Why the Key to COACH is Patient Engagement

One of the key goals of the proposed Canadian Obesity Awareness and Control initiative for Health (COACH) is to engage Canadians with excess weight to help them better manage their health.

This objective is in line with growing recognition that patient education and self-management (with appropriate professional guidance) can not only dramatically improve health but also translate into very real benefits both for the individuals concerned and society as a whole.

Such impacts have now been demonstrated for conditions ranging from diabetes to depression – in all cases with better adherence to treatment, reduced medical costs, fewer hospitalisations, greater patient satisfaction and other measurable improvements in health status.

But there are obviously a number of requirements and caveats for patient engagement and self-management strategies to work.

Some of these are nicely outlined in an article by Deborah Chase, published in a recent issue of Quality Matters.

According to Chase:

“The need for patients to be involved in their care has increased in recent decades because patients are living longer and in some cases handling greater disease burdens. Patients must navigate complicated health care systems and make multiple choices about their clinical care, including how to monitor and manage their own conditions.”

Although the paper focuses on several US case studies, I believe that many of the tenets apply to patients anywhere.

As noted in the paper,

“The Center for Advancing Health, a Washinton D.C., based policy organisation, defines patient engagement as “”actions individuals must take to obtain the greatest benefit from the health care services available to them.”Patients must be involved in the process of care, and their behavior is as important to health outcomes as provider or policy actions.”

One of the tools that appears essential to improving self-management is the Patient Activation Measure (PAM), developed by Judith Hibbard at the University of Oregan, which is now increasingly used by health organisations both in the US and elsewhere.

“The Patient Activation Measure (PAM) consists of a 13-question survey that assesses the level of a patient’s confidence in chronic disease self-management. The results rank patients on a scale of 0 to 100, based on how engaged they are in managing their health, placing them in one of four activation categories. At the lowest level, patients often demonstrate low levels of confidence and weak problem solving skills. Programs for these patients tend to focus on small steps that build confidence, such as designing an exercise program that involves taking the stairs twice a day. At the highest activation level, patients are engaged in their care and the focus is on maintenance. Those patients may only need assistance in problem solving when unusually challenging situations arise, so that they may deal with those without compromising attention to their health.”

With regard to the importance of understanding a patient’s skill level for self-management, Hibbard is quoted as saying:

“When thinking about self-management of chronic disease, we assume that everyone can jump in the deep end and swim laps. But we need to assume that not everyone can even swim.”

Another important aspect of patient engagement is the issue of health literacy, defined by the Institute of Medicine as,

“the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

Research shows that in the US, one of three adults find it difficult to understand and use health information. (Regular readers may recall my recent post on the new vital sign – the ability of individuals to understand simple nutrition or prescription labels.)

A variety of novel tools that can inform, empower, and help patients better navigate their heath systems and improve self-management now exist.

One example described in the paper was developed by John Wasson of Dartmouth Medical School, consists of a Web-based tool for patient self-assessment which also enables patients to assess their confidence in managing and understanding their disease. Patients not only receive a summary of findings and a list of resources for more information on their specific conditions, but the summary also offers patients a list of questions to ask their doctor during their next visit.

All of these tools and resources recognise that health care can no longer be a one-way-street – the “expert” professional instructing the “patient” on how to deal with their problems.

For many clinicians this will mean a change in the way they practice – for many patients it will mean taking greater responsibility for learning about and self-managing their conditions.

Several models exist on how patient self-management can be accomplished. These can include the use of professional coaches (e.g. nurses, dietitians, psychologists, etc.) specifically trained in behavioural psychology. But they can also effectively rely on peer-champions and buddy-systems, where people who have the condition share experiences, resources, and motivation through their social networks to better manage their health.

This approach appears particularly suited to dealing with Canada’s obesity problem – not only is it unrealistic to expect all of the 6,000,000 Canadians with excess weight to be seen by “obesity specialists” nor is “seeing a specialist” ever a good model for managing a chronic condition that ultimately requires a remarkable level of engagement and self-management.

If COACH can help create a national network of informed, knowledgeable and enthusiastic ambassadors (youth and adults), who can act as local champions and become a living resource to others struggling with excess weight, much will have been achieved.

Beijing, PR China