Engagement for good health outcomes!

 What is Patient Engagement?

“No blockbuster drug can make a difference if a patient doesn’t take it,”  noted Donald W. Kemper, Founder and CEO Healthwise.  To get the patient to “take the med”, the patient must believe that taking it is something they want to do.  Engagement moves the patient towards such action.

Patient engagement is helping patients take a more active role in self-managing their disease.  Providers can better engage patients by establishing a person-centered not patient-centered partnership, as this encompasses the whole person and their life — their body, mind, spirit, family, and full health community.  Person-centeredness is needed if we truly want to be able to set up a positive partnership with that person to improve their health.  Nurses play a central role in engaging patients by facilitating the provider-patient communications and emotional disclosure.  More definitively, engagement occurs when the provider or health coach spends time exploring what is most important to the person and allow them to choose their own course of action on whatever health concern they wish—through inquiry, personal discovery and accountability.

Why is it Important? 

Patient engagement is the key to improving quality, efficiency and health outcomes.  The absence of engagement is associated with preventable deaths —a shocking 40% of deaths are due to changeable lifestyle factors.  Half of all patients do not follow physician referrals, and most (75%) do not keep their follow-up appointments. 1  These factors are related to behaviors, and are maladaptive behaviors that can be unlearned and replaced by new healthy behaviors that will prolong life.  We know that changing behavior is hard, but entirely possible through focused attention by the patient that is supported and guided by a trained provider or health coach. 

Not long ago, when a patient refused treatment they were called “non-compliant”.  Within this paternalistic framework, physicians would tell patients what to do and were expected to adhere to that unilateral advice without having any opportunity to question or redirect.  They might have even felt uncomfortable questioning authority.  We now know that this can no longer be an excuse to not fully engage people in their care. When a provider demonstrates commitment to the patient and is caring and understanding, the result is an increase in their engagement in the relationship and their health goals .2  In fact, the way providers now interact with and motivate patients is touted as the new 21st century healthcare breakthrough.  A growing body of evidence clearly shows that providers who engage with their patients achieve significantly improved clinical outcomes. 3  Furthermore, health care organizations that emphasize patient engagement can improve productivity and patient satisfaction. 4 

Patient engagement is evolving from a perk to an necessary part of healthcare practices, academia, and government. Major health reform initiatives are zeroing in on patient and family engagement.  These include Accountable Care Organizations (ACOs), Patient-Centered Medical Home (PCMH), and CMS Stage 2 Meaningful Use of the EHR Incentive Programs, and. In 2014, Stage 2 Meaningful Use will require providers to allow for increased patient and family engagement, electronic transmission of medical summaries, e-prescribing and lab results, and rigorous health information exchange so they can receive incentive payment 5

How to get buy-in from your patient:

  • Make it easy to connect with their doctor: deploy an online patient portal that provides access to medical records, lab and other test results, appointment scheduling, registration, educational resources, and online bill payment.  Compliance with ICD-10 and Stage 2 Meaningful Use, and other mandates is essential.
  • Empower your patients:  provide an effective space for the client to develop new insights into their own health and to create a specific plan to reach their goals.  The client is responsible and held accountable for taking action on their plan.  A health coach can effectively motivate and support the patient’s health behavior change.  Coaching can elicit internal motivation and connect health goals to life purpose, increasing the chance the new behavior will be maintained.
  • Bridge care to technology:  A growing number of companies use cloud-based and patient monitoring technology to obtain complete and timely medical data.  For example, Philips uses salesforce.com to help improve patient engagement in its new cloud-based telehealth platform that focuses on medical device and data interoperability.  It compiles data gathered from electronic medical records, home-based monitoring equipment, and personal devices such as Apple’s HealthKit. The process compels both providers and patients to work together in using these data to design an dynamic personalized care plan that works best for them.  This has already seen success in Banner iCare of Arizona a pioneer accountable care organization (ACO).  As Marc Benioff, CEO of salesforce.com observes:

