Patient engagement strategies continue to be a key component of integrated healthcare, as outcomes-based reimbursement provides additional incentive for hospitals and other providers to deliver care in teams, with the patient at the center of information flow and decision-making.
When it comes to mental healthcare, however, concepts such as patient engagement tend to get overlooked, which is unfortunate considering that one in four American adults, or 57.7 million people, suffers from a mental disorder, and more than half of these cases are seen and treated by primary care physicians, according to statistics from the National Institute of Mental Health (NIMH).
But starting in 2014, health insurers will cover mental health services at parity with general physical services. Consequently, as the healthcare system moves towards a patient-centered model, and in anticipation of the flood of mental health patients into the healthcare system, stakeholders are looking to restructure mental healthcare. One area for improvement is communication between providers and mental health patients, including getting patients involved in their own care.
What’s more, mental health clinics are beginning to realize the effect that patient engagement can have on clinical outcomes. For one, the Belgium-based Broeders Alexianen mental healthcare clinic—a medium-sized hospital with five treatment units, and part of a chain of mental healthcare hospitals known as “de broeders van liefde”—has been using QuestLink, a cloud-based patient engagement product from the Minneapolis, Minn.-based healthcare software provider, Vital Health Software, for the purpose of supporting the diagnostic process of new patients, and measuring the outcome for inpatient treatment and their follow up measurement half a year after discharge.
The software can integrate to an electronic health record (EHR)—as seen in this clinic—or other clinical systems, and drive the assignment, delivery, and scoring of questionnaires to patients through a web-based portal. The results of the scoring are presented to the provider in a graphical format that shows cumulative and recent changes to the patient’s condition. The Broeders Alexianen clinic is using the data that is collected with QuestLink for research and outcome measurements, says Eva Dierckx, director of research at the clinic.
At admission, Dierckx explains, each patient fills in a set of self-rating questionnaires (which are standard clinical assessments) on a computer. QuestLink then analyzes the data, and a report of the results is given to the therapists. These psychologists discuss the results with their individual patients and together with the patient and the therapeutic team, an individual treatment plan is set up. Treatment goals are mutually agreed upon, Dierckx says.
Before the implementation of QuestLink, only a limited number of patients received a diagnostic examination, and most of the time, the results were only given to the treatment team and psychiatrist —not directly to the patient. It was mainly the team who decided what the treatment would look like, Dierckx says. “Nowadays, we are aiming to have a psychological assessment of all our patients as we believe that psychological assessment is an integral part of the therapeutic process. This is facilitated by the software program.”
The psychiatric clinic uses QuestLink within the light of psychological assessment as well as within the light of “so-called routine outcome measurements to establish evidence-based practice,” says Dierckx. Before, during, and at the end of the treatment program, patients fill in a questionnaire that was given at admission in order to see whether treatment goals are achieved and whether the given treatment as a whole was successful. By means of QuestLink, patients also have follow up measurements after discharge (they are invited by e-mail to fill in their follow up questionnaires six months and one year after discharge). “We see these routine outcome measurements as a way to give feedback: feedback to the individual patient and therapist (individual monitoring); and feedback to the therapeutic teams,” Dierckx says.
By monitoring changes, one looks at the comparison between different time points, she continues. This comparison of test results between two time points is displayed by the computer program both in text and graphs. The therapists, together with the patient, can look at possible changes. “Seeing improvement on domains can be very motivating for the patient (and therapist). Moreover, by systematically evaluating (monitoring), both the patient and therapist have a better view on the treatment progress so that treatment objectives may be adjusted in a timely manner if the desired goals are not met. At the end of the residential treatment period in our clinic, one gets a good view of possible working points for aftercare.”
AN INCREASED ROLE
Undoubtedly, at the Broeders Alexianen clinic, patients are involved in their own care in a variety of levels. Not only do providers and patients share the process and outcome of a decision, but patients also have an advisory role in the care policy of the institution in which they are present.
For one, patients are frequently part of staff meetings in each department, says Dierckx. “Also, patients of different departments meet monthly in order to formulate some point of improvement concerning things such as meals and process of admission. These points are discussed within the management team and improvement actions are proposed to the patient forum.”
To put it another way, patient participation can be seen as a continuum, going from little participation/involvement through high involvement. According to Dierckx, the continuum ranges from: information (the patient is recipient of information); to consultation (the patient knows and thinks and gets an opportunity to express his/her view, but there is no guarantee that these will be taken into account in decision-making); to advice (the patient gives and advises, and the care provider takes this into account by making decisions); to a partnership (the patient decides together with the care provider and has become a collaborator in his/her own treatment and care); to complete self-management/user control (the patient decides everything). Dierckx says her clinic is situated on the level of “advice” within the meso level and “partnership” at the micro level.
Dierckx admits that there can be challenges when it comes to patient engagement, including some that are unique to the mental health sector. For example, there is always the possibility of a mental health stigma among employees whereby there are concerns about patients’ capacities to participate in decisions, or the perception of some practitioners that the ultimate responsibility for treatment should remain under their authority.
Furthermore, sometimes patients simply do not want to receive treatment, as is often the case with so-called “forced” admission to mental healthcare, Dierckx says. “In that case, team members try to motivate the patient to start with treatment through giving information, thus starting at the lowest level of patient participation with the aim of getting the patient motivated to be treated and to reach a higher level of participation.”
With that being said, Dierckx does believe that as the industry continues to pay more attention to improving patient participation, patients—including those in inpatient mental care settings—are ready to become more active in their own healthcare.
“In fact, in our treatment unit for patients with a substance use disorder, our vision is that the patients themselves are responsible for their disease and also for their treatment. In general, we agree with the vision that patient involvement can lead to patient satisfaction and patient empowerment. However, some patients prefer the paternalistic approach, and in that case we have to consider if respecting that may also be a form of ‘shared decision making,’” she says.
Dierckx stresses that although the focus is often on psychological assessment, evidence-based practice, scientific research, and measuring outcome of treatments, measuring can mean so much more than just the collection of data. “In our clinic, we want to anchor the process of measuring in the treatment programs, contributing to good clinical practice. We will facilitate and embed the measurements into the therapeutic processes in such a way that diagnostics, therapy, and follow-up measurements become three hands on one belly with the most important priority [being] high quality of care for each individual patient—[something that is] represented in higher patient satisfaction and empowerment.”
