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Importance of The Patient Experience

Enhancing patients’ health care experiences means more than just providing top-notch clinical care.  It requires care that addresses every aspect of the patients’ encounters at the clinic – their physical comfort, their understanding of what’s happening and their emotional needs. The Triple Aim framework reinforces the importance of achieving three goals in health care: improving the patient experience of care; improving the health of populations; and reducing the per capita costs of care. The first of these, improving the patient experience, benefits not only the patients, but the clinics treating them as well. A better patient experience results in improved clinical and business outcomes.   As competition for patients increases, patients may make provider choices based not only on clinical outcomes, but also on whether their doctor or mental health clinician delivers compassionate patient-centered care.

A patient’s experience begins with their ability to get an appointment when they need it, and continues to the completion of their appointment, and ultimately, their longer term care plan.  Their satisfaction is affected by the ease of the logistics (getting to the appointment, parking, finding reception), customer service when they check-in, and the wait time in the waiting room and exam room. The single most critical element of the patient’s experience, however, may be how effectively they feel their provider communicates with them.  A Washington Health Alliance study, “Your Voice Matters” (2014), found that the top five drivers of patient satisfaction were patients’ perception of the following:

  • “The provider cared about me as a person.”
  • “The provider listened carefully to me.”
  • “The provider knew important information about my medical history.”
  • “The provider explained things in a way that was easy to understand.”
  • “The provider answered all my questions to my satisfaction.”

Another study found that the major determinants of patient satisfaction were physical comfort, emotional support and respect for patient preferences (Jenkinson et al., 2002). These studies reinforce the importance of the softer side of the patient experience.

Avoiding stigma. Mental health clients’ satisfaction with care depends not only on the drivers mentioned above, but also feeling welcomed when they seek services. Some clients with mental health issues report that their health care providers appear to be uncomfortable addressing psychological issues, or may not feel they have adequate time to explore them.  In the end, however, these patients suffer because they are less likely to get the physical care they need.  All health care providers need to be aware of strategies to improve the patient experience for patients with mental health concerns.

Clinical benefit. According to the Agency for Healthcare Research and Quality (AHRQ), improvements in patient experience are linked to improvements in clinical outcomes.  Multiple studies over the past two decades have concluded the same thing. Patients are more likely to accept medical care and follow treatment plans if they feel they communicate well with their providers (Zilnierek & DiMatteo, 2009).  A 55-study research review found positive associations between patient experience and health outcomes, adherence to a treatment plan and medication, and preventive care (Doyle et al., 2013).

Other studies focusing on particular patient populations found similar results.  For example, patients with HIV reported that if their provider knew them as a person, they were more likely to adhere to treatment than if they did not (Beach, Keruly & Moore, 2006).  Another study showed a positive correlation between a physician’s perceived empathy and attentiveness, and cancer patients’ capacity to deal with their disease (Zachariae et al, 2003).

Business benefit.  Practices with strong physician-patient communications realize a number of business benefits, such as better patient retention. Patients reporting poor-quality relationships with their physicians were three times more likely to leave the practice than those with the highest quality relationships (Safran et al, 2001).  Patient-centered communication is also associated with fewer unnecessary diagnostic tests and specialty referrals, as well as better recovery from discomfort, and better emotional health two months later (Stewart et al, 2000). Last but not least, physicians who were more skilled in patient communication were less likely to be sued.  These physicians educated patients about what to expect, laughed and used humor more, solicited patients’ opinions, and checked their understanding (Levinson et al, 1997).  Patient-centered care was shown to improve physician satisfaction and retention among primary care providers (Suchman, et al, 1993).

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Tips for Communicating with a Person with Mental Health Problems (.doc) are intended to help improve communication.

Triple Aim Measurement Toolkit: A Resource for Health Centers (website) produced by the American Institutes for Research and the Blue Shield of California Foundation.

