Read & View:
Revised: Lamb & Newhouse Part II: Action Issue 1-3 pg. 31-68
Introduction to Patient Engagement & Participation.
(18min) https://youtu.be/PhdlolZ5C4E (Links to an external site.)
Patient Centered Interventions, Self-management, patient engagement.
(15min)https://youtu.be/sZ-oqsoPvws (Links to an external site.)
Motivational Interviewing Skills (30min) https://youtu.be/ZxKZaKFzgF8 (Links to an
external site.)
The SHARE Approach to SDM Essential Steps. SHARE tool 2.pdf
Download SHARE
tool 2.pdf
Shared Decision-Making in WA (2min)https://youtu.be/HWIpMBQu8Uc (Links to an
external site.)
Shared Decision Making: What it looks like and what it does not
(10min)https://youtu.be/zpZ8JgE8DZc (Links to an external site.)
Collaboration in Health Care: The Journey of an Accidental Expert?
(20min)https://youtu.be/qOV-5h0FpAo (Links to an external site.)
Interprofessional Healthcare Team Meeting (IPE)
(20min)https://youtu.be/OZWBrXql_3s (Links to an external site.)
Worksheet #3: Patient-Centered Care
1. How does HIT interoperability support care coordination within a health care
organization? (ref. HIT videos in week 4 learning materials).
2. How about between health care organizations or between Dr. A and Dr. B? (ref. HIT
videos in week 4 learning materials).
3. How does HIT interoperability influence patient engagement?
An Engaged Patient could look like this…
BT’s Story Revisited
So far, you have learned about BT’s specific disease processes and how they
interact to influence his health. You have also learned how to use a population
health lens to identify gaps in BT’s preventative health screenings, and how chronic
disease management (CDM) through routine chronic care measures are important to
long-term health. Finally, you were asked to identify social determinants of health
that may influence BT’s health.
The focus of this exercise is to help you apply care coordination principles in the
context of a patient-centered care for individual people. Engaging patients in their
own care may be complex but you can start with a few basic principles.
1. Learn about what’s important to your patient, values and beliefs about health
and health care (patient-centered care)
2. Use motivational interviewing to meet people where they are, thinking about
change or ready to jump in. What are their health goals? (ability to selfmanage illness or problems)
3. Teach people how to better manage their health and illness. What are the
skills and knowledge they need? (ability to engage in activities that
maintain functioning and reduce health declines)
4. How will success be measured? (measuring outcomes of care)
5. Who is needed to assist patients in meeting their needs and goals? (ability to
collaborate with providers)
BT’s Story Continues
Instructions: Use the course materials (readings and videos) to complete this
worksheet.
It’s been 3 years since BT has visited his Primary Care Provider (PCP).
After a recent bought of abdominal pain, BT decided to go see his PCP. At that visit,
his PCP performed an annual physical exam, reviewed BTs preventative health
screenings, and asked BT about his health goals.
BT is concerned about his abdominal pain but thinks it might be due a pattern of ‘yoyo’ dieting. One health goal that BT identified that was that his weight was troubling,
it is too high, and he wants to get it under control.
The PCP let BT know that he could work with the Care Coordination RN on a plan to
accomplish his health goals and achieve his blood pressure target. An eReferral was
placed in the EMR to the CC RN to initiate CDM for BTs hypertension and weight
loss goal.
Additionally, to get to the bottom of BTs abdominal pain, the PCP initiated a
diagnostic work-up including labs and an ultrasound.
The CC RN initiated a telehealth video visit, that goes something like this…
Who
Conversation during the video visit
Motivational Interviewing
Techniques
CC RN
“Hi, BT! It is good to see you!”
Greet the patient
BT
“Good to see you too.”
CC RN
“Thank you for agreeing to meet with me
today. Tell me more about why we are
meeting.”
BT
“Well, I have had some abdominal pain
Patient expresses his
recently and I’ve lost about 5 pounds each
concerns.
week. I am still about 100 pounds overweight
though.”
CC RN
“Ok, how would you like to spend our time
together today?”
Ask open-ended
questions
“I’m watching what I eat because I know the
last time I was here, my PCP told me I was
Get the whole story
BT
Shared understanding
overweight and I wanted to ask your opinion
about weight loss programs too.”
CC RN
“OK, we can definitely talk more about diet
and weight loss. Is there anything else you
would like to talk about?”
