I have been a delinquent weblog writer.  And tonight I would like to catch you up.  Since my last entry in October, I have turned 50 year old; hosted the IHI Technical Assistance Site Visit Team of Maureen Bisgnano, Jim Reinersten and Andrea Kabcnell.  They brought along Alan Goldstein, a Group Health Cooperative cardiologist as well.  We have applied for a grant through Connecting Communities: an E-Health Initiative, and we are in the process of speaking with patients who receive the services of a Clinical Care Specialist about ways they think we can sustain and spread the services without additional positions/funding.

Additionally we have talked with patients/community members about what patient-centered care is and how they yearn to be a full partner in their care and what aspects of connection with their doctors and clinic staff invite them into the process. As a result of their feedback, we are improving the patient centered care experience survey for the clinics.  This includes feedback from the clinics, too...so that the information is meaningful and they can take action to improve it.

Data to prove our work has value and is making a difference is not easily available as we have such disconnected data systems across the community...however, we have identified the % of patients receiving the services of a clinical care specialist that prevented hospitalizations, an office visit, ER visit and found and corrected medication errors.  We used conservative estimates of these cost avoidance efforts and estimate we have possibly saved $368,215. And that was for 69 patients only. 

We are being asked by community members when they can have a shared care plan...we are connecting with the Volunteer Resources in the community who are interested in providing people to help support others in starting their own shared care plan.  We have connected with community assets such as the Technical College to begin dialogue about including training for nursing staff on the patient-centered model and use of the shared care plan as well as conversations with the University Wellness Program.  The City of Bellingham and Ferndale School District is interested in spreading the use of the shared care plan to employees and students.  A small trial is underway. 

At times progress seems slow..there is no big bang in transformation, subtle shifts occur that are the result of conversations occuring on the local, regional and national levels.  There is a yearning for a new way and an impatience and despair with the old.  Change is sought and resisted in the same moment within the same individual...much as a person with a chronic condition bargains and denies there is a need to change, yet knows change must come to move toward a healthier outcome.   Others read about what we do, call for information and amid the many questions- I hear an unspoken question...does it work...will it make a difference....what proof do we have this is the "right" way. 

I wonder did the pioneers, pilgrams, native americans moving to new lands or embracing new ways to respond to changes in the environment want to see proof before moving toward a desired state or destination...did they wait for all the maps to have specific roads drawn, miles calculated, gas stations/way stations identified before they began the journey?  I think not, I think they had a vision, they created teams/partnerships that worked and were forgiving and forged ahead.  Sometimes supplies ran low...both in terms of resources and resilience....yet they moved on...adjusted their course with new information and insights...sometimes they had to partner with others different from themselves to move to a new understanding. 

The other thing they did is look around at those on the journey, and stop to be grateful for how far they had come and to celebrate those who came along.  I had the opportunity to celebrate with patients who have come along with us by listening to their stories.  I heard through their own experiences how they were enriched by the experience, more self-confident and willing to pitch in and assist not only in their own health but to connect with others.  The community assets are people:  they have many titles, they come from many walks of life...but they are resourceful, dedicated, connected and caring.  Together within a community, the change will occur...outside of the clinics, hospitals and inside.the walls of institutions- everywhere..we must notice the value and riches that are right here and cultivate the will to continue learning and exploring the roles and contributions each one of us will make to build a new way of providing and being in service to each other. 

I am grateful to have the opportunity to participate in this journey.

Today, we spent some time with the Boston University Evaluators hired by Robert Wood Johnson Foundation.  Their job is to evaluate and learn from our transformational experience in Pursuing Perfection.  They asked us:  How will we sustain the effort beyond the initial funding...in light of the expectation that RWJF will reduce support signficantly in Phase 3.  Our answer was we weren't sure...the path was not clear before us.  No payers were coming to the table, offerring money and resources for a newly designed set of services aimed at preventing complications and the high costs of complications.  I wonder if it was difficult to people to get on the ships to sail to the New World?  How many had to be asked before a few signed on....

And I thought not just about financial sustainability but also what we would do to sustain the spirit and heart of what we are doing.  That truly is the challenge.   If we cannot capture the hearts and minds of a community, how will we maintain the intent/vision of a perfect healthcare system?  If we rely only on healthcare professionals in isolation from the larger community...we will not transform the system.  We need a space where everyone contributes to the whole and understands their role in promoting health and managing the challenges of chronic illness.  Patients and family members need to be invited and welcomed in to the help create those solutions.  We live in a community and we need the community to be partners who can lead the way.  When we have engaged others outside healthcare, I have been amazed at their resourceful, creative ideas and very mindful of the costs.  They want to be part of the solution.

As we talk about sustainability, we need to consider both...it will take both heart and money to truly transform a system.  As a community we have so much to gain...

