19 minute read
PUBLIC HEALTH Engaging Families in Health Care
Engaging Families in Health Care
Everybody Wins
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BY TAI MENDENHALL, PH.D., LMFT AND AALAA ALSHAREEF, MS, LAMFT
It is well-established that up to 40% of patients who present in primary care have a diagnosable mental illness, and that more than 70% of all clinical presentations carry some kind of exacerbating psychosocial foci (e.g., workplace stress, housing instability, unemployment, institutional racism, legal troubles, academic struggles). These statistics are arguably more diverse – and often higher – across secondary and tertiary care environments. What appears less universally agreed-upon – or even recognized – is the role(s) that patients’ families play in health, wellness, illness, disease, injury, and/or recovery. Modern Western medicine conventionally focuses on onepatient at-a-time. Patients’ physical illnesses, mental health struggles, and psychosocial stressors are usually addressed absent consideration of family dynamics. Our third-party payers and HIPAA rules reinforce this practice. But families play important roles in the lives of our patients. They can be a source of support or a source of stress; they can be part of a solution or part of a problem. They are almost always “there” somehow, and are consequently influential to the courses and outcomes of medical advice. They can be attended to and included; they can ignored or excluded (purposefully or passively). We argue that they be included and purposefully attended to.
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Data Talk: Families are Important
Proponents of the “medical home” – from pediatric to geriatric care contexts – agree. The Joint Principles of the Patient-Centered Medical Home (PCMH), advanced by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association, call for physicians to engage with patients and their families in active partnership(s) across all care processes so as to improve health.
Compelling data – across both individual studies and systematic reviews – are emerging to support such efforts. In primary care, family medicine studies have long-paired the inclusion of family members in preventive and therapeutic interventions to positive outcomes (e.g., physical activity, blood pressure, metabolic control, dyslipidemia, smoking, overall cardiovascular risk). In pediatrics, stalwart support for the involvement of multiple family members in treatment is extant for care targeting child/youth diabetes, asthma, and obesity. In internal medicine, similar trends are recognized in the treatment of patients with multiple and complex morbidities, including diabetes (and other weight-related foci) and substance use/abuse.
Examples supporting the inclusion of families in secondary care include: intensive care practices involving families have been paired with greater trust for care teams, satisfaction with care-related decision-making, and patient/ provider consensus in decision-making. In OBGYN contexts, familyinclusion in care is well-established in the reduction of perinatal distress, allayment of chronic genital pain, and improved coping with unexpected pregnancy termination for fetal abnormality. In emergency medicine, family involvement is strongly predictive of reduced psychological distress and improved follow-up with discharge planning. In oncology, it outperforms individual approaches in the promotion of coping, improved problemsolving skills, decreased psychological distress, and reduced depression. In psychiatry, including families in care has shown superior outcomes in the treatment of ADHD, anxiety, PTSD, depression, and suicidal ideation.
Examples of compelling data in tertiary care are also myriad. In palliative and hospice contexts, including families in treatment is strongly predictive of improved patient/caregiver coping, increased self-efficacy, better qualityof-life, and reduced caregiver burden. In endocrinology, diabetes-related outcomes (e.g., A1c, BMI, BP, dietary practices, physical activity) are consistently better when care includes patients’ family members as opposed when patients are treated in isolation from them. In alcohol and drug treatment, family-interventions almost universally outperform individual care for use/abuse of substances (ETOH, opioids, etc.) and other addictions (gambling, pornography, etc.) across both adolescent and adult samples.
