10 minute read
Value through the eyes of our patients
Our efforts to drive value-based care lie not only in process improvements, enhanced clinical models, and transdisciplinary services. More importantly, it is underpinned by our desire to deepen our engagement with patients, caregivers and communities.
As we move towards a more holistic understanding of what ‘good’ healthcare means, the goal of medicine becomes more than undergoing surgery or putting a cast on a setting bone; it also means expanding the idea of medical success from purely clinical aims to consider other outcomes.
Advertisement
For example, beyond achieving a safe and uneventful surgery for the patient, other factors need to be assessed by the care team: Will the patient be able to recover his or her independence after surgery? Will the surgery lead to a long and painful hospital stay and recovery? Can the treatment lead to an improved state of health?
In other words, does the immediate goal of treatment have long-term benefits to a patient’s quality of life? This is the value-based care approach. Apart from clinical goals, it is important to consider what happens after a hospital stay or medical treatment.
ADDING VALUE TO CRITICAL CARE
To enhance and optimise surgicaland critical care, this approach has been adopted at Yishun Health’s surgical intensive care unit (SICU).
According to Dr Kumaresh Venkatesan, Director of the Surgical Intensive Care Unit, Senior Consultant, Department of Anaesthesia, patients and their families go through high levels of stress during these periods that stem not only from the medical crisis, but also from being in the ICU. While the critical care environment of the SICU is one fraught with complexity, time pressures and serious illness, this does not make functional and qualityof-life outcomes any less important, he emphasises.
The challenge is that ICU patients are seriously ill and unable to communicate with their loved ones and medical team on how they wish to be cared for. For patients without an Advance Care Plan, it can become even more challenging when critical medical decisions need to be made in a timely manner that is aligned with the patients’ preferences. “There is usually a lot of anxiety and questions about outcomes and prognosis,” Dr Kumaresh says.
To help the family make informed decisions, the SICU team does more than critical care. It often engages family members to learn about the patient’s wishes and beliefs. The team is led by Anaesthesiologist Intensivists — anaesthesiologists who are specially trained in critical and intensive care — who work with intensive care nurses, surgeons, infectious disease specialists, dietitians, physiotherapists and respiratory therapists to coordinate multidisciplinary care for patients. Dr Kumaresh is one of five such specialists at Yishun Health. His role is to address a patient’s needs during critical care, and work with the patient and his family to develop care plans from the surgical stage and beyond.
“We want to bridge an important gap between medical outcomes and quality-of-life outcomes that are meaningful for a patient. This helps us to plan a course for the patient with the goals of successful completion of surgery and recovery in the ICU,” he explains.
DR KUMARESH VENKATESAN DIRECTOR, SURGICAL INTENSIVE CARE UNIT; SENIOR CONSULTANT, DEPARTMENT OF ANAESTHESIA
Dr Kumaresh meets with the patient’s family to gain better insights into his preferences and to help the family make decisions according to their loved one’s wishes
To do this, he sits down with the patient’s family over several sessions to gain better insights into his preferences and to help the family make decisions according to their loved one’s wishes. Treatment, if any, should be about meeting goals that are important to the patient while also addressing the concerns of the family members — such as cost of treatment. It is not about medicalising every issue, emphasises Dr Kumaresh. “How we bring value to patients is to avoid unnecessary and unwanted treatment, especially if it only brings about transient improvement.”
Dr Kumaresh points out that, in some cases — particularly for the very elderly and/or chronically ill — invasive surgery or treatments may not have curative value beyond the short term. Instead, they may cause longer-term stress and pain to the patient, and increase the medical cost borne by the family. “After we have handled the immediate issue, it is important to step back and take a broader look. We also need to consider longer-term needs and outcomes for the patients outside of the ICU,” he adds [see box story].
For instance, in life-limiting illness, the SICU team members may activate their palliative care colleagues to initiate interventions for comfort and pain management. “As intensivists, we recognise that there is a need to look beyond medical crisis and episodic care to take a more holistic and relationship-based approach,” he shares.
CONNECTIONS THAT MATTER
One Yishun Health programme that illustrates going beyond treating isolated acute episodes to take a more long-term view of health is the Ageing-In-Place Community Care Team (AIP-CCT). One of their goals is to address the root cause of hospitalisation for patients with three or more admissions to KTPH over a one-year period.
Community nurses identify not just medical issues, but other factors that contribute to readmissions. They may train caregivers, educate patients on medication compliance, and encourage healthier habits. Allied health professionals may also be called in to share dietary tips and teach simple rehabilitative exercises, as well as help improve the home environment to reduce fall risks, enhance mobility, and increase comfort for the patients.
Kimberly Lim, Senior Staff Nurse, AIP-CCT (left) not only makes home visits, but is available in between medical appointments to answer queries from patients and their caregivers
Kimberly Lim, Senior Staff Nurse, AIP-CCT, explains, “We ensure that patients receive care and support so that they can manage well at home and prevent unnecessary hospital visits.” After all, 70% of health determinants are actually modifiable and can be addressed via holistic post-discharge care.
Mdm Teo Nee Moi is a patient under Kimberly’s care. The 78-year-old broke her arm in a fall about two years ago, which led to a long hospital stay. The elderly lady was subsequently readmitted several times as her fracture site became infected. She even stopped eating regular meals for almost a year due to early stage dementia, resulting in extreme fluctuations in her blood sugar. “It was a very anxious period for my mother and the family,” shares her daughter, Ms Yenn Teo. “She lost confidence in herself after the fall and was in very low spirits.”
