Case managers can play an important role in educating patients and families and can connect them with appropriate community resources and services.
"Let's discuss living with . . ."
Four years ago, Mrs. Smoley suffered a stroke. Although she takes her pills just like the doctor ordered, she has not been able to quit smoking. Now she has emphysema and may soon need oxygen. Dr. Nguyen thinks she should participate in a disease management program at a local hospital that will give her the information she needs to manage on her own. "It could help you prevent the problems you've had with shortness of breath," the doctor explains. "And you might learn some tips about how to manage your day so that you have some more energy." She offers to help Mrs. Smoley schedule her first appointment.
Approximately 80 percent of older adults have at least one chronic health condition, and 50 percent have at least two chronic conditions. For many older people, coping with multiple chronic conditions is a real challenge. Learning to manage a variety of treatments while maintaining quality of life can be problematic. People with chronic conditions may have different needs, but they also share common challenges with other older adults, such as paying for care or navigating the complexities of the health care system.
Try to start by appreciating that people living with chronic disease are often living with loss—the loss of physical function, independence, or general well-being. Empathize with patients who feel angry, sad, lost, or bewildered. Ask, "Is it hard for you to live with these problems?" From there you can refer patients to community resources that may meet their needs or, when available, recommend a disease management program or case managers in the community.
Educating the Patient
Most older patients want to understand their medical conditions and are interested in learning how to manage them. Likewise, family members and other caregivers want this information. Physicians typically underestimate how much patients want to know and overestimate how long they spend giving information to patients. Devoting more attention to educating patients may seem like a luxury, but in the long run it can improve patients' adherence to treatment, increase patients' well-being, and save you time.
The following tips can help you inform patients and their caregivers about medical conditions and their treatment.
- Doctors' advice generally receives greatest credence, so the doctor should introduce treatment plans. Other medical team members have an important role, including building on the original instructions.
- Let your patient know you welcome questions. Indicate whom on your staff he or she can call to have questions answered later.
- Remember that some patients won't ask questions even if they want more information. Be aware of this tendency and think about making information available even if it is not requested.
- Provide information through more than one channel. In addition to talking to the patient, you can use fact sheets, drawings, models, videotapes, or audiotapes. In many cases, referrals to websites and support groups can be helpful.
- Encourage the patient or caregiver to take notes. It's helpful to offer a pad and pencil. Active involvement in recording information may promote your patient's retention and adherence.
- Repeat key points about the health problem and treatment at every office visit.
- Check that the patient and his or her caregivers understand what you say. One good approach is to ask that they repeat the main message in their own words.
- Provide encouragement. Call attention to strengths and ideas for improvement. Remember to provide continued reinforcement for new treatment or lifestyle changes.
Clear explanations of diagnoses are critical. Uncertainty about a health problem can be upsetting. When patients do not understand their medical conditions, they tend not to follow the treatment plans.
In explaining diagnoses, it is helpful to begin by finding out what the patient believes is wrong, what the patient thinks will happen, and how much more he or she wants to know. Based on the patient's responses, you can correct any misconceptions and provide appropriate types of information.
Some older patients may refuse treatment because they do not understand what it involves or how it will improve their health. In some cases, they may be frightened about side effects or have misinformation from friends and relatives with similar health problems. They may also be concerned about the cost of the treatment.
Treatment can involve lifestyle changes (such as diet and exercise) as well as medication. Make sure you develop and communicate treatment plans with the patient's input and consent. Tell the patient what to expect from the treatment, including recommended lifestyle change, what degree of improvement is realistic, and when he or she may start to feel better.
Keep medication plans as simple and straightforward as possible. For example, minimize the number of doses per day. Tailor the plan to the patient's situation and lifestyle, and try to reduce disruption to the patient's routine. Indicate the purpose of each medication. Make it clear which medications must be taken and on what schedule. It is helpful to say which drugs the patient should take only when having particular symptoms.
After proposing a treatment plan, check with the patient about its feasibility and acceptability. Work through what the patient feels may be obstacles to maintaining the plan. Try to resolve any misunderstandings. For example, make it clear that a referral to another doctor does not mean you are abandoning the patient. Provide oral and written instructions. Do not assume that all of your patients are able to read. Make sure the print is large enough for the patient to read.
Encourage your patient and his or her caregivers to take an active role in discovering how to manage chronic problems. Think in terms of joint problem solving or collaborative care. Such an approach can increase the patient's satisfaction while decreasing demands on your time.
- The physician should provide key information and advice for greatest impact; other team members can build on that.
- To explain diagnoses, start by asking the patient what he or she understands and how much more he or she wants to know.
- After proposing a treatment plan, check with the patient on feasibility and acceptability; confirm that the patient understands the plan.
- Encourage the patient and caregivers to take an active role in managing a chronic problem.