Engaging people as partners in their care and decision making can increase the likelihood that they will follow through on actions critical to attaining positive health outcomes, such as taking medications correctly, measuring blood glucose, monitoring blood pressure, and following recommendations on diet and exercise. AIR conducted site visits to several accountable care organizations (ACOs)—local physicians, hospitals and other providers who work together and take responsibility for improving quality, enhancing patient experience, and reducing waste to keep care affordable—and primary care settings around the country to observe provider strategies to increase patient involvement and engagement. Key findings indicated that stronger and more personalized relationships between providers and patients, as well as the use of nontraditional practices that meet individual needs, can improve patient engagement, quality of care, and health outcomes. Innovative patient engagement strategies included:
- Visiting patients in their homes allows providers to focus on providing efficient and effective care. One ACO achieved a 15 percent reduction in hospital admissions along with increased patient satisfaction scores.
- Meeting end-stage renal disease patients at dialysis centers allows providers to support patients in following recommendations between appointments and coordinate care. This helped an ACO engage patients in ways that improved follow up on important primary care needs.
- Using a “nurse navigator” to follow up with patients over the phone helps providers understand patient needs, answer questions, and develop effective approaches. This increases patients’ understanding of their conditions and helped an ACO provide appropriate at-home follow-up care.
- Including patients and family caregivers in care teams and in developing and reviewing care plans to work through medical, social, psychological, and logistical issues helps providers better care for patients with multiple chronic issues, such as dementia or end-stage cancer. An ACO that developed integrated plans with patient and family input and engagement found the practice lead to more effective care and greater patient satisfaction.