ENGAGING & EDUCATING Patients

  • The most important component of SDM is effectively engaging and educating patients. There are many considerations, from determining health literacy, to assessing confidence levels, to ascertaining primary languages spoken, to weighing willingness to even participate. Communication strategies, tools, and best practices must provide pathways and resources to easily tackle it all.

    Research has shown us that patient engagement not only improves the patient experience, but leads to healthcare business success. Consider these outcomes:

    1

    The use of patient decision aids in shared decision making for preference-sensitive conditions has been shown to reduce patients' selection of major elective invasive surgery in favor of more conservative treatment options.

    2

    In a 2008 report prepared for the Commonwealth Fund, researchers estimated that, with the implementation of shared decision making for 11 preference-sensitive procedures, the savings to national health spending would be approximately $3.8 billion over 5 years and $9.2 billion over 10 years.

    3

    Introduction of SDM patient aids lowered cardiac ED admissions by 19% (https://patientengagementhit.com/news/shared-decision-making-reduces-cardiac-admissions-from-the-ed).

    4

    Patients who opt out of expensive treatments they deem unnecessary may be more likely to experience lasting results from chosen treatments.

    Source:

    Stacey D., Légaré F., Col N.F., et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014 Jan 28;1:CD001431. PMID: 24470076.

    O'Connor A.M., Llewellyn-Thomas, H.A., Flood, A.B. Modifying unwarranted variations in health care: shared decision making using patient decision aids. Health Aff (Millwood) 2004;Suppl Variation:VAR63-72. PMID: 15471770.

    Schoen C., Guterman S., Shih A., et al., Bending the curve: options for achieving savings and improving value in U.S. health spending. The Commonwealth Fund. Commission on a High Performance Health System. December 2007.

    https://www.commonwealthfund.org/publications/fund-reports/2007/dec/bending-curve-options-achieving-savings-and-improving-value-us

    Patient Confidence & Knowledge

    To easily assess the confidence and knowledge levels of your patients, consider using the easy-to-implement, quick, 4-question Health Confidence Scores Questionnaire.

    Health Confidence Score Questionnaire
    Download

    What do you do to assess both patient confidence and health literacy levels before determining the best approach to communication?

    Michelle Keating
    RN, OCN, MSCN
  • Quick Quiz
    1 /3

    Do your patients, who are engaged or confident in their treatment plan, realize better outcomes?

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  • Assessing Patient Willingness to Participate

    Studies show that a patient’s knowledge, skills, and confidence, often referred to as a measure of patient activation, are predictive clinical indicators, and chronic illness patients who are less active, are more likely to experience issues with their coordination of care.

    Tips for determining your patient's engagement level

    What are some tips for other healthcare professionals like yourself?

    Michelle Keating
    RN, OCN, MSCN

    Screening for Depression

    The emotional toll of a cancer diagnosis can impede a patient’s ability to collaborate in decision making. The Patient Health Questionnaire-2 (PHQ-2) is an easy-to-administer 2-question survey to screen lung cancer patients for depression.

    Over the last 2 weeks, how often have you been bothered by the following problems ?

    •  
      Not at all Several days More than
      half the days
      Nearly
      every day
    • 1. Little intrest or pleasure in doing things
    • 2. Feeling down, depressed or hopeless

    The PHQ-2 score is obtained by adding the score for each question, scoring each as 0 for "Not at all" to 3 for "Nearly every day, with a total of 6 points possible. Patients who score 3 or higher should be referred for further mental health evaluation.

    Source:

    Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener. Medical Care. 2003;41:1284-92. Adapted from instead of the word source" and hyperlink the tile of this article to the pub med article link: https://www.ncbi.nlm.nih.gov/pubmed/14583691

  • Quick Tips

    What to do when your patient doesn’t want to be engaged?

    Encourage patients to audio record the appointment so they can play it back later.

    What do you do when your patient doesn’t want to be engaged? Have you ever encountered a patient like that?

  • The Methods and Importance of Communication

    Results from our patient interviews: 67% of men preferred in-person communication with their physician; while women were open to more means of communication including email, phone, and in-person communication.

    As identified in our common barriers section, an important starting point to communicate with patients is having a conversation on values, to better understand patient priorities and preferences.