Patient stigma and why physicians should be concerned

MEDICATION ADHERENCE: The more the perceived stigma, the less the medication adherence among outpatients with major depression. (Sirey et al., 2001)

DROP-OUTS: Perceived stigma is a predictor of treatment discontinuation among older outpatients with depression. (Sirey et al., 2001)

NO SHOWS: Latinos who report high levels of perceived stigma are more likely to miss scheduled appointments. (Vega et al., 2010)

ACCESS: Stigma is a strong barrier to people accessing needed mental health care. (Mental Health Association Poll, Chamberlin, 2004)

PHYSICAL HEALTH: People seen as having a mental disorder are less likely than others to get the physical care they need even when they seek it out. Those with schizophrenia are less likely than the general population to receive basic health checks like cholesterol and blood pressure measurements (Roberts, et al., 2007) and substantially less likely to undergo cardiovascular procedures (Druss et al., 2000).  Those with co-occurring mental disorders and diabetes are less likely to be admitted to the hospital for diabetic complications than those without mental disorders (Sullivan et al., 2006).

HEALTH REFORM: Enhancing the patient care experience is one of the Centers for Medicare Medicaid’s “triple aim” objectives.

QUALITY CARE: A welcoming environment is consistent with good patient care.

The Business and Clinical Case For The Patient Experience

The Business Case

More revenue
“Patient engagement consistently predicts hospital performance on an array of crucial business outcomes, including revenue.” (Robinson, J. Gallup Business Journal, 2010)
Less diagnostic testing; greater efficiency
  • Patient centered communication is associated with less diagnostic testing expenditure. (Epstein, R., “Patient Centered Communication and Diagnostic Testing”, Ann. Fam Med., 2005)
  • Patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals. (Stewart, M et al., “The impact of patient-centered care on outcomes”, Journal of Family Practice, 2000)
Less lawsuits
  • Physicians who demonstrate more patient centered communication are less likely than others to be sued. These MD’s educated patients more about what to expect; laughed and used humor more; solicited patients’ opinions; checked their understanding; and encouraged them to talk. (Levison, W., “Physician and Patient Communication: The Relationship with Malpractice Claims Among Primary Care Providers and Surgeons” JAMA, 1997)
  • Patients seeing physicians with the most frequent numbers of malpractice claims were significantly more likely to complain that they felt rushed, never received explanations for tests, and were ignored (Hickson, G. et al., “Obstetricians’ prior malpractice experience and patients’ satisfaction with care” JAMA, 1994)
  • For each drop in patient-reported scores along a five-step scale of “very good” to “very poor,” the likelihood of a provider being named in a malpractice suit increased by 21.7%. (Fullam F, et al., “The use of patient satisfaction surveys and alternate coding procedures to predict malpractice risk” Medical Care, 2009)
Greater retention of patients
  • Voluntary patient disenrollment from primary care practice was significantly correlated with patients’ low ratings of physician-patient relations (communication, interpersonal treatment, physician’s knowledge of the patient, and patient trust) and structural features of care (access, visit-based continuity, relationship duration, and integration of care). Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician’s practice than patients with the highest-quality relationships. (Safran D et al., “Switching doctors: predictors of voluntary disenrollment from a primary physician’s practice”. J Family Practice, 2001)
  • Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician’s practice than patients with the highest-quality relationships. (Safran, D et al., “Switching doctors: predictors of voluntary disenrollment from a primary physician’s practice”, Journal of Family Practice, 2001)
  • Acquiring a new customer is six to seven times more costly than keeping an existing one.9 Increasing customer retention rates by 5% increases profits by 25-95%. (Reichheld, F. et al., Harvard Business Review, 68, 1990)
Improved staff satisfaction
  • System changes focusing on improving patient satisfaction resulted in not only patient satisfaction above the 95th percentile, but improved staff satisfaction and productivity and a 4.7% reduction in staff turnover. ((Rave, N. et al., “ Radical Systems Change: Innovative Strategies to Improve Patient Satisfaction”, Journal of Ambulatory Care Management, 2003))
  • Patient-centered care was shown to improve physician satisfaction and retention among outpatient primary care providers. (Sushman, A et al., “Physician satisfaction with primary care office visits”, Medical Care, 1993)
Meeting health plan and government requirements
  • Health plans (such as Blue Cross Blue Shield of Massachusetts and HealthPlus of Michigan) and multi-stakeholder organizations (such as California’s Integrated Healthcare Association) are incorporating patient experience scores into provider pay-for-performance incentives.
  • The Accountable Care Act now links performance related to patient-experience metrics to reimbursement.

