Seniors as Patient Safety Self-Advocates in Primary Care

1. Seniors as Patient Safety Self-Advocates in Primary Care Saundra L. Regan, PhD University of Cincinnati Department of Family & Community Medicine Cincinnati, Ohio, U.S.

2. Objectives of Today’s Presentation • What are Patient-Centered & Family-Centered Health Care? • What are the issues in Patient-Centered & Family-Centered Care and why is it so important in Geriatrics? • The Seniors’ Empowerment and Advocacy in Patient Safety (SEAPs) tool. • What is the Patient-Centered Medical Home (PCMH) in Primary Care? • Next Steps

3. Brief Description of Patient-Centered & Family-Centered Health Care

4. Health Care Is Physician-Centered

5. Health Care is Facility-Centered Hospital Clinic Nursing Home

6. President Obama: “It use to be that most of us had a family doctor. You would consult with that family doctor. They knew your history. They knew your children. They helped deliver babies.” Today: “Oftentimes, people don’t have a primary care physician that they’re comfortable with, so they don’t get regular checkups. They don’t get regular consultations. Preventable diseases end up being missed.” 6/8/2010. Town Hall Meeting, Wheaton, Maryland President Obama Calls for Better Payment System for Primary Care Physicians

7. Patient-Centered Health Care* • The healing relationship between physicians and patients and patients' families • Grounded in strong communication and trust • Highlighted by clinicians and patientsengaging in a two-way dialogue • Sharing information • Exploring patients' values and preferences • Helping patients and families make clinical decisions *Institute of Medicine's Crossing the Quality Chasm 2001

8. Patient-Centered Health Care* • “Shared Information” — a physician tailors information to an individual patient's concerns, beliefs, and expectations, while also considering his or her level of health literacy • "Shared deliberations”—engage the patient in discussions and decision-making to help arrive at a…. • “Shared mind"—that is, consensus on an approach to care that goes beyond informed consent. *R. M. Epstein, K. Fiscella, C. S. Lesser, and K. C. Stange, "Why the Nation Needs a Policy Push on Patient-Centered Health Care," Health Affairs, Aug. 2010 (29)8:1489–95.

9. Family-Centered Health Care* • Health care providers listen to, respect and honorpatient and familyperspectives and choices • Health care providers communicate and sharecomplete and unbiased information with patients, families, and other providers • Patients and families are encouraged to participate and collaborate with their providers *http://www.familycenteredcare.org/

10. Issues in Patient-Centered & Family-Centered Care and theImportance in Geriatrics

11. The Aging Population

12. Canadian Demographics Median age: total: 40.7 years male: 39.6 years female: 41.8 years Life Expectancy: total population: 81.29 yrs. male: 78.72 yrs. female: 84 yrs. Fertility rate: 1.5 children per woman Total Population (2010 est.) • 34,019,000 (2010 est.) Age structure: • 0-14 years: 15.9% • 15-64 years: 68.6% • 65 years and over: 15.5% https://www.cia.gov/library/publications/the-world-factbook/geos/ca.html

13. Chronic Diseases • Changing epidemiology of disease burden from infectious disease to chronic disease related to: • Aging population • Lifestyle factors • Excessive calorie intake • Diminished physical activity • Smoking • Alcohol

14. Leading Causes of Death Ages 65 and Over* • Cancer • Heart Disease • Chronic Lower Respiratory Disease (Chronic Bronchitis, Emphysema, COPD, Asthma) • Stroke • Diabetes • Alzheimer’s (75+) *http://www.statcan.gc.ca/

15. Who Cares for Older Adults?

16. Why Teach Seniors to be Patient Safety Advocates? • Aging Population • More Chronic Disease • Older adults cared for in the community by their family and friends • Healthcare being provided by a family physician, general practitioner or healthcare team.

17. Senior Empowerment and Advocacy in Patient Safety

18. Senior Empowerment • The best way to empower older adults is to teach them to be advocates for their own safety. • If you don’t do it, who will?

19. Developing the Tool • At the time we started our study we couldn’t find an instrument to assess patients’ beliefs about participating in safety activities in a primary care office setting. • We wrote a grant and received funding from the National Patient Safety Foundation to develop the Seniors’ Empowerment and Advocacy in Patient Safety (SEAPs) tool.

20. Seniors’ Empowerment and Advocacy in Patient Safety Four Areas of Focus • Outcome efficacy: the belief that the actions will be a benefit to one’s health, • Attitudes: concerns about barriers to participating in the actions, • Self efficacy: confidence in one’s ability to effectively take action, • Behaviors: performance of patient safety actions

21. Seniors’ Empowerment and Advocacy in Patient Safety • Developed a tool that could be used to evaluate a program that taught older adults to be advocates in their own patient safety in a primary care office setting • The tool was tested and worked well with older persons regardless of gender, race, income or education level.

22. Why Teach Seniors to be Patient Safety Advocates? • Older adults are at higher risk for errors in health care: • Use the health care system more often • Often have multiple health problems • Often see several doctors for care • Often take multiple medications • Our culture teaches us not to question our doctors and until recently we’ve not been taught to take an active role in our own healthcare

23. Seniors’ Empowerment and Advocacy in Patient Safety Using the tool in the community to evaluate a community intervention with older adults about patient safety.

