Rick: Welcome to the Tuesday webinar series, “Chiro Economics Webinar for Doctors of Chiropractic.” I’m Rick Vach, Editor-in-Chief of Chiropractic Economics. Today’s webinar, “Key Strategies to Enhance Patient Engagement,” is sponsored by Fullscript. And as always, our program’s being recorded and we archive at Chiropractic Economics website, chiroeco.com/webinar for one year. Our expert is on board today to speak with you and when her presentation is complete, we’ll follow with a Q&A period. You can submit questions throughout the presentation by clicking on the appropriate icon on the right side of your screen.
Our presenter today is Dr. Natacha Montpellier, ND, a registered naturopathic doctor with the College of Naturopaths of Ontario and a medical education and research specialist on Fullscript’s Integrated Medical Advisory Team. She is passionate and committed to helping individuals see how they can transform their lives by living healthier. Her clinical practice focuses on women’s hormonal and reproductive health. She believes that to achieve our healthy goals and often really our life goals, we must be active participants in our healthcare and that love, trust, and empathy for oneself are vital for healing. Thank you for taking the time to participate in our webinar and for sharing your expertise regarding patient engagement.
Before we get started, could you please give us a brief background of your work with Fullscript?
Dr. Montpellier: Yes, no problem. Well, thank you for the introduction, Rick. So yes, I am a medical education research specialist. So essentially, my work with Fullscript is to create practitioner content so that practitioners can focus on their work and not necessarily have to spend hours on looking for research and whitepapers and things of that nature. So that’s kind of my work with Fullscript. I’m currently working on a whitepaper for health literacy in which we’ll be getting into a little bit of that today as well.
So, let’s get started. We have a lot of content to cover today regarding patient-centered care. So first off, for our outline today, as I mentioned, we’ll be talking about patient-centered care, but we’ll also be talking about treatment adherence, patient engagement, as well as patient empowerment and how that relates back to patient-centered care.
We’ll also be talking about the benefits of patient-centered care and how to integrate the model into your practice. And towards the end of the…well, actually, at the end of the presentation, I’ll be talking about some practitioner insights, so some research that Fullscript conducted in the last year largely due to treatment adherence but you’ll all see how these different things connect together.
So, my goals for today are really to raise awareness about patient-centered care, patient engagement, and also treatment adherence. I want to outline the benefits and the strategies associated with patient-centered care, and also discuss some tips, tools, and resources for integrating this model into your practice.
So first off, I want to lay a foundation for treatment adherence and I will be linking that back to patient-centered care. So first off, as a concept, treatment adherence was first recorded between 460 and 370 BC by Hippocrates. So, he noted that his patients were lying about taking their medications. And at that time, it was just, you know, concluded that the patients were being irresponsible and being careless with their health. And that was really the narrative for many years, that nonadherence was a patient problem. It didn’t take into consideration the role of the practitioner or potentially other influencing factors.
In the mid-1970s, that’s when we first start researching compliance, so treatment compliance. Now this is really a model that we’ve moved away from since compliance really implies a patient’s subservience to a practitioner’s recommendations.
In the early 1990s, this is when we shift towards emphasizing the importance of the patient-practitioner relationship. So, this is when we start talking about concordance. So that’s a described state of cooperation and mutual agreement for a prescribed treatment plan between the practitioner and the patient. And this is an element of course of treatment adherence and of the therapeutic relationship which comes around in the early 2000s and this was…the WHO actually published a report on the therapeutic alliance. Now the therapeutic alliance really emphasizes the participation of the patient in the development of their treatment plan. So, it’s no longer a unidirectional model where the practitioner is telling the patient what to do, but really a model where it encourages the participation of the patient in setting up treatment goals and tasks and things of that nature.
Now why does treatment adherence matter? Well, I think as, you know, practitioners, we can understand that when our patients are not adherent to their treatment plan, they’re not gonna receive the benefits of that treatment plan. But then it goes one step further than that. Nonadherence to treatment plan can really create a significant healthcare burden and also significant healthcare costs. So, if you can see on the slide, 15% to 30% of individuals are nonadherent to a nutrient plan. Now, largely, these studies are done with pharmaceutical treatments but we can kind of imply this in other types of medicines. So, 15% to 30%. And in regards to chronic disease, 50% of individuals are nonadherent to their treatment plan. And when we think about, like, 60% of individuals living in the United States have at least one chronic disease, that’s a lot of people who are nonadherent to their treatment plan. Now that translates to a 30% to 69% of hospital admissions being related to nonadherence to medications and that translates to $100 to $290 billion care cost in the United States.
Now here, like I mentioned, like, nonadherence has been traditionally considered as a patient problem. We now know about that the limitations actually stem from multiple sources. So, on this particular slide, it’s actually a diagram that the WHO published, and here, they’re highlighting five dimensions that could impact treatment adherence. Now we know that and this is actually highlighted in their larger document that there’s actually several hundred factors that can influence treatment adherence. But here are the top five that they mentioned. So, we have practitioner-induced barriers such as poor communication. We had systemic factors, so extremely short consultations that we see in the conventional system. We have condition-specific treatment adherence. So, the less severe, the more noticeable or even the more chronic a condition, the lower likelihood of adherence. And then we also have social and economic factors, cultural norms, and perception of treatments.