Everybody Wins
The inclusion of family members in treatment processes within other care environments and target populations that do not fit neatly into conventional
primary, secondary, or tertiary “boxes” are also being evaluated. These pressures to produce clinic revenue – to see 30, 50, or even more patients include – but are not limited to – community health centers, community- per day – communicate clearly to physicians that their “relative value units” engaged (i.e., “push” vs. “pull”) initiatives, disaster response teams, (RVUs) are more important to job-security than the outcomes of the care spiritual care, employee assistance programs, and military / veteran health that they provide. systems. All show promise for the inclusion of family members in the care of individual patients, alongside outcome data that support doing it. Doing Something “New” without Doing “More” Doing something “new” is almost always heard
It is also important to note that including by busy students, residents, and established patients’ families in care, regardless of where the care is positioned and/or who the patients are, Training future physicians to comfortably engage with physicians as doing something “more”. This can be an impossible call, as outlined above, insofar as saves money. From improved health per se (which patients’ families is essential. there is no room to do more. Further, such messages means less money paid-out by 3rd party payers for are easy to interpret as criticism – which are often visits, prescriptions, procedures, etc.) to reduced then understandably met with defensiveness by frequency of acute and/or emergency visits (which trainees and/or professionals who are already cost a great amount of money from intake to all working hard to meet the administrative quotapoints forward) and reductions in “frequent-fliers” demands that they are under while synchronously (who repeatedly take-up valuable appointment slots and otherwise encumber offering high-quality care. clinic scheduling), the administrative worlds of health care benefit from all of this too. And finally, data show that providers themselves benefit through The good news here is that learning (and continuing) to include families improved job satisfaction, lower burnout rates, and higher staff retention. is rarely something that requires more time. Classroom teachings about In short, everybody wins. common ways that patients and families respond and adjust to a variety of illnesses, for example, could be integrated into existing year one courses Are Families missing in Health Care? or those that explicitly include multiple members in care (e.g., pediatrics, Despite extant and growing data that support the inclusion of family family practice). More sophisticated learning and skill sets related to family members in care practices, it continues to be the “exception” as compared to the “rule” of treating patients in a vacuum. Responding to this circumstance Engaging Families in Health Care to page 304 effectively is complex and necessitates both thoughtful insight(s) regarding where we have been and realistic steps toward where we are going.
Training future physicians to comfortably engage with patients’ families is essential. However, it is not clear whether and/or how consistently our country’s medical schools are doing this. For example, the authors recently conducted a thematic analysis of the top-ten ranked (according to U.S. News & World Report) R-1 institutions’ course descriptions. We found no-to-minimal mention of communicating, working, and decision making with patients’ families. Follow-up inquiries to said schools’ administrative and curricular personnel – albeit with a low (30%) response rate – yielded comparatively favorable findings, wherein patient/family/physician communication was recognized as a learning objective. However, this objective was described as a “process” topic that comes up along the way – as opposed to a specifically articulated component of any specific classs content.
Reasons for the relative paucity of attention to working with patients’ families in medical education are numerous, and parallel reasons for why any other host of topics (e.g., health maintenance organization management, business modeling, public health planning, community engagement, team building, compassion-fatigue prevention / mitigation) are neglected. With only four years to adequately prepare students before residency, preference for time / attention to baseline domain knowledge is essential. The same can be said for residency training, insofar as no length- or amount- of education or timeframe is adequate to cover all foci that are required.
In post-residency practice, most physicians will not argue that families are important (they have families, too!). However, said physicians regularly and almost categorically reject engaging patients’ families in care because it will take too much time. This connects directly to what scholars across both biomedical and psychosocial fields call “time-famine”. Contemporary
3Engaging Families in Health Care from page 29
encouraging / ensuring compliance with medication regimens / routines, processes of adaptability, cohesion, and communication – and the manners sobriety maintenance), and a variety of other care-related activities. We can in which these often change and/or respond to health-related situations and improve outcomes when we include patients’ family members and other crises – could follow. Commonplace watch one, loved ones in our work. Doing this empathically, do one, teach one sequences could be integrated sensitively, curiously, and respectfully – and into internship and/or residency practices wherein with appropriate regard for the complex ethnic/ novice trainees observe more-advanced trainees cultural, intergenerational, interpersonal, and and/or faculty work with families, followed other intricacies of “family” that patients bring by working with families themselves (under Patient/family/physician with them will translate into better care. appropriate supervision paired with feedback about strengths and areas for growth), followed communication was recognized as a learning objective Other – and overlapping – ways of engaging patients’ families in care do not require anything by teaching newer cohorts the skills that they (“more”) from physicians other than a willingness have learned. to participate in the integrated care teams that
In practice, physicians are presented daily PCMH advocates are calling for. As these teams with opportunities to encourage patients to invite slowly replace less effective models of practice, family members into clinical visits. Examples of these opportunities, and the interdisciplinary efforts that engage behavioral care providers (e.g., medical ways that families can help in the care are myriad: facilitating conversations family therapists, health psychologists) and other care advocates (e.g., social about health decisions (e.g., birth control options, pros-and-cons related to workers, care coordinators) can translate into non-physician providers different medications), medical interventions (e.g., elective surgeries, DNR engaging families on physicians’ behalf. Shared-charting, curbside directions), delivering bad news and/or assisting in the communication of consultations, joint problem-solving, and other collaborative efforts have such news to others (e.g., parents diagnosed with cancer disclosing it to their all shown (through care outcomes, cost savings, etc.) that the energy is children), ongoing care processes (e.g., managing home-care services across worth the effort. Third-party payers like BlueCross/BlueShield, CMS, multiple providers and/or agencies), health behaviors (e.g., sharing in dietary- HealthPartners, Medicare, and Medicaid, while not historically supportive and/or physical activity- activities in diabetes management, reminding / of preventive (versus reparative) services, are quickly catching on to the value of these types of efforts and team-models.
