What is capacity coaching? And a new pilot initiative where they are trying it out!

Submitted by Kasey Boehmer, MPH

We’ve been talking with wellness coaches at Mayo Clinic a lot about the idea of “capacity coaching,” which marries some traditional elements of wellness coaching with the concepts of minimally disruptive medicine. Capacity coaches have conversations with patients that help them build capacity for both health and life, and when integrated with the care team, provide a point person for helping the team understand the current state of the patient’s workload-capacity balance. The Zablocki and Hines VAs are just kicking off a pilot in their women’s health clinics to implement the ICAN Discussion Aid in their practice for patients with diabetes or diabetes and depression and designate a member of the team as the capacity coach. I spent time discussing these ideas with Dr. Kathryn Havens of the Zablocki VA after our kickoff workshop together. Dr. Havens will have some thoughts regarding the workshop and the pilot here soon as well. More to come!

See video discussion

Pursuing Minimally Disruptive Medicine: Correlation of patient capacity with disruption from illness and healthcare-related demands

The Journal of Clinical Epidemiology published an article by Kasey R. Boehmer, MPH, Nathan D. Shippee, PhD, Timothy J. Beebe, PhD, Victor M. Montori, MD, MSc entitled Pursuing Minimally Disruptive Medicine: Correlation of patient capacity with disruption from illness and healthcare-related demands. Check it out here.

Careful and kind care, part 2: Slides & video from Maine Quality Counts By e-Patient Dave

REPOSTED with permission by e-Patient Dave

This series of posts to start 2016 is motivated by a desire to help healthcare achieve its potential. I believe that’s not possible unless we’re clear about what the potential is and clear about the challenges and obstacles.

Before moving to additional subjects, today I want to go one step deeper on Dr. Victor Montori’s concept of care that is “careful and kind.” (See Saturday’s post, if you missed it.) I have three reasons to go deeper before moving on:

  • The best care I personally have ever received (since childhood) has always been careful about how I’m feeling, and kind to me, now matter how badly I was feeling. Healthcare can be that great– it’s healthcare’s potential.
  • really, really honor the doctors and nurses who are able to blend their long professional education and clinical experience with that kind of caring – especially in the increasingly nasty financial environment they all face (at least in America) as money pressures imposed by management and insurance companies increasingly interfere with what both patients and clinicians want. All praise to these clinicians, who insist on being caring professionals regardless of the pressures.
  • It’s really, really important to understand how the principles in Saturday’s post translate into thinking about the patient’s world: the life of the individual patient, with his or her challenges. Why’s that important? Because so often health planners complain about the difficulties of patient “compliance” without thinking concretely about the challenges of doing everything right.
    • If you give anyone more work than they can handle, don’t blame the victim. That’s abusive … and besides, you’re recommending something that’s not going to work, which is a waste of breath.

In this 43 minute speech, Victor walks through the patient reality, especially what he’s discovered as a practicing physician. Note that by 1:25 in the video he lays it on the table:

I’ll put forward that the biggest challenge we have in our ability to provide care for people like Maria Luisa [the patient in slide 2] is to answer this question: “What’s best for her?”

That’s healthcare’s potential. See how it plays out in the speech video.

In a follow-up email to me about Saturday’s starter post, Dr. Montori said:

We are really obsessed with the question: What is best for me and for my family? From this question stems the others that require a joint understanding of what is the patient situation that requires action; what are the actions that are available and sensible and address the patient situation in a manner that fits their context and reflects what patients consider important and the reasons they have to value such things.

He also pointed out that the post really “didn’t do justice” to the concept. Well, yeah – one thing at a time.:-) We gotta start with the basic idea.

He continued:

For patients with chronic conditions, they have to make treatments work in their daily life. To enact those treatments they need time, attention, effort, support that normally goes to other aspects of life. So treatment competes with life for these “resources.” If the treatment work fails to note that, and life always win, then there will not be enough capacity to enact treatments and patients will be considered noncompliant, even though this is the result of OUR joint failure to design treatments that fit.

