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.

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