I also want to talk a little bit about some modality-specific treatment adherence consideration. So, for complementary and alternative medicine, having a belief in holistic medicine, having a positive attitude towards CAM-based therapies are all gonna have in this situation a positive impact on treatment adherence. We also have for physical activity, so availability of exercise, facility, equipment, level of energy, if there’s observed or perceived lack of time, weight loss, or change in body composition. That’s all gonna have an impact on somebody being adherent to physical activity recommendations and those are certainly barriers that I’ve encountered in my practice with my patients.
We also have…oh, I went too far. Diet and nutrition considerations. So, knowledge of specific diets, the ability to read nutritional labels, adapting recipes, having just access to foods or supermarkets or even having the cost or the feasibility in regards to cost of foods. For example, if you’re recommending a patient follow an organic diet, that can be cost-prohibitive for them. And then when it comes to supplements, again, largely, the studies done and that are cited here are pharmaceutical medications but the high number of pills, the high frequency of doses and even the low frequency of clinical visits or, like, follow-ups, that can all have a negative impact on somebody being adherent to their treatment plan.
So here I just wanna highlight a few key strategies for enhancing treatment adherence and this is where I’m gonna be linking it to patient-centered care. So, we wanna take in consideration costs. So that could be the cost of our appointments, it could be the cost of our…the actual treatments we’re recommending. So, we wanna take in consideration, you know, maybe we can’t change necessarily the cost of our appointments. Maybe we can, maybe we can’t, but we can consider if we’re prescribing, you know, vitamin B12, finding vitamin B12 that would be cheaper than another one but still effective. We could be finding also resources for…free resources for our patients that they don’t necessarily have to subscribe to, let’s say, the gym or to a yoga program and finding these free resources for them.
We also wanna simplify the treatment planning. We’re gonna be coming back to that one quite a few times. Simplification of the treatment plan will really help increase treatment adherence. So instead of fully realizing, you know, our ultimate goal and of course our treatment plan maybe in the first three appointments, we really wanna space that out so that our patients can easily achieve those goals and then that can have a positive reinforcement on treatment adherence. When it comes to education, I think that as integrative practitioners, we understand the importance of our patients understanding their condition and why we’re recommending certain treatments. So that’s always important in regards to education. And then reminders can be very helpful. So that could be using electronic reminders, so it could be emails or text. Things like that can all be very helpful for keeping our patients on track with their recommendations.
Now this is where I’m looking into patient-centered care, so I wanna bring to your attention that all these top strategies for increasing adherence are all focused on the patient. So, we’re shifting the patient at the center of this model. So that’s how treatment adherence from this perspective really intersects with patient-centered care.
Now we’re gonna focus a little more on patient-centered care, what it is, what is patient engagement and empowerment? Those are all components of patient-centered care. And then we’ll also talk about the six domains of healthcare.
Okay. So first off, what is patient-centered care? So, it’s providing care that is respectful and responsive to individual preferences, needs, and values, and also ensuring that patient values guide all clinical decisions. Also, patient-centered care takes into consideration the emotional, mental, spiritual, social, and also the financial perspective including the physical of patients when we’re putting together a treatment plan.
So, in other words, we are moving away from this disease-centered care where we have the patient who has diabetes is now diabetic. We consider them…they’re characterized as diabetic. They’re put into very restrictive treatment plan for diabetics and there’s not a lot of variation in that. And then we’re moving to more of a patient-centered care where we see the patient as an individual. So, it’s a person with diabetes. We really emphasize the patient-practitioner relationship, build up in trust, having shared decision-making, involving that patient in the development of their treatment plan. So, it could be very customized.
Now what is patient engagement? So, I wanna just give a few definitions here before I get into that. So patient-centered care is a model or framework for engaging and empowering patients. Patient engagement is a measure or a goal of patient-centered care and then we’re gonna be talking next about patient empowerment which is the process through which patients become more engaged. So, when patients play an active role in their healthcare, we see improved health outcomes. We have reduced use of emergency services and primary care services, increased use of integrative services, and also increased satisfaction, self-management, and also adherence.
So patient-centered care is often a stated metric or a goal for a lot of healthcare organizations and we do wanna be careful here because we don’t want our patients’ involvement to feel tokenistic if we’re not making any real change to adopt a patient-centered care model.
Now onto patient empowerment. So just a reminder, it’s a process through which patients become more engaged. Now what is patient empowerment? Well, it’s when patients are able to manage their own health independently. They’re able to take in information and use that information to make informed choices. There’s also a focus on a patient’s experiences, desires, expectations, and beliefs. So why is this important? Well, in one study, we interviewed 33 women who were going through the conventional model and they found that there were consistent themes of feeling dismissed by healthcare providers and also feelings of reluctance and decreased satisfaction. So, we know that when we have, you know, patient empowerment, there’s improved patient and clinical outcomes. It also reduces the gap for certain healthcare health disparity groups and we’ll be going over that in a little bit more detail I think just in the next few slides. And we know that introducing patient-centered care strategies to medical training is not only feasible but it reduced costs.