Summarize what you
heard so far and ask
again.
BT
“No, I think that’s everything!”
Shared Agenda
Who
Conversation during the video visit
CC RN “OK. I have a concern to add to our
conversation as well. Would that be OK? I
want to talk about a trend I noticed with your
blood pressure. So where should we start?”
BT
Motivational Interviewing
Techniques
Asking permission is
respectful and further
engages the patient
despite the sensitive
topic. Finally, the patient
is given the option to
prioritize the agenda.
“Well, my weight is out of control! So let’s start
there. You mentioned my blood pressure, and
I think it is a problem because I know that my
weight might also make my blood pressure go
up.”
CC RN “What do you understand about how your
weight affects your health?”
Ask an open-ended
question that elicits the
patient’s perspective.
“I know how important it is for me to lose
CC RNs are trained to
weight, but nothing I have tried has worked for listen for problems and
long!”
may hear “nothing
worked.” Instead, focus
on the importance of
CC RN “Ok, continue.”
weight loss.
BT
BT
“I know my weight makes my blood pressure
go up too. It is so frustrating that I cannot get
this under control.”
“I can see how challenging this is for you. You
CC RN understand a lot about how weight is related
This response again
indicates that the patient
understands the
importance of weight
loss, and the idea of
gaining control is raised
by the patient.
to your health, and you really want to be in
more control. Would it be OK if we talk about
some ways that we could work together on
this?”
BT
“I would really appreciate that!”
CC RN “You have been successful at losing weight in
the past, right? What has worked for you
before?”
BT
“Well, I lost weight a few times just by eating
fewer carbs. I was able to do a lot more
walking on the treadmill at the gym. But then
my job started to get more physically
demanding and I thought that would be
enough to keep my weight down. I am
frustrated that I seem to gain weight at the
drop of a hat. I really need to get my weight
down and be healthier so I can spend quality
time with my wife.”
CC RN “OK, let me recap what I think I heard. When
your job started to get physically demanding,
you slowed down your activities and the
weight came back. Until then, you were able
to lose weight several times by cutting back
on bread and pasta. You found you had more
energy and were able to go to the gym more
often. Did I get that right?”
“Being more fit and active for your wife is
really important to you!”
BT
Yes, it really is! I must do something. I have
lost weight before, it’s just hard to exercise
because of my job.
CC RN “Yes, you did a great job changing your diet
and increasing your activity. Would it help if
Empathize with the
patient’s struggle. Don’t
jump in with suggestions
or advice, but rather
seek partnership with
the patient to move
forward.
Asking the patient to
discuss a past success
is one way to discover
patient strengths.
Besides describing what
worked in the past, the
patient may also tell you
what caused weight loss
to stop.
Summarize what you’ve
heard. Emphasize what
worked, acknowledging
that the patient was
frustrated when the
weight loss stopped and
that healthier weight
appears to be important
to him. This shows that
you have been listening,
summarizes the reasons
for change, and
highlights past success.
Notice that this summary
ended on the weight loss
benefits that BT
described. Patients most
often will respond to
what they hear last.
Change talk, sustain
talk.
we talk about how some of my other patients
stay active?”
BT
Acknowledge the
patient’s sustain talk, but
move the conversation
forward by beginning
“Ask-Tell-Ask.”
“I have heard about tai chi but have never
tried it. I used to like to swim but the gym I go
to closed the pool. I like to walk, though I can’t Exploration, sustain talk,
seem to find the time. I want to figure this
change talk.
out!”
CC RN “OK, it sounds as though you have some
options to think about. That’s great! If it is OK
with you, we can talk more about the
specifics.”
Co-create an action plan
for weight loss
4. Does BT seem motivated for a health behavior change? How do you know? ______
______________________________________________________________________
______________________________________________________________________
5. After reading the script, which stage of behavior change do you think BT is in and
how do you know?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________.
6. What knowledge and skills does BT need to better manage his weight? (there may
be many answers to choose from. Go back to worksheet #1 and use your answers
as a guide.)
Knowledge
Skills
7. Which members of the health care team do you think need to be consulted, if any?
Who?
What for?
8. What information should the CC RN document in the EMR so that all members of
the health care team have an understanding of the BT health goals?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________.
*Please note: For some of these questions there could be multiple answers. Just
do your best to answer the questions by using BT’s story in the first worksheet
and your nursing experience.

Purchase answer to see full
attachment