CDC - Centers for Disease Control and Prevention  NIDDK - National Institute of Diabetes and Digestive and Kidney Diseases

NDEP is a partnership of the National Institutes of Health, the Centers for Disease Control and Prevention, and more than 200 public and private organizations.

Dimensions of Patient-Centered Care

Patient centered care is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions. [2] Collaborative diabetes management, with the patient as the key player, can improve communication and encourage shared decision-making, thus increasing the likelihood that the patient will succeed in self-care. [2]

Shared decision-making

Shared decision-making enables patients to make informed choices. It helps patients understand what is known and not known about the health outcomes that matter to them. Patients' values and preferences play an important role in the decision-making. This approach is counter to a paternalistic role of physicians as sole decision makers. To better involve patients, download: I Wish I had Asked that! A Worksheet for Patients

Patient-centered care differs significantly from provider-centered care where clinicians operate from their own agenda and tell patients to do behaviors to meet goals that the clinicians believe are in their best interests. This approach is not conducive to success with a chronic disease such as diabetes. [3] The U.S. Institute of Medicine's Quality Chasm report introduced the following seven dimensions of patient-centered care as they relate to people with diabetes. [2]

  1. Respect for patients' values, preferences, and expressed needs

    Patient-centered care responds to patients' needs, wants, and preferences and allows opportunities for patients to be informed and involved in medical decision-making. It is customized care and incorporates cross-cultural sensitivity. Because patient preferences may change over time, shared decision making is a dynamic process, changing as patients and circumstances change. Patients are better able to attain and sustain positive outcomes when they are active participants in their own care. Patient preferences may conflict with best practice guidelines. [4] [6]

  2. Coordination and integration of care

    Coordination of care takes on special importance for a chronic disease such as diabetes where a small or large health care team may be involved in patient care and education. Most patients depend on the health care team to coordinate services and ensure that the patient and all team members have accurate and timely information available as needed. For more information, please visit our section on Team-Based Care.

  3. Information and communication
    Information

    With respect to their health, most people want to know:

    • What is wrong or how to stay well
    • What is likely to happen and how it will affect them
    • What can be done to change or manage their prognosis

    They need answers that are accurate in a language they understand. [2]

    Communication

    The quality of communication during a patient/physician visit can positively influence patient health outcomes such as emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level), pain control, and adherence. [7] Yet it has been estimated that physicians interrupt patients within 23 seconds as they try to explain their problems. [8]

    An effective strategy to begin an office visit is to simply start with an open ended question like "What would you like to accomplish in the visit?" or "What issues, concerns or questions would you like to address before you leave today?"

    An awareness of, and appropriate responses to, cultural differences can improve the effectiveness of patient-provider relationships. Health care systems need to accommodate varying patient preferences and encourage patients to actively participate in their own disease management. [2]

    Stories can be powerful tools for healthcare communication. Inviting patients to tell their story to the clinician can be critical for patients’ participation in shared decision-making. Click here for more on using stories in healthcare communication.

    Developing the four habits (invest in the beginning, elicit the patient’s perspective, demonstrate empathy, and invest in the end) can help clinicians get the most out of clinical encounters. [9]

  4. Patient Education

    For people with diabetes, there is much for them to understand about diabetes, its long-term management, the prevention or management of complications, and how to maintain or improve their quality of life. As a result of patient empowerment and education, patient behaviors may change and lead to improved A1C, blood pressure, lipids, or weight, reduced medication needs, and lower use of health care services. [10] [12]

    For more information, see Provide Patient Education and Support.

  5. Physical comfort

    Patient-centered care requires attention to physical comfort and involves timely, tailored, and expert management of symptoms related to discomfort. People with diabetes may encounter physical discomfort associated with insulin injections, self-monitoring of blood glucose, medication side effects, hypoglycemia, hyperglycemia, and the conditions related to the numerous chronic complications of diabetes and co-morbidities.

  6. Emotional support — relieving fear and anxiety

    Screen for depression
    Click here to download the Patient Health Questionnaire PHQ-2 and PHQ-9 plus scoring instructions.

