Transforming Patient Care
Dr. Margaret “Lynn” Yonekura, senior advisor to LA Best Babies Network, likes to shake things up. Since attending the University of Southern California medical school in the 1970s, the perinatologist has been challenging a top-down medical system that is resistant to change. From the beginning of her career, Yonekura’s philosophy has been to reject that health system hierarchy in favor of helping patients participate in managing their own health.
Now, as a clinical associate professor in the Department of Obstetrics and Gynecology at the David Geffen School of Medicine at UCLA, as well as the Keck School of Medicine of USC, Yonekura is at the forefront of applying this novel “self-management support” approach to help pregnant women in Los Angeles County stay healthy.
“Currently many of the interactions between patients and doctors can be frustrating,” says Yonekura, who has received numerous honors over the years. “Imagine how different that experience can be if the doctor is prepared to see you and you were prepared to speak with the doctor.” A prepared doctor would review a patient’s records and laboratory results and have a clear idea of what is required to get the patient the help she needs. A patient who is prepared to see a doctor might have a list of specific questions to ask, as well as information that helps the doctor diagnose and treat her problem. |
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This self-management support concept represents one pillar of a Care Model that seeks to revamp a health system to manage disease by using evidence-tested guidelines. In practice, self-management support means systematically helping patients develop the skills and confidence they need to manage their own health problems. For the healthcare professional, that means assessing patients’ progress, helping them set goals and offering support to help them solve their own problems. For the patient, selfmanagement means possessing the knowledge and confidence to deal with the medical and emotional part of being ill.
Self-management support is also a critical aspect of the Chronic Care Model, a framework that helps patients manage chronic diseases such as diabetes, asthma and cardiovascular disease, as well as arthritis, hypertension and chronic obstructive pulmonary disease.
With Yonekura’s guidance, the Network’s Healthy Births Care Quality Collaborative plans to adapt this self-management support model for the first time to promote wellness among prenatal clients. Yonekura has been successful at developing comprehensive services for chemically dependent pregnant women from prenatal care through delivery.
Self-management support techniques have already had very positive effects. Providers have found that patients involved in their own care—while enlisting caregivers as supportive partners—remain healthier and are less likely to be hospitalized.
Kate Lorig, RN, DrPH, and her colleagues at Stanford University developed the Chronic Disease Self-Management Program, which helps transform patients into active “self-managers” through small group interventions.
This philosophy of preventive care is historically at odds with our current medical system, which was designed to manage acute, curable illnesses. For example, a patient might come in with appendicitis, receive a diagnosis, have surgery and go home. In this scenario, it’s the healthcare professional that often determines and conducts the therapy, while the patient simply follows the doctor’s orders. But that doesn’t work as well when managing chronic disease or promoting healthy behaviors in moms-to-be. Today, the healthcare professional should be more of a coach or teacher.
Providers don’t have to give up their white coats to be life coaches. They can use motivational interviewing techniques to become a patient’s collaborator. If a pregnant woman has diabetes, a provider might present a handout that prompts the patient to choose the type of activities that might work for her, whether it’s improving her diet or reducing stress. By asking more open-ended questions, such as: “What kind of exercise would you feel most comfortable doing?” the provider is able to better understand the patient’s attitudes toward exercise.
Once the action plan is set, it can be compressed into a simple document called a “shared-care plan,” which summarizes the agreed-upon actions related to the patient’s condition.
When patients trust their provider, they may feel more inclined to confide in them. They might want to discuss the reasons they don’t feel safe at home or why they don’t have adequate food to eat. Such personal conversations require trust between a health professional and a patient. That is why it’s critical to create a comfortable, non-judgmental atmosphere.
Apart from the connection between health professional and patient, the self management support idea can be applied to improving the efficiency of care in busy community clinics. It also can be used in Web-based virtual learning communities.
The Care Quality Collaborative is in the process of developing these virtual learning opportunities for its providers. Also, the Healthy Births Database, a Web-based registry, allows Care Quality Collaborative members to plan and follow patient care.
Yonekura hopes self-management support will become the norm in clinics and hospitals across Los Angeles County and the country. “This whole notion of productive interactions with patients would be revolutionary,” she says. “Caregivers have to take the initiative and ask, ‘What can I do for you?’ |