The Clinical Case

Greater patient satisfaction
  • Patient/Client-centered approaches generally are associated with greater satisfaction, compliance, feelings of being understood and resolution of patient concerns. (Ong, L et al., “Doctor-Patient Communication: A Review of the Literature”, Soc Sci Med 1995)
  • The major determinants of patient satisfaction with their health care were physical comfort, emotional support and respect for patient preferences. (Jenkinson, C et al., “Patients’ experiences and satisfaction with health care: results of a questionnaire of specific aspects of care”, Qual Saf Health Care, 2002)
Greater patient treatment adherence
  • Patient care experiences correlate to patient adherence to medical advice and treatment plans, and to improved outcomes of care. Adherence rates were 2.6 times higher among primary care patients whose providers had “whole person” knowledge of them (95th percentile), compared to patients of providers without that familiarity (5th percentile). (Safran, D. et al., “Linking Primary Care Performance to Outcomes of Care”, Journal of Family Practice, 1998)
  • HIV patients receiving therapy who reported that their provider “knows them as a person” were more likely to adhere to the therapy than others. (Beach, M, “Is the quality of patient-provider relationship associated with better adherence and treatment outcomes for patients with HIV”, Journal of Gen Internal Med, 2006)
Improved outcomes
  • Asthma patients’ report of their physician’s involvement of them in decision-making was significantly associated with health-related quality of life, work disability and need for health services. (Adams, R., et al., “Impact of the physician participatory style on asthma outcomes and patient satisfaction”, Annals of Allergy, Asthma and Immunology, 2001)
  • Patient dissatisfaction can lead to low understanding and recall of information, poor compliance, lengthier recovery and increased complication rates. (Fallowfield, L., et al.  “The Ideal Consultation”, Br. J. Hosp. Med., 1992)
  • A 21 study review found that most studies demonstrated a correlation between effective physician-patient communication and improved patient health outcomes (emotional health, symptom resolution, functioning, blood pressure, blood sugar and pain control). (Stewart, M, et al., Effective physician-patient communication and health outcomes: a review”, CMAJ, 1995)
  • Hypertensive patients expressing themselves in their own words and providers giving information in medical interviews were significantly correlated with reduction in blood pressure. (Orth, J et al., “Patient exposition and provider explanation in routine interviews and hypertensive patients’ blood pressure control”, Health Psychology, 1987)
  • In a post discharge survey, the patients most dissatisfied with their health care also reported lower ratings of overall health and more chest pain. (Fremont, A et al., “Patient-centered processes and long-term outcomes of myocardial infarction” J Gen Internal Med, 2001)
  • There is a positive correlation between the physician’s perceived empathy and attentiveness and cancer patients’ capacity to deal with their disease. (“Zachariae, R et al. “Association of Perceived Physician Communication Style with patient satisfaction, distress, cancer-related self-efficacy and perceived control over the disease”, Brit J Cancer, 2003)
  • Patients of physicians with high empathy scores were significantly more likely to have good control of hemoglobin A1C than were patients of physicians with low empathy scores. (Hojat,M. et al., “Physician empathy and clinical outcomes for diabetics”, Academic Med, 2011)
  • Evidence from 55 studies indicates consistent positive associations between patient experience, patient safety and clinical effectiveness for a wide range of disease areas. There were positive associations between patient experience and self-rated and objectively measured health outcomes; adherence to recommended clinical practice and medication; preventive care and resource use. (Doyle, C et al., “A systematic review of evidence on the links between patient experience and clinical safety and effectiveness”, BMJ, 2013)
  • Clinical empathy, as perceived by patients with the common cold, significantly predicts subsequent duration and severity of the illness and is associated with immune system changes. (Rakel D et all, “Practitioner Empathy and the Duration of the Common Cold”, Family  Med, 2009)
  • Diabetic patients of physicians with high empathy scores, compared to those of physicians with moderate or low scores, had a significantly lower rate of acute metabolic complications. (Del Canale, S et al., “The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary care Physicians and Their Diabetic Patients in Parma, Italy”, Academic Medicine, 2012)