”We have entered a new transformative era for healthcare, and technology is enabling the industry to connect to, care for and engage with patients and each other in a profound new way…We are creating an open health platform and ecosystem to benefit everyone that cares about one of the most important issues of our time.” 6 Eric Wicklund


1 Anand K, Parekh, “Winning their trust”, N Engl J Med 2011: 364:e5June 16, 2011

2 Duke Integrative Medicine

3 James, J. “Patient Engagement.” February 2013. Health Affairs/Robert Wood Johnson Foundation. Available at: http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/02/patient-engagement.html

4  http://www.athenahealth.com/knowledge-hub/patient-engagement/what-is-patient-engagement.php#sthash.cZwrhnWg.dpuf

5 http://www.cms.gov/eHealth/downloads/eHealthU_EPsGuideStage2EHR.pdf;   http://www.athenahealth.com/knowledge-hub/patient-engagement/what-is-patient-engagement.php#sthash.cZwrhnWg.dpuf 

6 Patient engagement: The unifying link in telehealth. August 20, 2014 | Eric Wicklund – Editor, mHealthNews; http://www.mhealthnews.com/news/patient-engagement-unifying-link-telehealth

What is a Health Coach and why do I need one?

Our current health care crisis shows that despite the top dollar spent on health care and technological advances, chronic diseases are on a steep rise.  The rate of diabetes rose by 50% in the last 30 years and will double again by 2050.  Heart disease kills 1 American every 37 seconds;  and 1 of every 3 Americans is obese.  These are related to unhealthy lifestyle choices.  We know how hard it is to make and keep healthy behaviors, and our health system is not set up to help them address the complex factors impacting these lifestyle choices.  Physicians have under 10 minutes to talk to their patients, only enough time for crucial medical recommendations.  Recommendations or information alone is insufficient incentive or resource for actual behavior change.  Physicians also are not trained to engage patients in health behavior change and patients often do not expect to participate in their own care.  This phenomenon of people not feeling motivated or empowered to direct their own care is called low patient engagement and activation.  Our healthcare system is missing a healthcare professional available with expertise in health behavior change and the skills and the time necessary to provide patients with the opportunity to discover their own direction, motivation, and support in reaching their goals.  To help meet this need, health coaches are trained to help people develop their individualized care plans focused on healthily lifestyle changes. 

Why would I ever need a Health Coach?

Health Coaches can understand your story.  Each of us has a unique story about our personal journey through life; we might also have a mission or purpose, a dream to fulfill.  Somewhere along the way, you or your loved one (or patient) was derailed off the path, disrupting the balance in your life.  This might have been due to an accident, stressor or life-changing event, or just bad luck.  Such events might not manifest initially, but may over time fester into maladaptive coping skills (i.e. smoking, drinking, overeating, or other addictive behaviors), discouragement, a sense of loss of control and possibly even a dependency on others.  Regardless of the specific cause or effect, you are where you are now…And now, you might be suffering from a chronic condition that has you and your loved ones overwhelmed. You might feel at a loss of where to turn for help.  Hospitals and rehab facilities treat your problem when it flares — but this feels just too little, too late. Your primary care doctor sees you for check ups, tests, and referrals for specific problems— but might not be able to take the time to probe deeper into all the challenges you face and why those things became challenging in the first place.  Who is there to see you through the time spent at home between visits, when you are resorting to the usual remedies that aren’t the type of cure you need?

What is a Health Coach?

 An Integrative Health Coach works in a dynamic partnership with clients to help them achieve and sustain optimal health and vitality. Our clients are living with conditions like cancer, heart and lung disease, cancer and diabetes.  Since most of these conditions are affected by lifestyle choices, research has shown that health coaches help such clients with lifestyle behavior change within a holistic framework of health. Significant improvements in dietary, exercise and weight management, and medication compliance behaviors were found in these studies.  The key elements to success were goal setting, motivational interviewing (which is part of health coaching), and collaboration with health care providers (Olsen JM, Nesbitt BJ).  


