Between primary care visits, most people are on their own to follow their physicians’ advice and instructions. Engaging people as partners in their care and decision-making can increase the likelihood that they will follow through on actions critical to positive health outcomes, such as taking medications correctly, measuring blood glucose, monitoring blood pressure, and following recommendations on diet and exercise.

AIR health experts conducted site visits to several accountable care organizations (ACOs - groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients) and primary care settings around the country to observe efforts by providers to increase patient involvement and engagement in their health care. Key learnings from these visits are that stronger and more personalized relationships between providers and patients, as well as the use of non-traditional practices that meet individual needs, can improve patient engagement, quality of care, and health outcomes.

Innovative patient engagement strategies observed 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 very high 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 about their conditions and helped an ACO ensure it was providing proper 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 correlated this to more effective care and greater patient satisfaction.

For more information, contact Susan Baseman, DrNP, APN-BC.