Rapid Communication
Gerontol Geriatr Res. 2016; 2(3): 1014.
“Patient Readiness” Form: A Pilot Study to Increase Patient-Centered Communication during Medical Appointments with Older Patients
Stults CD¹*, Cheng PH², Hagstrom A¹ and Tai- Seale M¹
¹Palo Alto Medical Foundation Research Institute, USA
²The Guzik Center for the Advancement of Geriatrics and Palliative Care, Palo Alto Medical Foundation, USA
*Corresponding author: Stults CD, Palo Alto Medical Foundation Research Institute, 2350 W. El Camino Real, 4th floor, Mountain View, CA 94040, USA
Received: April 22, 2016; Accepted: May 21, 2016; Published: May 24, 2016
Abstract
Agenda setting is an important component of patient-centered communication, yet it often does not happen in ambulatory encounters, particularly with older patients. The “Patient Readiness Form” was developed to have an older patient list their concerns in order of importance and their current medications/supplements and dosage. A small pilot study was conducted in a multi-specialty group practice and found that older patients and physicians were willing to use the Patient Readiness form to help with agenda setting before and during office visits, citing that it helped them focus on the visit. This form has potential to improve patient-centered communication, but more research is necessary.
Keywords: Agenda setting; Pilot projects; Older adults; Communication; Office visits
Abbreviations
HER: Electronic Health Record
Introduction
Patient-centered communication is a centerpiece of effective primary care. Evidence shows that when patients are engaged in revealing their agenda during an ambulatory encounter, the patient is usually more satisfied and more capable of managing their own health [1-3]. The reality of a typical ambulatory encounter, however, is that their agendas are not commonly known [4,5]. Barriers, such as time constraints, disrupt the best of intentions [6]. Multiple patient issues compete for physician’s attention and time, along with physician’s own agendas that need to be covered, often without explicit recognition that there are these competing agendas. In fact, use of Electronic Health Records (EHRs) has been documented to increase the competition, given the proliferation of reminders and care gap alerts [7]. As a consequence, communication continues to be unstructured: “For most patients, there is no systematic or effective method for communicating what happens outside the clinical encounter, such as perceived needs, symptoms, response to treatment, undesirable side effects, effect on function, and what matters to patients and their families” [8].
Effective clinical communication requires patients to actively participate in agenda setting, share information about symptoms and concerns, discuss expectations and options, and ask questions. But patient engagement is even more challenging in older patients as they participate less in medical interviews than do their younger counterparts [9]. Some online tools have been created to help elicit information about patient’s function, symptoms, health habits, preventative needs, and experience of care such as HowsYourHealth. org [8], but these do not specifically ask about what items are of greatest importance to the patient to be discussed with their physician. Given these concerns, we developed a “Patient Readiness” form (Figures 1&2) to help better prepare senior patients for their visit and to aid their physicians with agenda setting. Our objective with this pilot study was to determine if the “Patient Readiness” form affected the visit for both patients and physicians and what was the experience of using the form like for patients.
Figure 1: Sample of “Patient Readiness” Form: Front Page.
Figure 2: Sample of “Patient Readiness” Form: Back Page.
Methods
The pilot study occurred in a non-profit, multispecialty group practice in Northern California. The study was approved by the group practice Institutional Review Board. The “Patient Readiness” form was tested with 10 patients who met the following inclusion criteria: age 65 and older, members of the local senior aging in place community, received their health care from the group practice, had an appointment scheduled with their primary care physician in the 2 month study period, scored “normal” (23-30) on the Folstein Mini Mental State Exam [10], and were functionally able to write to be able to complete the form before the visit and take any notes during the visit. This convenience sample was selected and screened for inclusion by one of the co-authors who worked for the local senior aging in place community. She also selected participants who each had different primary care physicians (10 totals) to obtain more perspectives. In this cross-sectional study, participating subjects were given the “Readiness” form that they filled out before their physician visit listing their top three concerns in order of priority and current medications (Figures 1&2) and made a copy to give to the physician. Following the visit, a research team member surveyed the patient and physician participants about the impact of the form on the visit. There were 5 patient questions with a 5 point Likert scale for the responses (“strongly disagree” to “strongly agree”) (Table 1). Physicians also had to answer 5 similar questions on the same Likert scale (Table 2). On each survey, there was a free response space where participants could write in any additional comments. Given the small sample size, basic frequencies were used to analyze the survey data and the written comments were analyzed to view commonalities and differences in free text responses.
