August 9, 2024

Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 16 A patient’s health literacy has a dramatic impact on their ability to learn and adapt. The primary responsibility for assessing and adapting to the patient’s health literacy falls on the clinician. The patient’s cultural and conceptual knowledge, print health literacy (writing and reading skills), oral health literacy (listening and speaking), and numeracy can each effect their ability to respond positively to new information. A patient’s assumptions and ideas do matter. There are a variety of methods that clinicians who want to succeed in the value-based, prepaid payment world can use to succeed. The lack of health literacy can kill a patient and put a major dent in your success. You succeed when your patients succeed What is health literacy? Definitions Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. What are the 4 components of health literacy? Arguably, the Institute of Medicine (IoM) presented one of the most influential models of health literacy. The IoM model contains four underlying constructs: cultural and conceptual knowledge, print health literacy (writing and reading skills), oral health literacy (listening and speaking), and numeracy. One of the complaints expressed by some clinicians argues that the clinician’s financial success should not be at the mercy of their patient’s noncompliance. In a value-based prepaid contract, the clinician/organization succeeds by keeping their patients as healthy as possible and away from the urgent care center, the ER, the hospital and unnecessary care. Deprescribing is also critical. The patients’ understanding of their health risk and how to improve their health is a major component of both clinical outcomes and financial success. In the fee-for- service world lecturing the patients about what they need to do was often considered good medical practice. And yet we know that well over 50% of what the clinician tells the patient during the office encounter is gone from the patient’s mind the minute she/he walks out the exam room door and by the time the patient gets home it may be well be that over 80% of what the clinician said is gone from the patient’s memory. It gets even worse if the news the patient received during the office encounter was new diagnosis/information that scared the patient. It’s more than a little unfair to blame the patient for this normal behavior. Rather it is incumbent on the clinician and the practice to get smart about the strategies they use to help the patient learn and adapt. Let’s start with a few underlying ideas. Not all patients are the same Talk about oversimplification. Patients come in all sizes and shapes. Some are well educated, and some are not. Even among the well-educated, some can process complex ideas during an interpersonal encounter and some struggle especially in the confines of an office visit. From a motivational point of view, the key issue is aligning with the patient’s goals. Assessing the alignment between your therapeutic goal for the patient and their goals and readiness for action is critical. If there is lack of alignment, you will not succeed. The second element involves “baby steps”. If the first step the patient must take is too far from their current behavior, failure is likely. Become an effective coach by breaking down your instructions/guidance into “doable” steps. Small successes over time lead to sustainable change. Help them to articulate and focus on the next specific step he/she needs to take to more towards success. The focus is always on the next specific step. Patient risk You may have integrated the idea of level of risk into your medical thinking. Patients have not. When a patient says… “I feel fine” they are not basing that assessment on data. It’s a feeling. Helping the patient to grasp the concept of risk takes time. Moving from feeling fine to “I am a patient at high risk, and I need to take action” is a quantum leap. Be patient and allow time to absorb the idea. Expect denial when the idea is first presented to them. We all have some level of denial built into our thinking and action. Culture rules facts There is wide divergence across cultures regarding baseline knowledge surrounding a wide array of issues. Sone cultures see a physician in a positive way and others see physicians as being less than trustworthy especially when there is divergence in race and age. The burden here is on the physician/clinician. Are you capable of being the physician/clinician a patient needs on any given day. Some patients on some days need to talk and perhaps even unload on the clinician. Not a good day to remember new information. Can you adapt to where the patient is today? Group visits When clinicians offer group visits, they all realize that the interactions between the group participants is often more valuable than the interactions with the clinician leaders. Remember motivation, not just information, is required to help people to learn and adapt. Use of social media These days there are presentations on almost every topic under the sun accessible online. From medical conditions, to mental health, motivational and all types of  topics. Over time create a library of URLs that can be shared with the patient and their significant others. These resources can supplement the information you present during the office visit. One very smart first year resident had a brilliant idea. He noticed that he was giving the same basic talk to each of his patients who just learned that they are diabetic. He decided to video record his basic talk and he told his new onset patients… “I know what I just shared is a lot to remember so I will send to you a video I created with all of this information so you can listen to it when you want