Patient-Centered Care: A paradigm shift or old wine in new bottle?
1Associate Professor, 2Professor, 3Professor and Head, Department of Community Medicine, Kamineni Institute of Medical Sciences, Narketpally, Nalgonda District, Telangana State, India.
Patient-centered care is gaining increasing importance during recent years and has emerged as one of the key objectives of health care systems.1 Unfortunately, the concept has not achieved centre stage in Indian health scenario that comprise of a not-very-efficient public health system, and profit-driven private heath sector.2 It is being felt that physician-centered care is not assessing patients concerns and beliefs to influence their treatment. Social determinants of the disease are being ignored and the science is eclipsing the art.
Patients are reporting significant problems like gaining access to critical information, understanding treatment options, getting explanations regarding medications, and receiving responsive, compassionate service from their caregivers.
These gaps between health provider and health consumers have negative influences on treatment compliance, costs and outcomes.3 This article attempts to introduce the subject for introspection by medical fraternity, and discussions in boardrooms of corporate healthcare facilities.
Patient-centered care has been defined as ‘Health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.4 Studies have shown that orienting health care around the preferences and needs of patients has the potential to improve patients’ satisfaction, as well as their clinical outcomes. Patient-centered care has also been shown to reduce both underuse and overuse of medical services. The approach, in addition renders the healthcare more affordable,5 an issue of considerable significance in India where 29.5% (Rangarajan Committee Report, 2014) of population is surviving with incomes below ‘poverty cut off’, and 85.9% (World Bank Report for 2011-2015) of medical expenditure is out-of-pocket.
What Patient-centered Care is Not?
Confusion about what patient-centered care really means, may lead to actions that are superficial and unconvincing. In the name of patient centeredness, hospitals have been adopting models used by hospitality industry with greeters, greenery, and gadgetry. Although such amenities might enhance the patient’s experience, they do not necessarily achieve the goals of patient-centered care. Calls for patient centered care have often emphasized the implementation of infrastructural changes. These changes, such as electronic health records and advanced access scheduling, may be necessary to move medical care into the 21st century, but they should not be conflated with achieving patient centered care. Simply implementing an electronic health record in itself is not patient centered unless it strengthens the patient clinician relationship, promotes communication about things that matter, helps patients know more about their health, and facilitates their involvement in their own care.1
Key Components of Patient-centered Care
Patients are increasingly asking to be partners in their care. A patient-centered health care system can help achieve that partnership in a variety of ways. Multiple models and frameworks6-8 have been developed for describing patient-centered care, with many overlapping elements. The British Columbia Patient-Centered Care Framework is one of the models and is shown in Fig 1.
Factors Contributing to Patient-centered Care
Shaller9 through interviews and literature review identified seven key factors that contribute to patient-centered care at the organization level. These are- leadership, strategic vision, involvement of patients and families at multiple levels, care for the caregivers through a supportive work environment, systematic measurement and feedback, quality of the built or physical environment, and supportive technology. Although all are vital, the most important factor contributing to patient-centered care, whether in the hospital or in the ambulatory care setting, was the commitment and engagement of senior leadership. The organizational transformation required to actually achieve the sustained delivery of patient-centered care does not happen without top leadership support and participation. In the words of one observer, “There is no chance to succeed without it, and maybe not even with it.”
Barriers and Concerns regarding Patient-Centered Care.
Although leaders in health professions are advocating patient centeredness there remain several barriers in implementing a patient-centered care policy. Lack of clear understanding of patient-centered care, shortage of staff, absence of good teaching models and curricula on patient-centered care and dominance of biomedical model in healthcare have been identified as important barriers in progress towards its implementation.10
Concerns have been raised that patient-centered care, with its focus on individual and family needs, might be at odds with evidence-based medicine approach (EBM), which tends to focus on populations. Fortunately, that debate has been laid to rest, and proponents of EBM now accept that a good outcome must be defined in terms of what is meaningful and valuable to the individual patient.1
Fig1: The British Columbia Patient-Centered Care Framework6
It's been also being debated that patients in low- and middle-income countries may not prefer patient centered approach, especially in rural settings, and therefore, its universal adoption may not be wise. It should be appreciated that patient centered does not mean sharing all information and decisions about the disease. In actual, it means patients desire for information and sharing in decision making with an appropriate response.11 It also dictates that social determinants of the disease and economic consequences of disease management on individuals and families are factored in the ‘decision making’.
Is Patient-centered Care a Healthcare Evolution?
Patients and families have been central to practice of family medicine. Family physician has always been regarded as friend-philosopher-guide to individuals and families. The significance of that clinical practice culture is being re-recognized as it is increasingly being felt that direct sub-specialty based medical care at tertiary care facilities is technically inappropriate, geographically lopsided, culturally insensitive, fragmentized (organ-system based) and financially catastrophic. Is patient centered care a revisit to the time-tested, affordable, acceptable, and cost-effective traditions of family care? The authors feel that patient-centered care is much more than extension of principles of family care. It incorporates involvement of patients at all levels of healthcare i.e. primary, secondary and tertiary; both in public and private sector for all health-related activities. It also involves appropriate modification in medical education, biomedical research, public health policies and legislations, healthcare quality assessment and evaluation. It is an approach that considers patients as a whole person with biological, psychological and social needs. Respect, compassion, concern, shared decision making and communication are seen as basic elements of patient centered care. It is an attempt to reunite ‘the art and science’ of medicine in 21st century for the benefit of mankind.
- Epstein RM, Street RL. The Values and Value of Patient-Centered Care. Ann Fam Med 2011;9(2):100-3.
- Baruah MP, Kalra B, Kalra S. Patient centered approach in endocrinology: From introspection to action. Indiana J Endocr Metab 2012;16:679-81.
- Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The impact of Patient-Centered Care on Outcomes. J Fam Pract 2000: 49: 796-804
- Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC; National Academic Press,2001.
- Bertakis KD, Azari R. Patient-Centered Care is Associated with Decreased Health Care Utilization. J Am Board Fam Med 2011; 24:229-39.
- The British Columbia Patient-Centered Care Framework. Available at www.health.gov.bc.ca/library/publications/year/2015_a/pt-centered-care-framework.pdf
- Frampton S, Guastello S, Brady C, Hale M, Horowitz S, Smith SB et al. Patient-Centered Care Improvement Guide. Planttree Picker Institute, Camden 2008. Available at www.plantree.org/wp-content/ uploads/ 2015/03Patient-Centered-Care-Improvement-Guide-10.10.08.pdf
- Embracing Core Principles of Patient- and Family-Centered Care: Canada Updates Accreditation Standards. Institute for Patients and Family-Centered Care. Available at ipfcc.org
- Shaller D. Patient-Centered Care: What does it take? Shaller consulting 2007. Available at www.commonwealthfund.org/usr_doc/Shaller_patient-centered carewhatdo
- Pelzang R. Time to learn: understanding patient-centered care. Br J Nurs. 2010;19:912-7
- Anjum Q. Patient centered care - Evolution and Challenge. J Pak Med Assoc 2014;64(6):611-612