    Suffering involves more than physical pain and distressing symptoms; it also encompasses emotional and spiritual dimensions. Patient-centered care attends to the anxiety that accompanies the diagnosis of diabetes and living with the fear of disfigurement, disability, financial impact, and effect of one's family associated with vision loss, kidney failure, amputation, heart attack, stroke, and other diabetes complications.

    Depression is two times more prevalent in people with diabetes than in those without diabetes. [13] In samples of people with type 1 and type 2 diabetes, glycemic control and diabetes complications were each significantly associated with depression. [14]

    The Patient Health Questionnaire (PHQ-9) is a nine-item depression assessment tool. The first two questions, known as the PHQ-2, have been validated as a screening tool and are regularly administered to high-risk groups (e.g., those with chronic illnesses, those with a history of depression). [15]

    Click here for more tools to assess and manage depression.

    The DAWN (Diabetes Attitudes Wishes and Needs) collaborative program promotes patient-centered initiatives and best practices worldwide to help people with diabetes overcome psychosocial barriers to effective self-management and improve their quality of life. [16] For example, administer the Problem Areas In Diabetes Questionnaire to identify the diabetes problems a patient is experiencing.

  7. Involvement of family and friends

    Patient-centered care accommodates family and friends on whom patients may rely, involves them as appropriate in decision making, supports them as caregivers, makes them welcome and comfortable in the care delivery setting, and recognizes their needs and contributions. Cultural differences need to be recognized and appropriate accommodations adopted.

    For more information, see Build Cultural Competency.

References

1. Gabbay RA, Bailit MH, Mauger DT, Wagner EH, Siminerio L: Multipayer patient-centered medical home implementation guided by the chronic care model. Jt Comm J Qual Patient Saf 2011; 37(6): 265-73.

2. Committee on Quality of Health Care in America: Crossing the Quality Chasm: A New Health System for the 21st Century: The National Academies Press, Washington, DC, 2001.

3. Funnell MM, Anderson RM: Empowerment and self-management of diabetes. Clinical Diabetes 2004; 22(3): 123-127.

4. Detsky AS: What patients really want from health care. Jama; 306(22): 2500-1.

5. Polonsky WH, Skinner TC: Perceived treatment efficacy: an overlooked opportunity in diabetes care. Clinical Diabetes 2010; 28(2).

6. Groopman J, Hartzbard P: Your medical mind: how to decide what is right for you. New York: Penguin Press, 2011.

7. Stewart MA: Effective physician-patient communication and health outcomes: a review. Cmaj 1995; 152(9): 1423-33.

8. Marvel MK, Epstein RM, Flowers K, Beckman HB: Soliciting the patient's agenda: have we improved? Jama 1999; 281(3): 283-7.

9. Stein T, Frankel RM, Krupat E. Enhancing clinician communication skills in a large healthcare organization: A longitudinal case study. Patient Educ Couns. 2005;58(1):4-12.

10. Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH: Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann Behav Med 2002; 24(2): 80-7.

11. Robbins JM, Thatcher GE, Webb DA, Valdmanis VG: Nutritionist visits, diabetes classes, and hospitalization rates and charges: the Urban Diabetes Study. Diabetes Care 2008; 31(4): 655-60.

12. Duncan I, Birkmeyer C, Coughlin S, Li QE, Sherr D, Boren S: Assessing the value of diabetes education. Diabetes Educ 2009; 35(5): 752-60.

13. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ: The prevalence of comorbid depression in adults with diabetes: A meta- analysis. Diabetes Care 2001; 24(6): 1069-78.

14. de Groot M, Lustman PJ: Depression among African-Americans with diabetes: a dearth of studies. Diabetes Care 2001; 24(2): 407-8.

15. Kroenke K, Spitzer RL, Williams JB: The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care 2003; 41(11): 1284-92.

16. Alberti G: The DAWN (Diabetes Attitudes, Wishes and Needs) Study. Practical Diabetes International 2002; 19(22-24a).