If patient engagement is the new 'blockbuster drug,' why are we not seeing spectacular effects? A team of researchers from The Dartmouth Institute for Health Policy and Clinical Practice and the Berkeley School of Public Health at UC Berkeley recently conducted a study designed to help answer that question and to better understand how patient engagement and activation (PAE) practices --like goal-setting, motivational interviewing, and shared decision making--are being integrated into clinical practice. What they found was a great deal of positive sentiment about PAE among the healthcare professionals surveyed, but much less understanding and implementation of patient engagement and activation tools and approaches.
"Patient engagement has featured prominently in recent healthcare research and policy, probably most notably in the Medicare Access and CHIP Reauthorization Act (MACRA) legislation. Yet, there hasn't been much research to date on how patient engagement approaches are being integrated into new care delivery and payment models," says lead author and Dartmouth Institute Assistant Professor Manish K. Mishra, MD, MPH.
To address this gap, the research team assessed levels of patient engagement and activation at 71 primary care sites at two ACOs--the DaVita Healthcare Partners in Los Angeles and Advocate Healthcare in Chicago. They conducted 103 interviews with 68 healthcare professionals, including doctors, nurses, medical assistants, as well as, diabetic nurse educators, social workers, and site administrators. The researchers said they concentrated on particular aspects of PAE, such as, shared decision making, goal-setting, and motivational interviewing, due to The Dartmouth Institute's extensive work in these areas. They chose to focus on
ACOs because of their reputation for undertaking patient engagement activities. The interviews designed to measure understanding of PAE and barriers to implementation were conducted in May of 2015 and May of 2016.
In a report of their findings recently published in BMJ Open, the researchers say four dominant themes emerged during their analysis of the interviews: participants recognized and were well aware of PAE terminology; participants had positive appraisals of these PAE approaches; participants had limited understanding of specific PAE techniques including goal-setting, motivational interviewing, and shared decision making; participants reported or acknowledged partial implementation of PAE approaches.
While most interview participants expressed positive opinions about PAE and most (but not all) were comfortable answering questions about PAE concepts and skills, many had limited understanding of them--describing them in ways that didn't align with accepted definitions. Some clinicians, for example, described "goal-setting" as the assigning (without collaboration) of clinical targets to their patients, such as, losing a certain amount of weight within a time period. Many participants also often failed to understand the difference between general patient education materials (patient information) and patient-facing tools designed to help patients understand trade-offs when comparing treatment options.
Participants readily acknowledged that implementation of PAE was limited. However, they cited factors such as low levels of administrative support and lack of time as the primary barriers, as opposed to lack of understanding or training in PAE techniques. Researchers also described finding somewhat of a Dunning-Kruger effect, with health professionals and ACO leadership confident they are using PAE approaches, when, in reality, the in-depth, semi-structured interviews often revealed low levels of understanding and implementation.
"When PAE is misinterpreted as pressing patients to meet incentivized targets, which we found evidence of in our analysis, that sets the stage for conflict, frustration, and professional burnout. And, just as importantly, these types of incentivized targets can lead patients to become disengaged," Mishra says, adding that if healthcare organizations really want to achieve patient-centered care, they need to "move beyond a superficial understating of PAE."