And next we’re gonna go over the six domains of healthcare. We’re not gonna spend too much time on this slide but just to say that the Institute of Medicine put together one of the most influential frameworks regarding quality assessment in the healthcare system. It’s a very long document. It’s over 300 pages, very few figures so it can be a little bit of a dry read but you can see that in the five o’clock position, patient-centered care is actually one of those six domains of healthcare. So, we have safe, effective, timely, efficient, and then also equitable.
Now interestingly, since the publication of this framework, it was about, I think, in 2001, there’s been an increase in research in patient-centered care especially in the last 10 years. You can see 2011 to 2021, there’s been quite a bit of increasing research in that.
And this one also…we’re not gonna spend too much time on this particular slide because we’re gonna talk a little bit more about kinda the six components of…or key components of patient-centered care just towards the middle of the presentation.
Okay. So, the impact of patient-centered care. We’re gonna talk about the six key benefits and we’re also gonna talk about the importance of health literacy which is actually one of the benefits. We’ll spend a little bit more time on that particular benefit.
Okay, so here you can see the six key benefits. We have improved health knowledge which we will take a little bit more time in the upcoming slides. We have improved patient outcomes and treatment adherence. We have reduced healthcare burden, so lower service utilizations. That’s, like, the emergency services, primary care services. We have improved patient satisfaction, patient relationship. So, in this interesting study done in 2014, they found that there was a 23% improvement in patient satisfaction through the patient-centered care model and that was largely due to communication factors. We also have reduced healthcare disparities. So that one, I wanna spend just a few seconds here. So, one of the reasons why we can see this reduction in healthcare disparity is that when we start thinking of our patients as individuals and we involve them in the development enrichment plan, we can start to learn about their specific barriers and also involve them in the process of kind of brainstorming ways to try to overcome these barriers. So, it definitely doesn’t eliminate the health disparities but it just helps to bridge that gap a little bit more.
And then we also see one of the key benefits of patient-centered care is that there’s increased practitioner satisfaction, employee retention, and also patient adherence.
Okay, so health literacy. Like I mentioned, we’ll spend a little bit more time on that being one of the benefits of patient-centered care. So, actually, the Healthy Initiative or Healthy People Initiative 2030, they came up with these two definitions of health literacy. So, we have personal health literacy which is the degree to which individuals have the ability to find, understand, and use information to make health-related decisions. And then organization health literacy which is kind of a newer concept in the key of health literacy is the degree to which an organization enables individuals to find, understand, and use information to make health-related decisions.
And then below on the slide, you can see that there’s different types of health literacy. So, we can have condition-specific, supplement ingredients, diet and nutrition, and also lifestyle, exercise, sleep, and stress.
So why does health literacy matter? Well, it is a key social determinant of health. And individuals with low health literacy are 1.5 to 3 times more likely to experience poor health outcomes. And if you see on that blue image, they’re more likely to visit emergency rooms, have more hospital stays, they have a higher mortality rate, and also, they have lower treatment adherence which is gonna have a negative reinforcement of those three other images there.
And just a little bit more on patient…on education. So, we know that with educational engagement, that will increase our patient’s baseline knowledge. And that’s going to increase the likelihood of treatment adherence which then has a positive feedback loop on patient engagement. And then you can see at the bottom with those gray rectangles that in the process of that, we have increased patient motivation, engagement, satisfaction, empowerment. Also increased confidence in the treatment plan which will have increased…have an impact on adherence. We also have increased health outcomes, quality of care, and also decreased healthcare costs.
Now just kinda going back to health disparities. So over 33% of Americans have limited health literacy skills and the rates are disproportionally higher for racial and ethnic minorities, those with less education and functional literacy skills and limited English. And we know that when we increase health literacy, we get to decrease health disparities. And I wanna just get to the next slide because we see on the second bullet that there’s a greater effect, when we improve health literacy, there’s a great effect in patients with lower income and racial ethnic barriers. Also, we highlight on this particular slide the National Action Plan to improve health literacy by the U.S. Department of Health and Human Services. So, this is a very comprehensive document on health literacy. So, if you do want to learn a little bit more about health literacy, this could be something to look into.
Okay. So now we’re gonna be talking about…kind of this is the big part of the presentation, how we’re gonna be measuring patient engagement and empowerment since those are key components of essentially the patient-centered care. And then the six strategies to incorporate patient-centered care into your practice.
All right, so let’s start first with measuring. So, if you wanted to improve anything, you first have to measure it. So, if you wanna improve patient engagement, you first need to measure the baseline, introduce your intervention, and then measure again to see if there’s been improvement with patient engagement. Now here on this slide, we have 10 different questions. This is not a validated tool. Just questions that we put together on a one to five Likert scale and these are things that you can ask yourself either during your appointment, at the end of your appointment to try to assess the level of engagement of your patient. So, for example, you can ask yourself, you know, were your patients asking questions about their health or about their treatment plan during the appointment? Are they actively engaging in the patient portal that you have or the resources you provided them? Are they accurately echoing back the treatment recommendations that you’re mentioning to them? So, these are all different ways and of course, you can go through the different questions here and you can use that to just get a sense of where your patient is in regards to engagement.
