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Meeting Patient Flow Demands with Creative Case Management
Uninsured Americans Raise Medicare Expenditures
Helping Patients Take Charge of Their Chronic Illnesses

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ARTICLE: Meeting Patient Flow Demands with Creative Case Management
QHR, Sep 18, 2007

It’s a familiar story. A hospital has to put its emergency department on “divert” status. Patients are stacking up in hallways waiting for inpatient beds to become available. The operating suites are running behind schedule, delayed because of overcrowding in the recovery room.

The American health system is in the grip of a chronic shortage: there are not enough beds. . . or are there?

Bridging the “capacity gap” is the current imperative that underscores the call for throughput reform.The challenge is to do as much as possible with the beds you have. At its heart, that challenge involves faster patient throughput: treating more volume with the same level of capacity. Even hospitals that have already shortened length of stay can realize substantial gains from an aggressive focus on operational performance. Many of these gains can be orchestrated by case management. Best estimates from the Health Care Advisory Board indicate that hospitals could create about 25 percent more “virtual beds” from faster throughput.

This white paper provides a framework for case management excellence, with six strategies to better align operations with your organization’s bed capacity goals for effective occupancy.

Responding to the Capacity Challenge

There is no one tactic that will lessen the stress of bed demand, but the mantra of “the right patient in the right bed at the right time” could drive a combination of solutions.

Ensuring appropriate inpatient admissions, pushing harder on length of stay, minimizing the use of inpatient beds for outpatient services and accelerating placement in post acute settings are the most immediate, straightforward sources of new capacity.

The most promising – and most difficult – opportunity to manage a capacity shortage is through expediting each patient’s course of care. These gains require the most careful attention to physician enfranchisement. “All hands on deck” has been a common thread in the most successful throughput improvement efforts. What makes them work is the broad participation of the staff best positioned to identify barriers and develop solutions; what makes them keep working is ongoing monitoring and ongoing teamwork.

Engaging Case Management in Throughput Reform

The QHR Model for Engaging Case Management in Throughput Reform has assisted multiple facilities in reinforcing specific tools and techniques at the core of patient flow.

The following case management initiatives support practices that will result in additional bed capacity and organize the effort for faster throughput.

Strategy #1: Make the right call: inpatient, outpatient or observation.

Overcrowding results when inpatient beds are filled with outpatients or observation patients. Some 10% of admissions nationally are “avoidable” – most are elderly patients with chronic diseases. Aggressively treating patients in an outpatient or ED setting can prevent unnecessary admissions.

Many throughput improvement strategies engineered by case management result in incremental gains – measured in length of stay reductions of hours, not days. Research has shown that shaving hours off LOS is a worth-while endeavor for multiple reasons.These hours taken off of patient stays are likely to be the most frustrating and least satisfying for the patient.That is certain to improve both patient satisfaction and quality of care. Most importantly, the mathematical reality of hours saved can turn into days. Very often three or four hours saved could mean the difference between admitting another patient or not.

WHAT TO DO

Screen admissions: Position a case manager to evaluate incoming patients’ acuity levels, determine patient status appropriateness and provide guidance to the physician as he or she determines the right patient status and bed type.

Designate beds for outpatient recovery: Manage the short stay patient without compromising inpatient beds by dedicating a separate pool of beds to the recovery of outpatient procedural patients. Patients experiencing complications from outpatient surgery might be admitted; having these beds gives you time to decide.

Implement an observation unit: Patients who need to be aggressively managed but do not need to be admitted (such as those with head trauma, abdominal pains or complications from surgery) should be treated in an observation unit.

Use a clinical decision unit: Also a form of observation, this type of unit is primarily used for analysis of chest pain. It can help you avoid unnecessary admissions through rapid assessment and intervention for these critical cases. Most facilities locate it within the ER where appropriate resources are available.

Strategy #2: Set the game plan: daily bed briefings.

This strategy gives your team a good handle, early in the shift, on current occupancy, planned admissions and discharges, and what is soft – other potential discharges and admissions. The concept of daily bed briefings is frequently used to bridge the gap between admitting and floor staff. The benefit of the practice is that your team can be more efficient working the same plan: getting discharge orders, lining up skilled nursing beds, planning coverage for later shifts. But there are obstacles to the success of this strategy, such as spotty attendance and staff resistance to “policing” of beds since this has been somewhat of a territorial
issue for quite some time.