KER Treatment that Fits diagramThen, alluding to Saturday’s graphic, at right:

So we do not see much room for “doctor goals” and “patient goals”.There is the patient situation and we have to work out together how to address it. Goals are too future oriented to be real (try answering “how do you see yourself in 5 years” 5 years ago – would you see the [you] of today? I seriously doubt it). Ratherfocus on the present and see howpotential futures may play in what we need to do today. But not just in abstract but considering the challenges and opportunities of your life situation. And not just to make some tests look pretty but to really advance your situation in a manner that is meaningful to you and to your family.

To learn more about this approach – more rigorously – visit the MDM blog. “Check out the front page of that blog and you will see some additional resources including a full presentation with slides on MDM.”

(Even in its first few minutes, that’s an excellent presentation about the role of information in the conduct of care.)

Delivering – and insisting on – real care in a time of culture change

The other thing, which I think will start coming to a head in 2016, is that in addition to financial pressures, this change is full-blown culture change. As in all culture change, we as newly activated, responsible consumer-patients must raise our own consciousness about what’s important to us and what we say it would feel like to really be TAKEN CARE OF.

What stories do you have, of being well cared for or poorly cared for?  Please respond in comments.

epatient daveCancer survivor “e-Patient Dave” is an international keynote speaker on healthcare who consistently earns extraordinary ratings by understanding each audience and working closely with each client to define their unique “home run.” Audiences have ranged from the Institute for Healthcare Improvement to the Danish Patient Safety Association and the Israel Internet Society. His compelling TEDx Talk “Let Patients Help” was for years in the top half of most-watched TED talks of all time.  Visit his website at http://www.epatientdave.com.

ICAN and 4C: Complementary approaches to contextualizing care

by Saul J. Weiner

A care plan is “contextualized” when it takes into account the particular challenges a patient faces when trying to improve their health through health care.  For instance, if a patient can’t afford a particular brand name medication because they lost their health insurance, and the result is that their asthma has flared, a contextualized care plan might include switching them to a cheaper generic.  Unfortunately, all too often, physicians and the health care team do not identify the underlying contextual issues and the result is a care plan that looks good on paper, but is unlikely to work for the particular patient.  In the example of the patient with worsening asthma, above, s/he would leave the appointment with a higher dosage of a medication that is already too expensive to take.  We call such a failure to contextualize care a “contextual error.” In short, it apparently just did not occur to the doctor that their might be a contextual factor that would account for the worsening chronic condition. In a large observation study in we invited hundreds of patients to audio record their visits we found that when care is “contextualized” (meaning contextual errors are avoided) patients have better health care outcomes. In a secondary analysis of a randomized study in which we trained actors to portray patients with contextual issues and then looked at what tests and treatments doctors ordered, we also found that health care costs are lower because doctors order fewer unnecessary tests and treatments.

So, how do we promote contextualization of care? It’s helpful to compare two approaches that come at the program from different angles. Let’s consider first the Instrument for Patient Capacity Assessment (ICAN). As the authors explain, ICAN “is designed to help patients and health professionals discuss areas of the patient’s life and issues in treatment for context-centered care. It promotes consideration of the ways in which life, the pursuit of health, and health care interact. It does so by creating a conversation that: shifts the focus from the medical condition of the person to their situation in life, identifies what the person values doing and being, explores how healthcare and other resources serve or limit this person, and recognizes and cultivates opportunities to advance the person and their situation.”

Specifically, the discussion aid prompts patients with questions including “What are you doing when you’re not sitting here with me?” and “Where do you find the most joy in your life?” One could think of these as “big picture” questions that set up the conversation with a wide angle lens.  They can be a good way to begin to get to know the patient better, and that knowledge may in turn lead to contextualization of care.

