Last week, the Dartmouth Atlas Project published its report “Improving Patient Decision-Making in Health Care,” and pointed to the disparity of existing practices in the way decisions were made affecting patient care across the country. The challenge that provider decisions were more influential than patient preferences, in determining what care was provided, is a dilemma of historical proportions that apparently isn’t going away anytime soon.
Patients often lack sufficient information to effectively participate in care decisions. Often, the medical condition limits a patient’s ability to do so. And sometimes, patients relinquish all decisions for their health and welfare to the provider with blind trust expecting the best. While guidance is provided by professional organizations to use patient decision aids (i.e., brochures, videos, DVDs or Web-based interactive programs) to help patients understand their condition, treatment options and the potential benefits and risks of various care decisions; clinicians pressed for time, productivity or financial incentives too often do not make this a priority. “It takes too long” is often the cited reason for not doing the right thing and documenting that the patient has been informed and should not be interpreted as agreement with the goal. Without adequate information, patients are unable to make decisions and establish treatment goals.
The healthcare venue of IRFs, although not cited in this study, is not immune to these accusations. While IRFs do not perform surgeries, for which there are alternatives, IRF providers may impose their bias for patient outcome in many of the decisions made in the interest of good patient care. Deciding to admit or not admit based solely upon payer criteria, or denying a patient discharge to home with simple statements of being “unsafe,” should be questioned as being patient centric. Educating the patient and family to maximize the patient’s self efficacy is the business of rehab, perhaps more so than the 3Hour Rule. Without this education, patients are unable to make decisions and achieve treatment goals.
Somewhere in the transformation of healthcare, policy makers must realize that the work of an IRF provider is more than preparing a patient for discharge to the community and transferring the burden of care to the family. Identifying and achieving individual patient goals of self-efficacy and preparing each patient and family for these responsibilities are primary. The patient’s preference in this pursuit is not to be assumed by the clinician, but rather queried, documented and communicated as the primary objective for the care delivery process. With chronic illness impairing the physical function of one half of all adults (Wu SY, Green A. Projection of chronic illness prevalence and cost inflation. Santa Monica, CA: RAND Health; 2000.), the appropriateness of rehabilitation hospitalization must be assured. The ability to return patients to living in community settings is important, but the attainment of individual self-efficacy goals must be the preference of every patient admitted. IRF providers must ensure that these goals are primary to the patient’s interest and all decisions are fundamental to realizing these goals.
The percent of patients achieving self-efficacy goals may by a good metric for IRF quality in the new post acute care continuum.