Care Resource Mobilization (Part 2 of 3)
Continued from Part 1 – Aviation Beyond Checklists
Part 1 of this blog detailed how integrating knowledge and experience from aviation into medicine was straightforward in the case of checklists. This installment explores why now is the time to move beyond checklists to a more comprehensive approach – Care Resource Mobilization.
Care Resource Mobilization (CRM) is the optimal mobilization of available resources to engage clinicians and patients for better health, better care, and lower health care costs. There are existing resources that we can use, right now, to help that happen. Many of these resources may be unconventional, and many are available at no added cost to the health care system and are currently underutilized.
Discovering and leveraging these underutilized resources is the key to CRM. Overlooked resources can include communities, peers, families, friends. It often requires expanding the focus from just the patient to the circle of influence within which this individual dwells. Folks may be waiting in the wings ready and willing to help. They offer a resource base for everything from moral support to help with rehabilitative exercise.
Harnessing these additional resources is the reasonable and responsible thing to do. This may require changes in both clinician and patient behavior as we increasingly recognize there are areas of expertise on both sides of the exam table. Moving from the familiar paternalistic model may feel uncomfortable to all involved. Yet the complexity of medicine and the prevalence of co-morbidities has created a situation too big for clinicians to handle alone. Following the trail already blazed by aviation, we can leverage CRM in medicine to mobilize all our available resources.
The first installment of this blog explained how checklists have been readily adopted in both aviation and medicine. Adopting CRM will require broader changes in behaviors to develop a highly functioning team. This is made even more complex in medicine because we are dealing with two sets of CRM: intra-care team and care team + patient.
Whether in aviation or medicine, the focus of CRM is less on technical knowledge and skills than “cognitive and interpersonal skills needed to manage resources within an organized system. In this context, cognitive skills are defined as the mental processes used for gaining and maintaining situational awareness, for solving problems and for making decisions. Interpersonal skills are regarded as communications and a range of behavioral activities associated with teamwork.”
As mentioned, integrating CRM into medicine is going to be more challenging than it was in aviation. On the one hand, intra-care teams, like flight crews, have the advantage of common work space, training, jargon and knowledge base.
On the other hand, care team + patient does not have a common lexicon nor a common experience to build upon. They will need to “train” each other to achieve common expectations of their roles in this partnership. As is often the case, the hardest part will be getting started.
Permission and a Path
The ultimate goal of CRM in medicine, like aviation, is to have fully functional partners bringing their expertise to the situation. The realization of that goal in medicine is the Self-Mobilized Patient. A Self-Mobilized Patient feels confident they can be an active partner in making decisions about their health, carrying out those choices, and taking responsibility for their decisions.
Today, however, even if patients and physicians want to begin to work toward this goal, they may be reluctant or uncertain how to honestly and safely share their perspectives and information.
I’ve seen this in action myself. One of my work groups for a palliative care initiative included a cancer survivor and oncologist who had not previously met. When asked about their experience with palliative care discussions, the patient piped up with, “I could never ask my doctor about palliative care. I don’t want to disappoint him.” To which the oncologist remarked, “I could never talk to my patient about palliative care. They’d think I gave up.” Both of them needed permission and a path to honestly exchange information that they knew best.
Thus, the first and foremost means to access the resources available through patient self-mobilization is communication. The challenges associated with improving communication can seem immense, but so are the benefits. Aviation’s move from checklists to cockpit resource management to crew resource management was in response to the recognized need to improve flight crew communication. Changes in behavior were required by all crew members, regardless of their place in the hierarchy. This necessitated more than an intuitive leap and training was created to address the needed changes in behavior and culture. Fortunately, medicine’s Collaborative Conversation™ can play the same role.
There are many established approaches available to facilitate the other cultural and behavioral changes required for clinicians and patients. However, to maximize their effectiveness, the clinician must understand the patient’s level of engagement.
One tool that can be used to do this is the Patient Activation Measure (PAM) developed by Dr. Judith Hibbard. This tool helps clinicians understand where the patient feels they are on the continuum between needing to be passive to wanting to be an active participant in their health care. Modifying the interaction to the patient’s specific needs and abilities helps jumpstart the patient on their journey towards self-mobilization.
Once the initial level is understood, there are three broad categories of approach that make effective care resource mobilization: Patient Mobilization, Provider Mobilization, and Co-Creation. These approaches can work by themselves or in combination and vary in effectiveness depending on the patient’s level of engagement and activation.
Patient Mobilization methods include Motivational Interviewing, Shared Decision-Making and the Collaborative Conversation™ (for more details, follow the link to Collaborative Conversation™).
Provider Mobilization techniques include Practice Coaching, which helps practices improve in a variety of areas such as patient access, care coordination, team building and patient centeredness. These are areas of focus because improvement in these areas is proven to improve patient experience and outcomes. Another approach is Adaptive Leadership training, which can help clinicians recognize and take advantage of the opportunities embedded within changes in culture that occur as patients are increasingly self-mobilized.
Co-Creation melds the activation of patients into creating enhanced patient involvement. Peer coaching for chronic disease patients is one example.
At the core, all of these components need explicit permission from the experts to be part of the process. Remember there are two sets of experts involved here – clinicians and patients.
Whether it’s Crew Resource Management in aviation or Care Resource Mobilization in medicine, using all available resources on the team is a path to better outcomes. As medicine adopts this approach, it gets closer to its destination of better patient experience and population health at an affordable cost. Expediency is needed for the sake of our nation’s health and financial well-being.
But remember, CRM in aviation was introduced 30 years ago. What is aviation dealing with today and how can its failures and lessons help us face tomorrow (or should I say later today) in medicine? Part 3 will explore the next great challenge.
Read about the next great challenge in Part 3 – It’s Not Automatically OK.