The AlignMap Vision: Alignment Of All Healthcare Stakeholders
The No-Nonsense Summary
1. Infuse the principles of the Engagement Model into every aspect of the organization
2. Focus on implementing the best workable treatment plan for the patient rather than the patient’s compliance with an ideal treatment plan
3. Alignment of all stakeholders starts with explicit conversations between those stakeholders
The Engagement Model: An Expectation Of Patient Involvement
Implementing the best workable treatment plan for the patient requires the participation of the client.
While simplistic and so integral to to our Western notion of healthcare that stating this axiom explicitly seems a declaration of the obvious, the difficulty of implementing this principle is a major factor in the phenomenon of noncompliance.
In recent years, an increasing number of organizations invested in or providing healthcare (most pertinently, disease management programs) have realized that offering clients the option of participating in a health-enhancement program, regardless of how alluringly the invitation is offered, automatically excludes not only those who decide not to participate but also that significant fraction of the population who are not opposed to the plan but do not join because of passivity, social inhibitions, procrastination, lack of awareness, and other reasons that have little to do with the real or perceived value of the program.
Because such individuals are not opposed to the proposed program, they are likely among those who could most benefit from special protocols and activities that help them manage or prevent medical disorders.
Instead of expecting patients to self-enroll, the engagement model calls for the identification of all patients within a population who fit the criteria for the specific program, their automatic enrollment, and, only then, the extension of an opportunity to opt out of the program.
Disease management programs report participation of 90-95% of the population with the engagement model, compared to typical participation rates of 10-30% typical when patients are required to self-enroll.1
Even in the worst case scenario (i.e., everyone except those who would have signed up for the program on their own opts out), as many patients are reached, albeit at greater cost, as in the self-enrollment model. And, the self-enrollment model is not without its own problems; I have, for example, been antagonized by repeated and increasingly aggressive computer-generated written notifications from my health plan administrator, urging me to opt in to a special program for diabetics that I have decided would not provide an acceptable benefit/cost ratio in my case.
Using The Engagement Model To Create A Culture Of Cooperation
A key AlignMap percept is extending the Engagement Model beyond the purpose of driving participation in a specific program to infusing its principles throughout the entire healthcare system to create an environment in which cooperation is the expectation (making the offer of an opportunity to opt out all the more important).
The pragmatic significance of this concept for a specific clinical practice or healthcare organization is straightforward:
Strategies for Aligning Patient and Clinician
1. Cease Firing At The Wrong Targets
Just Say No To Snipe Hunts & Compliance Showdowns
The snipe hunt is a traditional practical joke in the Ozarks where I was raised. The victim is indoctrinated to the lore of snipe hunting, taught a special snipe call, and assigned the job of catcher, i.e., holding a gunnysack, while everyone else serves as beaters, driving the snipe toward the catcher. The snipe hunt takes place at night in the middle of a thicket or, preferably, a swamp. The “snipe” in “snipe hunt,” however, is a hoax; the beaters disperse to the local bar to wait for the victim, who is left in the dark holding the bag, to realize he’s been duped.
Similarly, the single-minded pursuit of improved compliance is typically unsuccessful because, as discussed here, the compliance being sought, the massive information published about it and the equipment sold to manage it notwithstanding, is, for pragmatic purposes, nonexistent. Consequently, even though the problem is noncompliance, the answer is not simply “fix the noncompliance.”
In fact, a direct assault on noncompliance is often counterproductive because of its potential for divisiveness. Given the nature of the patient-clinician relationship, the clinician is, by default, responsible for evaluating the quality of patient’s execution of the treatment. If compliance is the goal, how can the clinician even address adherence to treatment with the patient without implicitly blaming the client for treatment problems? When intoned in a compliance is good for you fashion, for example, healthcare recommendations can seem sanctimonious and condescending while a more vigorous, enthusiastic presentation is likely to come across as a attempt to “sell” or even bully the patient, Even using a neutral tone can make the clinician seem detached rather than caring. And if there has been no clinical progress or the patient’s condition has worsened, it requires a special skill to ask the appropriate question of patient – if he or she has actually followed the prescribed treatment plan since the last visit – without evoking the perception of an accusation.
