Patient and Family Engagement in Chronic Care
Engaged patients, famillies and caregivers can help lower medical costs, reduce hospital admissions, and improve health behaviors. The patients' health has a greater chance for improving when the family and caregivers can better communicate the importance of incorporating a healthier diet, increasing levels of physical activity, and medication compliance for chronic diseases management. However, recent data on health care consumers found that 1 in 3 patients are disengaged in their own care. Meaning that patients did not have a clear understanding of their diagnosis and conditions, and they weren’t actively working towards better self-management and care.
Language, cultural background, and previous experiences in healthcare can have a signficant positive or negative impact on one's approach to health care. With patients, families, their caregivers, and health professionals working in active partnership at various connecting points of care older patients with chronic conditions can have a more positive care experience, and realize reduced risks and complications. For example, during a hospital admission or discharge, providing patients and families with detailed information and walking them through discharge planning throughout the hospital stay can reduce issues post-discharge. Perhaps, more importantly, what really works is improved and ongoing post hospitilization communication that encourages patients and family members to participate as advisors. As the advisor, they become more aware of medication and community resources, recognize and connected with support services and health care professionals as a diversion to readmissio and acute care services?
Increasingly, health systems and independent practices have recognized the potential for improved health outcomes and patient satisfaction with enhanced patient and family engagement. Chronic Care Management (CCM) and Transitional Care Management (TCM)can promote stronger interaction and communication amongst older patients, families, and health professionals. For example, Care Managers can be actively involved in assessment and care planning that leads to better “handoffs” between hospitals and families, or between rehabilitation facilities and families. Care Managers can help older patients and their family with interpreting the cross-institutional complexities, coordinating and monitoring care on a monthly basis. This alone can boost patient and family awareness, interests, activity, and engagement.
Older patients and even their family caregivers can benefit from greater engagement in health-related activities instrumental to daily living. This can include, healthier eating, reducing the risk of falling during bathing, cleaner and safer toileting, and assistance with dressing. Care Managers can provide the kind on self-management education and care coordination support family caregivers can find valuable in helping to manage the care of individuals with one or more chronic illnesses. Together with engaged and proactive providers, Care Managers can draw in family caregivers and increase patient involvement to maximize the benefits of chronic care support.
About the Author
Joseph F. West, ScD, is a population health and data analytics leader with over 10 years of research and enterprise consulting experience. He is a recognized leader in the development of outcomes-based healthcare. Joseph has served as Chief Population Health Officer, Senior Epidemiologist, Program Director, and Adjunct Assistant Professor. As a consultant and content creator, his current work focuses on population health management (PHM), health information technology (HIT), care coordination innovation, and healthcare risk management.