Engage Patients / Enhance Experience

Improving Patient Engagement and Experience
Patient experience and patient engagement are closely related. Patient engagement is essential to achieving improved health outcomes, better patient care and lower costs. By including patients and caregivers in collaborative, team-based decisions, home based care organizations can increase adherence and improve patient experience. Patient engagement impacts the effectiveness of patient education, one of the core interventions used by home health. Important to home health agencies, patient-centered care is an important priority to CMS and other payers. The CAHPS survey captures measure of patient experience, and is publicly reported in Hospice Compare and Home Health Compare, as well as in Home Health Star Ratings.

Use these links to navigate between sections of this module:

Patient Engagement

Patient engagement is a crucial aspect of self-management, education effectiveness, and experience. Engagement begins with communication based on an understanding of literacy, principles of adult learning and information sharing. Once the provider understands how the patient/caregiver learns and what motivates the patient to learn, patient education can be targeted most effectively. Care providers can support engagement and patient participation through use of motivational interviewing, dignity, respect and collaboration. Patient engagement is increased when the organization ensures that the patient has a positive experience with the home health organization and care providers. Positive patient experience increases trust in the provider, and thus an increased willingness to collaborate on the treatment plan.
Elements of engagement include:  

  • Self-management: the ability to manage symptoms, treatment, lifestyle changes, and psychosocial, cultural and spiritual consequence of health conditions (HHQI, 2012).
  • Patient Activation: the ability and willingness to take on the role of managing their own health and health care (Hubbard and Cunningham, 2008). Motivational interviewing and coaching, health literacy, appropriate materials/instruction and adult learning principles are strategies that contribute to accomplishing the goal of patient engagement and activation. A confidence ruler or other activation tool can assess the patient’s readiness to take action.

Best Practice Recommendations

Goal: Engage and activate patients /caregivers in self-management learning by addressing their learning needs and goals
Best Practice Interventions

  • Assess and address health literacy. Offer a variety of learning tools that may include written material, videos or online information such as YouTube, or graphic information.
  • Provide patient with appropriate materials based on level of education. Fourth grade level is recommended for basic understanding.
  • Communicate with both patients and family/caregivers using teachback techniques 
  • Use appropriate, consistent teaching materials
  • Use coaching to support patient engagement and self-management
  • Train staff in empathetic listening and motivational interviewing
  • Develop patient-centered goals based on the principles of motivational interviewing
  • Use a confidence ruler to measure patient readiness and take steps to increase readiness/activation
  • See Resources and Tools sections for models of these tools and strategies

Patient Self-Management Education

Relevant Medicare Measures:
  • No measures but education impacts all other outcomes and CAHPS scores
Patient and caregiver education is a critical element of every home based-care episode. Education can help the patient with self-management, and to understand what actions to take in the event of exacerbations or emergencies. Education starts with an assessment of the patient/caregiver's learning style and needs. Motivational interviewing and teachback techniques are used to personalize the education, confirm patient and caregiver understanding, and assess activation level. Self-management education should address recognition of signs that the condition may be worsening. Agencies should help patients and caregivers identify and manage changes in the patient’s condition and recognize the “red flags” that indicate potential deterioration. 
Goal: Using adult learning principles and motivational techniques, while targeting patients' priority issues
Best Practice Interventions:
  • Assess and document patient language, health literacy, and learning style. For learning style ask how the patient prefers to get information
  • Identify personal and specific patient priorities - for example, the patietn may want to get well enough to attend a family event or to be comfortable watching TV
  • Once staff have elicited patient priorities and goals for their care,  use these in motivational discussions highlighting incremental steps the patient/caregiver can take for activation
  • Train all staff on the importance of communication and patient engagement (self-management/activation).
  • Use technology to assist in patient education – including videos, internet sources, games, etc.
  • Use symptom exacerbation/red flag lists as part of the comprehensive plan of care. (Find examples in the 'Tools' section)
  • Embed red flag identification in processes, provide tools and plan and measure success
Goal: Help patients/caregivers manage their care and confidently understand what to do if they have problems.
Best Practice Interventions:
  • Work with the patient and caregivers to develop an at-home care plan that includes red flags, an Emergency Plan and self-management strategies to prevent exacerbations
  • Complete an individualized red flag document at admission for every patient. Teach the patient to identify condition-specific red flags
  • Personalize patient educational material by reviewing it with the patient and documenting patient specific goals
  • Have patient teach back goals and / or document them and post in the patient home
  • Identify tools to enhance patients' self-management and communication skills with the home health agency and physician
  • Use ‘Zone’ or ‘stoplight’ tools that illustrate patient actions for various clinical scenarios and document physician-ordered parameters
  • Develop an emergency plan in written or other format and have the patient or caregiver describe what they will do in various clinical scenarios.  Post the plan prominently in the residence
  • Educate staff to educate patients to call VNA office “Call home care first”
  • Post lists and agency contact information in patient's residence or facility