Compliance-driven healthcare offers clinicians only two choices: (1) ignore noncompliance or (2) adjudge patients as compliant (“good patients”) or noncompliant (“bad patients”). The former alternative entirely precludes improvement while the second leads to either nihilistic inaction (“what can I do if the patient won’t cooperate”) or to the clinician-patient interactions featuring pleas, demands, arguments, and ultimatums, none of which are likely to increase adherence or support the patient’s overall alliance with his healthcare professional.
2. Aim Beyond Compliance At The Real Target
Ultimately, the purpose of any patient-clinician interaction is to provide the patient with the best healthcare possible; that’s the goal.
It’s a primary AlignMap percept, in fact, that a first step in achieving optimal healthcare efficacy is the adoption of this operational principle:
to implement the best workable treatment plan for the patient
Pragmatically, the shared goal of implementing the best workable treatment plan for the patient aligns patient and clinician in a joint effort to achieve a goal that is fundamental, identifiable, and important to both parties. It affords, in fact, the purpose (or, for the more philosophically inclined, the telos) of any healthcare intervention on whatever scale. In this scheme, compliance is relegated to a secondary, more appropriate role as a useful statistical measure rather than the end-point of the patient-clinician dynamic.
Further, the aligned patient and clinician are mutually and interdependently empowered as a function of this goal.
The patient is explicitly (and pragmatically) authorized the final arbiter of the treatment plan. To implement the best workable treatment plan for the patient, after all, only declares openly what has always been true, albeit acknowledged only tacitly if at all: the real treatment plan is the treatment plan the patient carries out. The patient’s involvement also directly increases the likelihood of the patient executing the agreed-upon course of treatment. Implicit in the notion of implementing the best workable treatment plan for the patient is the expectation that the patient understands and is capable of carrying out the components of that plan. There is also a growing collection of evidence demonstrating that patients who select their own course of treatment (from a clinician-approved menu of potentially beneficial treatments) are more likely to follow that regimen and have better outcomes than those who are offered only one treatment choice.
The clinician, as the healthcare expert, is responsible for not only informing the patient of the pros and cons of appropriate courses of treatment but also advocating those courses of treatment with the greatest chance of success for the specific patient. Further, the clinician is obligated to refuse to prescribe a patient-requested treatment if its risk exceeds its potential value because, applying the “first, do no harm” heuristic, the best workable treatment plan for the patient may be, quite literally, no treatment at all.
3. Pull The Trigger: Putting Alignment Into Practice
Refocusing on implementing the best workable treatment plan for the patient as the primary clinical goal requires a shift in perspective for clinician with its attendant cognitive and attitudinal adjustments. These shifts must then be orchestrated to play out in clinical practice.
The starting point in systematically realigning a practice is to consciously aim at this new target. Clinicians must talk overtly and specifically talk with patients about the objective of alignment. The same concepts should be published in materials provided clients, clinical and business staff must be familiarized with the notion, and issues at staff meetings must be considered in light of this goal. It must become the practice’s mantra. Such conversations facilitate the role changes of both clinicians and patients necessitated when the shared goal of interaction becomes to implement the best workable treatment plan for the patient.
The training of personnel, the interviewing techniques used in patient visits, the formation and integration of healthcare-enhancement programs, the patient education tactics, and the myriad of other specifics involved in this approach are beyond the scope of this Section.
- Given that disease management companies use high enrollment rates in their marketing and may even benefit directly by charging fees based on the number of patients enrolled, one may question these numbers and, perhaps more significantly, the extent and quality of participation when patients are automatically enrolled. Nonetheless, this phenomenon certainly correlates with clinical experience, and there are objective measures of participation (e.g., the rate of hemoglobin A1c levels completed for diabetic patients) that support the claimed advantage of the engagement model.↩
- Including but not limited to scheduling, screenings, vaccination programs, specific promotions, treatment, and patient education↩