This document discusses different styles of patient-centered care: directive, shared, and facilitated.
The directive style treats patients as passive recipients who submit to tests and treatment without understanding. The shared style engages patients as participants who understand options and are involved in decisions. The facilitated style empowers patients as responsible managers of their own health with support from doctors.
Moving along this continuum requires training doctors in new skills, empowering patients to access evidence and question, and making systems more flexible to provide treatment choices. While challenging, a facilitated model may achieve the greatest benefits like prevention and demand management, through listening to patients and providing tools for shared decision making.
2. Styles within Evidence Based Medicine
the patient experience
• Directed – passive patient
• Shared – participating patient
• Facilitative – responsible patient
3. Styles within Evidence Based Medicine
the patient experience
• Directed – passive patient
• Expected to
submit to tests without understanding them
accept treatment because that’s what’s on offer
fulfil system requirements, targets and outcomes
be a case or record, not a person
be treated episodically
4. Patient centred care tools
style of medicine: directive
Doctor and
system
decisions
Pathways
and guidance
as Rules
patient role: passive
System
management
Controlled
information
delivery mode: reactive
Focus on records/clinical outcomes
Cumulative/episodic
5. Styles within Evidence Based Medicine
the patient experience
• Shared – participating patient expects to
understand tests
understand treatment options
understand risks and benefits
understand the likelihood of occurrence
have fears and preferences taken into account
have an opportunity to discuss and consider options
be part of any decisions ‘about me’
be a person first, a case second
be able to exercise choice
6. Patient centred care tools
style of medicine: shared
Doctor and
patient
decisions
Pathways
and
guidance
as
boundaries
patient role: participative
SDM
Decision
aids
delivery mode: informed
Focus on consultation and satisfaction
Episodic/incremental
7. Changes needed
passive to participative
Doctor
• New skills & Tools
Patient
• Activation to access evidence & empowerment
to question
System
• Flexibility & Provision of Choice of treatment
8. SDM Benefits (and costs)
• Benefits
– Adherence
– Less expensive options
- Greater satisfaction
Costs
- reconfiguration
- new demands
- new behaviours
9. Styles within Evidence Based Medicine
the patient experience
Facilitative – responsible patient expects
everything above and
the support to manage their own health
a service that reflect their needs
a say in the design of the service
a dynamic interaction via a plan
clear division and sharing of responsibilities
treatment of the person not just the condition
continuity across time and conditions
10. Patient centred care tools
style of medicine: facilitated
Patient choice
decisions
facilitated by
doctor
Pathways and
guidance as a
starting point
patient role: responsible
Self –management
support
Motivational
interviewing
Shared decision
making
Structured patient
education
delivery mode: planned
Focus on shared patient plan
dynamic
11. Changes needed
participatory to responsible
Doctor
• New attitudes, values & skills
Patient
• Taking ownership & control
System
• Support for patients in their choice of service
and care – co-creation
12. Facilitated medicine benefits (and
costs)
• Benefits
– Prevention
– LTC management
– Demand management
Costs
Reconfiguration
New demands
New behaviours
13. What produces the most significant
change?
• Training clinicians in skills to engage with
patients as partners
• A clear strategic message of support for
patient centred care
• Listening to patients about their experience as
the basis for change
• Some tools for clinicians and patients to
support the new process
14. Will it happen?
• Drivers for change
– Information technology
– Clinical technology
– Cost constraints in current system
– The Francis watershed
• So the opportunity is there!
Editor's Notes
EBM can be delivered in a number of different ways: the advent of Cochrane and NICE doesn’t on its on change anything
What kind of health service do patients want? And what role do patients want to play? They are unanimous that they don’t want this
This patient expectations and experience are shown in this model. Information is largely hidden from the patient who is processed through pathways which are not explained nor understood to achieve a system outcome. Not any longer acceptable.
What kind of health service do patients want? And what role do patients want to play? There is evidence that they quite like this, mainly from satisfaction studies. There is also evidence of system benefits.
This illustrates the shift in a number of key areas, notably the importance of information to ‘oil’ the process of sdm, the shift from system needs to patient centred ones (satisfaction) and the importance of the clinical encounter in involving the patient.
These are the main things that you might need to change and we know that at least the first two can be done. There is also evidence of benfits. But patients may want to go further than this, they might want
But patients might want more than this
What kind of health service do patients want? And what role do patients want to play? There is evidence that they will choose this style if they are given the choice
This diagram shows what such a system would look like. Based on choice the doctors role changes into a facilitaor, using a mltitude of engagement techniques – this has one major additional benefit: Prevention
Benefits mainly accrue in terms of continuity and demand reduction resulting from self management.
Costs will be incurred in any event.
The antidote to the complacent belief that we are already doing this is training for clinicians. Once they realise that they are not delivering patient centred care they start to address the issues.
Changing micro-systems only works if the rest of the system supports the change so where ther is dtrategic commitment we see systems and process realignment.
Where patients have a voice, whether in decisions about treatment or service provision, decisions are better particularly in terms of adherence.
Tools help best if they support a pathway and inform choices and provide ongoing support – so the right information at the right time helps to generate not just a better decision but a process for review involving joint responsibility.
Patients have spent a long time saying what they don’t want – they are now articulating what they do want.
The internet has democratised knowledge, it’s starting to provide choices, including self-care.
Advances in clinical knowledge has resulted not just in better treatment but more choices including what where, when and by whom.
We cannot afford to run a system which encourages dependency and neglects prevention and individual responsibility.
Francis showed us that the national treasure wasn’t working, it was letting people down at a very basic level. The root of the problem was an imbalance of power at every level from bedside to boardroom.
These drivers have unsettled the system and present a opportunity to build healthcare around people.
The message from MAGIC is that shared decision making is one of a number of tools that can both provoke change and harness it for patient benefit.
