Bringing Health Care Consumers Into Their Own Care

Implementing shared decision making in Minnesota

Empowerment, self determination, personal responsibility, and patient activation are terms used throughout the arenas of politics and social issues when discussing the need to engage Americans in their health and health care.

With statistics like “nearly 63 percent of Minnesota adults are overweight or obese,” everyone working on health reform recognizes that consumers are not effectively engaging in their own health care. Instead, patients expect doctors to take action to fix them. We want technical fixes for our problems, when what’s really needed are adaptive changes—which require people to act differently than they have in the past and adopt new behavior. That’s much harder than taking a pill.

Health care strategies are moving away from a more traditional paternalism in clinical care, to providers and patients as active partners involved in managing health. Many growing and emerging strategies reflect this approach—health care homes (medical home) and care coordination, palliative care and consultations, and Honoring Choices and advance directive planning, all areas that Stratis Health is actively working in.

Another strategy being adopted that advances this principle is shared decision making (SDM)—an approach that aims for clinicians and patients to partner in making treatment decisions for complex medical decisions when the “best” therapeutic option is unclear. This applies well to conditions like prostate cancer and low back pain, for which the “best” treatment option differs by individual patient.

Communication is central to SDM. Patients need evidence-based information to understand treatment options and likely outcomes, as well as potential benefits and risks to weigh in light of their own values and preferences. Providers need to ask for and be willing to hear what is important to patients and factor that information into care decisions.

“Until we help people think about decisions and what’s important to them, we are not getting at solving the problems they face,” said Larry Morrissey, medical director of quality improvement for Stillwater Medical Group, which is using SDM with breast and prostate cancer patients. According to findings in a 2009 Robert Wood Johnson report, the efficacy of health care strategies is tied to a patient’s level of engagement in health care. Evidence shows that financial incentives and information-only strategies are insufficient to change consumer behavior.

Understanding whether a patient is activated is a communication challenge for clinicians. Patients need a sense of their ability to make health care decisions, along with permission and support to participate in the decision making process. Clinicians can get at this somewhat through health coaching and motivational interviewing.

“Getting patients engaged has been the roadblock,” said Morrissey. “What happens between doctor’s visits is what drives health.”

A University of Western Ontario study indicated a strong correlation between good outcomes—better recovery from discomfort and concern, better emotional health two months later, and reducing diagnostic tests and referrals about 50 percent—and the patient’s perception that the physician and the patient had found common ground in deciding the treatment option.

“If you ask providers if they do shared decision making, most will say ‘yes’,” commented Penny Moran, HealthPartners, which has piloted SDM. “When you explain how shared decision making is different than informed consent, they realize they are not really achieving the desired level of engagement.”

Minnesota moving forward

Several pilots exploring SDM have been conducted in Minnesota. To promote its use in clinical practice throughout the state, a community-wide multi-stakeholder group, the Minnesota Shared Decision Making Collaborative, came together starting in December 2008. Stratis Health is part of this collaborative working to develop standardized approaches to defining, performing, and measuring SDM and decision quality.

Leaders from diverse perspectives are coming together to see how they can change the whole system. In January, the Minnesota Department of Human Services shared its recommendations with the state legislature about how to support SDM in practice.
Morrissey acknowledges that there is uncertainty about how to measure SDM. “We need to keep our minds open about moving forward. We know enough to work on this.”

This fall the collaborative plans to host an educational event to familiarize more providers with SDM and accelerate the adoption of this patient engagement practice.

“Once you experience shared decision making and see the value, you can’t help but get behind it,” said Morrissey.