PATIENTS (n=8)
Strongly Disagree
Disagree
Neutral
Agree
Strongly
Agree
1. The "Patient Readiness" form was useful in improving my understanding of the goals and priorities of this visit.
4
4
2. The "Patient Readiness" form helped my physician explain things in a way that was easy to understand.
3
3
2
3. The "Patient Readiness" form increased my satisfaction with the quality of this visit.
2
2
4
4.� My time invested in preparing this "Patient Readiness" form was worthwhile.
2
6
5. I would be willing to use the "Patient Readiness" form for all physician visits at PAMF.
2
6
Table 1: Patient Survey Responses about “Patient Readiness” Form.
PHYSICIANS (n=6)
Strongly Disagree
Disagree
Neutral
Agree
Strongly
Agree
1. The "Patient Readiness" form was useful in improving my understanding of this patient’s goals and priorities of this visit, from the patient’s perspective.
3
3
2. With this "Patient Readiness" form the patient was more attentive and prepared for his/her visit than previous visits before.
1
2
3
3 The "Patient Readiness" form helped me address specific patient concerns during the visit.
1
2
3
4. The "Patient Readiness" form increased my satisfaction with the quality of this visit.
2
4
5. I would like to see a "Patient Readiness" form used by all senior patients at PAMF.
1
1
4
Table 2: Physician Survey Responses about “Patient Readiness” Form.
We also convened a focus group with six of the patient participants to gain further understanding about their experience using the Readiness form. Conducted by a qualitative medical sociologist, questions included “What was your experience like with the Patient Readiness form?” and “What was the overall effect of the form on the visit?” The focus group was audio recorded to obtain the exact language of participants. Comments were analyzed by a qualitative medical sociologist using grounded theory where the main ideas emerged from the data.
Results
Survey
Of the 10 patient participants, six were female, all 10 were white/ Caucasian, most were very educated (college degree or higher) and affluent. Four of the 6 physicians were female, race/ethnicity, and most were from family or internal medicine. Eight of 10 patients and six of 10 physicians completed the survey (Table 1). All eight respondents “agreed/strongly agreed” that the Readiness form improved their understanding of the goals and priorities of the visit, the time spent preparing the form was worthwhile, and that they would be willing to use the form for all physician visits. Most “agreed/strongly agreed” that the Readiness form helped their physician explain things in an easy to understand way and increased their overall satisfaction with the visit. Of the six additional comments written by patients, four related to the overall visit length that using the form “did not require extra time” as compared to a traditional office visit and that the form kept the visit “on track and [on] time”: “My doctor was so pleased to use this form that it appeared as if we required less time”. From the other written comments, one participant noted that she used the form as a “note taking guide” after each concern and gave her a chance to “take accurate notes but also to have a record afterwards”.
Six of the 10 participating physicians completed the survey (Table 2). All six respondents “agreed/strongly agreed” that the Readiness form improved understanding the patient’s goals and priorities. Most physicians “agreed/strongly agreed” that the Readiness form helped the patient be more attentive and prepared with the form helped them address specific patient concerns at the visit, and increased their overall satisfaction with the visit. With the exception of one physician, respondents indicated that they wanted to see the form used by all group practice senior patients. The only written comment was “This form was very helpful in eliciting the patient’s concern and setting an agenda for the visit. This is a very simple but powerful tool, which allows us to provide better care, and improve patient satisfaction”.
Focus group
We conducted a focus group with six of the patient participants to probe more into what they liked about the Readiness form, their experience with it, and any changes that could be made to improve the form. Most participants found the form to be “helpful”. One participant who found it “extremely helpful” compared her use of the Readiness form to “preparing for a class I am interested in, compared to a class that I didn’t care very darn much about and just needed to pass.” The main way it was helpful to her was to have “very good focus” for the visit. Another participant said that having to focus on just four priorities was difficult for her at age 80 as “something very minor can be bugging the hell out of you.” The form helped her to really evaluate what concerns were most important to share with her doctor at this visit.
Several others elaborated upon how the Readiness form helped them to focus on the visit. This “attention concentrator device” (as termed by one participant) was beneficial for the physician, but mostly for the patient:
I was surprised at how useful it [the form] was. This helps to concentrate attention- the patient’s attention. … I’m sure it helped the doctor, but it helped me more than I thought it would and I was surprised at that. It seems very simple but what it does is concentrate your attention onto what is in fact a brief encounter. It’s huge.