Under the AIP-CCT programme, Ms Teo saw a remarkable improvement in her mother’s wellbeing. Over time, with advice from a dietitian and friendly persuasion from Kimberly, Mdm Teo was encouraged to eat more regular and healthier meals to manage her blood sugar and dizzy spells. Grab bars were also recommended and installed in the home to prevent future falls.
“The monthly home visits are a relief for the family, and my parents are always so happy when it is time for Kimberly to visit,” observes Ms Teo. In the past, the family was often unsure of what to do for dizzy spells or vomiting besides seeing their neighbourhood general practitioner. “Having someone to turn to for advice between medical appointments is very reassuring,” says Ms Teo.
A quick call to Kimberly for advice usually resolves episodic issues and prevents them from getting worse. Kimberly also provides advice on medication and arranges delivery of medication when needed, bringing convenience to the family. It also helps that these episodic issues and changes are updated on Mdm Teo’s file so that her specialists are also kept in the loop.
These efforts not only demedicalise care but, more importantly, build trust and rapport. It is this connection between the healthcare provider and patient that drives compliance and healthier habits.
A RELATIONSHIP OF TRUST
For patients, this connection is thecrux of ‘value’ in their perception of value-based healthcare. Taking into consideration a patient’s personhood can lay the foundation to a trusted and long-standing doctor-patient relationship, especially in the face of a serious medical condition.
Take Mr Wong Foo Phang, 72, who was diagnosed with Stage Three colorectal cancer in 2007 during Yishun Health’s early days as Alexandra Hospital. His surgeon is A/Prof Tan Kok Yang, Deputy CMB (Service Development), Yishun Health, and Head of Surgery, KTPH. Mr Wong recalls that he was devastated by the diagnosis. “I kept asking, ‘Why me?’ No one else in my family had cancer. It was hard to accept,” he admits. He had surgery to remove the cancerous growths, and stayed in hospital for over a month, during which he suffered several post-surgery complications and needed multiple surgeries.
A/PROF TAN KOK YANG DEPUTY CMB (SERVICE DEVELOPMENT), YISHUN HEALTH; HEAD OF SURGERY, KTPH
“I could not eat and became very thin and weak,” he shares.
Despite the many crises and challenges that arose during his hospital stay, one thing stood out for him: A/Prof Tan’s professionalism and dedication to his care. Even when Mr Wong raised complaints, he saw that A/Prof Tan listened, empathised, and was sincere during their interactions. In fact, Mr Wong’s strongest memories of that period were not about their conversations about medical care; instead, they were the occasions when A/Prof Tan efficiently tended to problems or when he noticed Mr Wong’s poor appetite. Mr Wong also remembers their casual chats about his scooter and their favourite hawker food.
He appreciates that A/Prof Tan is not just a doctor who is dedicated to treating his condition but is someone who cares about him as a whole person. “His manner touched me,” affirms Mr Wong. “A/Prof Tan observes and takes an interest in me. I have developed every confidence in him.” It is for this reason that, for the last nine years, Mr Wong — who lives in Tiong Bahru — still makes the one-and-a-half-hour journey to see A/Prof Tan for follow-up appointments at KTPH.
VALUE: PUTTING PEOPLE FIRST
Building relationships andempathetic communication are intangible ingredients that make a big difference in improving care delivery and enhancing the patient experience. It is why Yishun Health’s value-based care model comprises not only metrics for clinical, functional, experience and cost — all these factors are underpinned by empathy.
It is by knowing what matters to patients that drives good clinical processes and relevant services programmes that lead to successful long-term outcomes. This approach shifts the dynamic from a paternalistic doctor-patient relationship to a partnership based on understanding. As Hippocrates once noted, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” This insight helps healthcare providers design meaningful treatment that respects a patient’s experience and autonomy. This brings value to patients and truly puts them in the centre of care.
As A/Prof Tan sums up, “A good outcome is about more than a single cutting-edge technology or medical specialty. Patient-centric care is seeing beyond the pathology and treatments to see each patient as a person.”
SAYING “I DO” IN THE ICU
When 69-year-old Mr Lim was warded in the ICU in late July 2019 for pneumonia, he knew he was nearing the end of his journey. He had been cared for at KTPH for over nine years for his chronic diseases. Unfortunately, the prognosis was not good when he was admitted this time.
His last wish was to see his daughter get married. Learning of this request, Pamela Foong, Assistant Nurse Clinician, worked with the family to organise a solemnisation ceremony in Mr Lim’s ICU room.
Strict rules about infection control typically apply in the ICU. However, to make allowances for this event, the ICU’s nurses and doctors requested for help from several departments to garner the necessary approvals and special concessions. A comprehensive infection control plan was also implemented. To ensure Mr Lim would be well enough for the special day, the ICU team took extra care to monitor his condition and motivate him to keep his spirits up.
On 13 August, Mr Lim and his family witnessed a simple but beautifully poignant ceremony. Mr Lim passed away a few days after, with his final wish fulfilled. Expressing appreciation to the ICU team and the various departments that had cared for Mr Lim over the past nine years, the Lim family wrote a short note of thanks, remarking that the elder Lim “passed on peacefully with no regrets”.
How we care for our patients and their families, beyond the medical aspects, matters to them. This episode is an affirming nod to our staff, who have gone beyond the call of duty to show empathy and love, touching the lives of those who pass through our hospital.