Patient Experience

Relevant Medicare Measures - Home Health:
  • Care of patients 
  • Communication between providers and patient
  • Specific care issues
  • Overall rating of care provided by the home health agency 
Hospice CAHPS to be Publicly Reported in 2018

The patient's experience with home health and hospice influences multiple metrics captured in Home Health  and Hospice Compare. Every aspect of an agency must be directed to creating a positive experience for the patient and his/her caregivers. Patients who trust their providers may be more likely to contact the provider before making a trip to the hospital, and may be more motivated to adhere to a treatment plan. 
Top Tip: Make it an ‘always event’ to ask about the patient’s personal goal for each specific visit: “what can I do for you today?”
Goal: Use continuous quality improvement to provide excellent customer service
Best Practice Interventions
  • Strengthen customer service program to manage areas that most commonly have adverse impact on patient experience: scheduling, schedule changes, phone response, complaint response, changes in staffing
  • Designate an agency lead for customer service issues
  • Provide customer service training at staff meetings, and as an aspect of all trainings
  • Add customer service to orientation of all staff to stress importance
  • Survey patients on their experience with care during the episode to proactively identify issues
  • Make a routine call to every patient 1-2 weeks after admission to assess experience and make corrections
  • Make an outbound call to the patient when any issue develops or any complaint identified by staff or patient
  • Adopt routine follow up phone call to patients who reported a concern to ensure that concern is resolved
  • Implement continuous customer service improvement on phone coverage/schedulers
Goal: Provide patient-centered home care that addresses patient identified goals
Best Practice Interventions:
  • Establish agency-wide ‘always events’ related to identifying the patient’s goals and responding to them each visit
  • Ask about patient patient-specific goals in each of the measure areas covered in Star Ratings; leave documentation of the goals in the home so that patients will remember the home-based care intervention
  • Provide dynamic staff education on problem solving difficult patients: scripting, role playing
  • Have clinicians preview survey with patients and caregivers using a laminated survey
  • Using teach back to provide evidence of patient/caregiver understanding of plan of care, visit schedules
Recommended Resource: 
CAHPS Experience of Care Inventory of Improvement Activities (not home health or hospice specific)

ElevatingHome Best Practice to Enhance Home Care Customer Experience / Satisfaction Measures
  • Provide staff education and training about patient experience, reports and influencers of satisfaction
  • Make a welcome phone call to each new patient 24 hours before start of care
  • Make a management telephone check in with patient within the first 2 weeks of care, to ensure satisfaction with quality of care
  • Provide an in-home agency branded calendar on which the case manager writes the visit schedule for each discipline and posts it on the refrigerator
  • Have professional staff call to confirm before visiting
  • Develop weekly/monthly measurement reports: team/clinician measures reviewed with supervisors “critical for improvement”
  • Spotlight positive stories of staff actions and positive feedback
  • Recognize the very low margin for error in home care - correct negative patient experiences
  • From the Visiting Nurse Associations of New England (VNANE) - strategy based on Press Ganey’s “The Banner Story: Improving Home Care Patient Satisfaction to Stay Ahead in a Competitive Market
Recommended Resource: 
Page updated August 2019