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Individualizing Patient Care

Written By : Joe Casciani

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The older adult population in the U.S. is exploding. Since 2010, over 10,000 people began turning 65 every day in the U.S. Though we are living longer, there is a growing incidence of mental and physical disorders in this population, along with a shortage of professional and paraprofessional geriatric workers.

According to the Centers for Disease Control, 133 million people have one or more chronic medical conditions in the US, such as diabetes or hypertension. Furthermore, 80% of the $1.4 trillion price tag for treating these chronic conditions (direct and indirect costs) are for those not institutionalized. The remaining 20% of the cost goes for those treated in hospitals and nursing homes. Compounding this high incidence chronic disease is the fact that depression is co-morbid in 30% to 50% of these conditions, a factor that complicates the patient’s management of the chronic disease.

Shortage of Geriatric WorkforceHelping the Disabled

There is a severe shortage of trained health care professionals to meet the current demands of the rapidly growing older adult population. The American Hospital Association reports that over 100,000 vacancies currently exist for nurses in the U.S. and the University of Pennsylvania reported that an additional 30,000 nurses will be needed annually to meet the expected needs, 30% more than are now graduating. The geriatric physician numbers are similar: the Alliance for Aging Research reports that the number of geriatricians will need to increase fivefold, from 7,100 to 36,000 by 2030. As for paraprofessionals, the Family Caregiver Alliance reports that caregivers are present in 1 in every 5 households in the US, and over 80% of these caregivers are family members.

These are staggering figures. If these estimates prove to be even close to accurate, the demand for caregivers will clearly outpace the supply of trained personnel in the very near future, an event that could reach crisis proportions. In addition to the myriad training and education initiatives underway to offset these workforce shortages, however, we must consider a different tack: individualize the care that older adults receive and foster a patient-driven model of care. In other words, decrease the demands on the health care system by adjusting our approaches and mobilizing new resources, including the patient himself.

What Does Individualized Care Look Like?

Individualizing care means a number of adjustments from the usual approaches. First, expect the patient to assume more responsibility for his or her own physical and emotional well being, and to adopt more of a self-care mindset. What we will see when this occurs is more older adults saying, “I’m responsible for my health” and fewer people looking to their health care providers for all answers, all direction, and all fixes. The patient can then become engaged in problem solving, and is much more inclined to change health risk behavior patterns when he sees himself as part of the solution.

In order for this shift to greater self-care to occur, however, a second task is necessary, and this involves training caregivers on basic two-way communication with their patients. Unilateral communication, characterized by one-way direction and instruction, and often with an authoritative tone, leaves patients feeling uninformed, and uninvolved in the management of their own condition. A study published in the Annals of Emergency Medicine (July, 2008) reported that 78% of the patients discharged from emergency rooms did not understand either their diagnosis, their treatment, their at-home care, or the warning signs of when to return to the hospital. Communication improvements also will touch on the inter-disciplinary teamwork process, and the inherent need for all members of the team to have equal voices, and say when important needs of the patient are being missed or minimized.

The “teach back” method addresses the health literacy barrier by asking patients to repeat what they heard about their condition and treatment recommendations back to their provider to confirm that they have the right information. Changes in informed consent have made them more understandable, written at a 6th grade level, and explaining things until they are fully understood. Also, physicians’ practice of informing patients about their diagnosis has a way to go; the Journal of the American Geriatrics Society (March, 2008), reported that about half of the MD’s studied were not telling patients their diagnoses. Unfortunately, the desire to protect the patients from the realities of their condition also deprives them of the opportunity to make informed decisions about what to do next.

Understanding Patients’ Uniqueness

The third step to individualized care is to understand patients’ uniqueness, and what traits they bring to the caregiving relationship. These include their values, attitudes about health care and health care providers, and the cultural sensitivities that impact their care. Though most people acknowledge that there will be increases in the older adult population, less well known is the fact that these increases will come primarily in ethnic minority groups, including African-American, American Indian, Asians, and Hispanics, two to four times faster than in Caucasians. This puts a premium on greater cultural awareness and competence for all health care providers.

Resistance to Care

The fourth necessary adjustment for more individualized care is to better understand non-compliant patients, the reasons for non-compliance, and approaches to overcoming it. Reasons for resistance range from emotional and personality factors, like fear, distrust, limited coping ability, and limited control over one’s environment to misunderstanding, misinterpretation, and limited cognitive ability.

Overcoming this resistance to treatment is one of the central ingredients in individualized patient care. Demonstrating understanding and empathy are essential, but even more important is an acceptance of the patient’s views, whether we agree or not. Without this understanding and acceptance, the desire to comply with the treatment plan or to change health risk behaviors never becomes internally-directed, and externally-directed behavior tends to be temporary. And, lastly, understanding non-compliance means considering the patient’s belief and confidence in the ability to change, also known as self-efficacy, and is a pretty good measure of how much he is on board with greater self-care.

Conclusion

Taken together, these four steps to individualize the care of older adult patients can greatly affect the individual, and greatly impact the health care system. By mobilizing the patient’s interest in his own treatment, better informing him of what his condition is all about, and understanding his unique outlook and resistances to treatment, we gain another, very important ally in the geriatric workforce, the patient himself.

Filed under: Geriatric Care

Written By :

Joseph M. Casciani, PhD, is the founder and President of Concept Healthcare and CoHealth Psychology Services.

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