal priorities. In most cases, this does not mean hitting a certain metric on a screening or test, but attaining a certain life goal.

“It’s not health that people want, per se,” the authors explained. “Simply educating or reminding them about the negative health consequences of their behavior will not, in isolation, drive required behavior change. It’s something more than health, and something more specific, that people want. They want progress in their lives, as they themselves define it.”

The theory broadly states that clinicians should not try to push their patients to prioritize their health over jobs – defined as lifestyle goals and needs, not necessarily careers – they are already working toward. Rather, clinicians should work to uncover these jobs and assist patients in accomplishing them using skills and tools that will also better their health.

For example, an overweight patient working to improve in her career as a team manager might take public speaking classes or support her interpersonal skills by personally interacting with her team members. Those active improvements will benefit her health more than sitting and reading about managerial skills, which would likely yield no health benefit.

READ MORE: Overcoming Patient Barriers to Chronic Disease Management

A patient feeling lonely might join an athletic or walking group, or adopt a pet. Those individuals could also choose going on smoking breaks with their colleagues, the authors said, but that would have adverse health effects. It is up to clinicians to guide patients away from making the less beneficial decision.

Designing chronic care management plans around this theory has five key benefits, the authors said:

  • It takes into account a patient’s ability to change her behavior
  • It works with a patient’s pre-existing beliefs about health
  • It illuminates social determinants of patient health
  • It shows where a patient’s health priorities lay so doctors can help create paths that work within a patient’s lifestyle
  • It shifts the mindset from outcomes to progress, supporting the “long game” that is chronic care management

Many healthcare organizations have either implicitly or explicitly integrated the Jobs Theory into their practices, the researchers said. Although specific strategies varied depending on organization type and patient populations, there were some key commonalities.

Each organization had a health-centric purpose, meaning that the organization is centered on patient wellness as opposed to the types of acute services it provides.

“A health-centric purpose allows organizations to innovate however necessary to create health solutions addressing patients’ ever-changing jobs,” the authors wrote.

READ MORE: What is Motivational Interviewing in Patient Care Management?

Organizations also had an explicit process for jobs discovery, which aided clinicians in uncovering where patients want to improve their lives, and resultantly their health. Jobs, or patient goals, are based on unique patient viewpoints, priorities, and circumstances, and therefore discovering them “is a process, not an event.”

Surveys, focus groups, and big data analytics are not sufficient discovery tools because discovery is a very unique and patient-centric task.

Successful organizations also conduct hot-spotting, which is similar to risk stratification. Organizations focus health and lifestyle interventions on patients whose health improvement could yield the biggest cost savings.

“Hot-spotting facilitates a jobs-based approach because it demands that organizations gain a holistic view of patients’ circumstances,” the authors said. “This in turn sheds light on both their Jobs to Be Done, and the medical and nonmedical factors affecting their health, so that the organization can develop health solutions that address both.”

Once the patient goals or jobs have been identified, successful organizations integrate key resources.

“In healthcare, integration can encompass a wide range of resources, including clinical professionals, nonclinical professionals such as health coaches or peer mentors, data and Health Information Technology, physical space design, community social services, and patients’ social networks,” the researchers explained. “Astute integration specifies how each of the relevant resources must work with every other resource to promote patients’ long-term health.”

Organizations also integrate social and community mechanisms in their wellness programs. Patients typically like to connect with peers while making health improvements, and chronic care solutions can be more effective when social interaction tools are leveraged.

Supporting overall patient jobs or goals, not simply clinical metrics, will ensure that chronic care management strategies successfully fit into patient lifestyles. If a patient makes a positive wellness change because it aligns with her highest priority, it will be easier to improve her health. Ultimately, this is the goal of successful chronic care management.

“There’s a cavernous gap between the kind of care people need to avert or address chronic disease, and the episodic, acute care our traditional healthcare system is designed to provide,” the researchers concluded. “Innovators can bridge this gap by creating health solutions patients have the capacity to embrace, and which unleash their potential to manage their health more effectively and independently.”

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