Person and family engagement initiatives can nurture collaboration between patients, families, and clinicians to move toward goal-setting, better self-care management and outcomes in a person- and family-centered health system. Recently the Centers for Medicare & Medicaid Services (CMS) updated their Quality Strategy to advance the ongoing work to shift Medicare from paying for the number of services provided to paying for better outcomes for patients. One of the six goals outlined in the update was the Person and Family Engagement (PFE) Strategy which is to “strengthen person and family engagement as partners in care.”
The voices of patients and their family members are essential to improving health care systems, value-based care and enhanced chronic care management. As active participants in health care services, patients and family members can offer a perspective often overlooked during care transitions, in-home care, or self-management. Specifically, for older adults with complex chronic conditions and care needs, PFE care initiatives entail helping patients and family caregivers to become partners and allies in efforts to improve quality and safety. This may include identifying potential safety issues, reducing or eliminating risks, or developing preventive strategies for the home. The most promising PFE care initiatives enable hospitals, home care and other connected agencies and institutions to incorporate what matters most to patients and family caregivers to achieve long-term improvements in quality and safety. For example, PFE care initiatives can lead to improved patient outcomes related to reduced rates of preventable readmissions, medication adherence, mobility and pain control, emotional health, and symptom resolution.
One of the first steps in PFE strategy is patient activation or education. Chronic Care Management (CCM) and Transitional Care Management (TCM) care teams can help facilitate patient and family member knowledge and skills, as well as confidence for managing health care and performing specific health-related behaviors. CCM and TCM Care Managers can work with healthcare providers to motivate patients and family caregivers, provide direction, and offer the right tools and support.
Beyond information sharing, PFE core principles include dignity, respect, and collaboration on critical components of a patient and family-centered health care. Physicians and hospitals partner with Care Managers to plan, deliver, and evaluate mutually beneficial relationships and methods of communication (e.g. mobile messaging, home visits, routine phone calls,) among health care providers, patients, and family caregivers.
PFE care initiatives are proactive and partner decision-making with patients, family caregivers, and healthcare providers. Health care decision-making isn’t always limited to the patient and provider. Engaging patients in their own healthcare is recognized as a significant component in increasing quality, reducing costs, and making patients safer. Care Managers engaged in PFE care initiatives build care relationships that instill trust and inclusion of patients’ and family caregivers’ beliefs, values, preferences, and culture. PFE care initiatives lead to specific individual and organizational actions that foster behaviors aimed at achieving better outcomes.
Written by Joseph F. West, ScD on Tuesday, 20 December 2016. Posted in Patient and Family Engagement, PFE Care Initiative, TCM, CCM