Now when it comes to measuring empowerment…and a reminder, this is the process through which patients become more engaged. There’s this great systematic review which looked at 13 different measures of empowerment. Six of them were specific to patient empowerment and I’m just gonna talk about two in specific which, you know, “would potentially be the best to use” in regards to measuring patient empowerment.
Okay. So first off, we have the Health Empowerment Scale. So, this is an eight-question questionnaire. It’s on, again, that one to five Likert scale. It is a shorter questionnaire, so it could be something that can be integrated into your intake forms because it’s a little bit on the shorter end. That being said, because it is shorter, it’s less comprehensive than the next one which is the Patient Activation Measurement. This one has…it’s a 13 item scale out of 100 points and then that scores translate into these different levels that you see. Level one being the least engaged and level four being the most engaged. It is definitely more comprehensive and it’s also a validated tool. And here are some of the questions. Because it’s a longer tool, it kinda has a broader scope when looking at the different measurements for engagement.
Okay. Now before I get into the six keys for patient-centered care, I just wanna remind us of the barriers for patient engagement and I wanna point out that the barriers for patient engagement are also the barriers for treatment adherence. And the reason why, likely, is that when a patient is not engaged in their treatment plan, they’re likely not adherent to their treatment plan. If they’re not adherent to their treatment plan, it’s because they’re likely not engaged in the treatment plan. So, some of these barriers include confusing or unclear communication, cultural, language barriers, financial restrictions, high provider or clinic workload, lack of community-based services and health resources, lack of health improvement or positive results, lack of patient motivation or willingness or trust, low levels of health literacy, and also low priority for the provider themselves.
Okay. So here are the six strategies for patient-centered care. We’re gonna be starting at that nine o’clock position, engaging with your patient as a whole person. We’re gonna be going clockwise through all six of those bubbles, and in some of these bubbles, there’s a few concepts we’re gonna spend a little bit more time on before we move on to the next component.
So first off, we want to engage our patient as a whole person. Now what does that mean? For me, I see that as twofold. So, we want to provide individualized care. So, what are our patients needs, preferences, and goals? But we also wanna address not only the physical but the mental, emotional, and spiritual aspects of our patients. And if this is not something that we’re comfortable with or have the time for, then we wanna provide these resources for our patients.
Which brings us to number two, oops, recognizing and responding to emotion. So, I just wanna give a little bit of a story here. So, I see a lot of patients who are dealing with issues of fertility and also to the other spectrum, with postpartum anxiety and depression. And I’m always very clear with my patients that I’m not a counselor. However, that does not stop me from recognizing and responding to my patient’s emotions and using empathy and acknowledging their emotions and their nonverbal cues and then also offering resources so that they can get that holistic care.
Now within this section, the number two for patient-centered care, we’re gonna spend a little bit more time on empathy and also on motivational interviewing. So first off, let’s go on to empathy.
Real interesting information here. So, empathy is the ability to understand and share feelings of another. Interestingly, patient satisfaction or distress is related to the perception of their practitioner’s level of empathy. And practitioners with higher empathy scores lead to better health outcomes for their patients and that’s just empathy. So, ways that you can improve your patients’ perception of your empathy. You can, like, sit with them during the appointment versus standing, using nonverbal emotions, cues for empathy, eye contact, and also validating how they feel.
Now when it comes to motivation, this is also another topic with…there’s just a lot and we’re actually getting towards the end of creating a whitepaper on behavioral change and treatment adherence. But there are three key reasons why patients may not be ready for change. They do not easily embrace the reason that they need to change and that’s where health education can come…would be an asset at that point to help educate them as to why maybe change would be necessary. You can also use labs to help that visual aspect to show, you know, if cholesterol’s very high or if blood glucose is very high. Seeing that might be helpful for patients to understand the need for change.
Patients may feel that change is too hard. And this is when we want to kind of look into that mental and emotional aspect, see if there’s any limiting thoughts, beliefs when it comes to change. And then they may believe that the benefits of change do not outweigh the efforts of change. So, if you have a very large treatment plan, the patient may feel like there’s just too much that they…and it’s not worth it. And this is when we wanna focus on small achievable goals so that we can really build up our patient’s motivation versus giving them a lot to do. And ultimately, patients will either be inspired to change or desperate for change. And ideally, we would prefer that the change comes from an intrinsic or self-driven motivation versus an external or extrinsic motivation.
Okay. Now we’re gonna get into motivational interviewing which is a huge component of motivation behavioral change. So motivational interviewing is a collaborative goal-oriented style of communication with particular attention to the language of change. It’s designed to strengthen personal motivation and for a commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion. So, you can see how this is very patient-centered. And it was originally designed for counseling individuals with alcohol or substance abuse and now we’re using it in other types of behavior change. So, there is diet, exercise, and smoking cessation. As I mentioned, very patient-centered, there’s a lot of active and reflective listening, a lot of kind of eliciting change talk. And a systematic review meta-analysis showed that motivational interviewing outperformed traditional advice giving. And I wanna just kind of highlight or show what they mean by that on the next slide.