I had a bad river-rafting trip once.  Actually, it was my last river rafting trip and it took place a few years ago on the McKenzie River, near Eugene, Oregon.  I'd been on that river before with a trusted friend and skilled river guide.  This time the person directing the raft was someone else with less skill and less judgment.  Have I mentioned that I am a proponent of teamwork?

To make a long story short, the climax of the trip was getting caught in Brown's Hole.  Picture this... three desperate mice clinging onto an inflated soap dish in a washing machine set in the spin cycle.  I think you get the drift... While we did provide some captivating, and apparently humorous entertainment to some kids standing on the near-by boulders, my only though at the time was... well, I actually had two thoughts - "I'm going to die"; and "How do I get out of this situation?".  Creativity went the way of the broken paddle.  We were clinging onto our increasingly damaged raft with all our might, throwing ourselves from side to side, trying to stabilize things.  Apparently, the river tired of us, and the next thing I knew, we were ejected out of the hole (and out of the raft).  In the brief moment before hitting the water, I remember thinking one thing, OK, two things... "Iâm going to die", and "Hang onto the raft."   When I surfaced in the VERY COLD water, I realized that I had listened to my second thought and came up hanging onto a rope attached to the raft.  If I hadn't been so scared, and so cold, this could have been a thrilling ride. When I related the story to my sons later, they were almost envious.  All I can say is thank goodness for lifejackets.

Obviously, I lived to tell the story... but the memory popped into my head tonight for some reason, and I reflected that sometimes working in health care feels a little like being in that raft in Brown's Hole... spinning around and around, and being tossed from side to side, desperately trying to hold on.  In these types of situations, creativity is abruptly replaced with an intense focus on survival. 

In his book, "The Consultant's Journey"  Roger Harrison, makes the point that organizations are so inundated with non-stop change, and people are so change weary, that what is needed instead of change agents are "facilitators of healing".  I think he makes a good point.  What I'm realizing once again is the incredible importance of relationship building in any change effort.  Relationship building and breathing.  We need to find ways to acknowledge and appreciate each other and breathe and reflect upon the work that is being done.  These things seem like luxuries sometimes, but they are just as essential as efficient processes.

 

 

Charon's description of the use of narrative in her medical practice  is registering with some thinking I've been doing lately.  I've been wondering what truly transformed medical practice looks like for the patient, the family, and the health care clinicians.  It has seemed to me that time for the patient's story is an integral part of this practice.

 I'm recalling working with Dr. Andrew Elliott, ND, a physician in Eugene, Oregon. This man has been one of my greatest teachers in the field of healthcare.  One thing that was integral part of Dr. Elliott's practice was listening compassionately, non judgmentally and intently to patient's stories.  Being a classical homeopath, gleaning the small details about symptoms, reactions, even states of mind was an essential part of his effective practice.  Andrew's compassionate and quiet listening approach almost always drew out very complete pictures of the patient's current state and also built a trusting relationship.  Part of the reason he was able to do this (and still does, in a thriving practice), is that he also respected and cared for his own physical, mental, and spiritual needs.

So how does a practice with established production demands take the time to listen to patients' stories? Isn't part of efficiency, trying to get just what you need out of a patient to make an accurate diagnosis, and move on to the next patient as quickly as possible?  How does one balance this with taking a comprehensive approach to patient care?

I certainly don't have the answers and I've never practiced medicine.  I keep coming back to the wisdom of another teacher:  David Cooperrider at Case Western University. http://connection.cwru.edu/ai/ David's quote, "We are made and imagined in each other's eyes." comes to me at least once a day.  

When I reflect upon my experience as a patient, I realize what matters more to me than the amount of time spent with me in the exam room, is how present the care provider is. Is she/he really there - really listening?  And, what are they doing with their judgments?  How is this person's belief about me impact how they imagine me, their presence with me, and, my response or reaction.    How does the image I hold about my care providers impact my presence and response to them?  How can we really see each other?

  Once my medical record got confused with someone else's at an office.  The other patient has a very complicated and challenging social history.  The assistant , thinking I was actually someone else, approached with an aura of suspicion, caution and judgment.  It wasn't until she began asking me questions that didn't make sense, that we identified the source of the confusion and her demeanor changed entirely.  As she shifted in her approach, my defenses began to drop and my responsiveness to her shifted back to what is normal for me.

So, it seems to me, if we believe that patient stories are a vital part of healing care, then we must help ourselves be in a state of mind in which patients feel comfortable sharing them.  Self awareness can help here.. recognizing one's own internal reactions,  keeping our intent and desire towards healing at the foremost of our approach, and therefore enhance our responsiveness.   And, remember healers need to take care of themselves, too!