Collaborative Care Planning – An Invaluable Process to Improve Patient Engagement and Self-Management

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Collaborative Care Planning – An Invaluable Process to Improve Patient Engagement and Self-Management

Collaboration is a foundational concept to improve health outcomes in primary care. Gone are the days of just telling patients what to do and, if they don't comply, telling them more emphatically. (i) In a more effective model of care, partnership and collaboration are seen as great assets in the journey of improving the health of our patients. Primary care providers and team members frequently share frustrations about patients who take significant visit and non-visit time because they have complex medical problems exacerbated by the patients' inability or refusal to follow clinical recommendations to improve their health. In addition, there is frustration with patients who do not seem to engage in health improvement and continue with choices that cause their health to deteriorate. The time spent with populations of patients with complex health problems and non-engaged patients presents many challenges for the primary care team that is already burdened with increasing demand for visits, messages or call follow-ups and the many needs presented by their patient population. Effective processes and resources that foster patient engagement and activation are essential to improve efficiency for the primary care team and health outcomes for patients.

Collaborative Care Planning can be an invaluable process to build patient engagement and meet the needs of populations with poorly controlled chronic conditions. This process can apply across the entire primary care population, but the most value or initial priority resides in the patient population with complex health problems. Collaborative Care Planning or Collaborative Problem Solving is defined as a “problem-solving process that consists of a set of steps whereby individuals define a problem, brainstorm possible solutions, choose a strategy, try it, evaluate the response and repeat the process.” (ii) This process of collaboration is seen as a key principle to improve patient engagement, self-management, and ultimately patient health outcomes because it identifies and places priority on what is important to the patient.

Effective Collaborative Care Planning is evident in the culture of the primary care setting when all team members value the process and own tasks associated with initial care plan creation, updating of the care plan, or support of the collaborative care plan as a resource to improve patient engagement. Collaborative Care Planning in most settings occurs as a task of care management, but in the most effective models, all on the team have a role in supporting the work of other team members and the patients. Ensuring that collaborative care plan work does not occur in a silo but rather as a shared task of the team is important to success for the patients. Clearly defining who owns specific tasks and how to efficiently complete those tasks promotes accountability and consistency in the practice setting. In addition, training and ongoing education in basic concepts of collaborative care planning, health coaching, motivational interviewing, and Specific, Measurable, Achievable, Realistic, and Timely (SMART) goals(iii) for the primary care team fosters a culture of patient engagement with collaborative care planning.

Some may ask, how in primary care do we find the time? Or, how do we make this a priority? As with any new initiative starting with drivers of change, easing frustrations can be a powerful and motivating step. Building team engagement is important to any new process or a review of current processes. Guiding the team through a collaborative planning process is a great way to model the work and the value of collaborative planning with patients. Correlating collaborative care planning as a solution to some of these frustrations can be an effective impetus for the team to engage in developing and implementing a new approach and a new process.

A new opportunity is created if the primary care team begins to think of patients with poorly controlled chronic conditions and/or poor adherence to clinical recommendations, as patients whose story is not fully known by the care team. Uncovering this can reveal unknown obstacles and allow the care team to discover what is important to that patient. This new opportunity prompts the need for a new approach; an approach that includes stepping back and looking at health needs from the view of the patient. Success in supporting the patient to manage their health depends on knowing these pieces of their story. The Collaborative Care Planning process can provide structure to this new approach and ensure that the primary care team recognizes and supports the patient with their priorities, action steps, and goals. Many times, this process can include how to uncover, overcome or deal with obstacles that are unknown to the primary care team, such as financial challenges, housing concerns, personal safety, or just feeling overwhelmed with life. Regardless, it is an obstacle that the patient struggles with overcoming on their own, but with some effective guided conversation and team support, they can be engaged to develop a plan to move forward on their journey to improved health.

As a primary care practice explores implementing a Collaborative Care Planning process for their patient population, consider the following steps:

Discuss the value of collaborative care planning with the team, create the 'why’ this is important for all members of the team, and make the connection with this as a solution to some of their frustrations.
Engage a team member to own the project. The project work should include regular updates, team education, and problem-solving.
Identify priority populations for the initial work, consider a population such as the 'non-compliant’ or those with poorly controlled chronic conditions, but also consider populations such as asthma or hypertension that are important to all on the primary clinical team. Consider a Plan-Do-Study-Act (PDSA) cycle by starting with a smaller population for initial efforts to test or refine the process.
Define the process for collaborative care planning. This should include identifying specific roles (e.g., primary care clinicians, care manager, or both) to initiate the process and specific skills/verbiage for success. Ensure team training on skills such as motivational interviewing, change talk, and effective problem-solving. Lack of investment in effective initial and ongoing training is a common reason for project failure in primary care.
Discuss how to make collaboration a component of the culture of the practice. This may include a defined collaborative care plan support task for each member of the team. Some examples include:
1. Call center staff: I see you are working on a patient identified goal. I hope this is going well. I am sure your provider and clinical team will review any successes or obstacles with you.
2. Rooming staff: After reviewing chief complaints, I know you were working on action steps. How is this going?
3. Provider: After reviewing the reason for the visit, if different from chronic problems or seems unrelated to the patient's identified goal, Tell me about your identified goals and action steps?
Provide effective resources for collaborative care planning. Identify EMR resources for patient identified goals and care planning. Make priority content such as patient identified goals and action steps easily accessible to all on the team. Develop or update resources as needed to ensure they are valued by the patient and efficient for the team.
Define the team's measure of success for the work of implementing collaborative care planning. Use SMART goals. Review the goals, progress, and challenges on a regular basis, consider weekly review initially, then monthly on an ongoing basis.

Working through the process of effective collaborative care planning ensures that the patient partners with the care team to identify the problem, define the solution and create a clearly stated goal. These key steps increase patient engagement and activation because it is driven by the patient and ensures a focus on what is important to the patient. The population with complex health problems or poorly controlled health conditions can be the greatest opportunity for success with a collaborative care planning initiative. This process can also help boost the confidence and trust the patient has in their primary care team, contributing to the improvement in patient experience and patient health outcomes.

Written by Diane Cardwell, MPA, NP, PA-C - Practice Facilitator, HealthTeamWorks

(i) Mauksch, L & Saffold, B, Engaging Patients in Collaborative Care Planning. Fam Pract Manag. 2013 May-June;20(3):35-39 https://www.aafp.org/fpm/2013/0500/fpm20130500p35.pdf

(ii) Battersby M, Von Korff M, Schaefer J, Davis C, Ludman E, Greene SM, Parkerton M, Wagner EH. Twelve evidence-based principles for implementing self-management support in primary care. Jt Comm J Qual Patient Saf. 2010 Dec;36(12):561-70. doi: 10.1016/s1553-7250(10)36084-3. PMID: 21222358.

(iii) SAMHSA Native Connections "Setting Goals and Developing Specific, Measurable, Achievable, Relevant, and Time -Bound Objectives". https://www.samhsa.gov/sites/default/files/nc-smart-goals-fact-sheet.pdf