Now let’s consider “4C” which stands for Content Coding for Contextualization of Care. 4C is actually a coding system designed for listening to audio recordings of provider patient encounters to assess the provider’s attention to patient context. The 4C model precisely tracks the pragmatic problem solving approach to contextualizing care in the setting of the clinic encounter. It consists of 4 consecutive steps, each with its own term: First, the clinician looks for signs that something might be going on in the patient’s life that is posing challenges for their health care.  This is called a “contextual red flag.” Going back to the asthma case above, a comment by the patient that “boy, it’s been tough since I lost my job” would be such a red flag. The mere fact of losing control of a chronic condition that was previously well controlled is a contextual red flag. Second, if a contextual red flag is present, does the provider explore it, typically by asking the patient what is going on?: “Mr. Jones, I’m sorry your asthma has recently gotten worse. Are their challenges you are facing that might account for that?” We call this step “contextual probing.” Third, in response to the probe does the patient reveal the underlying contextual issues that account for the presenting problem?: “Yes, doctor. Ever since I lost my insurance it’s been hard to afford that inhaler so I’m not taking it regularly.” That’s a “contextual factor.” And, finally, does the provider make use of the information to actually craft a contextually appropriate plan? As noted, switching the patient to a generic would count. Doing so constitutes “contextualizing care.” As illustrated, 4C tracks whether a health care provider identified a clinically relevant problem that might be du
e to a life challenge and then gone looking for that life challenge to see if it can be addressed.

How do the ICAN and 4C approaches compare? ICAN starts wide and zooms in. 4C starts by zeroing in on a problem and then zooming out.  Each has the shared aim of arriving at a plan of care that fits the individual needs, circumstances and preferences of each patient – that is, the patient’s context.

If you’d like to learn to measure the health care implications and costs of effectivelybook cover
contextualizing care, check out Listening for What Matters: Avoiding Contextual Errors in Health Care or click here, for a new book published by Oxford University Press, and released January 2016.

–Saul J. WSaul J Weiner.Photoeiner, MD is Staff Physician at Jesse Brown VA Medical Center and Professor of Medicine, Pediatrics and Medical Education at the University of Illinois at Chicago.

With acknowledgement to Kasey Boehmer for helpful feedback.

Why minimally disruptive medicine matters by Kerri Sparling

“So what happened here,” and my doctor would point to a single blood sugar from three Thursdays ago, a 243 mg/dL at 3 am.

And I wracked my brain trying to remember what happened that night. Had I changed my pump site before bed? Sometimes that causes a high afterwards. Did I eat a snack and miscalculate the insulin dose to cover it? Did I over-treat a low?  I couldn’t remember specifically what happened.  Do I make something up?  Do I lie?

I shrugged with frustration. “I think diabetes happened there.”

Type 1 diabetes doesn’t exist outside of the context of life.  I wish it did; I wish diabetes was something that existed independent of everything else in my life, making it absent the influence of variables like exercise, eating, and emotions.  But diabetes is a pervasive, persistent thread that weaves its way around every aspect of my life, from breakfast to the last thought before falling asleep at night.  It’s the preposition that dangles off of every thought – “,with diabetes” – and makes my disease a constant and necessary priority.

Minimally Disruptive Medicine makes sense as an approach for chronic illness because it flies in the face of what chronic illness attempts to do, which is to disrupt.  Diabetes is very disruptive and intrusive, so making my care approach towards the disease more streamlined and integrated creates a culture of hope, motivation, and effort.

When it comes to building a care plan with my medical team, my personalized variables need to take center stage.  Ask me what my goals are, instead of building treatment recommendations around what you think my goals should be.  Do I want an A1C that’s within ADA guidelines?  Of course.  But am I willing to achieve that goal by way of several low blood sugar events per week?  No way.  My doctor’s goal may be to improve my fasting blood sugars, while my goal might be to overcome my fear of overnight hypoglycemia.  How do we take medical guidelines and best practices and balance those within the context of my real life?

Diabetes maps differently in every single life, so personal preferences take precedence.  You recommend that I wear an insulin pump to help best control my blood sugars?  Prescribing the device is one thing, but I also need training on how to integrate this technology into my real life.  Connect me with peers who wear their insulin pumps safely and confidently at the beach, or while running, or while tending to the needs of their small child.

