A Healthesystems publication

Winter 2018/2019

Patient Engagement Is Personal: How to Help Injured Workers Help Themselves

FAST FOCUS

Patient engagement can lead to better health outcomes, but not all engagement strategies are equally effective. Viewing patient engagement as a collaborative effort between the care team and the patient is key to successful recovery for injured workers.

Patient engagement is an important aspect of healthcare strategies to achieve the triple aim of improving population health and the patient experience, while also reducing the cost of care. A large collection of studies from around the world have shown that positive patient engagement leads to better health outcomes,1 as well as stark differences in the healthcare experiences of engaged vs non-engaged patients.

For example, a Commonwealth Fund Survey of 11 countries found that engaged patients reported fewer medical errors, more positive views of their healthcare systems and, by a significant margin, higher quality of care than their non-engaged counterparts.2

ENGAGED PATIENTS MORE LIKELY TO REPORT HIGH-QUALITY CARE

enagaged patients

Patient engagement has also been credited with reducing costs. One study showed that patients who received enhanced decision–making support had 5.3% lower medical costs and another study demonstrated a more dramatic inverse correlation – disengaged patients incurred costs up to 21% higher than those who were highly engaged.3

Medical costs up to 21% higher for disengaged patients

PATIENT EXPERIENCE =

The sum of all interactions that influence patient perceptions across the continuum of care

PATIENT EMPOWERMENT =

Shifting authority or power to patients so they can make more informed healthcare decisions

PATIENT ACTIVATION =

The knowledge, skills and confidence a person has in managing their own health and care

PATIENT ENGAGEMENT =

The knowledge, skills and confidence a person has in managing their own health and care

Interestingly, while there is broad agreement within the healthcare community that patient engagement reaps many benefits, there is much less consensus on precisely how to define it. Some confusion stems from similar terms, such as patient experience, which is a broader concept, and patient empowerment or patient activation, both of which are components of patient engagement.

For this article, we will use the following definition, which speaks directly to the active role stakeholders can take in driving patient engagement:

Patient engagement is the use of intervention by the care team to increase the patient’s positive role in their care.

The challenge, of course, lies in how to do this. What methods should providers, payers, and their pharmacy partners employ to engage patients in meaningful ways that produce positive results?

PATIENT ENGAGEMENT TECHNOLOGY

Technology has long been at the forefront of patient engagement efforts, largely due to meaningful use requirements of the Affordable Care Act, which mandate that some percentage of patients be engaged with their providers through electronic health records (EHRs) or patient portals. EHR adoption and implementation dominated technology resources for years, but patient portals, which automate the exchange of information between healthcare organizations and patients within a secure environment, are now a top investment priority for many.4 Secure communications and online/mobile scheduling are usually part of patient portals when they are available.5

Other applications grouped under the patient engagement umbrella are in use to varying degrees, including:

  • Telemedicine, which allows patients and providers to meet virtually from remote locations
  • Remote health monitoring apps, including “wearables,” which enable remote tracking and reporting of patient medical data
  • Customer relationship management (CRM) software, which stores medical history, personal health information, and lifestyle choices – often in combination with relevant consumer data such as occupation, economic class, and ethnicity – to provide a complete view of the healthcare “customer”
  • Social media networks used to educate patients about diseases and treatments and as a platform for affected individuals to share information and support
  • Mobile apps for patient education and awareness

These technologies can make healthcare interactions more convenient for the patients who use them, while also saving time for administrative and clinical staff. How successful they will be in engaging patients remains to be seen. Usage rates for patient portals, as measured in real-world studies, average below 25% 6 and market penetration for telemedicine consultations is below 1%.7

Acceptance of these applications will likely grow over time, but it is important to note that technology is only a tool that can be used to facilitate the flow of information between clinicians and patients.

Patient portal usage rates averaged below 25% in real-world studies

THE HUMAN ELEMENT

Human interaction and communication between clinicians and patients are essential to better patient engagement. According to a survey of healthcare clinicians and administrators by the New England Journal of Medicine, the two tactics that are most effective at improving patient engagement are clinicians spending more time with patients and shared decision making.8

Spending more time with patients would surely allow for better engagement, including the opportunity to discuss treatment options and facilitate informed decisions based on the patient’s specific needs and preferences. Personal interaction is at the heart of both these initiatives and several other effective patient engagement strategies rely heavily on the human element, including:

  • Coaching to help patients gain better understanding of their conditions and treatment options, advising them about navigating the healthcare system, and assisting with any behavioral changes and skills needed to improve health and wellness
  • Patient education that integrates materials, such as drug and disease information sheets, with participatory learning, most commonly the “teach-back” method in which care team members ask patients to explain back to them what they have learned
  • Medication therapy review meetings to gather information regarding all medications that the patient is taking and determine whether the medications are effective according to the treatment goals, recommend changes if necessary, and advise patients on correct dosing, the importance of taking the medications as prescribed, and potential side effects
  • Wellness programs to promote health and fitness and provide structured guidance on nutrition, exercise, medication adherence, and condition monitoring to assist patients in managing the factors within their control that contribute to better health outcomes
  • Facilitated support groups led by clinicians, which focus on sharing credible information, guiding discussion, and providing support for a wide variety of conditions from cancer to chronic pain

More personal approaches to patient engagement naturally take more time, which is an increasingly rare and valuable commodity in healthcare. The average visit time between physicians and patients has shrunk to below 15 minutes, 9 and physician assistants and nurse practitioners manage only marginally more time with their patients.10 Consequently, effective patient engagement requires participation from the entire care team, including case managers and clinical staff partners, such as PBM pharmacists. The participants and manner of engagement should be determined by focusing on areas that will reap the greatest benefit to patients.