WHAT TO DO

Form your team: Assemble representatives from all patient care areas, emergency room, operating room, nursing, admitting, bed control and case management daily to discuss current and expected census, anticipated discharges, final discharges and encourage coordination of resources between units. These meetings allow for a “best-guess” snapshot of day’s capacity and projected bed needs.

Keep it brief: Meetings should take less than 30 minutes and be held twice daily.

Be accountable: Maintain executive oversight. Be clear about who’s responsible for what. Unit representatives are expected to bring accurate information to these meetings and complete follow-up steps as agreed. Run effectively, the process resembles a game strategy session, with incredible teamwork. Leaving with assignments from the team, nurses and case managers negotiate between units to float staff as needed, with vendors to accept post-acute patients, or with payers to accept a rate or cover another day.The result is efficient operations for the hospital, a faster return home for the patient, and a more empowered staff.

Strategy #3: Fix processes: expedite care; reduce delays.

Hospitals realize house wide throughput gains by tightening care delivery processes and operational factors contributing to length of stay, with a particular focus on case management interventions and physician resource support.This strategy is highly effective for freeing inpatient beds by accommodating incremental admissions since the impact of each change is magnified house wide.

In recent years,ALOS measures have begun to level off, with many hospitals saying they’ve hit a floor on length of stay. A closer look reveals evidence to the contrary.3 High variability around aggregate DRG-level measures suggests plenty of opportunity left for most hospitals. Research and pilot studies point to three real time tactics presenting the most potential improvement for reducing ALOS: physician-based case management, access to a physician advisor and physician profiling.

WHAT TO DO

First, refocus case management on patients: We’re under such time demands to get patients in and out that sometimes we overlook the obvious.We might evaluate how many steps are in the home, whether the patient can keep up with her medications, etc., without stopping to question why this is her fourth admission this year. Could she need education about her condition? Does she know what she can do to manage it, or prevent another crisis? We may need to improve our interview and assessment skills.

Revisit physician rounding: Has your hospital done away with nursing rounding with physicians? If so, reconsider.This practice clarifies expectations. To make it happen, case managers often have to be assertive.

Leverage the physician advisor, your liaison: Often a semi retired physician, he or she has a real interest in quality and efficiency. This is your go-to doctor when you have a problem case or need direction. Reviewing the case, he/she will offer the attending physician an alternate plan, discuss and negotiate, acting as your advocate for the good of the patient and the hospital.

Profile physicians: This “score card” approach allows doctors to see how they compare to their colleagues regionally and nationally in terms of length of stay, cost per case and number and type of tests ordered. Scientists as well as caregivers and business people, physicians usually respond positively to solid information but reject less documented claims. Therefore the success of this initiative depends on beginning with reliable severity adjusted data and analyzing it with expertise.The best approach is to have the physician advisor present quarterly reports to the staff, and offer the option of further investigation.

Strategy #4: Take a team approach: all players on the field.

The most significant shortfalls of unit-based utilization review are its minimal contact with patients and its marginal impact on length of stay and resource consumption. In response to bed capacity demands, a supporting practice is to form multidisciplinary teams of physician, case manager and social worker. As a result, the case manager and social worker become integral components of patient care planning and are viewed as resources for physicians. The physician benefits by being treated as a partner in length of stay management and knowing which case manager to contact.

WHAT TO DO

Pick teams: Assign case managers and social workers to work individually with specific physicians. This arrangement allows the case management team to become accustomed to and complement the physician practice patterns.

Put your heads together: Have at least one member from each case management team round with physicians each morning.When the team meets as a group, discuss treatment, discharge plans and special needs.

Have a back up plan: In the event the team is unavailable, have the clinical care unit manager serve as a backstop for case management.

Document and study results: As case manager and physician review the aggregate physician performance data together, it becomes a much more meaningful experience .Working toward shared goals, they share a vested interest in the success of their work, as proven by patient outcomes and other performance indicators.

Strategy #5: Stay ahead of the game: morning discharges start the day right.

When patient admissions and discharges are misaligned, a bulk of patients requiring beds hit the hospital in advance of the discharge-ready patient pool. Jump starting patient disposition or placement planning within the first twenty-four hours of each stay will accommodate additional admissions by discharging patients earlier in the day.This strategy is very effective for maximizing the use of existing capacity and accommodating additional admissions if the facility is turning away patients at peak times of the day.

