Helping patients improve their health-related behaviors: what system changes do we need?

A large gap separates actual clinical outcomes of patients with chronic disease from optimal outcomes. This gap may be attributable to physician problems (physicians unaware of practice guidelines), patient problems (patients who choose not to follow medical advice) or system problems (physicians lack time to assist patients in managing their chronic condition). A goal for chronic illness care is to assist people with chronic conditions to become informed, activated patients. Patients who are informed and activated (activated = participating in health-related decisions) have better health-related behaviors and clinical outcomes. Primary care is often conducted within a 15-minute, multi-agenda visit between physician and patient. Such a structure has led to (1) patients being inadequately informed about their chronic conditions and (2) patients being passive recipients of medical advice rather than active participants in medical decisions. The result has been poorly informed, passive patients. This situation constitutes a system problem. Three redesign elements have the potential to address this system problem: (1) Pre-activating patients prior to the clinical visit appears to encourage more active patients and--in one study--improved clinical outcomes. (2) Planned visits, with a care manager spending time with patients, individually or in groups, providing education and medical management, have been shown to improve clinical outcomes. (3) Regular sustained follow-up, by face-to-face visits, telephone, or electronic means, is associated with healthier behaviors. Not all patients receiving disease management through redesigned primary care will adopt healthier behaviors because many factors outside the medical care system influence personal choices. However, until the medical care system regularly offers adequate information and encourages collaborative decision-making, it is improper to place the responsibility for unhealthy behaviors onto patients.