Revolutionizing Patient Engagement


“What we have learned is there’s not a lot of trust among individuals in this population. They are fearful in the hospital where we recruit them into the enhanced care program. We really needed to come into the hospital, dress differently than the hospital staff, and sit down with the patients. We need to hire the right people to do this work, for example, social workers are good at it. We hire community health workers that are pretty sophisticated, and they’re paired up with social workers to engage patients. They sit down with patients, for an hour to two hours sometimes, and start a conversation: ‘My name is Susie Jones and I work for a group called the Camden Coalition. We work closely with the hospital here and we understand that you’ve been hospitalized a couple times in the last few months. Might you be interested in talking to us about some of the problems you might have been having — getting to the doctor, or sorting out medications, or getting the services you might need?’

Our staff take the time to build a relationship and see if the person will agree to let us help them. A lot of the hospital interventions are very goal-directed. The doctors on rounds, they come in, ask the patient two questions and run out. Whereas we’re asking open-ended questions. We’re sitting down at the level of the patient. We’re talking slowly and clearly and willing to spend time getting to know them. It is not an intensely goal-directed activity that we’re pushing on patients.”Jeffrey Brenner, MD, Executive Director, Camden Coalition of Healthcare Providers

Why is this important? And what do we know?

  • What are revolutionary engagement methods? 
    • The fundamental idea that each individual patient is the true expert on his or her health and holds the key to their own health and life is the foundation of this approach.
    • Traditionally, medical care is carried out as a hierarchical endeavor, with doctors and nurses dispensing information and expertise to patients. Years of experience demonstrates that with the population of people with complex needs and high costs, this hierarchical approach is not effective. In fact, top-down care management with goals determined by the care team can isolate patients and keep them from engaging in care.
    • The core of effective engagement methods is an empathetic, human relationship between a care manager and each patient. The relationship deepens throughout the care journey, as trust grows, the patient becomes freer to share his or her story, and the care manager demonstrates an ability to consistently partner with the patient to achieve the patient’s own goals, meet challenges and weather crises.
  • A revolutionized approach to patient engagement is required for many reasons:
    • People with complex needs and high costs have, by definition, engaged in many health care interventions, but still experience poor health outcomes. This juxtaposition is frustrating for both health care providers and patients, who may be reluctant to engage in yet another health care approach.
    • Many people with complex needs and high costs have experienced disrespectful treatment in health care settings.
    • Effectively engaging patients to achieve their health goals and decrease their use of costly health care interventions is further complicated by the array of overlapping health and social needs faced by many people with complex needs and high costs.
  • Enhanced care models dedicated to helping individuals with complex needs and high costs become more activated to manage their health use evidence-based engagement methods and rely on a person-centered approach to engage patients and foster behavior change.
  • Characteristics of effective engagement methods include:

Core recommendations

Develop a trusting relationship with each patient to support positive health outcomes.
  • A trusting, caring relationship is the foundation of the care journey toward improved health outcomes and self-management skills. To be able to identify specific health and life goals, and then define steps and exert effort toward achieving those goals, almost all patients need the support of a trusted partner in care.
  • Given that the path toward achieving goals takes time and often involves setbacks or crises, the development of an open, trusting, supportive relationship between the patient and the care team forms the foundation of the care journey.
  • Detail to develop a trusting relationship with each patient to support positive health outcomes.
Adopt patient engagement methods that build self-efficacy and patient confidence to manage their own health.
Recruit patients for the enhanced care model.
  • Recruitment is the work of reaching out to people to help them understand that it makes sense to participate in — or refer people to — your enhanced care model.
  • Recruitment may be targeted at providers or organizations that will refer patients to your enhanced care program, clinics that will participate in your program as providers, and individuals who will participate in your program.
  • Detail to recruit patients for the enhanced care model.
Assess each patient’s experiences, strengths, and needs.
  • As previously described, people with complex needs and high costs often have an array of physical health, behavioral health, and social needs.
  • Assessment processes that aim to learn about each patient’s experiences, strengths, and needs are crucial tools to enable the care team to uncover potential areas of focus for a person’s care plan.
  • Detail to assess each patient’s experiences, strengths, and needs.
Co-create individualized care plans with each patient.
  • Co-created care plans are a key intervention in supporting people to develop skills in managing their health and life challenges.
  • Co-creation of goals requires inquiry and deep listening to elicit life and health goals, but most importantly requires the ability of the care team to partner and support the patient’s own care journey.
  • Detail to co-create individualized care plans with each patient.
Align one care manager as the primary support for each patient.
  • Care teams need to streamline care delivery for each patient, replacing fragmented and chaotic care with simplified care delivery.
  • A key tool is the alignment of a specific care manager to each patient. That way, the patient and care manager can develop an ongoing relationship, with the patient able to call on the care manager for support, and the care manager an empathetic listener and trusted support who is  skilled in leveraging the skills of other care team members and external supports as needed.
  • Detail to align one care manager as the primary support for each patient.
Build engagement skills among the care team and support the care team in carrying out effective engagement methods.
Develop work processes to engage and support patients throughout the care journey.
Foster peer-to-peer support among patients.
  • Peer-to-peer support is social support shared between people with a common challenge. It can boost patient knowledge about self-management and navigating the health care system, build interpersonal connectivity, and lend hope for the future to those earlier in the self-management journey.

  • Detail to foster peer-to-peer support among patients.


How to get started engaging your population with complex needs and high costs

  • Learn who on the care team is skilled in deep listening, consistently able to access empathy towards others, and capable of engaging a wide range of people. If this skill set is missing, the team will need to hire someone with these capabilities.
  • Begin by building the care team’s skill in using evidence-based engagement methods as described in the Tips and Guidance section. Effective engagement methods throughout the care journey are developed and refined through practice, intention, and ongoing support.
  • The way to get started engaging people in care is by listening to their stories. Learn what is important to them, what they need, how they manage their daily lives, how has health care helped or hindered their care before.
  • Begin with five patients and work alongside them to co-create individualized care plans. This requires humility and curiosity: for this person, what will be helpful? What strategies will fail? How will each patient build his or her capacity for self-management? What will support or get in the way of increasing levels of patient activation?
  • Once the care team has co-created and carried out care plans with five patients, come together as a team to reflect on key themes, similarities in care delivery, and ways in which the care delivery was unique and different from traditional care.

Overall tips and guidance

  • Learn how to most effectively engage your patient population using evidence-based patient engagement methods.
  • Learn from your patient population what you need to do differently than the status quo. What helps them gain confidence to manage their health? What gets in the way?
  • Develop discipline around pausing as a care team to reflect on what is and is not working in engaging your population.
  • Study which patient populations are well-engaged in your enhanced care model and which ones are not. If some segments are not engaging, different recruitment and engagement strategies may be needed.
  • Not all staff can successfully make the shift to providing more patient-centered care required in an enhanced care model. For staff who are committed to a more traditional top-down medical model, redeploy them to work with patients who are not served by the enhanced care model.

“We serve a very diverse community and cultural sensitivity plays a big role in acceptance of hospice care. We’ve added two VNSNY liaison positions that are onsite in the nursing facilities to work with the nursing facility teams to outreach to patients and their families. We did a lot of meetings in the facilities to engage patients and families in order to educate them on end of life options and build trust in the process- tailoring our family engagement strategies to address different cultural groups.

We had to drill down to learn why people who met the criteria for participation in the enhanced care model were not engaging. We provided over 28 educational workshops on various hospice topics to both clinical teams and their families. A key focus in engagement was helping clinicians have end-of-life care conversations with families.” Adina Kolatch, Consultant, Visiting Nurse Service of New York