The patient who is deemed by the attending as “will discharge in AM if stable” can be discharged at 9 AM or 7 PM depending on time of physician rounding, diagnostic results reporting promptness, transportation arrangements and a multitude of other controllable factors. Proactive planning and information transfer can make the difference.

WHAT TO DO

Instill a “hotel checkout” mind-set: Patients and families must clearly understand the need to vacate the bed by a specified time. Operational refinements may be needed to ensure that the case manager and healthcare team confirm that the patient, family and physician are all ready for a morning discharge.

Mitigate the midday squeeze for beds: Case management should target two key facets of the patient discharge process: assembly of critical information for discharge ready patients and education of patients and families about the discharge process and expectations.

Be creative with the “late rounding” physician: Implement “tuck in rounds” where a physician designates patients for next day discharge on the prior evening.This strategy will help ensure discharge readiness and on-time checkout.

Dedicate staff to facilitate earlier discharges: Nurse practitioners can function as discharge expeditors with key responsibilities of rounding with physicians, writing and executing patient care orders in doctor’s absence with sign off by attending within specified time frames.

Strategy #6: Know your end-game: refine post acute transfers.

Some patients stay a little too long because we’re inefficient. A few end up staying way too long. . . because they don’t have an ideal place to go. Both represent significant opportunities. Placement is often compromised by internal factors such as incomplete patient profiles, bulky and labor intensive processes and cumbersome communication between providers.The first correction, and one that will help you correct all the others, is to instill a sense of urgency in your team.

WHAT TO DO

Dig into your avoidable delay data: Sort it by attributable cause and validate it. You’ll have an eye-opening experience that will spur your team to action. This data helps you understand why patients who could have moved on stayed in your acute care beds. There is a system or human reason for the failure. Is it that

  • Their families refused to take them home?
  • Their lab or radiology results weren’t available?
  • Nursing failed to prep them for a procedure?
  • A physician failed to write the order?
  • A bed was not available at the SNF?

Study this data and you’ll identify your best opportunities to improve. Once validated, diffusing this type of delay presents multiple obstacles and therefore should be approached by considering many options. Although local market availability of beds and patient funding can limit achievable gains, you can get creative with each individual case.

Stay positive: Some facilities have a concern about using avoidable delay data because it can come across as finger pointing.The answer is to keep the focus on improving.You may identify bottlenecks in a certain ancillary area; be careful to involve that department in the solutions you develop, and keep the process upbeat and the focus on the patient as you implement them.

Target difficult discharges: Long-stay cases are contributing heavily to your overall length of stay. Many have clinical and psycho-social needs requiring consistent dedicated resources. Use a SWAT team, comprised of physicians, case managers, social workers and executives, meeting twice weekly to discuss difficult to place patients.Work with the patients’ families to select the best options and to prompt earlier SNF referrals, minimize evaluation delays and encourage faster responses from providers.




ARTICLE: Uninsured Americans Raise Medicare Expenditures

WEDNESDAY, July 11 (HealthDay News) -- Americans who weren't insured before they reached age 65 and gained access to Medicare cost the program a lot more than those who did have health insurance, a new study finds.

Data on more than 5,000 older people from a national study found that the previously uninsured needed 13 percent more doctors visits, experienced 20 percent more hospitalizations and had 51 percent higher total medical expenditures after their care began to be covered by the government program.

"Providing health insurance coverage for these adults [before age 65] could not only improve their health but also partially offset the costs of expanding coverage," said Dr. J. Michael McWilliams, a research associate in the Harvard Medical School department of health care policy and lead author of a report in the July 12New England Journal of Medicine.

The report did not attempt to estimate the possible savings for Americans over 65 if earlier coverage had been provided to all. "Short of a randomized trial, it would be difficult to know exactly what the effect would be," McWilliams said.

However, health coverage earlier in life clearly would provide benefits in terms of Americans' quality of life, he said. "For uninsured adults in this age group, the consequences of being uninsured can be quite impressive," McWilliams said.

The boost in Medicare expenditure for the previously uninsured was concentrated among adults with some of the most common chronic conditions -- high blood pressure, diabetes, heart disease and stroke, according to the researchers. There was no comparable increase in medical care demands among adults who were uninsured during their 50s and 60s but had none of those conditions, when compared to a matched group that had medical insurance during those years.

In all, the study included 5,158 adults, 1,385 of whom did not have medical insurance before they turned 65 and 3,773 who did.