Integrative health coaches work with the Wheel of Health, developed by Duke Integrative Medicine, to examine the areas that influence their health.  The areas include: relationships, personal/professional development, exercise, environment, spirituality, nutrition, and mind-body connection.  Health coaches empower clients by building on their strengths in any of these areas so they can achieve the change they desire.  Together, they design a care plan that allows the client to work at their own pace.  The process takes time, sometimes up to six months with weekly face-to-face meetings or teleconferencing.  Regardless, your health coach will see you through the day-to-day, when you are home, to gently guide you back on track to the healthiest YOU!

 Olsen JM, Nesbitt BJ. Am J Health Promot. 2010 Sep-Oct; 25(1)e1-e12. doi: 10.4278/ajhp.090313-LIT-101.


Telehealth Is the Future Now

 What is Telehealth? 

Telehealth is the integration of telecommunication systems into practice of protecting and promoting health, while telemedicine is the incorporation of these systems into curative medicine” (World Health Organization, 1997)

 How is it used?

First used successfully in the military to provide care for wounded soldiers in the field, telemedicine is expanding not only within the government but spilling over to the private sector.   You can guess what’s driving this enormous change in how we deliver care — the pressure to cut costs!  The move towards telehealth is also prompted by Obamacare pressures to improve quality, reduce ER visits and readmissions, and allow for better access to care by the elderly, disabled and rural residents. 

Patients who find it hard to visit a doctor or specialist can now teleconference their office for personalized medical advice…from the comfort of home.  When heart failure patients are remotely monitored on a daily basis for any subtle changes in weight or vitals, their doctor will be alerted immediately and will make timely adjustments in their diuretic and blood pressure medications to keep them from returning to the hospital with fluid overload.  Providers can push text messages to clients needing a daily nudge with their diet and exercise regimen and help them stick to an exercise and diet plan they designed with their providers.  This technology is an excellent way to deliver patient-centered care.  How many times has a simple injury or infection been ignored because it was a hassle to see the doctor, only to have it explode into a fulminating painful medical emergency?  With monthly prepaid contracts with the primary doctor, people will be less likely to delay seeking help and more inclined to fire-off a text or video call to their provider that is covered in their plan.  

Real-time communication using online voice and video interactions or “teleconferencing” allows providers to conduct consultations and deliver care, health education and health coaching at a distance.  Providers can also gather real-time data from patients through store-and-forward imaging, streaming media and remote wireless devices that detect subtle day-to-day changes in their physical and mental states.  

Patients and providers can save a lot of time and money engaging in this electronic information exchange.  They use a variety of platforms that suit the needs of both provider and client, such as smartphones, mobile apps, cloud-computing, tablets and laptops.  For $49 per cyber visit, people seeking medical advice on common symptoms like coughing or on how to better manage their chronic illness can quickly access a doctor 24/7.  To enroll, they simply use their smartphones to download a mobile app such as “Amwell” by American Well. 

What does the research show on its effectiveness?

Studies on hypertensive and diabetic patients that were telemonitored at home reported a significant decrease in blood pressure and glucose level, respectively.  Also, cardiac patients on such monitors showed significant improvement in their quality of life.  Data transmitted is reliable and well received by patients.  Research on home-based telemonitoring of chronically ill patients is promising; its data is reliable and accurate, it empowers and influences their behaviors, and this technology might improve their medical status.  

What are the laws on telehealth?

Reimbursement for telehealth services is crucial in its expansion.  Medicaid reimbursement for telehealth services is required on some level in a total of 43 states and the District of Columbia.  Telehealth is covered by private insurance plans that are based in 19 states and the District of Columbia, and soon in Arizona.  Fortunately, Michigan has passed laws to allow for both state and private insurance reimbursement for telehealth services in the state.

Further reading:




Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base. Guy Paré, PhD, Mirou Jaana, PhD, and Claude Sicotte, PhD


Why do we need Care Coordination?

