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Three keys to value from patient’s perspective: time, communication, education
Over the last decade, the health care community has become familiar with the concept of value and the idea that it must be a central part of our care delivery system.
However, many of us have difficulty defining what value means for us as providers, as well as for our patients and the entire health care system.
This is due largely to the fact that value has a broad and frequently unclear definition. The word often is used to describe relative worth, utility or importance; however, our values are based on our individual beliefs, perceptions, experiences and expectations. In other words, value is relative.
It is no surprise that the various stakeholders in health care often have conflicting definitions of value.
The general theme of providing value thus far has focused on cost reduction through maximizing efficiency.
Although more affordable health care certainly is beneficial to our patients, this single definition is not necessarily patient centric. As a health care team, we need to examine how we look at value and ensure we are considering our patients’ ideals, as well as our own and those of our institution.
To accomplish this, we must have a basic understanding of what our patients value and then engage the entire care team to help achieve these goals.
In this column, I will share my perspective on value from my standpoint as an advanced clinical practitioner (ACP) and discuss how the contributions of these providers relate to patients’ preferences and expectations.
Maximizing resources
It has been well documented that patients consider adequate face-to-face time with their provider to be a high priority. Not surprisingly, patients also value their personal time, a cost often overlooked in a busy clinic.
Thus, ideal patient satisfaction would be a result of maximizing provider face-to-face time while staying on time and expediting time spent at the clinic.
This model does not fit with the current clinical practice of medicine. Long wait times and rushed office visits are continually at the top of our patients’ complaint list. Both are strongly linked to overall patient satisfaction.
Although staying on time often seems beyond our control, a team-based approach can help.
In a study published in 2013 in Journal Health Affairs, Dill and colleagues concluded: “When presented with scenarios wherein they could see a physician assistant or a nurse practitioner sooner than a physician, most elected to see one of the other health care professionals instead of waiting.”
At my institution — Levine Cancer Institute at Carolinas HealthCare System — many of our ACPs divide the clinic schedule with their supervising physicians each day. Our ACPs often focus on routine visits, sick work-ins and chemotherapy education appointments, freeing the physicians to spend time with more complex patients.
Because both providers are practicing in the same clinic area, there is close communication between physicians and ACPs regarding each encounter, even if the physician does not see each patient. This allows our teams to see a higher volume of patients without getting too far behind schedule or sacrificing team coordination.
Effective communication
Patients often cite effective communication as a priority.
It is important to recognize that communication is a general term and, often, our patients are referring more specifically to accessibility and coordination of their care.
They are dissatisfied when they have difficulty reaching the right person when they call the office with a question or concern. They feel frustrated when one provider is not aware of changes someone else made to their care. This is a particular concern in oncology, given many modalities within the specialty are involved in a patient’s care.
Nurse navigators are valuable teammates in the effort to optimize coordinated care.
At many institutions, nurse navigators have become an essential part of the team through improving coordination of patient care and ensuring effective communication.
A study by Wagner and colleagues, published in 2013 in Journal of Clinical Oncology, showed that patients who had nurse navigators involved in their case reported a better patient experience and fewer overall problems with their care.
In the 4-month study period, nurse navigators called patients by phone, met with them and attended office visits. Results showed patients who had a nurse navigator were considerably more likely than controls to indicate individuals on their oncology team went out of their way to make them feel better emotionally (89% vs. 59%).
Patient education
Patients also want to be well educated about their medical conditions.
A study by Weeks and colleagues, published in 2012 in The New England Journal of Medicine, showed that a majority of patients with metastatic cancer did not understand that their chemotherapy was not curative, even though they discussed their regimen with at least one physician.
This lack of understanding is worrisome, as patients who misunderstand or are not educated about the goals of treatment early in the care process are more likely to feel shocked and dissatisfied when their disease progresses after several cycles of chemotherapy or other treatment.
Formal chemotherapy education — which, at my institution, frequently is performed by an ACP — is an excellent way to ensure patients have access to more information. This office visit is dedicated to educating patients about a treatment plan already outlined by their physician.
Chemotherapy education visits reinforce understanding of the goals of therapy. They also address topics such as prevention of side effects or management of expected toxicities. This helps ensure the patient and medical team are on the same page from day one.
Patient education does not stop after completion of therapy. The commitment to provide guidance beyond active treatment and into survivorship is an essential component of value-based care.
There is a considerable gap in survivorship care, as highlighted in the book From Cancer Patient to Cancer Survivor: Lost in Transition.
Although patients often seek counseling after treatment, many feel there is not enough time — or, in some cases, no time — spent discussing what to expect after treatment. Patients report little attention to psychosocial concerns, sexual dysfunction and financial issues, and this leads to patient dissatisfaction.
Survivorship programs are an important and growing piece of oncology care. Many of these clinics are led and staffed by ACPs under the guidance of supervising physicians, and their focus is to improve care, experience and education throughout and beyond patients’ cancer journey.
Focus on patients
Many of the goals outlined above can be achieved through the proper utilization of an ACP.
Chemotherapy education and survivorship visits are billable services that provide real value. These visits can be performed entirely by an ACP.
An ACP’s salary is a fraction of a physician’s, yet their ability to provide meaningful services is expanding, particularly in oncology. These providers are a low-cost way to improve patient care and provide value while adding revenue to a practice or institution.
The concept of providing quality and value may be confusing or overwhelming when examining these topics on a large scale, particularly when value to the health care system may be slightly — or remarkably — different than value to the patient or provider.
However, when we break it down to its simplest form — what is valuable to the patient — our goals become much clearer.
It is the ideals discussed above that make the difference for our patients each day, even over cost and outcomes.
We have to approach value in health care with our patients’ concerns at the center of our focus. If we consistently keep time, communication and education at top of our priority list, we undoubtedly will see a positive effect on all quality measures.
To accomplish these goals, we must employ a team-based approach. Systems, physicians, ACPs, nurses and support staff all share the responsibility of providing value to our patients. However, proper utilization of ACPs and nurse navigators can maximize efficiency and minimize cost while providing real and perceived value to our patients.
Together, we can provide a cost-effective, efficient, health care delivery system to all of the patients for whom we care.
References:
Dill MJ, et al. Health Aff (Millwood). 2013;doi:10.1377/hlthaff.2012.1150.
Hewitt ME, Greenfeld S and Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2006.
Wagner EH, et al. J Clin Oncol. 2014;doi:10.1200/JCO.2013.51.7359.
Weeks JC, et al. N Engl J Med. 2012;doi:10.1056/NEJMoa1204410.
For more information:
Lindsey E. Sirianno, MSPAS, PA-C, is director of solid tumor advanced care practitioners at Levine Cancer Institute at Carolinas HealthCare System. She is also a HemOnc Today Editorial Board member. She can be reached at Levine Cancer Institute, Carolinas HealthCare System, 1021 Morehead Medical Drive, Suite 3200, Charlotte, NC 28204; email: lindsey.e.sirianno@carolinashealthcare.org.
Disclosure: Sirianno reports no relevant financial disclosures.