The greater health care needs for previously uninsured persons with chronic conditions persisted at least through age 72, McWilliams noted.

Another expert said the findings came as no surprise.

"This study demonstrates conclusively what common sense tells us -- that people with ongoing health care coverage are healthier people," said Robert M. Hayes, president of the Medicare Rights Center, a consumer advocacy group based in New York City.

Offering government health care insurance before age 65 "will mean that people entering Medicare will be in better health with less expensive health care needs," Hayes said. While newer studies "suggest that such coverage will provide savings on high-cost medical care, ultimately it is more an issue of values and morality than money," he said.

The Harvard report comes at a time when the future of Medicare is being hotly debated. According to the researchers, the program now covers nearly 43 million older and disabled Americans, with a 2006 cost of $374 billion -- 14 percent of the federal budget. Federal spending on Medicare is predicted to reach $524 billion in 2011.

Jonathan Weiner is professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore. He said he was disappointed that the Harvard report lacked any estimate of the potential Medicare savings for the over-65 group if coverage were provided earlier for the uninsured.

"I also would have liked more on its effect on the quality of life as well as the impact on length of life," Weiner said. "But I could hazard a guess that society would save money, and there is no question these people would be healthier and have a higher quality of life if they had insurance earlier."

Getting health insurance remains a challenge for people in the 60- to 64-age group, especially, Weiner said, because more than half are unemployed and thus outside the reach of company-provided coverage.

"Health care is especially expensive for this age group," he said. "Fixing this part of the problem clearly will not be cheap, and exactly where health insurance policy would impact longevity is unclear."

More information

Basic information on health insurance (including an estimate of the number of uninsured Americans) is available from the U.S. National Library of Medicine .

SOURCES: J. Michael McWilliams, M.D., research associate, Harvard Medical School department of health care policy, Boston; Jonathan Weiner, Ph.D., professor, health care policy and management, Johns Hopkins Bloomberg School of Public Health, Baltimore; Robert M. Hayes, president, Medicare Rights Center, New York City; July 12, 2007,New England Journal of Medicine.

Top

Washingtonpost.com
By Ed Edelson HealthDay Reporter
Wednesday, July 11, 2007; 12:00 AM



ARTICLE: Helping Patients Take Charge of Their Chronic Illnesses

The best thing you can do for your patients with chronic diseases is to let them run with the ball.

KEY POINTS:

  • The old models of care, where physicians tell patients what to do and try to motivate them to change, do not work.
  • Because patients' day-to-day decisions have a tremendous impact on their health, they must be active, informed participants in the health care process.
  • Physicians can help patients take charge of their conditions by encouraging them to set self-management goals.

Noncompliance has always been a significant challenge in chronic disease care, and it's one of the issues Family Care Network has had to confront as part of its diabetes quality improvement project, which FPM is following. This article is derived from a presentation the author made to the physicians and staff members of Family Care Network as part of that project. As you'll see, the author's solution to noncompliance is simply to render it obsolete.

It's been said that, as health care professionals, we take credit for our patients' successes and blame them for our failures. How often have you heard a colleague say something like, "I got Mrs. Smith's HbA 1c down to 7 percent, but Mr. Jones was noncompliant." The truth is that, in both cases, the responsibility is shared, but ultimately the patient has more control of the outcome than we do.

Think about two of your patients who have, say, type-2 diabetes. Focus on one patient whose condition is well managed and another whose condition is not well managed. What would you say are the differences between those two? Why is one more successful at controlling the disease than the other? Very often, if you examine it closely, the key difference is the patient's level of involvement and responsibility for his or her own condition.

The old models

Our health care systems are not always designed with the patient in mind and do little to empower patients to take charge of their conditions. Instead, they are based on an old acute-care model, where the patient presents to his or her physician and the physician tells the patient what to do to get better. It is a "do as I say" model of care, and the patient's role is fairly passive.

That model works fine for a good deal of acute care and in some other circumstances, but it doesn't work well for chronic illness. Having recognized this, many health care systems have tried a different model in which the focus is compliance, or adherence. This model does a better job of recognizing that the patient needs to do something, but it doesn't give the patient any more power. The health care professional is still very much the authority trying to get the patient to do what is needed; the patient's job is simply to be obedient. What we've found, however, is that you can't get patients to do anything. The motivation to change one's behavior -- even to take one's medication -- is largely internal. The patient is responsible and must take an active role in his or her own care.

Of course the idea of an active patient can be taken to the extreme. Some patients, in response to the old models of care that haven't been working for them, have become not just active patients but activists. They come to their visits with (mis)information from the Internet and other sources; and, although they are involved in their care, they are involved in an adversarial way. This doesn't create better outcomes, and it can result in an unproductive doctor-patient relationship.

The failure of the traditional models has led the health care community to ask, what kind of approach can we use to deal with chronic illness, recognizing that our influence over patients' behavior is limited and fairly temporary? In other words, how can we change chronic illness care so that it better fits with chronic illness?

The patient is the solution

We have learned over the years at our center that effective chronic illness care requires two things. First, it requires a team with the patient at the center. Second, it requires active, involved participants -- especially an active, involved patient. This model of care can be described using various terms -- empowerment, informed choice, patient centered -- but they all have the same underlying concept: The patient is at the center and is actively involved in his or her own health care.

But why can't we stick with the old models? Why does the patient need to be so involved? There are several reasons.

  • First , most chronic illness care does not even involve physicians and other health care professionals. Instead, it's estimated that between 95 percent and 99 percent of chronic illness care is given by the person who has the illness. On a day-to-day basis, the patient is in charge of his or her own health, and the daily decisions people make have a huge impact on patient outcomes and quality of life.

  • Second , as a family physician, you may know what's best for treating diabetes or asthma or congestive heart failure, but that does not mean you necessarily know what's best for an individual patient. Even in close doctor-patient relationships, you can't always know the details of your patient's lives: what's most important to them, what their other priorities are, what motivates them, what their financial situation is, and so on. Each patient is the expert in his or her own life.

    As a physician, then, you can think of your role as providing clinical expertise and information, collaborating with the patient to solve his or her problems and supporting the patient throughout the process. In other words, it's saying, "Here's what I know about diabetes. How can I help you put this in context in your life so that you can make decisions that will help you?" This new mind-set requires that you give up any illusion you may have that you have control of and are responsible for your patients. Instead, consider yourself responsible to your patients -- to tell them, to advise them, to warn them. You cannot make their decisions for them and you cannot make them change their behavior. Only they can do that.

  • Finally , we know from several studies that when patients are encouraged to be more involved and when their physicians are less prescriptive, patients do have better outcomes. We also know that this approach does not take any more time but, in fact, can be more efficient because the health care team is addressing the patient's agenda first -- and the patient's agenda is, after all, the real reason for the visit. 1

    In addition to being a more effective approach, it can also be a relief. As a physician, you may feel less frustrated because it is no longer your responsibility to make change happen. It is a joint process. When you create that partnership and get out of the role of simply telling patients what to do, you pave the way for the patient to make significant, lasting change.

Empowerment through education

It's very difficult for patients to do what they don't understand, so the first step in equipping patients to take on a more active role in their health care is to educate them. Start by communicating to patients that education is perhaps as important to their health as getting their prescriptions filled. They need to know all they can about their disease.

The old model vs. the new

Patient says:
Doctor responds:
OLD model NEW model
"I hate this exercise plan." "Then try walking after dinner every night with your husband for 10 minutes." "What do you hate about it? What would help you do better at it?"
"I don't think I can quit smoking." "Smoking is the leading cause of preventable death ..." "Why do you think that? What has happened in the past when you tried to quit? What concerns you most whenyou think about trying to quit?
"I haven't been able to test my blood sugar four times a day." "It's hard at first, but just keep trying. You really need to keep track of it." "What is preventing you from doing that? Do you know what the numbers mean?"

But just as patient-centered care can be more effective, patient-centered education is better education. The old education program, where you bring people in, sit them down and lecture to them, doesn't work any better than bringing them in, sitting them down and telling them to lose 20 pounds. Instead, the patient's needs should drive the education. For example, our center is testing diabetes education courses based entirely on questions from the audience. We do have a checklist of topics we want to cover, but we address those topics in the context of patient questions rather than through an impersonal lecture. Patients aren't interested in their disease from an intellectual perspective, as we are. They want to know about themselves. What does this mean to me? How's this different for me? How's it going to affect my life?

Four of the most important lessons patients with chronic diseases need to understand are the following:

1. Their illness is serious. There are still patients out there who believe they have the "not-so-serious kind of diabetes." If they don't believe it is a problem, they will never make changes to improve their health.