Sorry for skipping the slides here. So rather than emphasizing the sickness aspect of the condition, there’s an emphasis on how we can improve their personal choices. Rather than trying to convince a patient that there’s an issue, we want to elicit concern like concern for themselves. Rather than correcting a patient’s perception, we want to explore their perception and try to understand it. And rather than meeting displays of denial with argumentation, we wanna meet that with more reflection and again kind of seeing where maybe your patient may be coming from. So that’s how we can see that motivational interviewing really fits in nicely with patient-centered care because again we’re putting the patient at the center of the model.
Now here are some three key steps for motivational interviewing. One, empower patients and have them identify their own desires and capacity for change. And then we wanna use that coach approach and help guide them through their change. And then we wanna honor their autonomy. So, once they find basically that independence, we wanna support that. And essentially, motivational interviewing really emphasizes the therapeutic relationship and where the patient and the practitioner equally contribute in this point.
Okay. So, for additional key components of motivational interviewing, I’m not gonna spend too much time on this slide. We have open-ended questions, affirming what you’re hearing, reflecting what you’re hearing, summarizing what you’re hearing, paying attention to language of change, and then there’s also the information exchange.
And sorry. The dos and don’ts of motivational interviewing. Here you can see again open-ended questions, recognizing efforts, intention, strengths and values, reflecting thought towards the behavior, objections, and all those types of things. So those are things that you can do for motivational interviewing.
And just to summarize this second key component, we wanna remember that the practitioner’s role is that of support. So yes, in the first appointment, we do want to identify possible treatment plans but that shouldn’t be the sole focus. We also wanna learn about the patient’s story, their goals, and we wanna help them prioritize which goals or problems to focus on. And something that we need to remember is that our patients are motivated enough to have sought out our help. And so, it’s up to us to learn what their goals are, where their motivations lie, and to help them develop strategies to break through those barriers.
Now the next is a really great quote by Dr. Hoffmann which…work hard, provide real value at each encounter. Listen, show empathy, and be sincere, and be generous with your time. And at the end of the day, really, is about providing value at each appointment. And personally, I believe that listening to our patients and showing empathy are really of great value. And sometimes I forget this and I feel like I didn’t provide enough treatment recommendations and then I’m quickly reminded by my patients that they value the fact that I just tried to listen and understand where they were coming from.
All right, so now onto the third key component of patient-centered care which is fostering a therapeutic alliance which we’ve talked quite a bit about. In a survey, 70% of practitioners said that trust is a key facilitator for adherence. And so, we really want to use clear, transparent communication to establish trust and be especially clear about the expectations regarding the treatment plans. So how effective it is. There’s the safety issues. Timeline wise, how much time in order to see an improvement? The frequency and the duration of our visits, the appointment costs, if there’s any clinical policies such as, you know, late cancelation fee. And also, what happens if they were, you know, not to address their condition, their diabetes, their hypertension? So those are all things that help to foster trust and a very strong therapeutic relationship as well.
Onto the fourth component and that’s to promote information exchange. So again, we revisit health literacy. Now health literacy not only increases visits to the hospital and longer stays at the hospital, increases the mortality rate and nonadherence, but it also increases the risk of patients feeling overwhelmed by their treatment plan. So, a recent survey by NDs, 83% of naturopathic doctors said that they shared unique relevant information regarding…like, to their patients regarding their health history. So again, I think that as integrated practitioners, we understand the importance of having that information exchange.
Now the AHRQ toolkit also has additional information that you can look into. So, it talks about addressing language barriers and, you know, talking about translation services using echo backs so that you can…not only your patient understands what you’re saying but what you feel like your patient is saying as well. Open-ended questions comes back again. We wanna speak slowly and give them time to process information. And then using simple terms versus medical terms. And then I go back and forth sometimes. It can be beneficial to use a medical term to enhance health literacy but that’s really patient and practitioner-specific.
And here are some examples on how you can enhance or how you can foster that information exchange or that health literacy. So having really clear treatment plans, what are the treatment goals, what are the expectations from the patient, what are the expectations from the practitioner? So, for example, you may have a patient with, let’s say, with anxiety. You’ve given them, you know, meditation and maybe following the Mediterranean diet. And then you’ve identified as well that you’re gonna look into additional therapies that would be compatible with their anxiolytic that they’re taking. And so, the patient knows what they’re doing and they also understand what you were doing between appointments.
Another way to help with that information exchange is to attach handouts to your electronic health record or to your dispensary so that patients can continue learning outside of the appointment. And also, onto that, if you have any wellness emails, that’s also another great way to foster continuation of education, learning outside of the appointment. There are, you know, electronic health records and also dispensaries that offer that as a function as well to their practitioners for their patient base.
Now number five, shared decision-making. So that’s really all about the patient-practitioner relationship, encouraging the participation of the patient in the development of their treatment plan and also, it’s a huge component of health literacy. So, we wanna ask about perceived barriers, preferences, concerns. We want to identify goals for patients and the appointment agendas before your appointments so they know that’s what they wanna talk about. We wanna recap on action items so what’s left to do at the end of the appointment. And then you can also consider goalsetting templates such as, like, the SMART template. You can even consider decision aids which helps to increase health literacy and it ultimately empowers the patients in making decisions regarding their health which we’re gonna talk a little bit more about the decision aids in just a moment.