Show me “how” instead of telling me “why.”

Talk to me about my preferences, my goals, and my life, because that’s where my diabetes exists.  Diabetes exists around my life, not the other way around.  I don’t build my life around diabetes.  It’s not a hole in me or the whole of me.  There’s life to be found after diagnosis, and my focus remains on making the most of that life.

Kerri Sparling has been living with type 1 diabetes for over 29 years, diagnosed in 1986.  She manages her diabetes and lives her life by the mantra “Diabetes doesn’t define me, but it helps explain me.”

Kerri is a passionate advocate for all-things diabetes. She is the creator and author of Six Until Me, one of the first and most widely-read diabetes patient blogs, reaching a global audience of patients, caregivers, and industry.  Well-versed in social media and its influence on patients, Kerri presents regularly at conferences and works full-time as a writer and consultant.  Her first book, Balancing Diabetes (Spry Publishing), was released in the Spring of 2014.


Kerri and her husband, Chris, live in Rhode Island, USA with their daughter. 

Dan Abraham Healthy Living Center Introduces ICAN to Internal Medicine Residents

Submitted by Jason SoyringDAHLC-Jason

The Dan Abraham Healthy Living Center (DAHLC) hosts two residents electing to participate in the Internal Medicine Rotation at Mayo Clinic.  These residents partake in a 3 1/2 day health and wellness rotation that includes an immersive, hands-on experience into the programs and services that are available to all employees, volunteers, retirees, students, and patients eligible for membership. Not only do the residents acquire an enhanced understanding of how the facility can be leveraged to assist in improving their patients¹ health, but how they can utilize the programs and services to improve their personal health and well-being.

A respectable portion of the rotation provides an extensive look into wellness coaching and communication skills.  In addition, the residents have an opportunity to participate in 3-4 wellness coaching sessions to work on areas of change in their own lives. Again, the purpose of this experience is to allow the resident an opportunity to comprehend how wellness coaching can be of benefit to them and their patients in regards to behavior change.  The feedback around this portion of the experience has been incredibly positive thus far.

Residents are introduced to the Mayo Clinic Wellness Coaching Program¹s 5-E Model and how the different coaching concepts and communication strategies outlined in the model are used to help move clients closer to their health and wellness goals.  These strategies are also introduced in the context of a provider/patient interaction.  This is where Minimally Disruptive Medicine (MDM) and the ICAN Tool come into play. Residents are asked to create a common, but complex patient scenario to bring to one of their peer coaching sessions.  They are then asked to role play the patient and to fill out the ICAN Tool accordingly.  This activity gives the resident an opportunity to understand more deeply the pitfalls of patient capacity and the true burden of treatment and disease. 3478089_0011 Each resident plays the patient role and the provider role as part of the session.

DAHLC resident rotations are offered on an ongoing basis and will be available to Internal Medicine residents throughout 2016.

Introducing the new ICAN tool

We are excited to announce to the Minimally Disruptive Medicine community that the first tool developed to support MDM practice, ICAN, is now available for download.

ICAN is a Discussion Aid for clinicians and other health professionals to use together in visits with their patients to better understand their patients’ capacity and treatment burden. ICAN was developed using a rigorous, user-centered design process that included observations and prototyping in a range of settings with a variety of health professionals (primary care clinicians, specialists, nurses, wellness coaches, and community health workers), making its use broadly applicable. We hope you’ll visit the page (minimallydisruptivemedicine.org/ican/) to learn more about ICAN and to download the tool to try in practice.

Is Diabetes Improvement Too Complex for Patients?

Repost from Linkedin with permission from Jerry Penso

For the past year, I have been exploring strategies for diabetes care improvement with The American Medical Group Foundation (AMGF), planning our next national campaign to address this chronic disease. As a result I have had many conversations with national diabetes experts, medical group endocrinologists, primary care physicians, and quality improvement specialists. In AMGF’s first national campaign, Measure Up/Pressure Down®, we promoted systematic care delivery improvements to improve high blood pressure detection and control. With the aid of this improvement framework, teams were able to figure out what to improve, measure it, and test changes in the system to see if they made a difference. Our goal is to create the same kind of targeted improvement in the care of diabetes.

