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Monday, June 27, 2016

Co-production of diabetes care: Not doing me justice

Dr. Maren Batalden’s story:
In a diabetes group, a woman who was being seen by one my colleagues said to her doctor:  “Why are you so obsessed with this blood sugar number [Hemoglobin A1c]?!  In so many ways I’m so much healthier:  I’m eating better, exercising, losing weight.  I have a job, and I’m not drinking like I was six months ago.  I feel so good, and so empowered and supported by this group.  But my HgbA1C hasn’t moved yet.  I feel like these measures are not actually doing me justice.”  

Hemoglobin A1C is a blood test which measures average blood sugars over a three month period.  Doctors and patients use it to evaluate the degree to which a person’s diabetes has been “in control” in recent months. Ultimately the HbA1c should reflect the positive changes that the woman above is making, but sometimes it takes a while.  We have to be patient with that process.  Sometimes a person with diabetes needs to focus on some more foundational life changes that will eventually be reflected in the blood test, but may take several months to manifest.

Our efforts to measure and improve health outcomes in chronic diseases like diabetes have become “performance measures” for health professionals by which payers evaluate the “quality” of care being provided. In a subtle way, this has confused us about the nature of health professional work.  We’ve come to see numbers like the Hemoglobin A1c as if they are something that health professionals produce.  In fact, of course, numbers like these are co-produced by patients and health professionals working together.  In fact, blood sugar is largely controlled by people with diabetes – not their nurses and doctors and nutritionists. Blood sugar is determined by the everyday decisions of a person with diabetes -- what they eat and how they exercise.  The doctor is a bit player.  The doctor prescribes medication, helps to decide when it’s time to start insulin, or go up on a dose, and does a little teaching.  But most of the learning happens outside of the clinic, in the life of the person with diabetes in relationship with their families, by trial and error.

If they care about health outcomes for their patients, health professionals need to reframe their work.  Health professionals need to ask themselves not “How can I be successful in lowering my patient’s hemoglobin A1C” but rather “How can I be most useful, most helpful, most supportive to the person with diabetes who is already working in whatever way he or she can to be healthy?”

Thanks to Dr. Maren Batalden for her story.  Read Dr. Batalden's article on co-production, mentioned by the Institute for Healthcare Improvement today.

Thursday, June 16, 2016

Prostate Talk: To limit the poking and prodding

OK, adult sons, can I have your attention please?   When you were a teenager, your father might have had The Talk with you. Remember how awkward that was for both of you?  Now it’s your turn to stammer out to him some important information, to have A Talk with him, about his prostate and what to do about the damn thing.  June is Men’s Health Month, and with Father’s Day coming up on Sunday, there’s no better time for The Talk.

You can see a short video of advice by Dr. Harry Fisch, a Board-certified urologist at New York Presbyterian Hospital/Weill Medical College of Cornell University, or read excerpts from the interview below.

Q:  What is the best way for men to educate themselves about prostate treatment?

A: 4Kscore.com is a website about the most modern and sophisticated test for the aggressive form of prostate cancer—that’s prostate cancer that can kill you.

A lot of times men are getting prostate biopsies that are unnecessary.  Three out of four men, when they get a biopsy, don’t have cancer.  We want to limit the poking and prodding that men get.  The more sophisticated 4K test can decrease the number of unnecessary biopsies and gauge the risk of having aggressive cancer.  That’s what the 4K score test is all about.

Q:  How would you advise adult sons to talk to their fathers about prostate cancer?

A:  We don’t want denial.  Men are in denial, denial, denial about their health.  Men who are older tend to not want to go to the doctor. and are more reticent to really discuss their health.  Young men can talk to their parents, and say, “Look,  I’m doing it.  It’s my turn to teach you about proper health.”  Young men are more attuned to information.  It’s the Information Age on the Web.  Get that information from the Web. Show it to your father, and your mother too, as well, so they can get as much information as you got.   Make them more savvy.

Thanks to Dr. Fisch, and Mike Bako and Alex Cole of D.S. Simon Media for organizing and producing the interview.  Read another story on prostate cancer decision-making.

Friday, June 3, 2016

Patient-centered care at Planetree: It sounds like the ocean

This is Part 2 of Debi Janway’s story about her mother’s care at Planetree. You can read Part 1 here.

It was a home-like feeling. I was here late in the evening, and my family would come. The waiting room in MedSurg is home-like, with round tables to eat at and relax with nice chairs, on the same floor as my Mom. So you know if the doctor or nurse wants to see you, you’re right there. You can heat up your own food in the kitchen that’s right there. If your family member is allowed to eat the same food while she’s in the hospital that she eats at home, you can cook that food for them.

They did aromatherapy. Mom absolutely loved the lavender they’d put in her room, it was so soothing. It was very quiet. You could hear a pin drop. No one just entered the room; they always knocked first, and asked, Would it be all right to come in? The lab techs would ask, Is this a good time to come in? It wasn’t intrusive. They’d ask, Is there anything else I can do for you? My Mom might say, Yeah, I’d like some more ice water. The lab tech or whoever would get her what she needed. As a Care Partner, we could do that too.

I feel very blessed. Mom is back at home now.

Hospital CEO Susan Stone adds:

We have a program, Lights Out Lavender. We’ll do a back massage for the patient, and ask if they’re ready for bed. Our staff round every hour.

We worked hard to make it quiet at night. For example, we have reminders to make sure the environment is quiet. We did an assessment and realized that the Housekeeping carts were too squeaky. The doors for the patient laundry used to click shut really loudly, so we’ve changed those. Also, we use soothing sound machines if patients like them, to create white noise, which can sound like rain, or the ocean.

Ken’s comment: The healing environment creates tangible results. Patients have high satisfaction, as do physicians and other staff. The environment seems to quicken healing, as patients’ length of stay is significantly shorter than in a comparison unit, according to “A Retrospective Evaluation of the Impact of the Planetree Patient-Centered Model of Care on Inpatient Quality Outcomes," abstracted here. Even so, the hospital has been profitable since 2010, perhaps because so many have heard about the spa-like hospital.

Thanks to Dr. Susan Stone and Debi Janway for sharing their story.