So right here, we have the impact of shared decision-making. Essentially, shared decision-making increases patient satisfaction with treatment and then there’s also small benefit to clinical outcomes and treatment adherence as well. Onto the decision aids. So, this is just an example of one for acne but here you can see that patients on, like, the one introduction, they learn more about acne. You know, maybe the different types and then options. So, if acne could be bad. Maybe, like, conventionally, let’s say they have Accutane, birth control and antibiotics and then maybe there is, like, exploring hormonal components for the integrative component or exploring digestive issues as an option. They get to learn more about their skin, about their values, is it important for them to have rapid results regardless whether it’s a natural approach or a conventional approach or is that more important for them that they don’t mind if it takes longer if it means that they get to use a natural route? Tradeoffs. So, for example, if someone’s trying to conceive, then, you know, Accutane and birth control wouldn’t work ideally for that person. Would not work for that person.
And then ultimately, getting to six. Get them close to that decision. Maybe at the end they’re not exactly there but they are at least one step closer and they have a little bit more information regarding their options.
And so, decision aids, they’re beneficial tools to use. They help patients improve their knowledge. They decrease indecision due to feeling uninformed, and also increases the likelihood of health screening and starting new medications.
And another great quote and this one’s by Dr. Bongiorno. So, it’s not always the testing and the protocols you use for a patient that creates an effective patient engagement. It’s having patients feel heard and cared for and that would make the greatest difference and I agree 100%. Okay, so this is the last component of patient-centered care. So, enabling continued care and patient self-management. So, it’s essentially kind of the long-term plan. So, this interesting study done in 2020, 40% of patients said that they would not be able to continue the efforts of their treatment plan long-term. And that was regardless of whether they were experiencing positive effects or no effects or negative effects. They wouldn’t be able to maintain that. We really have to come back and think about, “Okay, we need to use a stage approach. We need to prioritize and streamline care to prevent overwhelm and to enable our patients to continue their treatment plan, not that it doesn’t change over time, but to continue their efforts towards their health goals.
Another study done in 2009 found that there was an increase from 13% to 36% in regards to treatment adherence when we just decrease their twice daily dosing to once daily dosing. So, these are different strategies that can be helpful for enabling our patients to continue long-term with their care.
Other things to consider. We wanna set clear expectations for frequency of visits as I mentioned at the beginning of the presentation. The longer…the bigger gaps between follow-ups, there’s a decrease in treatment adherence.
We also wanna offer and maintain regular communication through multiple channels. That can be, again, newsletters. That can be electronic devices. For example, in the third bullet in this particular study, there’s an 18% to 22% improvement in adherence when using mobile device reminders. So that could be another way of using that. Social media. So, it doesn’t necessarily have to be direct communication but it can also be direct communication that can be helpful for enabling our patients contributing their long-term improvements.
And here is an example of kind of prioritizing. So, where we have that staged approach. So, we may have a patient where it would benefit from all three of these supplements but for whatever reason, due to finances or maybe…whatever the case may be, starting all three of those at the same time is not possible. So, within your dispensary settings or even if you do electronic health records or even if you’re doing it in paper, you can prioritize which supplement to start with and then, you know, once that particular barrier, kind of period, whatever the case may be, then add that third one or add the second one and then go on so forth.
Another way to help with patients keeping on track with their treatment plan would be to use reminders. So, this is a specific example of using reminders for patients who haven’t renewed or bought their supplements but you can use that for also appointments. But this is just an example for their different supplements that they should be taking on a regular basis.
Okay. And now we’re at the last section of our presentation for today. This is gonna be…we’re gonna talk a little bit about the research that we’ve done on treatment adherence. So, I’m gonna just start. And we’ll click the next slide here. So, in 2020, we began actually researching treatment adherence and these are kind of the goals that we were looking to achieve. I don’t wanna spend too much time on certain slides. So, this one…we’re gonna go to the next one. And so, the research paper was or is divided into two sections. We did a literature review and then we also did real world practitioner insights and we developed this paper in conjunction with the Institute of Functional Medicine and also the University of Maryland School of Medicine.
So here you can see the study overview. So, as I mentioned, there is the literature review. So, this is a comprehensive literature review, semi-systematic approach and really wanted to assess what was the current state of knowledge for treatment adherence. And then we interviewed our practitioners. So, we conducted 25 interviews and then we surveyed 185 practitioners. We packaged all that together into a whitepaper and that was published in a peer reviewed journal, so the Integrative Medicine and Clinicians Journal which was really cool.
So in regards to the literature review, so these four bullets condense 80 pages of literature review. We found that most of the research on treatment adherence was done in the realm of pharmaceutical therapies which is not as a surprise. But the themes are likely applicable to other medical models. We also found that there are several ways to measure adherence and there’s no gold standard which is a complicating factor. There’s also several hundred factors that could influence adherence and it’s rally up to the practitioner and I would say also the patient of course to identify what’s the most relevant factor. And then generally, rates of treatment adherence will decline over time.
