Patient Engagement Tip of the Month

People often leave the clinician’s office without asking any questions. Some people think it’s not their place to ask questions, that the doctor would be insulted or doesn’t have time to answer them. Others go blank when a clinician asks, “Do you have any questions?” – only to think of many later on.

As one patient, Bill Lee, explained: “Some patients are reluctant to ask questions. I used to be like that myself. A doctor would tell me something and I’d say, ‘Okay, thanks.’”

After 7 heart attacks, Lee found a new doctor and started asking questions. Before he saw a doctor, he would make a list of his questions.

        “When I ask questions, I’m more likely to follow through with the advice from the doctor.”

Despite his history of heart attacks and diabetes, Lee said he felt better than he ever had. “If I hadn’t started to ask my doctors questions, I honestly think I would be dead today.”

Research confirms people are more likely to get accurate diagnoses and have better outcomes when they ask questions and communicate clearly with their healthcare team.

Inviting people to ask questions
Making people feel okay about asking questions is easier said than done. Patients and families can find clinicians intimidating even when they’re friendly. Coming from different cultural backgrounds and speaking different languages can also inhibit question asking. Furthermore, people may worry that their clinician will think they’re stupid if they ask questions.

Beyond asking people if they have questions, how do we invite and encourage them to ask?
One resource is in the AHRQ Health Literacy Universal Precautions Toolkit; it is called Encourage Questions. It suggests clinicians should invite questions verbally and with body language and involve office staff in encouraging questions as well.

Another strategy is to help people organize questions and other information ahead of time. AHRQ’s Question Builder helps people create a list of questions to take with them. And now a free Question Builder mobile app is available on the App Store and Google Play. The app lets people save their questions in an email or as a calendar appointment that allows for note taking during medical visits.

The app also integrates with a smartphone’s camera. People can snap a photo of important visual information such as an insurance card, a pill bottle, or a skin rash.

The app helps people formulate good questions.
It suggests key questions relevant to the type of appointment or issue they wish to discuss:

• Health problems
• Getting or changing a medication
• A medical test
• An upcoming procedure or surgery

For example, a suggested question many people may not think to ask or feel uncomfortable asking is:

        What will happen if I choose to not have treatment?

These suggested questions help normalize questions people may be afraid to ask. Seeing a question as part of a standardized list helps them know it’s okay to ask this question.

The app also helps people prepare to answer common questions their clinician may have for them based on the reason for their visit.

Mobile apps won’t solve the complex challenges of healthcare, but AHRQ’s Question Builder app is a free and simple way to help people overcome their hesitancy to ask questions and participate in their care.



Cindy Brach is a Senior Health Care Researcher at the U.S. Agency for Healthcare Research and Quality (AHRQ). She’s is the Co-Chair of the Department of Health and Human Services Health Literacy Workgroup.

Geri Lynn Baumblatt MA, For the last 20 years, Geri has worked to help people understand health conditions and procedures, orient them to their diagnoses, make more informed decisions about their care, and partner with their care teams.  She oversaw the creation of the Emmi program library, and she regularly speaks and serves on patient engagement, patient experience, health literacy, shared decision making, health design, family caregiving, and heath communication panels for organizations like AHRQ, the Brookings Institute, Stanford Medicine X, and the Center for Plain Language. She serves on the editorial board for the Journal of Patient Experience, is on the board of the Society for Participatory Medicine, and published a chapter in Transformative Healthcare Practice through Patient Engagement (IGI Global). She currently consults on patient engagement, family caregiving, and health communication. Follow her on Twitter @GeriLynn
 

• In a health system, ask about the availability of health educators to support you.
• In a private practice, when thinking about new roles, consider a health educator or those with a public health background when creating job descriptions.

By Geri Lynn Baumblatt & Chris Heddon

With all the efforts to communicate better with patients— do you ever wonder if they can hear you? Not metaphorically, but literally.