24. Seniors’ Empowerment and Advocacy in Patient Safety Part I: Group Educational Event • Introduction and description of medical errors in physicians’ offices • Stories of medical errors that occurred to real patients (misdiagnosis, mishandled records) • Group discussion of participants experiences with medical error and preventable problems • Description and training in patient safety practices

25. Patient Safety Practices PREPARING FOR THE VISIT • Write down all your medical problems and questions • Write down all the medications • Learn more about your medical problem before going to the doctor DEALING WITH THE OFFICE STAFF • Try to make your appointment the first or last of the day • Speak up to the office staff, and let them know what you want TALKING WITH THE DOCTOR • Give a thorough medical history • Ask questions about what your doctor tells you • Ask questions about your medications

26. Patient Safety Practices MAKING DECISIONS ABOUT A DOCTOR • Choose your doctor wisely by checking him/her out beforehand • Get another opinion if you are not satisfied with your care • Change to another doctor or office if you continue to be dissatisfied with your care AFTER THE DOCTOR’S VISIT • Check the medicine at the pharmacy to make sure it is the right one • Learn all you can about your health problems • Call or visit the doctor if you don’t get lab results in a reasonable amount of time GENERAL IDEAS • Trust your gut feelings or instincts about whether something is working or not • Get a friend or family member to come with you to the visit

27. Seniors’ Empowerment and Advocacy in Patient Safety Individual Training Session • Introduction and description of PACE program (Present, Ask, Check and Express) (Cegela et al, 2000) • Detailed instruction in how to present detailed information to the doctor • Training about communicating about medications and keeping a medication record form • Training about communicating about tests and their results and keeping a test results record • Participant selection of patient safety practices and PACE skills to adopt

28. The PACE Guide Sheet Present Detailed Information • Describe your problems and concerns Ask Questions • Ask doctor to repeat or clarify information that is unclear about diagnoses, tests, medications, treatments Check Your Understanding • Repeat aloud what the doctor just said • Summarize your understanding of what the doctor said EXPRESS Concerns

29. The PACE Guide Sheet Don't Forget To: • Bring all your medications, or make a list of them and how they are taken • Ask for a copy of test results or procedure reports Practice: • Participant selected a patient safety practice and a PACE skill to adopt and we role-played that skill

30. Results-Participant Comments • PACE helped organize their thoughts and questions before they went into the doctor’s office • Have the 2 or 3 things that they really needed to talk about because they get in the doctor’s office and forget what they wanted to ask • If I can go in with a summary of what is wrong such as, “I have a pain in my upper back that started 2 weeks ago after I worked putting in some flower gardens. It hurts when I have been standing or sitting too long so I have to get up a walk every so many minutes. Tylenol has really not been helping so I tried Advil and that helped a little more but the pain still comes back”

31. Results-Participant Comments • Being able to tell the doctor what happened, when, how it feels and what you’ve tried to make it better is really helpful to the doctor • Supplements: Many people expressed they don’t think of their supplements and vitamins as medication. Many didn’t realize their prescription medication and the supplements they might be taking could interact with each other • Over-the-counter: Many didn’t realize the importance of listing all medications, supplements, vitamins, other over the counter medications, eye drops and so forth.

32. Results-Participant Comments • Specialists: Also many made the assumption that if one doctor put them on something another doctor would automatically know that and so it was important to always bring a list of your most recent medications, supplements, etc. • Testing: almost everyone expressed the same thought, “they never think to call their doctor if they haven’t heard about test or procedure results.” Almost all believed that no news is good news.

33. A Cancer Test Result • “No News is Good News” • Or • “No News is No News”

34. Seniors’ Empowerment and Advocacy in Patient Safety • We developed safety self advocacy recommendations for patients that: • Covered important areas of errors and safety in primary care • Are realistic and feasible for many patients to undertake • Can be taught to patients in a community setting BUT………………..

35. Results-Participant CommentsTheir Parting Shot…….. • If we are going to activate and empower patients to be their own patient safety advocates….. • We need doctors and other healthcare providers who understand and incorporate this into their clinical practices

36. Next Steps We Enter………The Patient-Centered Medical Home (PCMH) in Primary Care

37. Patient Centered Medical Home • The American Academy of Pediatrics introduced the term “medical home” in the 1960’s • The Institute of Medicine began to use the term in 2001 as one of six aims for high quality in patient-centered care • The American Academy of Family Physicians adopted it in 2004 • The College of Family Physicians of Canada (CFPC) recommended it in 2009

38. Patient Centered Medical Home Core Components • Personal physician with whom you develop an ongoing relationship • Physician Directed Medical Practice of a Health Care Team • Whole Person Orientation • Care is Coordinated and Integrated • Quality and Safety • Enhanced Access-Open access • Payment Reform

39. THE TEAM

40. THANK YOU!QUESTIONS? COMMENTS? saundra.regan@uc.edu