    Michelle suggests approaches to conversations on values with patients

    Michelle Keating
    RN, OCN, MSCN

    Consider the important functions of patient-clinician communication

    Function Description
    Fostering
    Healing
    Relationship
    Developing a patient-clinician relationship that is characterized by trust and rapport is critical to patient-centred communication and shared decision-making. This involves mutual understanding of patient and clinician roles, as well as clinician self-awareness and provision of emotional support, guidance, and understanding.
    Exchanging
    Information
    The cancer care team should ascertain patients' informational needs. Conveying information to patients can be facilitated through the ask-tell-ask method, an approach described in the section on prioritizing clinician training in communication. The exchange includes the cancer care team's provision of accurate prognostic information and treatment options, realistic expectations for response to treatment, and the cost of cancer care to inform patients' decisions.
    Responding
    to Emotions
    The cancer care team should recognize and respond to patients' emotions, which involves verbally expressing understanding, legitimizing feelings, and providing empathy and support. This also includes the development of a psychosocial care plan and linking patients to psychosocial care, if they experience high levels of emotional distress, anxiety, and depressive symptoms.
    Managing
    Uncertainty
    Clinicians play an important role in reducing and managing the uncertainty associated with cancer care. This can include cognitive behavioral interventions to help patients cope with this uncertainty and, if possible, improve understanding.
    Making
    Decisions
    Shared decision making involves three processes—information exchange, deliberation, and reaching a final decision. A patient’s decision often extends beyond medical issues and includes factors, such as finances and the expense of treatment and impact on employement and family. The logistics of scheduling and receiving cancer treatment can be an enromous strain for patients, families and caregivers; can disrupt family life; and may require negotiations with employers for time off or flexible work schedules.
    Enabling
    Patient
    Self-Management
    The cancer care team should provide individuals with resources to be proactive in their care. Examples of self-management tools and enablers include cancer care plans, survivorship care plans, and patient navigators, who assist patients in overcoming health care system barriers and facilitate timely access to health care services.
    Source:

    C-Change. Cancer patient navigation overview. 2005. [September 26, 2012].

    https://www.ncbi.nlm.nih.gov/books/NBK202146/table/tab_3_1/?report=objectonly.

    The conversation is different when discussing treatment versus palliative or end-of-life needs.

    Michelle Keating
    RN, OCN, MSCN

    Resources clinicians can use to support discussions on transitioning patients from treatment to palliative care.

    Michelle Keating
    RN, OCN, MSCN

    How to identify and refer patients to support groups/social media groups for education and patient support?

    Michelle Keating
    RN, OCN, MSCN

    Consider some of the examples of communication strategies clinicians can use to present complicated information to patients.

    Strategy Description
    Absolute risk Patients and caregivers are better at comprehending absolute risk than relative risk. Relative risk compares risk in two different populations. For example, people who smoke are about 15 to 30 times more likely to develop lung cancer or die from lung cancer compared to people who do not smoke. In contrast, absolute risk represents an individual's overall risk. For example, the risk that a woman who is 40 years old will be diagnosed with breast cancer during the next 10 years is 1.47 percent (or 1 in 68 women).
    Graphical formats Graphs can help patients and caregivers comprehend risk. Some graphical formats are easier for patients and caregivers to interpret. For example, pictographs (diagrams representing statistical data in pictorial form) improve patients' and caregivers' comprehension compared to bar graphs or pie charts.
    Rare events Comparing the likelihood of a medical event to the likelihood of a commonly understood rare event can help patients and caregivers understand risk. For example, “an individual has a 1-in-10,000,000 chance of getting struck by lightning, and about a 1-in-100 chance of dying, if they smoke 10 cigarettes a day for one year.”
    Multiple formats Presenting patients and caregivers with complicated information in multiple formats improves comprehension. For example, clinicians can present information as both percentages and as frequencies, and numerical information can be presented both orally and visually (e.g., in a graph).
    Read back When clinicians ask their patients to repeat the information they heard, rather than just ask whether they understood the information, comprehension improves. Repetition requires patients to demonstrate to the clinicians that they understand the information. It also gives clinicians the opportunity to clarify information or emphasize necessary details.
    Videos Clinicians can use videos to provide realistic visual images of various treatment options and outcomes. For example, a study evaluating the effect of a video on the cardiopulmonary resuscitation (CPR) preferences of patients with advanced cancer found that patients who watched the video had improved knowledge of CPR and more confidence in their health care decisions, compared to patients who did not watch the video.

    Additionally, consider developing a cancer care plan to facilitate your communication of key information to patients and assist with communications. These plans can also be imported into Electronic Health Records (EHRs) and assist in coordination of care with support team members, including primary care.

    Cancer Care Plan
    Download
    Source:

    Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population; Board on Health Care Services; Institute of Medicine; Levit L,Balogh E, Nass S, et al., editors. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington (DC): National Academies Press (US); 2013 Dec 27. 3, Patient-Centered Communication and Shared Decision Making. Available from:

    https://www.ncbi.nlm.nih.gov/books/NBK202146/

    Importance of Providing Feedback

    Michelle offers her thoughts on regular feedback for the patient and the importance of patients/caregivers receiving feedback regularly.

