Effective communication and management for patients with multiple health problems in primary care

1. 15th international Course, Slovenia EURACT Effective communication and management for patients with multiple health problems in primary care Amanda Howe MA MEd MD FRCGP Professor of Primary Care Medical Course Director, UEA

2. 15th international Course, Slovenia EURACT Outline • Review of common problems and issues • Principles and values • Core facts • Key skills • Who else to communicate with • Safety and quality • Next steps School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH

3. 15th international Course, Slovenia EURACT Co-morbidity – the management challenge • major noncommunicable diseases - CVDs, cancer, diabetes, chronic respiratory diseases & hereditary disorders - responsible for ~ 19 million deaths worldwide annually, with developed and developing world sharing the burden more or less equally (WHO) • 65% of US elderly (65+) have two or more diseases • likelihood of admission with 4+ comorbid conditions 100 x that of a single illness • massive variation in primary – specialty interface and referral patterns across different nationalities and health care systems • primary care providers are the major providers of care BOTH for particular chronic conditions as well as other conditions, for all degrees of co-morbidity, except in the case of a few unusual chronic conditions School of eicine, Health Policy and Practice, INSTITUTE OF HEALTH

4. 15th international Course, Slovenia EURACT Holistic care in family medicine • define and interpret the disease and their experience of it to the patient and family • find common ground with patients about their problems and how to manage these • enhance the doctor–patient relationship to maximise therapeutic benefit • incorporate prevention and health promotion into the routine care of individuals, family units and the local community • manage care effectively within the context of the team, time and other resources, using the current evidence base appropriately School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH

5. 15th international Course, Slovenia EURACT Principles and values • Patient’s best interests must come first • Co-morbidity makes communication complex, costly, and time consuming • Time consuming to assess & discuss the patient thoroughly • Complex to evaluate and apply the evidence base • Costly because of use of human and investigative resources, including referral • Medical, psychological, cultural and economic imperatives may conflict, so • Expertise and attitude of the patient, doctor and team will be very influential on care pathway • Effective management will need good communication.

6. 15th international Course, Slovenia EURACT The facts about communication • Communication is essential to successful outcomes – both diagnostic and relational • There are recognisable components to the consultation (not necessarily sequential in time) > initiating, building rapport, gathering information, providing structure, effective explanation, shared decision making • The opening component of the consultation must give scope to the patient to communicate ‘reveal’ • Some parts of the consultation must be doctor – led • ‘Microbehaviours’ e.g. clarification, checking, and safety netting are crucial to effective communication. School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH

7. 15th international Course, Slovenia EURACT How is communication altered by co-morbidity? • Principles of good communication still apply • Doctor led part of agenda may be more dominant (systems history, examination, explanation) • Uncertainty will need to be tolerated for longer (because diagnosis and decisions take longer) • Shared decision making of greater importance – need to ensure concordance with management plan, process of referral, careful use of drugs, followup • Absolute time needed is greater for complex patients • More interpersonal communication also needed with other professionals including hospital (direct or indirect) School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH

8. 15th international Course, Slovenia EURACT Shared decision making • Doctors who are patient centred tend to be good at shared decision making – allows ill patient to retain some control • Exceptional communication skills challenge to • Elicit accurate symptoms and signs • Know the facts about possible diagnoses and Rx options • be clear about presenting them in a way patient and their carers can understand • make clear decisions in our own mind but allow patient chance to make some choices • Parallel with ‘breaking bad news’ • ‘chunks and checks’ - information in chunks & checks understanding: uses patient’s own words: paces & safety nets • ‘this is what I’ve found’, ‘this is what I think’, ‘do you understand what I’ve said so far?’ ‘what do you think? • Additional info e.g. copy referral letter, writing down instructions School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH

9. 15th international Course, Slovenia EURACT Who else to communicate with? • Other family or carers • Colleagues – case discussion • Other team members – for advice and care • Specialists – for advice, or referral if needed • Expert resources – Internet, articles – evidence base very important in co-morbidity • Community resources / voluntary groups – to maximise support and improve quality of life • Ourselves – complex patients often benefit from their doctors’ reflection on their case School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH

10. 15th international Course, Slovenia EURACT Patient safety and communication breakdown in co-morbidity • Communication errors and transfer of information e.g. drug allergies are much commoner in complex patients • Drug dosage, repeat prescribing and drug monitoring are very important - doctor / pharmacist / patient need to communicate • Continuity of care within each team can improve communication and minimise risk • A well informed patient can be self – protecting if they are • Able to communicate (conscious, no language or motor barrier) • Willing to communicate (be assertive if they perceive risk) • Negative impact of errors can be contained if early and honest communication occurs School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH

11. 15th international Course, Slovenia EURACT Quality of care and communication in co-morbidity • The ‘expert patient’ – empowered patients can improve their own care by coordination • Lead professionals – to minimise duplication of effort and risk of communication breakdown • Quality indicators may be altered by co-morbidity but e.g. continuity, evidence of proactive and timely review, avoidance of polypharmacy and evidence of shared decision making in records are QI in UK • “the patient with multiple problems needs a clinician who does not add to his problems with muddle or confusion”. School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH

12. 15th international Course, Slovenia EURACT Next steps • Practise examples of communicating with complex patients • Define main areas of risk to communication between professionals • Consider practice based interventions to minimise risks of communication breakdowns • Other issues to discuss • Using diagnostic labels • Avoiding medicalisation • Explaining / exploring different perspectives and priorities School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH

13. 15th international Course, Slovenia EURACT Effective communication and management for patients with multiple health problems in primary care Amanda Howe MA MEd MD FRCGP Professor of Primary Care Medical Course Director, UEA School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH