Gary Oftedahl: Empowerment/Engagement…Easy Does It
I love a good discussion, especially when someone I respect causes me to flinch, and rethink an area of interest. Such is the follow-up to my discussion of empowerment in my last blog. I knew I was being more than “just clever” when I used the (pre)cautionary term in my title. While the term “empowerment” is indeed prevalent in many discussions regarding health care reform and patient involvement, it’s outlawed in some arenas. At least according to Jessie Gruman, CEO of CFAH (Center For Advancing Health), with whom I had a most engaging conversation earlier this week. She raises valid issues, and with a patient perspective, provides a different view than I who have a set of shaded (or perhaps jaded) lenses with which I view the world of health care.
After reading my previous blog (which she found “interesting”—hmmm), she provided two reasons for her avoidance of the term: 1) it implies that someone or something outside gives me power, and by the same token, can take it away, 2) it is a politically correct and ostensibly innocent word that often provides cover for the abandonment of roles and responsibilities by professionals that by default are now the patients. Rather, she presents an argument for understanding what patients (people in her vernacular) need to be able to do to become engaged.
Hence, we have another “E” word—is it engagement or is it empowerment? Or is this an interesting intellectual discussion for those of us excited by reading a thesaurus? (Hopefully, that’s a very small, but treatable group). But I submit that perhaps this is not another either/or question, but rather one of considering each in it’s’ specific context.
As a result of a recent accidental meeting with Jessie, and a subsequent conversation and search of her web site (http://www.cfah.org/) I’m thinking about patient engagement in a different light, and it’s a much brighter one than I previously sat beneath. In her work, she defines engagement as “actions individuals must take to obtain the greatest benefit from the health care services available to them.”
Let’s consider the implications of that statement as we consider the empowerment/engagement conundrum—if indeed that’s what it is. I think we all understand that with all the advances and challenges facing us in health care today, it is increasingly important that we have patients who are actively participating in their care. In reality, with the increasing concerns about safety, and the recognition of the dangers lurking around every health care corner, it is imperative they have an active role.
But it is not enough to say they’re empowered (sorry, Jessie, I used that word again). We need to have them engaged, at least as defined by her use of the term. In fact, much of the work we’re doing has an implicit, often explicit, commitment to the need for shared responsibility, accountability on the part of the patient, active participation—in effect, “engagement.”
If we agree with that, what are the implications for us—both from the patient perspective, as well as that of a provider with shaded/jaded lenses? It is not enough to discuss compliance—one of the terms I’d like outlawed. Compliance implies passivity, obeying an externally delivered order. Engagement suggests active involvement in a process wherein one harmonizes information and professional input with personal needs, preferences, values, and abilities, leading to an action of some sort.
We’ve focused much work in the past several years on the development of the patient-centered medical home. Inherent in that is the assumption that patients/families will be actively engaged. But what does engagement specifically mean? And what must we within the system provide to support those wishing to be engaged? Judith Hibbard, from the University of Oregon, has for years been working on a usable tool which can identify levels of patient activation (Patient Activation Measure). In a personal conversation with her at one time, we discussed whether some or many of the issues with “de-activated” patients were in part due to a health care system which made engagement difficult if not impossible.
That is why I am interested in the results of some work done by CFAH, in creating a “Patient Engagement Framework” (http://bit.ly/av4MrJ). It is the result of a process which identifies a measurable set of behaviors that individuals (“patients” to many of us with those jaded lenses) must perform in order to benefit from the care provided by the health care system, and to maximize their health.
In brief, she describes 10 behaviors:
- Find Safe, Decent Care
- Communicate with Health Care Professionals
- Organize Health Care
- Pay for Health Care
- Make Good Treatment Decisions
- Participate in Treatment
- Promote Health
- Get Preventive Health Care
- Plan for End of Life
- Seek Health Knowledge
Within each of these items is a list of activities that further delineate what is included in demonstrating these behaviors. While perhaps appearing simplistic to some, I would argue that it is the parsimony of the list that is appealing. If indeed, we are to be engaged, while not being asked to do all 10 things simultaneously (I’m Norwegian—walking and chewing gum at the same time can be physically challenging, and that’s only two activities) we will likely at some time have to engage in some or many of these activities if we are to ensure the best outcome for any health or wellness issue which we confront in our journey through life.
There is a great opportunity to use this to identify any gaps that exist in the eyes of those planning patient-centered medical home interventions, or improving our ability to manage chronic conditions. Does our health care system, our environment, our lifestyle provide the opportunity to become engaged? It is difficult enough under perfect circumstances to assume responsibility and take accountability for life’s challenges. With the complexity of the health care system, and the exploding uncertainty about the future of that system, we should pay attention to this lens, and ensure we in the health care system (those who often wear jaded glasses) don’t erect barriers that inhibit the potential for engagement.
My previous blog raised issues that I believe are still relevant, but after my conversations and reflection with Ms. Gruman, it’s not enough to discuss empowerment. While I’m not about to “outlaw” the term empowerment, I discussed it because it is a commonly expressed trait, which made me uncomfortable at times in its use. Jessie has concretized some of those concerns. Now, armed with her framework, and her considerations regarding engagement, I’ll crosswalk this with work in health care home, consider it’s impact on shared decision making, reassess efforts on patient-centered care, consider the challenges of motivating one to become engaged, and look forward to your thoughts on this topic.
For beyond empowerment, with increased understanding of engagement, but sensing an alliterative opportunity, should we also discuss “expectations,” “extenuating circumstances,” “evidence-based medicine,” and “entitlement” to name a few. I sense this won’t be “easy” but could be “exceptional.” I think there’s a treatment for this, but it’s not “evident” to me at present.