Hearing is a baseline essential for engaging in care and navigating the healthcare system, but how often do we take it for granted that patients can hear what we say?

Only about 15% of people who need hearing aids have them. We also tend to assume hearing is only an issue for seniors. But over 60% of people with hearing loss are under age 65. And while cost is an issue, so is diagnosis and awareness of the other problems it contributes to.

Right now, many people nod along and didn’t quite hear what you said about their medication or follow-up care. They’re embarrassed. Or they think they understood enough and want to move the conversation along, especially if they know you’re pressed for time.

Picking Up on Signs of Hearing Loss

The exam room is usually quiet, so in that setting it may be hard to pick up on hearing loss that isn’t profound. Some clues:

• Are they having issues with balance and falls? People with a mild (25-decibel) hearing loss are 3 times more likely to have a history of falling. And every10-decibel loss increased the chances of falling by 1.4 fold. So addressing hearing can be a 2-for and map help prevent falls. (Lin, et al, 2012)
• Do they have trouble hearing you when you’re facing away from them? Even if they can’t lip read, people often supplement auditory information with visual clues.
• Do they ask fewer questions? They may stop asking if they won't be able to make out the answer.
• Do they seem less social or more withdrawn? People often stop going to social gatherings and restaurants when they can’t hear well enough to follow or join conversations.

It’s no wonder hearing loss is associated with social isolation in older adults, which also contributes to health problems. Untreated hearing loss is also associated with cognitive decline and diseases of isolation, so higher rates of depression, anxiety, and other psychosocial disorders.

With the health risks piling up, why isn’t screening more common?

One issue is recognition. Too many seniors and families may see it as “just part of aging.” But there’s also social stigma. People are both embarrassed they may have a disability, and they’re often in denial as a result. It often takes 7 to 10 years from the time that someone first realizes that they have hearing loss to the time that they first get a hearing aid.

Helping people adapt to hearing aids

Once people get diagnosed and fitted for hearing aids, there are still challenges. Even though hearing aids are now smaller and less noticeable, people still need to adapt to them. It’s important to encourage people to wear them every day for a month. This helps people get used to a new and more “digital” hearing experience. And it gives their brain a chance to remodel around this new information input. Unfortunately, many hearing aids end up in a dresser drawer or returned because people don’t give their brain a chance to acclimate. So follow-up to find out if they’re being used.

Only when people can hear well can they be part of the conversation.

For more, also check out this brief interview about best practices when talking to someone with hearing loss.

Chris Heddon, DO is a physician-entrepreneur. He began his career as an anesthesiologist. After years of progressive hearing loss, he left medicine to found Resonance Medical, which developed a clinically validated, artificially intelligent, mobile-based hearing test that was sold to a hearing aid manufacturer in November 2018. @hearresonance

Geri Lynn Baumblatt MA, For the last 20 years, Geri has worked to help people understand health conditions and procedures, orient them to their diagnoses, make more informed decisions about their care, and partner with their care teams.  She oversaw the creation of the Emmi program library, and she regularly speaks and serves on patient engagement, patient experience, health literacy, shared decision making, health design, family caregiving, and heath communication panels for organizations like AHRQ, the Brookings Institute, Stanford Medicine X, and the Center for Plain Language. She serves on the editorial board for the Journal of Patient Experience, is on the board of the Society for Participatory Medicine, and published a chapter in Transformative Healthcare Practice through Patient Engagement (IGI Global). She currently consults on patient engagement, family caregiving, and health communication. Follow her on Twitter @GeriLynn

Non-Emergency Medical Transportation: A new opportunity for patient engagement

A core challenge health systems and services providers face in patient engagement is attention. Thinking about one’s health care proactively requires thinking about one’s mortality, and who wants to do that?
 
Consequently, most patient engagement and patient experience centers around the few moments when people are required to think about their health: medical appointments, hospitalizations, discharges, and pharmacy visits.
 