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Concluding Thoughts
Highly competent practice necessitates physicians’ purposeful attention to multiple systems – biological, psychological, relational/social – that patients inhabit (or that inhabit patients). And while most physicians are highly skilled in the physical and psychological arenas of their work, engaging patients’ families in health and health care is oftentimes not pursued. However, learning how to navigate these territories is worth the effort – and that “effort” does not need to take any more time away from providers who are already-overextended in terms of (un)available time. Patients benefit. So do their families. We do, too. Everybody wins.
Tai J. Mendenhall, Ph.D., LMFT, is a Medical Family Therapist and Associate Professor in the Couple and Family Therapy Program at the University of Minnesota (UMN) in the Department of Family Social Science. He is an adjunct professor and clinician in the UMN’s Department of Family Medicine & Community Health, and an Associate Director of the UMN’s Citizen Professional Center. He works actively in the conduct of integrated behavioral healthcare and community-based participatory research (CBPR) focused on a variety of public health issues.
Aalaa Alshareef, MS, LAMFT, is a doctoral candidate in the Couple and Family Therapy Program at the University of Minnesota (UMN) in the Department of Family Social Science. She holds a Master of Science in Marriage and Family Therapy, and serves as a faculty member in a large Psychology department in Saudi Arabia.
3The Future of Gastroenterology from page 15
software systems requires its own login, password, and even multi-factor authentication prompts. vendor level with the help of AI experts like Iterative Scopes. However, if Fingerprint and face recognition will help alleviate much of the burden, we take that a step further and integrate the AI-powered scope software while still remaining highly secure. Fingerprint and face recognition into the documentation platform, it could not only detect the polyps, for sign-in authentication and e-signatures is but could also suggest the characteristics of the something that is becoming more common in polyp (i.e. type, size, and location) and capture GI software, but is not readily available in most that information as discrete data points for the applications.physician’s review and sign-off. More dynamic machine learning As mentioned earlier, the current state of AI can reduce physician burnout. AI in Gi is creating better patient outcomes and new opportunities for specialists and primary machine learning in GI documentation allows care providers to collaborate to achieve the best the software to learn and suggest common patient outcomes. selections. In the near future, machine learning AI can provide enhanced data but will never will evolve to being able to recommend full replace the art of medicine- the ability gained templates based on what the physician has through years of experience to know how one documented in the past. AI will not only provide documentation individual metabolism will respond differently than another to very suggestions, but also clinical decision support (i.e. identifying similar conditions. It is already speeding and improving care and forging contradictory indications, suggested medications, and alerts), allowing valuable new industry partnerships.nurses and physicians to be extremely thorough and efficient in their patient charting and procedure documentation. Authentication Although absolutely critical, secure authentication and e-signing can Jonathan Ng, NBBA, MPA, MBA, is the CEO at Iterative Scopes, a software-only company, spun out of MIT, working to deliver AI still be burdensome for physicians and members of the care team. With toolkits to the practice of gastroenterology. healthcare cybersecurity threats still on the rise, it is likely each of your
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3The Minnesota EHR Consortium from page 27
so current allocation phases have resulted in smaller proportions of these groups being vaccinated. Vaccination rates among White, non-Hispanic and Native American populations were similar and may reflect early efforts to allocate vaccines to Native American Minnesotans
As vaccination became available to all Minnesotans 16 and over effective April 19th, the EHR Consortium data will further inform the state, federal and local vaccination sites on strategies to provide vaccinations where the need is the highest with the lens to health equity.