INFLUENCERS
  OF PATIENT ENGAGEMENT

some-image

PATIENT ENGAGEMENT IN WORKERS’ COMP

Workers who are injured on the job are always under stress and often in serious pain. Anxiety about potential financial and employment consequences can hinder a worker’s ability to focus on treatment and recovery. This makes workers’ comp patients highly likely to be among the 50% who leave the physician’s office not understanding what they were told.11 So, it is especially important that the rest of the care team step in to provide interpretation and guidance about the prescribed treatment regimen.

Case managers, claims adjustors, pharmacists and others must be on the lookout for health concerns such as comorbidities, opioid abuse, and medication adherence.

Comorbidities can complicate recovery and delay return to work (approximately 50% of claims with a comorbidity diagnosis experience lost time).12 Prescription medications are at the crux of treatment for most workers’ comp injuries, accounting for an average 18% of medical costs and more than double that for older claims. 13 At least 25% of drugs prescribed for injured workers are controlled medications14 and the risk of opioid abuse is high. Poor adherence to necessary drugs is also common, with only 50% of patients taking their medications as directed.15

only 50%

of patients take their medication as directed

Proper adherence to medication as well as other treatment regimens, such as physical therapy, is essential for optimal recovery. Engaging workers’ comp patients through medication reviews and other types of follow up has achieved some very positive results:

section-icon

One study reported a decrease of 17% in average cost per claimant and a 24% decrease in drug utilization three months following pharmacist-provided medication review 13

section-icon

Based on analysis of nearly 300,000 claims, organizations with a formal follow-up process for injured workers reduced total claim costs by 14%, or more than $1,550 per claim 16

section-icon

Lost work days were reduced by 15% when injured workers were engaged through follow-up efforts 16

section-icon

Medication reviews led to a 24% decrease in morphine equivalent dose (MED) in one study 13

In addition to reducing costs, speeding return to work, and improving adherence, patient engagement reaps other benefits that contribute to superior health outcomes for injured workers. Engaging patients, especially through human-to-human interaction, builds trust, which is an important predictor of better health outcomes for workers’ comp patients.17 Patient health knowledge is enhanced through engagement, which not only contributes to initial healing, but carries over to assist with general wellness. And both patients’ and care team members’ satisfaction levels are positively impacted by successful collaboration.

BEST PRACTICES
TO ENGAGE INJURED WORKERS

Workers’ compensation rules and regulations make it necessary for patients to navigate a complex claims system and interact with various stakeholders including physicians, employers, insurers, case managers, pharmacists and others. Successful engagement that improves health outcomes for injured workers depends on participation from the full care team – across the healthcare continuum – includes:

POPULATION ANALYSIS

section-icon

An important first step is to stratify patient populations according to health and safety risk factors to identify the patients who will benefit most from higher levels of engagement, as well as the care team members best positioned to help them. For example, patients with comorbidities who face greater risk of adverse drug reactions and/or medication non-adherence due to polypharmacy may benefit most from engagement with pharmacists. Stratifying patient populations allows for more personalized and effective patient engagement strategies.

COMMUNICATION

section-icon

Accounting for differences between patients can be as important in communicating with them as it is in treating them. Health literacy, language fluency, and age are important considerations. Younger patients may prefer to engage via text messages, while older patients respond better to live telephone conversations. And patients of all ages will engage much more actively in their most fluent language. Communications should also be relevant and timely. An annual broad-based message about physician dispensing will not yield the same results as a targeted communication to a patient who recently accepted medications from a physician.

EDUCATION

section-icon

As noted earlier, patients often leave the doctor’s office not understanding what they have been told and it is a mistake to take for granted that patients have all of the information they need. Every touchpoint along the care continuum is an opportunity to educate and engage. Patients absorb information at different rates and through different mediums, making it important to use a variety of channels including print, online, video, live presentations, and good old one-to-one conversation.

Engaged patients who take an active interest in their own care can influence their health outcomes enormously, but they cannot do it alone. Clinical expertise and appropriate guidance from the entire care team is essential. And, while the right technology will facilitate the flow of information and achieve efficiencies, it cannot replace the human interaction required for the most meaningful and effective engagement – care teams and patients working together to improve health.

OUTREACH

section-icon

“If you build it, they will come” does not apply in patient engagement. Providing resources to patients is helpful, but most are not likely to find and use them on their own. This is especially true in workers’ comp where patients often believe they are at the mercy of ‘the system.’ Proactively reaching out to offer information and assistance will go a long way in ensuring appropriate care, improving adherence and, perhaps most important, building trust. This is especially true when outreach comes from clinicians, such as pharmacists and nurses, who are perceived as highly credible and trustworthy by patients.