Lately, a new touchpoint in the care journey is emerging as an important opportunity to build patient experience and drive greater patient engagement: non-emergency medical transport (NEMT). NEMT is any transportation service for people who aren’t in an emergency situation, but who need more assistance than a taxi service provides. It is a fast-growing segment in the healthcare workflow, where stakeholders can capture the attention of the patient or family member while they are already thinking about their care.

The recent entrance of Lyft and Uber into healthcare, Ford Motors’ GoRide, as well as several venture backed startups such as Circulation Health and RoundTrip provide solutions for the over 3.6M Americans who miss at least one medical appointment each year. The annual cost of missed appointments in the U.S. is $150B (including lost revenues and idle labor). And the Centers for Medicare and Medicaid Services (CMS) will begin to reimburse NEMT for medicare advantage beneficiaries. This new touchpoint in the healthcare experience is here to stay.
 
There are 3 NEMT opportunities for engagement:
 
1. Scheduling
If stakeholders are able to solve transportation for the patient during appointment scheduling and reminders, the focus of outreach can shift to preparation. Scheduling can transform a neutral process to a positive one, with patients able to focus more on their care. Hospitals could take information from the medical record and send SMS or email reminders along with tailored questions for patients to consider as they get ready for their upcoming appointment. 
 
2. The Departing Trip
The ride itself is a valuable, defined window of opportunity to provide patients with information about their condition, community resource information via their own app, or utilize the NEMT provider app. During the trip, patients and family members could interact with chatbots, or take a call with a healthcare professional to provide basic information to make the appointment more productive, or enable hospital labor to be more effective during the appointment. For example, Circulation is currently rolling out pilots to prove the effectiveness of healthcare engagement during transportation. Patients are a captive audience during these trips, presenting stakeholders with the opportunity to engage them with important healthcare information such as pre- and post-visit data, or content to promote vaccine awareness.
 
3. The Return Trip
The NEMT ride back from an appointment may present an even greater patient engagement opportunity than the ride there.  During this time, patients are in a mindset to reflect, and could digitally record or answer any questions people have. They could review their care plan and go over next steps. After all, how many times have you thought of a really important question after you have left the doctor?
 
Challenges
NEMT is not free of challenges when it comes to engagement. It requires coordinating multiple stakeholders, whether it’s the health system, the NEMT provider, or even the driver, to make the experience work. When it comes to drivers, NEMT requires training a new labor force of transportation drivers that are prepared to provide not just a ride-sharing experience, but a healthcare experience.
 
Creating an effective NEMT patient engagement experience requires both a time and capital investment with results that must be quantified. However, NEMT presents a rare opportunity to create new experiences, and gain valuable information and access from patients while they are in transit.

Geri Lynn Baumblatt MA, For the last 20 years, Geri has worked to help people understand health conditions and procedures, orient them to their diagnoses, make more informed decisions about their care, and partner with their care teams.  She oversaw the creation of the Emmi program library, and she regularly speaks and serves on patient engagement, patient experience, health literacy, shared decision making, health design, family caregiving, and heath communication panels for organizations like AHRQ, the Brookings Institute, Stanford Medicine X, and the Center for Plain Language. She serves on the editorial board for the Journal of Patient Experience, is on the board of the Society for Participatory Medicine, and published a chapter in Transformative Healthcare Practice through Patient Engagement (IGI Global). She currently consults on patient engagement, family caregiving, and health communication. Follow her on Twitter @GeriLynn

 
Dhruv Vasishtha is a healthcare technologist with experience in early stage mobile, wearable, and AI technology. His experience includes strategy and product management at healthcare companies including Medidata and ZS Associates, as well as founding two health IT startups. He received his MBA from The Wharton School in Health Care Management, and his BA from Columbia University.  He currently invests in and advises healthcare technology startups and is organizing the inaugural Innovation in Caregiving conference. @dvasishtha

Co-author: Kerry O’Connell, a construction executive from Denver, CO

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