What is Care Coordination?

Care coordination is the effort by multidisciplinary teams of two or more providers working with the patient to facilitate  appropriate delivery of healthcare services to improve quality of care and reduce hospital admissions. (Technical Reviews,  No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al. Rockville (MD): Agency for Healthcare Research and Quality (US)2007 Jun)

The Problem:  Fragmentation

The cost of caring for people with complex medical needs is spiraling out of control.  We spend 17.6% (and rising) of our GDP on healthcare.  The WHO ranks the US #1 in healthcare expenditures, yet our healthcare system is in 37th place behind Canada and Costa Rica.  Most of these healthcare dollars (84%) were spent on chronic illnesses…increasingly being treated in the outpatient or home setting.   Such treatments are inadequate and a fraught with insufficient care coordination, resulting in poor care quality. 
The typical Medicare beneficiary sees 2 primary care physicians and 5 specialists across 4 different practices; 50% of these folks are being treated for 5 or more conditions.  Over 19% of beneficiaries are readmitted to hospitals within 30 days of discharge.  These are the “complex need” patients that face high risk for fragmented and inadequate care, resulting in poor outcomes.  Many readmissions to hospitals can and should be avoided to save our tax dollars to the tune of $25 Billion each year.
What conditions and factors contribute to these high readmission rates?  
The top conditions are:   heart failure, COPD (lung disease), psychoses, intestinal problems, and post-surgical patients (cardiac, joint replacement, or bariatric procedures).  
The top factors are:  access to care post-discharge, inadequate discharge instructions, medication reconciliation, poor communication with and record transmission to care providers, medical errors in hospital.  Elders report problems with their medical care including medical errors 23%, poor communication 20%, readmission 15% and lack of follow-up 6% (AARP, 2009).  

The Solution:  Care Coordination

Beyond upgrading discharge processes, which many hospitals are in process of doing, patients need timely access to care in the community through Care Coordination and using telehealth technologies to transmit clinical data to providers and to exchange information to facilitate their self-management (National Priorities Partnership). 
Care coordination keeps patients on their care plan for follow-up visits and tests, medication, diet, and exercise. Old habits die hard and a care coordinator can help keep patients on plan to avoid setbacks, hospital readmissions, and ultimately higher health care costs. Through care coordination, the providers will engage the patient by viewing the patient as a whole, and giving the patient-client the opportunity to drive the course of their care plan and coaching them along towards better health.  If done well, the patient will experience continuity of care and communication as they move from a healthcare facility to home.
This is not new. The idea of coordinating care in the form of case management has been around for more than a century.  Primarily practiced by nurses and social workers, its goal has always been to coordinate complex, fragmented healthcare services to meet client the needs while controlling their costs  (Nurs Outlook. 1996 Jul-Aug;44(4):169-72. Kersbergen AL).  
This goes beyond redux….as care coordination is supported by Obamacare!  Provisions in the Affordable Care Act 2010 give financial incentives to primary care providers for their care coordination services that are value-based; and penalize hospitals for high readmission rates.  As research grows on how this can be done in a cost-effective manner, it is the hope this practice will spread to providers and hospitals.  Medicare could save $188 billion in spending through 2019 by preventing avoidable readmissions, based on early research from the Congressional Budget Office.

HAS Case Study:

Our 48 year old male, diagnosed with Type 2 Diabetes on insulin, heart disease, and depression, recently lost his job and health insurance.  With limited resources to care for his family, he could no longer afford the $800 plus monthly cost of medications and stopped taking his them.  His blood sugars soared to 400-600 range, risking serious complications and hospital admission.  When they came to us, the wife was distraught and overwhelmed. We obtained a stop-gap supply of insulin, test strips and syringes from a local charity and a few days later his sugars were lowered to low 200’s.  We also guided him on his unemployment application. Now on Medicaid, the couple feels more encouraged about taking further steps with nutrition education and our health coaching.