In regards to the practitioner insights, so again, we did interviews and we also did the surveys. I’m just gonna go onto the next one. This is for the interviews. We did 25 interviews. The majority were with naturopathic doctors but then also medical doctors and chiropractors were also interviewed. We had a mixture of practitioners with either high treatment adherence, so that was defined as having more than 70% of their patients order every supplement from their first treatment plan. And then also we had clinicians with low treatment adherence, so having less than 45.
And then for the surveys, you can see that’s a greater diversity of different types of practitioners that were surveyed for this. Again, we talked about or interviewed them or surveyed them about various aspects of treatment adherence in their practices.
So, from the survey and from the interview, we found that there were three key barriers to adherence. So cost was a big one. Patients’ readiness to change and also patients feeling overwhelmed. And that was echoed by both. So, the surveys and the interviews both mentioned those as three top barriers for treatment adherence.
I’m just gonna go over this one to this one. So, this is the top strategies that were used by the different practitioners for helping treatment adherence. So, we have…from them the interview, the top three that they prioritized was using a stage approach to avoid feelings overwhelm and cost issues. They were also meeting their patients where they were at and prioritizing supplements. From the survey, they had some different ones. So, booking follow-up appointments at the end of the visit, using labs to rationalize treatment plans, using a stage approach, and also communication between appointments were some of the approaches that they used to maintain treatment adherence.
And this is just a summary of those key findings from the research. So, to enhance patient adherence, we wanna consider costs. So, we wanna use a staged approach, we wanna set realistic goals with financial restrictions. And also, if you are using a dispensary, an online dispensary for your supplements, you can use that filter to sort by price and that can also be very helpful for patients who have financial restrictions. We wanna assess our patients’ readiness for change. So, we wanna use open-ended questions, ask about motivations and attitudes and beliefs about the treatment. We want to also use motivational interviewing and empathy and really communicate a shared partnership with the patient. We wanna use education, so about the treatment plan, about their condition, and then we can always use the lab testing as a way to show or educate. We wanna use that stage approach which I mentioned just at the beginning here. So, we really wanna simplify the regimes. We can reduce dose frequency or use fewer therapies. And we can also provide different options for increased flexibility.
And then we wanna use clear communication to provide multiple opportunities for treatment reminders. That could be text messages, phone calls, also other types of applications. And we can also provide multiple points of contact. So, follow-ups between appointments. So usually, what I’ll do is I really want to follow up with a patient in two weeks, I’ll tell them in the appointment that I’m creating an email today that’s going to be sent to them in two weeks and so that they know to expect that email as a follow-up. So that could be something as well to kinda help with treatment adherence through very clear communication.
And then we really wanna simplify and streamline care. We can involve other practitioners also in their treatment plan, use various, you know…getting that holistic care. We can also incorporate other types of strategies to streamline care. So, it could be pill packs or pill organizers or timing supplements or whatever, treatment recommendations with specific daily tasks. And ultimately, as practitioners, we definitely want to engage in…adhere to training to really help our patients along their journey.
And we’re just going to summarize some of the resources and some of the key takeaways from today’s presentation. So top barriers for adherence will be treatment cost, patient’s readiness to change, and then also feelings of overwhelm. And additional contributing factors, we wanna support our patient’s motivation through…and behavioral change, so reminders, things of that nature. We wanna provide education for health and understanding the treatment plan and also maintain clear communication with our patients.
And also lack of patient inclusion, engagement, and empowerment is really a fundamental barrier for adherence, so that’s why we’re talking about patient-centered care, engagement, the therapeutic alliance. And we really want to be exploring these barriers with our patients, right? Again, clear communication, trust that there are certain barriers in healthcare system. We wanna try to be very clear and transparent about that so that we can overcome that with our patients.
And I just wanna go onto the next slide here. Oops. This one right here. So, it’s just to mention that there’s a lot of work being done in the arena of patient-centered care, empowerment, engagement, behavioral change, health literacy. There’s so much stuff going on there. So, if there’s anything that you want to learn more about or even have access to in terms of resources, please feel free to reach out and we’ll definitely try to get you connected to these resources.
And this is just the many references that were used to put together this presentation for you today. And that is everything. So, I am all done with the presentation. Are there any questions, Rick?
Rick: Thank you, Dr. Natacha. That was extremely informative. We’ve collected a few questions.
Dr. Montpellier: Great.
Rick: Let’s take a look here. One, what would you say is the biggest challenge with trying to make care more patient-centered?
Dr. Montpellier: Yeah, that’s a great question. I think that the biggest challenge would definitely be that it takes time to get that patient-centered care. And one of the reasons for that is that patient-centered care has that patient-practitioner relationship. And like all relationships, it takes time to build up that trust. So, time for sure. And then the second part to that is still from the context of time is that sometimes we don’t learn about our patient’s level of engagement or even some of the barriers that they’re encountering in their life until later on, until we’ve tried a few different treatment approaches and been unsuccessful. So that part also takes time. So that would be definitely the biggest barrier for patient-centered care.
Rick: Thank you. And another question. What is the best tool or questionnaire to assess whether a patient is engaged in their treatment plan?
