Lessons from the Field
“A lot of what we learned about was how do you begin to engage people rather than do what has traditionally been done —such as case management (which has abysmal results nationally), which is calling people up, doing assembly-line-type work. The whole focus is on what do people really care about? What are their goals? And how do we gain their trust? Trust is often really lacking in these patients. And then what are the skills that allow us to appropriately help them move along the path of higher activation around their own health?
Number one is the concept that the core value is activating people to take better care of themselves rather than doing things for them, and to understand that there are a lot of barriers to patients or people that fit the criteria for our program. We see a lot of the trauma inflicted by the medical system in their course of getting health care, and then also an overlap of a lot of trauma inflicted on their lives before health care became the big issue.
Trust needs to be earned. We consciously try to gain the patient’s trust by delivering what we promise and, perhaps most importantly, really focusing on what they care about rather than what the health care system or the payer may care about. This goes under the name of what’s sometimes referred to as ‘patient self-identified goals.’
It’s not about us, it’s about them. So, you can’t walk into a room and say, “You’re going to the ER too much,” because the person going to the ER often has made the very best choice available to them given their circumstances and access. And they don’t see that as a problem, going to the ER all the time, because it’s maybe the one place they feel safe. They can see a specialist. But in the ER they can get their needs met rather than wait three months to see a specialist in the outpatient setting. From a patient point of view, what the health care system sees as overutilization behavior is actually people in a very creative way getting their needs met. That’s really why a lot of programs don’t work is that they approach it from the perspective of “your diabetes is way out of control, or your hypertension’s out of control, or your behavior is bad and you’re manipulating the system” — when, in fact, from the patient’s point of view, those behaviors make perfect sense. If I were to pick a single word to describe what I’m talking about, it would be empathy with the patient in their present state, which is different than pity and sympathy.
The center of this is the shared care plan which are the patient’s goals, not the system’s goals, and then the series of action plans which are small steps, or the patient’s own PDSA cycles. Although with individuals who are lowly activated, you really don’t want failure because for these patients, success is what helps, not failure. They tend to come in with a lifetime of failure and then it sort of builds iteratively over time. We’re usually able to engage everybody pretty well by about month three and they’re often blown away by the level of service that they’ve never had before. Sometimes it takes two or three years to really engage people and we don’t give up if they fit the criteria for us, which is they cost a lot of money and they’re doing badly health-wise. Because it’s still worth it even if it takes three years.
That’s a differentiator from what I hear about a lot case management programs driven by health plans, where they basically say, I call somebody three times; if they don’t respond, I leave and move on to the next person. We don’t do that. We go to great lengths to not move on. We will show up at their work place. We will, very honestly, send a text message saying, “Are you avoiding us?” We write letters to them. We celebrate every little thing. Every time they contact us, we respond with, “It’s so great to hear from you.” We’re also on time all the time. What we get by treating people the way we do is incredible reciprocity from them. When you treat people well, it comes back to you. If you treat people badly, it also comes back to you.
In our design phase our patients told us, “I don’t want an assembly line of people interacting with me. I want trusting relationships.” In our model, the care coordinator builds the core relationship. To have this be effective with the patient, the care coordinator is present during all patient interactions with the health care system, or as many as possible. Coordinators can’t attend every single specialty visit, but they do a lot. Every visit at our clinic, the care coordinator is present in the room during the visit. We avoid the handoffs that become the reason why the patient doesn’t get engaged. There’s accountability between the care coordinator and the patient and it’s a two-way relationship. We find that if people are successful, intrinsic motivation starts to appear. It’s been there all along, but it’s been beaten down and crushed and we have to develop it. That’s what success breeds, I think, is intrinsic motivation.
It’s about being real with people, which builds reciprocity in the relationship. We put a huge amount of effort into making our access and our service extraordinary, treating people the way you would want to be treated. Then what we get in return is people doing things for us — often the thing they’re doing is taking better care of themselves.”Alan Glaseroff, MD, Co-Founder, Stanford Coordinated Care