Patient Engagement - Comprehensive Care is a Way
Patient engagement is a dynamic process that requires different sources by the physician and patient, as well as preparation, infrastructure, leadership and time for the result to be successful that is to improve patients and take responsibility for their own health.
Patient engagement is a process that allows a way to improve the quality of healthcare more efficient and better patient and family health. The result of this process is a cooperative patient. Comprehensive care is a very good way for patient engagement.
Comprehensive care is one of the four pillars that support the specialty of Family Medicine and complements the paradigm of patient care in their bio-psycho-social spheres proposed by Engel.
Once a good clinical diagnosis is made, the first step is to prescribe a drug treatment according to the diagnosis. This is basic, and obvious, but sometimes is not performed correctly, for this reason it is of utmost importance to make a good diagnosis and to give pharmacological treatment according to clinical diagnosis. This point is also supported with dietary and exercise guidelines, and health education.
Brief therapy techniques such as normalization, facilitation, clarification, re-labeling, reinforcement, confrontation, among others, and sometimes a combination of these techniques have proven that they are useful.
There are principles to treat the psychological aspect of the disease, condition or problem in the patient. First, it requires knowledge of the matter and to have had a previous basic training.
Second, the application of the following 5 steps: Assess advice, agree, assist and arrange.
Keywords: Patient Education; Family Health; Quality of Care; Continuity of care; Mental health
Patient engagement means taking specific actions to benefit from healthcare [1].
Patient engagement is a dynamic process that requires different sources by the physician and patient, as well as preparation, infrastructure, leadership and time for the result to be successful that is to improve patients and take responsibility for their own health [2-4].
Patient engagement is a process that allows a way to improve the quality of healthcare more efficient and better patient and family health. The result of this process is a more cooperative patient [5].
Comprehensive care is one of the four pillars that support the specialty of Family Medicine and complements the paradigm of patient care in their bio-psycho-social spheres proposed by Engel. The other pillars are: continuity, community and preventive approach [6-8].
The concept of comprehensive care has led to confusion and stress for many doctors because they do not fully understand how to do it.
The experience of 30 years is presented below in a very simple and practical way based on a methodology called Working with Families described by Janet Christie-Seely [9,10].
Since family physicians usually have to care for many patients in a regular working day, whether in an institution or in private practice, or both, comprehensive care appears impossible, especially for residents, because it demands more time for each patient and a larger period of care [11].
Multidisciplinary care seems to be the solution, since family physicians can refer the patient to other specialists according to the patient´s needs, and thus they are providing comprehensive care in a biological context and also in a psychological context when the patient is referred to a psychologist or psychiatrist [12].
Family physician is the specialist who has the obligation to provide a comprehensive care to his/her patients, and the reference to other specialist only complements medical care when the clinical problem is beyond his/her expertise.
The amount of time and effort required for this responsibility, raises the first question: To who of the patients should the family physician provides comprehensive care?
The response is to everyone, but in the practice this is impossible, especially in first encounters. Besides, continuing care means linking visits, so comprehensive care can do it in several subsequent encounters and not only at the first one, which favors time management and the choice of patients for whom the family physician must offer comprehensive care.
It is obvious that comprehensive care requires more consultation time which in most cases is scarce, for this reason the physician should select the patients requiring comprehensive care and devote more attention and time to treatment at any encounter or special meeting.
To pick out or screen these patients, criteria have been established, and patients who meet them have been called critical or vulnerable patients, they account for 30% of family physicians outpatient encounters [13].
Criteria may be the following, or can be used other criteria of vulnerability:
1. Patients with multiple visits to primary care (Frequent users).
2. Patients with two or more diagnoses in medical records in the past year (Polypharmacy).
3. Patients with non-specific diagnoses (MUS: Medical Unexplained Symptoms).
4. Patients with chronic diseases poorly controlled.
5. Patients with predominantly psychological symptoms (Depression, anxiety).
6. Patients who are caregivers of a family member with chronic illness or disability.
Once an encounter has taken place with a patient who meets one or more of the above criteria, the physician should offer him/her comprehensive care.
Then the second question comes: What tools should the family physician use to perform successful comprehensive care?
Initially is necessary to determine the level of intervention (any treatment is an intervention) in any of the 5 levels described by Doherty. Accurate diagnosis is essential for an intervention [14].
