Patient preferences: it’s not all that bad.
The Medicare and Medicaid Conditions of Participation (CoP) Final Rule regulatory changes place the patient in the “driver’s seat” in directing their care. On the flip side, the new approach places an obligation on patients to participate.
There is ample regulatory guidance available. There should be. This has been years in the making. Please see the attached summary of regulatory guidance. I’ve read the “War and Peace” version from the Centers for Medicare & Medicaid Services (CMS). This summary beautifully captures what’s necessary to know.
Even though every patient gets a discharge needs evaluation, most patients return home without case management intervention. Deducing patient preferences, therefore, includes all clinical staff. The logic in the CoP is that proper preparation for discharge, wherever that may be, hinges on understanding patient expectations for their recovery.
It starts with questions and ends with listening.
The regulatory guidance makes it clear that patient satisfaction, preparation for success after discharge, readmissions being avoided, and a clear understanding of the treatment patients receive is the objective. Understanding what a patient expects out of the hospital stay has real value in forming a treatment plan. Improved outcomes are a reasonable expectation.
This can be as straightforward as asking for a preferred name, code status, who can come visit, who is to help make decisions, and whether there is a preferred arm to start an IV. If a request cannot be accommodated, explain why an alternative is preferable. At every point, the staff and providers should communicate what will happen and why. If there are choices, outline them.
And leaving against medical advice? It’s another way of expressing preferences – not simply stupidity.
Here are some suggestions to add to the initial interview:
- What has your doctor told you about why you are here?
- What has your doctor said to you about how long you would be here?
- What do you expect to happen during the stay? What have you been told?
- Who is your primary care provider, and when did you see him or her last?
- I see you were in the ED a few days back, and frequently in the last two months, including an admission. What can you tell me about this?
- Do you have any questions?
- Is there anything else I can do for you?
These do not directly go to preferences. They do open the door to discussion. It is remarkable what patients will tell you.
When asked what they see happening, given choices (and an explanation, when choices do not exist), the patient is in control, in the driver’s seat. Being more in control leads to increased satisfaction and adherence to a prescribed regimen.
Nothing here is new. What is mandated is something we could and should be doing anyway.