What We Want to Achieve Through Systems Changes

Patient-Centered Care: Dimensions

Seven dimensions of patient-centered care are identified in the Institute of Medicine's Quality Chasm report and each is briefly discussed here.2 7

1. Respect for patients' values, preferences, and expressed needs.
Patient-centered care responds to patients' needs, wants and preferences and allows opportunities for patients to be informed and involved in medical decision-making.8 9 It is customized care and incorporates cross cultural sensitivity. Because patient preferences may change over time, shared decision making is a dynamic process, changing as patients and circumstances change. Patients are better able to attain and sustain positive outcomes when they are active participants in their own care. Click here for more information on Cultural Competence.

2. Coordination and integration of care.
Coordination of care takes on special importance for a chronic disease such as diabetes where a team of health care providers may be involved in patient care and education on an ongoing basis. Most patients depend on the health care provider team to coordinate services and ensure that the patient and all team members have accurate and timely information available as needed. Click here for more information on Team Care.

3. Information and communication
Information
With respect to their health, most people want to know:

• what is wrong or how to stay well,
• what is likely to happen and how it will affect them, and
• what can be done to change or manage their prognosis.
  They need answers that are accurate in a language they understand.2

Communication
To be effective, medical management and self-management education need to be integrated, coordinated efforts that use clear communication channels.10

In 25 Veterans' Affairs facilities, patient rankings indicated that physicians' communication effectiveness was more important than their participatory decision-making style in predicting diabetes self-management.11 Yet in a study of physician-patient interaction during visits to general internal medicine specialists, physicians listened to patients' concerns for an average of 18 seconds before interrupting.12

The quality of communication in the history-taking segment of a visit and during discussion of the management plan has been shown to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control.13

Studies have assessed how patients present clues about personal aspects of their lives and how physicians respond to these clues as an opportunity to deepen the therapeutic alliance in routine primary care and surgical settings.14 15 One study found that 52 percent of the visits in primary care and 53 percent in surgery included 1 or more clues. In primary care, most (80 percent) were emotional clues related to psychological or social concerns in patients' lives. Physicians responded positively to patient emotions in 38 percent of cases in surgery and 21 percent in primary care, but more frequently they missed opportunities to adequately acknowledge patients' feelings. Visits with missed opportunities tended to be longer than visits with a positive response.15

4. Education
For people with diabetes, there is much for them to understand about diabetes, its long-term management, the prevention or management of complications, and how to maintain or improve their quality of life. Diabetes self-management education is an essential component of diabetes therapy because it can produce both behavioral and biological improvements.3 As a result of patient empowerment and education, patient behaviors may change and lead to improved A1C, blood pressure, lipids, or weight, and reduced medication needs. Collaborative management supports self-care while assuring that effective medical, preventive, and health maintenance interventions take place.16

At each visit, the provider and patient need to consider the following patient self- management tasks. How to:

• take care of diabetes and it's complications
• incorporate behavior changes into daily life activities
• manage emotions, including future concerns.

People with diabetes may be in different stages of change for different behaviors. Re-assessment of progress is important at every interaction and self-management support tailored accordingly. One of the most effective strategies for an office visit is to simply start the visit with "What would you like to accomplish in the visit?" or "What issues, concerns or questions would you like to address before you leave today?"

Rather than formal, didactic teaching focused on the transfer of information, patient education should identify the patient's readiness to make changes and help the patient assume responsibility for his or her disease management. Problem solving discussions can help prepare the patient to deal effectively with self-management issues. Many studies have shown that patients with diabetes who participated in a brief self-management program improved their health or had less deterioration and used fewer health care services over time, compared with their status when they began the program.17 10, 18-23

5. Physical comfort
Patient-centered care requires attention to physical comfort and involves timely, tailored, and expert management of symptoms related to discomfort. People with diabetes may encounter physical discomfort associated with insulin injections, self-monitoring of blood glucose, medication side effects, hypoglycemia, hyperglycemia, and the conditions related to the numerous chronic complications of diabetes.

6. Emotional support — relieving fear and anxiety
Suffering involves more than physical pain and distressing symptoms; it also encompasses emotional and spiritual dimensions. Patient-centered care attends to the anxiety that accompanies the diagnosis of diabetes and living with the fear of disfigurement, disability, financial impact, and effect of one's family associated with vision loss, kidney failure, amputation, heart attack, stroke and other diabetes complications. Depression is two times more prevalent in people with diabetes than in those without diabetes.13 In samples of people with type 1 and type 2 diabetes, glycemic control and diabetes complications were each significantly associated with depression.14

The DAWN (Diabetes Attitudes Wishes and Needs) program is a global collaboration between Novo Nordisk, the International Diabetes Federation, and an international expert advisory board. In 2001 the first DAWN study showed that diabetes care focused solely on medical targets is seriously flawed. The study found that over half of people with diabetes do not enjoy good health and life quality, and that a major underlying cause is the negative effect of ignoring the psychosocial impact of diabetes. As a result the DAWN program promotes patient-centered initiatives and best practices worldwide to help people with diabetes overcome the psychosocial barriers to effective self-management and improve their quality of life.15

7. Involvement of family and friends
Patient-centered care will accomodate family and friends on whom patients may rely, involving them as appropriate in decision making, supporting them as caregivers, making them welcome and comfortable in the care delivery setting, and recognizing their needs and contributions. Cultural differences need to be recognized and appropriate accomodations adopted when involving family and friends in diabetes care. For more information, see the Cultural Comptency section.

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