Everyone strives to be “patient centered,” but truthfully, there’s been a bit of marketing spin on that, with not a lot of shift in institutional focus. CMS’s new regulations for home health really make the patient’s goals the meaningful centerpiece of the care plan. I have just returned from the New England Home Care and Hospice conference and was thrilled to see how much attention is being placed on shared decision making and patient engagement.
Motivational interviewing meets the care plan
Although they may not be calling it motivational interviewing, the required documentation is to list the goals that the patient hopes to achieve as a result of care.
- “I’d like to be able to work in my garden again.”
- “I’d like to have the stamina to go to church again.”
- “I’d like to go to my grandchild’s wedding.”
Requiring a discussion of personal goals paves the way for recognizing that behavioral changes (e.g., reducing salt in the diet, consistently doing one’s physical therapy exercises, regularly going to the Better Breathers meetings) are the means to achieve those goals. It removes the “should” and encourages an “I want to” attitude. And, according to the Agency for Health Care Research and Quality, it improves adherence and outcomes.
Teaching motivational interviewing
Many spouses and adult children have spent years feeling exasperated, frustrated that their ailing loved one is not following the doctor’s recommendations. By teaching family caregivers to ask about goals and shifting the focus, they are able to move from being a nagging relative to a partner in care. (See our e-library article “Your Changing Role” for family caregivers. Many of our clients use this as a staff training resource also!)
Engage, don’t tell
It’s amazing what a difference it can make to ask someone their thoughts about recommended changes rather than tell them what to do. Not only does it help the client move from an abstract list to actually envisioning themselves engaging in the activity, it also promotes self-care and ownership of the change. This is why all our educational resources have engagement prompts throughout, applicable for the patient or the family caregiver:
- For Staying abreast of the medication schedule: “What method do you use to track medications? How do you keep it up to date?”
- For Avoiding crises with congestive heart failure: “What is realistic for you to monitor every day?”
- For Preventing falls: Talk with the doctor: “What would you like to ask the doctor to order to help with preventing a fall?”
Reducing barriers, building confidence
A big advantage of asking these questions is that the care provider will learn about perceived obstacles that he or she might never have thought of. This makes way for joint problem solving to come up with solutions that the patient and family have confidence they can use. (Behavior change research has demonstrated that “self-efficacy”—confidence in one’s ability to accomplish a given task—is highly predictive of success in accomplishing a change. Having realistic strategies for overcoming barriers is key to increasing self-efficacy.)
Changing family behaviors
Sometimes it’s the family that needs to make a behavior change. For instance, the loving wife who insists that her husband eat even though he has late-stage cancer and is not hungry. Or the adult daughter, genuinely worried about her mom’s cholesterol, who insists mom continue with her low-fat diet even though Mom has advanced heart failure. Check out the examples of caregiver engagement in the Nutrition article of our serious illness e-library.
Quality of life moves upstream
When you think of it, aren’t these goals questions really quality of life questions (and depression resolution questions as well)? What gives you joy? What pleasant activities give meaning to your life? Instead of waiting for a terminal diagnosis, as a society we are starting to ask those questions earlier. Bravo!
Putting the person at the center of the Triple Aim
I think this new CoP regulation is a fine example of facilitating individualized care plans that are more likely to deliver better outcomes AND increased satisfaction. I have a lot of compassion for the burden of regulation felt by home health and hospice. In this case, however, I think it’s an enlightened rule, and I’m excited to support engagement and shared decision making in all our educational resources.