Karen Tallman

The Active Client: Therapy as Self-Help

A model of how therapy works is proposed that locates the source of therapeutic change in the client, while the therapist is the provider of opportunities, ideas, and experiences. Ultimately all therapy is self-help. This model is contrasted with the medical-like model of therapy as treatment and hopes to account for research findings of equal effectiveness among different therapies. Although the active client model developed from existential-humanistic ideas, it can be compatible with all approaches.

Understanding panel management: a comparative study of an emerging approach to population care.

CONTEXT Panel management is an innovative approach for population care that is tightly linked with primary care. This approach, which is spreading rapidly across Kaiser Permanente, represents an important shift in population-care structure and emphasis, but its potential and implications have not been previously studied. OBJECTIVE To inform the ongoing spread of panel management by providing an early understanding of its impact on patients, physicians, and staff and to identify barriers and facilitators. DESIGN Qualitative studies at four sites, including patient focus groups, physician and staff interviews, and direct observation. FINDINGS Panel management allows primary care physicians to use dedicated time to direct proactive care for their patients, uses staff support to conduct outreach, and leverages new panel-based information technology tools. Patients reported appreciating the panel management outreach, although some also reported coordination issues. Two of four study sites seemed to provide a more coordinated patient experience of care; factors common to these sites included longer maturation of their panel management programs and a more circumscribed role for outreach staff. Some physicians reported tension in the approachs implementation: All believed that panel management improved care for their patients but many also expressed feeling that the approach added more tasks to their already busy days. Challenges yet to be fully addressed include providing program oversight to monitor for safe and reliable coordination of care and incorporation of self-management support. CONCLUSION Subsequent spread of panel management should be informed by these lessons and findings from early adopters and should include continued monitoring of the impact of this rapidly developing approach on quality, patient satisfaction, primary care sustainability, and cost.

Communication Practices of Physicians With High Patient-Satisfaction Ratings

How do primary care physicians with outstanding patient-satisfaction ratings communicate with their patients? Which specific practices distinguish them from less effective communicators on the basis of measured performance? To answer this question, we videotaped 92 adult primary care visits in Southern California and Hawaii and interviewed both physicians and patients separately. Each participating physician and patient viewed the tapes of the visit and shared their perceptions of the communication aspects of the visit. We also audiotaped these debriefing sessions. To identify successful physician communication practices, exam room visit behaviors and comments from the postvisit debriefs were coded and compared with each physicians panel-level patient satisfaction. In the final section, we describe communication strategies reported by physicians with high patient-satisfaction ratings. The quality of physician-patient communication in primary care visits is related to patient satisfaction,1 adherence,2,3 litigation,4 quality of data collection,5 utilization patterns, and clinical outcomes.6 There is evidence that communications between physicians and patients are sometimes inadequate.7–9 In addition, disruptive communications reduce the quality of worklife for physicians. Thus, improvement in physician communication skills has great potential for both the quality of medical care and for the physician work environment.

Living with advanced illness: longitudinal study of patient, family, and caregiver needs.

BACKGROUND AND OBJECTIVES Inpatient palliative care (IPC) consults are associated with improved quality of care and less intensive utilization. However, little is known about how the needs of patients with advanced illness and the needs of their families and caregivers evolve or how effectively those needs are addressed. The objectives of this study were 1) to summarize findings in the literature about the needs of patients with advanced illness and the needs of their families and caregivers; 2) to identify the primary needs of patients, families, and caregivers across the continuum of care from their vantage point; and 3) to learn how IPC teams affect the care experience. METHODS We used a longitudinal, video-ethnographic approach to observe and to interview 12 patients and their families before, during, and after an IPC consult at 3 urban medical centers. Additional interviews took place up to 12 months after discharge. RESULTS Five patient/family/caregiver needs were important to all family units. IPC teams responded effectively to a variety of needs that were not met in the hospital, but some postdischarge needs, beyond the scope of IPC or health care coverage, were not completely met. CONCLUSION Findings built upon the needs identified in the literature. The longitudinal approach highlighted changes in needs of patients, families, and caregivers in response to emerging medical and nonmedical developments, from their perspective. Areas for improvement include clear, integrated communications in the hospital and coordinated, comprehensive postdischarge support for patients not under hospice care and for their caregivers.

Practical Steps for Practice Transfer: The Four A's of Adoption.

• Journals and internal Web sites of white papers, conference sessions, quality briefings, etc. However, one person learning about a practice isn’t enough. The next step is building awareness among a group of people. In the past few years, in order to encourage people at KP to bring successful practices and ideas back to their regions, many KP conference and meeting organizers are incorporating tools to help people share information back home. This work is being supported by regional and local sponsors who are setting the expectation that conference/meeting participants share successful practices with others in their region upon their return. When information is gathered at a conference or peer meeting, the important next steps are: • Hold meetings to describe the practice and answer questions • Share written materials and eviPractical Steps for Practice Transfer: The Four A’s of Adoption

C-B3-02: Doctors? Role in Their Patient?s Healing: Practices of the Highest Performing Physicians by Patient Survey.

Background and Aims: The MD-Patient Communication Study aims were the best practice communication behaviors of physicians during outpatient clinic visits; and to collect physician perspectives of communication behaviors. Researchers have consistently found the top predictors of overall patient satisfaction are quality of the physician-patient relationship and contributing communications. There is limited understanding however, of the range of specific behaviors in the interaction associated with positive and negative patient perceptions and reactions. Methods: In phase 1, we conducted a naturalistic, observational study of fifty-five, Permanente Primary Care physician-patient visits using videotape recordings, and incorporating patient and physician reactions to the tape. The physicians, who practiced in Los Angeles and Honolulu, spanned the three strata of high, medium, and low historical patient satisfaction scores. In phase 2, a standardized six-question set was posed, in semi-structured, 60-minute interviews, to 77 of the highest-performing physicians on this patient survey, including: 20 of the highest performers (top 5%) from the LA and Honolulu groups; and 42 and 15, respectively, of the highest performing physicians in Portland and Oakland. These interviews were audio taped with permission, transcribed and coded for patterns. Results: This abstract addresses the 4th question: “What role do you feel you play in your patients’ healing? Do you think you, as a doctor, contribute to your patients’ healing through nontechnical, non-physical, or non-scientific ways?” All physicians agreed but varied in their role. Representative quotes: “Giving people the confidence to go through something.” “People feel better coming in and seeing/talking to you.” “People realizing they have the power to heal themselves–their involvement is essential.” “Our relationship: interpersonal connection is so powerful.” “The art of medicine is the art of healing.” These narratives provide deep, coherent learning about physicians’ role in healing: relationship, education, empowerment, emotion, personal connection, hope. Conclusions: With primary care in crisis nationally, and specialists increasingly procedure-focused, understanding physicians’ role in patients’ healing, especially as it creates high patient satisfaction, is of great importance to sustaining the highest quality medical care and service.

Stealing shamelessly: practice transfer success factors.

Organizational leaders might expect that once a successful practice is identified, the practice will be quickly adopted within the organization. However, practice dissemination within firms can require 27 months, even in organizations committed to transferring successful practices.1