Recently, I became familiar with two AMGA members that are demonstrating outstanding performance in diabetes management: Cornerstone Healthcare, PA, in North Carolina and Geisinger Health Systems in Pennsylvania. These two health systems have achieved better quality for tens of thousands of patients with diabetes through careful workflow redesign—automating manual work, delegating duties to non-physician staff, standardizing treatment algorithms, and measuring key outcomes to report back to their physicians. These efforts have made quantifiable reductions in complications due to poorly controlled diabetes, including diabetic retinopathy, heart attacks, and strokes.

Two conversations in the past month have begun to alter my thinking about AMGF’s upcoming campaign. One was with Lorraine Stiehl, Consultant, Stiehlworks and Board Member, JDRF who is an advocate for people with diabetes and also works closely with organizations that promote patient empowerment, like diaTribe and Diabetes Hands. What struck me after talking with Ms. Stiehl was the tremendous yearning among patients for better conversations about the day-to-day existence living with diabetes. They look to their healthcare professionals for information, care, and support, yet many are not finding the current system responsive to their daily needs. So many are turning to social media in greater and greater numbers to address these unmet needs, especially emotional support.

I was also impressed by a conversation with Dr. Victor Montori, an endocrinologist who serves as director of late-stage translational research for the Mayo Clinic Center for Clinical and Translational Science. Dr. Montori is a leading proponent of minimally disruptive medicine (http://minimallydisruptivemedicine.org), an approach that seeks to advance patient goals for health, health care, and life. He emphasized the need for care teams to design interventions that respect the capacity of patients and caregivers, and systematically reduce the burden of treatment. Today’s diabetes care increasingly involves complex treatment regimens, yet these recommendations often ignore the tremendous burden this places on a patient with chronic conditions.

The question I now ponder is how we move the needle for populations of patients with diabetes, while honoring our patients’ personal needs, wishes, values, and capacity for change. We’ll want to promote systemic, standardized approaches to performance improvement because we know many patients with diabetes are not at optimal target range and are at risk for serious complications. At the same time however, we must continue to be vigilant in developing interventions that do not create undue burdens or unrealistic expectations for patients, care teams, or health systems.

Jerry Penso

Jerry Penso is Chief Medical and Quality Officer at American Medical Group Association

Debriefing the NIH Training Institute for Dissemination and Implementation Research in Health: what can minimally disruptive medicine contribute?

By Aaron Leppin

Just last week I had the privilege of attending the NIH’ 5th annual Training Institute for the Dissemination and Implementation of Research in Health (hyperlink). The objective of this program is to train and develop a cohort of researchers with expertise in promoting and evaluating processes that translate evidence into practice.

Consonant with an MDM-based approach to care, the desire of implementation science is to ensure that the safest and most effective care is delivered to patients reliably. Traditionally, this field has focused its efforts on overcoming the underuse of evidence-based interventions. We now realize, however, that many interventions are implemented in practice that are of low or no value. What has become increasingly clear to me in my own research, however, is that many interventions become less effective and/or fail to achieve their full impact as a result of the way they are implemented. This idea, termed “mis-implementation,” is related to but distinct from the misuse of medical interventions.

In 2014, Prasad and Ioannidis outlined the evidence-based rationale for “de-implementing” contradicted, unproven, and aspiring healthcare practices (Imp Sci. 2014; 9:1) (hyperlink). This paper has been well received by the implementation science community, yet no clear and actionable guidance exists for practice-based efforts to de-implement interventions or, for that matter, to avoid mis-implementation entirely.

I am struck by the collective capacity of the MDM community to guide this emerging science. How does our expertise in evidence-based medicine, over-medicalization, and implementation science coalesce in this space? I have my ideas but am interested in others. What are examples of mis-implementation that you have experienced? How were you able (or unable) to overcome these challenges? How have you de-implemented ineffective interventions?