    Michelle Keating
    RN, OCN, MSCN

    As a clinician, do you want to receive feedback from your patients regularly?

    Michelle Keating
    RN, OCN, MSCN
  • Quick Quiz
    2 /3

    How often do you or your clinical team reach out to the patients (pro-actively communicate with patients)?

    Submit Answer
  • Lung Cancer Screening

    As presented by Dr. Robert Volk at a 2016 NCPF workshop, lung cancer decision aid screening tools should:

    • Provide clinicians with a concise summary of the current clinical evidence and recommendations.

    • Provide a way to ensure the patient counseling and shared decision making visit is consistent with the Centers for Medicare & Medicaid Services (CMS) beneficiary eligibility criteria.

    • Exist in multiple formats and be used in multiple ways to support deliberation between patients and clinicians.

    Generally speaking, the inability or unwillingness to engage in shared decision making results in diminished implementation and success in terms of improved patient outcomes. Therefore, successful adoption of shared decision making is critical to ensuring better outcomes for patients! This has proven true across studies where shared decision making has been examined.

    Available Decision Aids

    Decision Aid Description
    Screening with Low-dose Computed Tomography Here is a decision aid for people considering lung cancer screening with low-dose computed tomography. This includes points for evaluating the possible harm of over-diagnosing and radiation exposure.
    “Is Lung Cancer Screening Right for Me? A decision aid for people considering lung cancer screening with low-dose computed tomography.” Lung Cancer Screening Tools For Patients & Clinicians. (AHRQ Publication No. 16-EHC007-12-A) Rockville, MD: Agency for Healthcare Research and Quality. March 2016
    Screening with Computerized Tomography In this decision aid, doctors from the American Thoracic Society walk through considerations for lung cancer screening using computerized tomography imaging.
    Screening Using Prophylactic Cranial Irradiation The following is a decision aid produced by University of Colorado for patients to evaluate prophylactic cranial irradiation for screening of small cell lung cancer.
    Stage IB, II, III NSCLC After Surgery In this decision aid produced by the American Society of Clinical Oncology (ASCO), clinicians as well as patients, families, or other members of the patient's social support network can evaluate taking cisplatin-vinorelbine chemotherapy after surgery for Stage IB, II, III Non-Small Cell Lung Cancer (NSCLC).
    Stage IV NSCLC Chemotherapy Options Included in this decision aid, also produced by ASCO, medical oncologists treating patients diagnosed with stage IV NSCLC, as well as caregivers or patients diagnosed with stage IV NSCLC, can evaluate first-, second-, third- and fourth-line chemotherapy as well as second- or third-line chemotherapy with erlotinib.
    Considerations of Life-prolonging Treatments For palliative care, this decision aid, produced by Healthwise, allows patients who have a life-limiting illness or disease to consider stopping all life-prolonging treatments.
    Consulting Palliative Care A second decision aid on palliative care helps patients navigate consulting palliative care specialists to consider treatment plans that respect individual hopes and values.

    Here is a decision aid for people considering lung cancer screening with low-dose computed tomography. This includes points for evaluating the possible harm of over-diagnosing and radiation exposure.

    In this decision aid, doctors from the American Thoracic Society walk through considerations for lung cancer screening using computerized tomography imaging.

    The following is a decision aid produced by University of Colorado for patients to evaluate prophylactic cranial irradiation for screening of small cell lung cancer.

    In this decision aid produced by the American Society of Clinical Oncology (ASCO), clinicians as well as patients, families, other members of patient's social support network can evaluate taking cisplatin-vinorelbine chemotherapy after surgery for Stage IB, II, III Non-Small Cell Lung Cancer (NSCLC).

    Included in this decision aid also produced by ASCO, medical oncologists treating patients diagnosed with stage IV NSCLC as well as caregivers or patients diagnosed with stage IV NSCLC can evaluate first-, second-, third- and fourth-line chemotherapy as well as second- or third-line chemotherapy with erlotinib.

    For palliative care, this decision aid produced by Healthwise allows patients who have a life-limiting illness or disease to consider stopping all life-prolonging treatments.

    A second decision aid on palliative care helps patients navigate consulting palliative care specialists to consider treatment plans that respect individual hopes and values.

    How are Lung Cancer Patients Processing Information? In Our Patient Survey:

    • 5% opted to think about the information and contact the physician later with questions

      45% of patients engaged in a conversation at the time of introduction

    • 32% immediately agreed with the physician recommendation without question

      14% conducted independent research to support their decision making

  • Quick Tips

    Do your patients/caregivers have low health literacy or numeracy?

    Are they nonnative speakers of English?

    Do they have physical disabilities (low vision, hearing impairment) or cognitive disabilities?