According to Doherty intervention, the practice of family physicians is on levels 1 to 4. Levels one, two, and three are limited to biomedical aspects. Doctors working on the fourth level of intervention are not limited to data collection; but actively show interest in the feelings and concerns of patients and their families. The physician, who practices at this level, typically has formal training in general systems theory and must be competent in some brief therapy techniques in order to provide comprehensive care. The fifth level is reserved for interventions that must be performed by a family therapist [15].
Once a good clinical diagnosis is made, the first step is to prescribe a drug treatment according to the diagnosis. This is basic, and obvious, but sometimes is not performed correctly, for this reason it is of utmost importance to make a good diagnosis and to give pharmacological treatment according to clinical diagnosis. This point is also supported with dietary and exercise guidelines, and health education.
Because patients, who meet one or more of the mentioned criteria, have a strong psychological component in its pathology, the second step is to establish a psychological treatment according to the condition. The above does not mean that the family physician will replace the psychologist, but just to apply simple techniques to complement the drug treatment.
There are different techniques to accomplish this:
The simplest one are counseling techniques such as patient education, anticipatory guidance or facilitation of communication, based on the natural history of disease, knowledge of family dynamics and common sense; either with an individual patient or with the entire family.
Brief therapy techniques such as normalization, facilitation, clarification, re-labeling, reinforcement, confrontation, among others, and sometimes a combination of these techniques have proven that they are useful [16].
A common support is the performance of the family development tasks to complement the comprehensive care, because if these have not been fulfilled to a certain stage of family life cycle it is likely that the patient and family will develop complications. “Development tasks are the tasks related to the steps that the family must necessarily goes through to develop itself” [17,18].
“These tasks require largely on the ability to adapt, adjust and balance the family to ensure that it is able to develop and face the critical moments in a proper manner and keep the bio-psycho-social balance of its members “[14]. Therefore fulfilling these tasks ensures a better understanding by the patient of his/her family dynamics.
Another technique is educational intervention, although this technique requires more time and usually is used in groups. In some cases, health education is a psychological technique in the comprehensive treatment.
Finally, for family physicians who have received adequate training, family therapy at the fifth level of Doherty intervention will be the proper solution. However it is recommended that this level of intervention be performed by referral to a family therapist.
Health teams also help family physicians provide comprehensive care. The World Health Organization defines them as non-hierarchical associations between different disciplines. Primary care units consists of different professionals such as nurses, social workers, health promoters, dentists, nutritionists, the family physician usually coordinates the health team when patients require in clinical care. This integration is called multi-professional care [12].
The third question, the most difficult, is how to apply this elected technique?
The maneuvers of union such as empathy and the therapeutic contract that should have been made at the beginning of the encounter really help here.
There are principles to treat the psychological aspect of the disease, condition or problem in the patient.
First, it requires knowledge of the matter and to have had a previous basic training.
Second, the application of the following 5 steps: Assess, advice, agree, assist and arrange [19].
Assess beliefs, behavior and knowledge.
Advise the patient with a plan of action, according to a list of his/her problems, either expressed or unexpressed, and provide information about the benefits of change that the family physician is looking for.
Collaboratively agree on objectives based on a conviction of patient safety and achieve a change or adherence to the proposed treatment.
Assist the patient to identify barriers and strategies to resolve his/her problems.
Organize (arrange) a monitoring plan no more than 6 encounters and have a plan to include or be clear about the objectives of the intervention, taking into account patient barriers (obstacles to improve or change).
Have a strategy in solving problems. If a patient presents several problems he/she should generally first try the simplest so that the patient initiates a learning process in the effective resolution of their problems. The family physician has a maximum of 4-6 encounters to solve a problem and then establish a new therapeutic contract to address the following problem. When problems are multiple, sometimes it is not the simplest first but the most important for the patient or the problem which represents the reason for the encounter.
Finally, the social aspect of the disease: In this area there is less than doctors can do for the patient because usually the social aspect is dominated by economic or cultural problems, but family physicians can mention the proper use of resources on family support gaps in the social field, such as teaching the use of household resources, religious resource, the resource of the friendships, the use of social support organizations, Alcoholics Anonymous (AA), Epilepsy Foundation, among others.
The first encounter obviously takes longer but subsequent are much quicker because the physician is going deeper into the patient’s medical problems.
In the last few years some authors have published case reports that exemplify the comprehensive care by family physicians, and reflect the difference in the care of other specialties [20].
Each of these concepts requires further explanation and should be studied extensively. With these simple ideas well organized, family physician scan offer patients a truly comprehensive medical care.