ONGOING ENGAGEMENT

section-icon

The recovery process for injured workers can be volatile, and clinical oversight and intervention are essential to ensure that patients continue on an optimal path. Because patients typically see physicians at infrequent intervals, ongoing monitoring and counseling from other care team members are important components of patient engagement. For example, medication reviews with PBM pharmacists can engage patients and foster collaboration between care team members. Such reviews often lead to adjustments in medications, which must then be monitored to ensure intended results. Regular and ongoing follow-up with patients about adherence and their response to modifications in the medication regiments is truly meaningful engagement that helps build a trusting relationship while providing crucial clinical information.

Engaged patients who take an active interest in their own care can influence their health outcomes enormously, but they cannot do it alone. Clinical expertise and appropriate guidance from the entire care team is essential. And, while the right technology will facilitate the flow of information and achieve efficiencies, it cannot replace the human interaction required for the most meaningful and effective engagement – care teams and patients working together to improve health.

RATE THIS ARTICLE

SOURCES

1 -Hibberd, J, Greene, J. What the evidence shows about patient activation; better health outcomes and care experiences; fewer data on costs. Health Affairs. https://doi.org/10.1377/hlthaff.2012.1061 Feb 2013.
2 -Osborn R, Squires D. International perspectives on patient engagement: Results from the 2011 Commonwealth Fund survey. Journal of Ambulatory Care Management. 35(2) (2012): 118-28 https://www.commonwealthfund.org/publications/journal-article/2012/mar/international-perspectives-patient-engagement-results-2011
3 -Patient engagement. People actively involved in their health and health care tend to have better outcomes—and, some evidence suggests, lower costs. Health Policy Brief, Health Affairs, Robert Wood Johnson Foundation. https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404446 Feb 14, 2013.
4 -Rouse, M. Patient engagement. SearchHealthIT. https://searchhealthit.techtarget.com/definition/patient-engagement 2017.
5 -Ballou-Nelson, P. Are portals a means to patient activations?. Medical Group Management Association. https://www.mgma.com/data/data-stories/are-portals-a-means-to-patient-activation 2018
6 -Fraccaro P, et.al. Patient portal adoption rates: A systematic literature review and meta-analysis. IOS Press. doi: 10.3233/978-1-61499-830-3-79. 2017.
7 -29 statistics you need to know about healthcare & telemedicine. First Stop Health. https://www.fshealth.com/blog/29-statistics-about-telemedicine-healthcare August 1, 2017.
8 -Patient engagement survey: improved engagement leads to better outcomes, but better tools are needed. Insights Report, New England Journal of Medicine Catalyst. https://catalyst.nejm.org/patient-engagement-report-improved-engagement-leads-better-outcomes-better-tools-needed May 12, 2016
9 -Hasson, J. Older patients, longer visits. AthenaInsight. https://www.athenahealth.com/insight/older-patients-longer-visits June 10, 2016.
10 -Morgan P, Everett CM, Hing E. Time spent with patients by physicians, nurse practitioners, and physician assistants in community health centers, 2006-2010. Healthcare. Healthc (Amst). 2014 Dec;2(4):232-7. https://doi.org/10.1016/j.hjdsi.2014.09.009
11 -Atreja A, Bellam N, Levy SR. Strategies to enhance patient adherence: making it simple. MedGenMed. 2005; 7(1): 4. https://pdfs.semanticscholar.org/b74a/a02f422d380861b81c3839136c80089cc9ce.pdf
12 -Comorbidities in Workers’ Compensation, National Council on Compensation Insurance (NCCI). https://www.ncci.com/Articles/Pages/II_Comorbidities_in_Workers_Compensation.aspx Nov 2012
13 -Link, B. Role of pharmacist-provided medication reviews in workers’ compensation claims management. Healthcare Solutions. https://www.cypresscare.com/pdf/Role_of_Pharmacist_Provided_Medication_Reviews_FINAL.pdf
14 -Lipton, B, Colon D, Robertson J. Workers’ compensation prescription drug study: 2013 update. National Council on Compensation Insurance (NCCI). https://www.ncci.com/Articles/Documents/II_Prescription_Drugs-2013.pdf Sep 2013.
15 -8 Reasons patients don’t take their medications. American Medical Association. https://wire.ama-assn.org/practice-management/8-reasons-patients-dont-take-their-medications Oct 16, 2015.
16 -Improving engagement of injured employees. Gallagher Bassett. https://www.gallagherbassett.com/media/3268/final-10_20_employeeengagement_rnote.pdf 2016.
17 -Robinson, TA. WCRI identifies trust in the workplace as a key “predictor” of outcomes important to injured workers. LexisNexis. https://www.lexisnexis.com/legalnewsroom/workers-compensation/b/recent-cases-news-trends-developments/posts/wcri-identifies-trust-in-the-workplace-as-a-key-predictor-of-outcomes-important-to-injured-workers July 6, 2014.
Table of Contents