What Clients Have to Say About Why They Don’t Feel Welcome, Heard Or Empowered By Their Health Providers

Excerpts from the “Listening” video produced by the California Mental Health Directors Association Social Justice Advisory Committee, sponsored by Santa Clara County Mental Health

“There’s been a long-standing awareness among clients in primary care clinics that doctors assume that we’re not reliable witnesses to our own health care.”

“There are so many physical health problems that cause symptoms similar to those labeled as mental health conditions.  Without doing the proper checks on physical health problems, and social and environmental problems that people have, it’s all too easy to reduce them to a biological brain problem that’s considered a mental illness.  And that’s a huge problem.”

“I wish they would tell me other ways to deal with my symptoms instead of just trying to prescribe a pill for it.  I feel like they go to prescriptions first.”

“There are so many alternative and holistic approaches….  The single-minded heroic pill approach that has become so popular since the decade of the brain is a terrible path for western medicine.  It reduces so many of our mental problems to a simple biological issue which is a terrible oversimplification at best.”

“Shared decision-making is recognized as giving a much fuller spectrum of options and making a strong effort to apprise people of all the risks and benefits that are known for a particular treatment.”

photo-pills“I got really scared because who would take a list of meds for something they haven’t even been educated about.”

“When you walk into a visit with the psychiatrist, they have nine minutes for you.  They recommend a particular drug or two or three and if the client has any questions, the answers are terse and gloss over some of the most important risks…”

“Sometimes people in mental health think your brain is broken and they treat you like that.”

“I feel like I’m being rushed out and don’t have time to tell them what’s happening.  They just want to treat what I initially said.  But if I say something else is happening, they say I need to make another appointment.  But I say ‘I’m here.  At least let me tell you.’”

“They should look the patient in the eye.  Take the time to listen and not be distracted.  Listen to what’s really going on with that person.”

Patients/clients who have been historically judged and stigmatized and subsequently dismissed and given poorer care are the most vulnerable in systems with substandard customer service.   Those with severe mental health conditions, addictive disorders, chronic pain, or those who are homeless suffer more from a lack of empathy and understanding in healthcare organizations.   Building organizational climates where skilled empathy conveyance is expected and practiced with these most vulnerable patients/clients ensures that all patients will receive the most respectful care.

One of the primary drivers behind the integrated behavioral health movement is the fact that receiving mental health treatment in a primary care clinic is a less stigmatizing and more normalizing experience for the clients than accessing specialty mental health.  But according to clients’ reports, stigma still dwells within primary care.

“Of 3,000 uninsured clients diagnosed with mental illness, 90% preferred that their medical and mental health providers communicate with one another about their health care.”—L. Mauksch, Journal of Family Practice, January, 2001

Though news headlines and films forge a pejorative link between mental illness and violence, the truth is that persons with mental disorders are far more likely to be victims than victimizers.  Mental illness alone does not increase the risk for violence.  As with the general public, the risk goes up when substance use is introduced.  A landmark study (Elbogen and Johnson, 2009) of more than 35,000 persons concluded that “mental illness did not independently predict future violent behavior.” As with the general population, about 1% – 5% of all people with mental illness are exceptionally easily provoked to violence. (NAMI 1990)