Dr. Montpellier: Yeah. And yeah. And like I mentioned, if you wanna help with engagement and empowerment, you want to measure it. So right now, there’s actually no gold standard for measuring patient’s engagement. But the tools that I did mention in the presentation would be a good place to start. So, the Health Empowerment Scale or the Patient Activation Measurement questionnaire. The Health Empowerment Scale being the shorter one and the Patient Activation Measure being the longer 13-question validated tool having a broader scope. But that being said, I mean, it’s not necessary to have or to use a validated tool to try to understand your patient’s level of engagement. The fact that you are trying or you’re asking that question, how do I measure that, is good and good enough that it’s a good starting point. And it doesn’t have to be something that’s formal like a questionnaire. Just kind of, again, asking yourself some of those questions and you can kind of get a baseline idea. But those would be…if you’re looking for a validated tool, then the patient activation measurement questionnaire would be a good place to start.
Rick: Thank you. I like your points about patient adherence and the pill box. That really helped my adherence and confirmed to me that I’m old now.
Dr. Montpellier: Yeah. Yeah. Me too.
Rick: And we’ve got another question. How can I support a patient who doesn’t seem like they’re ready or open to change?
Dr. Montpellier: So that’s something I think that we’ve all encountered at least once in our practices, that perception for sure. And I guess what I want to bring back is that, well, they’re there for a reason. They’ve taken the time, the energy to book an appointment to see you. And so, where I would start is to ask them what their expectations, what are their needs from today’s appointment? We may think that our patient who has a history of diabetes is coming in for more recommendations for their diabetes but they may be coming in for a second opinion on something else, for more health education, or maybe it is for their treatment plan. But we definitely always wanna see what it is that they’re looking for. So just asking your patient can be very helpful to determine, you know, what it is that they’re looking for and that can be the starting point for potentially change.
Rick: Thank you. And another question. When a patient’s struggling, what would you say is the best way to keep them motivated?
Dr. Montpellier: Okay. So, another great question. This might feel counterintuitive but to keep our patients motivated, to keep them adherent to their treatment plan, the best way…it’s not a gadget or a tool. It’s just to really keep your treatment plan simple. If your patients are struggling for motivation, they may not feel like they’re able to achieve the goals that you’ve put out for them. So really simplifying the treatment plan, maybe having, you know, two or three interventions and really making it simple for them to achieve so that when they do achieve it, they feel great, they feel motivated, and that enhances their treatment adherence, enhances their motivation, enhances their engagement. And we kinda get that snowballing effect.
The other thing that comes with simplifying treatment plan is that you really wanna have a few key focused goals, right, or treatment objectives and that’s where you really wanna talk with your patients and determine like, “Okay, what’s important for you?” And then, again, if they know that they’re addressing what’s important to them, that may also help with their motivation to say, “Okay, we’re not going down this other path. We’re treating really what I’m here for which is my headaches.” So that could be also another way to keep patients motivated and also engaged in their treatment plans.
Rick: Thank you. And for our audience, if you have any questions, feel free to type them in our chat box. And another question. What if I don’t have a lot of time to spend with patients? How can I still provide them with patient-centered support?
Dr. Montpellier: Yeah. For sure. I mean, definitely not everybody has, you know, a lot of time to spend with their patients so that can be very…a big obstacle for integrating patients under care. But I guess where I wanna bring us back to is Dr. Hoffmann’s quote which is providing value at each appointment and that’s not restricted by time. So, we want to first focus on what’s important for our patients. So why are they here today or what are their objectives, what are their goals? And if they don’t know, helping them figure out what’s most important to address. But we want to also provide them with educational material that they can consume outside of the appointment. So, for example, let’s say you have a patient come in with PCOS and you don’t have time to talk about the whole pathophysiology of PCOS and why insulin resistance is so important to discuss. You can provide that material for them and they can consume that outside of the appointment. So, when you have the follow-up, they can have more precise questions versus like, “What is PCOS?” They can be like, “Okay. I learned about all of this. I have a very specific question.” So that can be very helpful. So, if you do have an educational library, it could be helpful to go over that and to make sure that the resources that you are using most often or the types of patients or conditions you’re seeing most often are up to date so that you can readily give that to your patients, attach them to your electronic health record or your supplement dispensary. And then they can have that right away.
You could also be just providing them…if you’re not able to create content, having resources or links to different content that they can consume as well. So that would be very helpful. And I guess the third component to that would be to ask your patient about their support network. So that is, yes, for sure family and friends but are they seeing other practitioners and if they aren’t…and for example, going back to kind of that mental health component, if you’re not comfortable, don’t have the time to provide counseling to somebody who has a lot of trauma, providing resources whether that may be free, discounted, or other types of resources that they can use so that they’re still getting that holistic care, just not necessarily all dependent on you because your appointments are shorter.
Rick: Thank you. And that’s the last of our questions. Is there anything you wanted to add in conclusion?
Dr. Montpellier: Only if anybody wants to have additional resources, my information’s on the slide. I’d be more than happy to share them with you.
Rick: Thank you so much. At this time, we’d like to thank our sponsor, Fullscript, and Dr. Natacha for today’s webinar and thank you all for attending. Remember, this webinar including our speaker’s PowerPoint presentation has been recorded. We’ll alert you via email when the webinar is available online. Thank you again for attending and we look forward to seeing you next time. Have a great day.
Dr. Montpellier: Thank you, everyone.
