We’ve all encountered them – clients who, in their optimistic perspective, feel that they don’t need any additional help or support. They are thrilled to be going home. But you’re worried. You know their well-being is a fragile state that continues to need some guidance and oversight.
So now what? How do you engage them? How do you get them to see beyond this current moment in time and know the risks that your experience tells you are out there? How do you keep them from being a readmission statistic?
Know them: Start with understanding their goals and priorities. The better you understand, the easier it will be to plug into these goals. According to Joel Theisen, CEO & Founder of Lifesprk, one of the reasons Lifesprk developed its Lifesprk Experience model was ensure that the Lifesprk team always started by first looking at the whole person and discovering individual goals, then working with the person to prioritize those goals. “When you can plug into what THEY want, and tie the steps back to helping them achieve their goals, the results are amazing,” Theisen explained.
Connect them: You need to meet people where they are and connect them to appropriate level of continuing coordination in the community. Care transitions are a great start and so are medical homes. Ensure your patients become connected to these valuable services. However, keep in mind that most care transitions, case management and medical home services are time-limited. Look also for care coordination that continues over time, one that closes all the gaps that can occur between settings and services. Check out what Minneapolis leaders have to say about care coordination in the community.
Understand their perspective, and share yours: Take a moment to look through their eyes. They are not being obstinate or defiant. They simply want to be better and as independent as possible. They want to get their life back on course, the way it was before whatever interfered with it. They count on us as professionals to share our experience and wisdom. We have an obligation to be their guide.
Outline the pros / cons: What is the risk of going home and not following the discharge plan? What might happen? What have you seen happen? And how does this impact their goals and priorities? How does this impact their loved ones and families? What does it cost? These questions can foster good dialogue to help them develop a better understanding of their situation and make a more informed choice.
Use directive language: When someone calls 911, the dispatcher doesn’t hesitate or layout three options for the caller. The dispatcher provides the direction and guidance that is needed to get the caller through the immediate situation with the best possible outcome. That doesn’t mean that the dispatcher disregards the individual or negates the caller’s right to choose. In fact, the dispatcher asks questions, listens and then responds, giving the caller clear direction on what the dispatcher feels in his or her professional opinion to be the best option for the caller.
Consider your own language in talking with clients: Is it hesitant, are you overwhelming people with too many choices, or failing to give clear direction on the best options for the client? While clients retain the right to choose, as professionals we need to fulfill our professional obligation to provide the guidance they need to make an informed choice for themselves.
Share stories and examples: Theisen often uses the story of Phil, who had been through several hospital readmissions for a wound on his foot that wouldn’t heal. The cycle kept repeating: Phil’s wound would exacerbate and he’d be hospitalized, then he’d go to a transitional care unit (TCU) and then to a Medicare Home Health program, where he’d quickly be discharged because he wasn’t homebound.
All Phil wanted to do was to go to the local VFW to socialize with his friends, and upon discharge from the TCU that is exactly what he’d do. The problem: it meant he wasn’t homebound and his wound would exacerbate and the cycle would start again. The key to stopping this cycle? According to Theisen, it was taking the time to understand Phil’s priorities. Once the importance of the VFW in Phil’s life was understood, then Lifesprk could work with him to break the cycle of readmissions, and more importantly, to help Phil live a sparked life.
Every patient is unique and requires an individualized approach, but research on patient engagement has shown that these are the essential steps for building better engagement for improved outcomes.