Minnesota has always been on the forefront of novel healthcare innovations but despite repeated attempts over the past decades and despite high use of electronic health records in the state since the early 1980’s, we have not succeeded in creating a seamless state level data exchange. The EHR consortium fills a much needed gap and we hope the value this effort has brought forth will result in a more permanent data sharing structure for the State. During a pandemic, health systems cannot operate in silos. Collaboration is needed to understand where and how the disease progresses and to plan for capacity and operational needs. This work also benefits the State’s response efforts by complementing other data.
Looking Ahead
The Consortium meets weekly and has representative members from all its participant systems. Each week there is a review of summary reports, ongoing needs and gaps to address the pandemic, develop governance structures to support decision-making, and make improvements. The coalition now has several sub groups who work on niche problem solving such as research and publications, refining data and analytics, public relations and outreach etc.
This work is adapting to address future COVID-19 surges, the potential for other epidemics/pandemics and improving future vaccination activities. Other topics, such as long-term impacts of COVID-19 infection and other public health issues may be addressed and the data can be used to drive future public policy. The Consortium’s partnership, infrastructure and methodology for producing summary data will help Minnesota be prepared for future public health crises, syndromic surveillance and even for chronic disease management with the ultimate goal of creating healthy communities and improving the health of the residents of Minnesota. The data can guide clinicians and other care providers in the state to dive deeper into their own patient populations to identify gaps and better serve the needs of the populations they serve. In the future there is the potential to have partnerships with health plans, patient advocacy groups and other nonprofits that support health equity. Through this research we can design human-centered solutions for the health of our state using a lens of equity.
Deepti Pandita MD, FACP, FAMIA, is the Chief Health Information Officer for Hennepin Healthcare.
Laamy Tiadjeri, MD – Obstetrics & Gynecology, Willmar, MN
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3The MinuteMan from page 25
the MinuteMan device, other neuromodulation therapies such as spinal cord stimulation are more effective.
Patient Selection:
cord stimulation or targeted drug delivery. The MinuteMan fusion device offers the opportunity to correct the underlying anatomical problem for these patients via a minimally invasive, outpatient surgery. If other treatments, such as spinal cord stimulation or targeted drug delivery Patients who demonstrate clinical signs of lumbar are needed to treat irreversible neuropathic pain spinal stenosis such as neurogenic claudication after placing the MinuteMan fusion device, they are (i.e., increased back and leg discomfort when likely to be more successful. walking upright that is relieved by resting and/ Patients report being able to Younger patients with mild to moderate or hunching forward) are ideal candidates for reduce their use of opioid and lumbar spondylolisthesis can also benefit from the treatment with the MinuteMan fusion device. other pain medications. MinuteMan fusion device. Such patients often Radiographic findings on lumbar MRI or CT scan have fewer lumbosacral issues. Therefore treating of central stenosis or lateral recess and foraminal lumbar spinal stenosis with this minimally stenosis at a single level are obtained to determine invasive technique can result in profound changes the spinal level to treat. Flexion/extension X-ray in function and pain. Coverage for this treatment studies are also needed to ensure that the patient for non-Medicare plans is expanding as well. does not have more than Grade 2 spondylolisthesis and to determine if the spinous processes at the treatment level are adequately sized. R. Scott Stayner, MD, PhD, is the Medical Director of Nura Ambulatory
Currently, the MinuteMan device is on formulary with Medicare and most Surgery Centers. He is board certified in anesthesiology and pain management. Medicare Advantage plans. Elderly patients, especially those with symptomatic He completed his anesthesiology residency at the University of Minnesota, his spinal stenosis, are often ideal candidates for the MinuteMan fusion device since Fellowship in Pain Management with the University of California, Davis, and is spine surgeons are hesitant to recommend open fusion to correct lumbar spinal a graduate of the University of Minnesota Medical School. He earned a PhD in stenosis due to increased risk of postoperative complications. Until recently, Bioengineering from the University of Utah. the only interventional treatment options for such non-operative patients with spondylolisthesis and spinal stenosis have been injections and potentially spinal
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