Other participants mentioned that the Readiness form could be particularly beneficial for older people who are losing the focus and who cannot remember their issues when they get to the visit.
However, one participant had a more “complicated” relationship with the Readiness form as it caused her to be so “busy” writing notes down that she was unable to follow up on some things that she would have in a regular visit. But, she ultimately felt good about the form as it made her realize what she had talked about in the visit: “You didn’t just rattle your mouth and go home and wonder ‘now what did I talk about?’”A few others also expressed that they did not like that they had to write down notes during the visit. As expressed by one participant, there is “no time to write anything besides a few words in the decisions” because “if you are listening and writing, that’s not good [as] then you are missing something” else that the physician is saying.
When asked if they would use the Readiness form for future visits, many participants expressed that they would use it. At that time, one patient had used it with a different doctor. Another said that she “will continue to do this [use the form] whether it is required or institutionalized”. One participant noted that they might not use the exact form, but that they would definitely think about and potentially write out their concerns before their visit. Using the Readiness form was a “win-win for both provider and patient” as they “both benefit from a more task oriented, clear specifications of” the appointment.
Discussion
This pilot study demonstrates the pre-requisites for a larger study as most patients and physicians were willing to use the Readiness form to help with agenda setting before and during office visits. Most patients felt that it helped them prepare for the visit by being more focused and concentrating on what was most important to them. The form also did not appear to lengthen the visit, according to the written patient participant comments, by allowing both the patient and physician to remain on task by collaborating on agenda setting.
There are several limitations to this study, primarily due to our sample being a small, convenience sample of participants with higher education and income without significant functional and cognitive impairment. We also did not obtain more qualitative responses from the participating physicians beyond the one written comment on the survey.
Our findings are in line with previous research which has shown that older patients can be taught to be more active in medical visits, including inputting data about their health and wellbeing online into a system like HowsYourHealth.org [8,9]. The Readiness form also engages both the patient and the physician, which is required for true patient-centered communication [11]. Since active patients have measurably better health outcomes [9], it is possible that the Readiness form could also lead to improved health outcomes for seniors, but further research is necessary. We are pleased to report that a modified paper version of the Readiness form was incorporated into a larger pilot study funded by the Patient Centered Outcomes Research Institute [12]. The revised form still has the list of patient concerns and notes on what their next steps are, but no longer includes the medication list since that is contained in the EHR. Some additional areas for research include further refining the pen and paper tool for specific populations (eg. language, culture), adapting the tool for seniors with functional and/or cognitive impairments since they have more significant communication needs, having a companion accompany the patient to the visit to be the “note taker” so that the patient can focus on the conversation with the physician, integrating the Readiness form into the EHR, and having a mobile application version.
References
- Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995; 152: 1423-1433.
- Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract. 2002; 15: 25-38.
- Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centered care and adherence: Definitions and applications to improve outcomes. J Am Acad Nurse Pract. 2008; 20: 600-607.
- Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA. 1997; 277: 350-356.
- Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda: have we improved? JAMA. 1999; 281: 283-287.
- Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Aff (Millwood). 2010; 29: 1310-1318.
- Shires DA, Stange KC, Divine G, Ratliff S, Vashi R, Tai-Seale M, et al. Prioritization of evidence-based preventive health services during periodic health examinations. Am J Prevent Med. 2012; 42: 164-173.
- Nelson EC, Eftimovska E, Lind C, Hager A, Wasson JH, Lindblad S. Patient reported outcome measures in practice. BMJ. 2015; 350: g7818.
- Cegala DJ, Post DM, McClure L. The effects of patient communication skills training on the discourse of older patients during a primary care interview. J Am Geriatr Soc. 2001; 49: 1505-1511.
- Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12: 189-198.
- Rao J, Anderson L, Inui T, Frankel R. Communication Interventions Make a Difference in Conversations between Physicians and Patients: A Systematic Review of the Evidence. Med Care. 2007; 45: 340-349.
- Tai-Seale M, Elwyn G, Wilson C, Stults C, Dillon E, Li M, et al. Enhancing shared decision making through carefully designed interventions that target patient and provider behavior. Health Aff (Millwood). 2016; 35: 605-612.
Download PDF