2. Their condition is essentially self-managed. Every decision patients make throughout the day, from what they eat to whether they walk or ride the bus, has an influence on their health. Communicate to patients that they are the most important individuals in managing their illnesses.

3. They have options. There is rarely one perfect way to treat a condition. In the case of diabetes, for example, patients can be treated through diet and exercise, oral medication, insulin and so on. Patients need to understand the different treatment options available and should be encouraged to look at the personal costs and benefits of each. Only the patient can decide if the benefits are greater than the costs.

4. They can change their behavior. Rarely do patients leave the doctor's office and immediately enact whatever change was recommended. The reality is that it often has to be spread out into a series of steps. Teach patients that significant behavioral changes can be made by setting goals, taking that first step and figuring out what you learn about yourself along the way.

Helping patients set goals

In the patient-centered model of care, the driving force behind each patient visit is the patient's agenda or goals related to his or her condition. Ideally, the goal is clearly displayed in the patient's chart, and each person who handles the chart plays a part in supporting the patient in that goal, asking, "How did it go? What have you done this week? How can we help you do better?"

You might be thinking, "My patients don't have goals," but they do. Even "noncompliant" patients have goals. Probably the best definition of noncompliance is a doctor and patient working toward different goals.

The process of setting "self-management" goals with the patient involves essentially two steps.

1 . Start at the problem. Rather than beginning the patient encounter focused on lab values or weight or blood pressure readings, begin by saying, "Tell me what concerns you most. Tell me what is hardest for you. Tell me what you're most distressed about and what you'd most like to change." You'll get to the lab values and other issues later, but it will be in the context of the patient's personal goal, which will make it more meaningful for the patient.

As you begin to get a sense of the patient's concerns, explore those issues together. Ask, "Is there an underlying problem? Do you really want this problem to be solved? What's the real issue?"

2. Develop a collaborative goal. Once you have worked with the patient to identify the real problem, your instinct may be to try to solve it, but don't. Don't try to fix it. Don't just say, "It will be OK." Instead, validate the patient's feelings and his or her capacity to deal with the problem, and continue asking questions that will lead the patient to his or her own solution. Ask, "What do you think would work? What have you tried in the past? What would you like to try?"

It's always more meaningful when patients find the "ah ha!" on their own, so give them that chance. Encourage them to come up with ideas first, then offer your own suggestions or additional information that they may need. You can say "this works for some people" or "have you tried this?" or "here's why I don't think that's a good idea." The important thing is to give the patient the opportunity to say "no" and to make the final decision on what goal to try.

Ultimately , at the end of the conversation, the patient should be able to tell you one step he or she is going to take. It should be very specific. If the patient says, "I'm going to exercise more," ask what that means. Will they exercise four times a week? What activity will they be doing? How far will they walk? Help them to come up with a specific plan that they have created for themselves. It may not be the ultimate goal you would have chosen for the patient, but it's one they are more likely to accomplish. At the next visit, then, you can build on that.

Who actually works with patients to set their goals, whether you or the nurse or the diabetes educator, is perhaps less important than the fact that patients are encouraged to be more involved. The emphasis on self-management goals suggests that the visit is for them . It is their agenda, and they are active participants in the outcome.

Empowering patients with information

One way to help patients focus and begin thinking about their health care goals is to talk with them about their individual health measures (e.g., blood pressure, LDL, HbA 1c ) and what those numbers mean. At our center, for example, we give patients a handout that lists the critical measures for their condition (ideal and actual), explains what those numbers mean and offers strategies for improvement. When faced with this information, patients can see for themselves where they are struggling and what they can do to better their scores.

Go to a sample handout here.

Unnatural instincts?

The patient-centered model of care, and the emphasis on empowering patients to find their own solutions, may go against your instincts as a physician. As health care professionals, we often feel most helpful when we've given advice. The truth is, however, that we don't really help people solve their problems or make lasting changes in their lives by telling them what they should do. Ultimately, patients need to find their own solutions and motivation and must take responsibility for their health. We must empower them to do just that.

Martha Funnell, a certified diabetes educator, is the director for administration at the Michigan Diabetes Research and Training Center, University of Michigan Health System at Ann Arbor. The MDRTC has been funded by the National Institutes of Health since 1977 and is one of six such centers in the United States.

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By Martha M. Funnell, MS, RN
Copyright © 2000 by the American Academy of Family Physicians.
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