Types of Engagement Strategies to Engage High-Risk Patients in VA

Abstract

Background

Many healthcare systems seek to improve care for complex high-risk patients, but engaging such patients to actively participate in their healthcare can be challenging.

Objective

To identify and describe types of patient engagement strategies reported as successfully deployed by providers/teams and experienced by patients in a Veterans Health Administration (VA) intensive primary care (IPC) pilot program.

Methods

We conducted semi-structured qualitative telephone interviews with 29 VA IPC staff (e.g., physicians, nurses, psychologists) and 51 patients who had at least four IPC team encounters. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach.

Results

The engagement strategies successfully deployed by the IPC providers/teams could be considered either more “facilitative,” i.e., facilitated by and dependent on staff actions, or more “self-sustaining,” i.e., taught to patients, thus cultivating their ongoing patient self-care. Facilitative strategies revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health. Self-sustaining strategies were oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. When patients described their experiences with the “facilitative” strategies, many discussed positive proximal outcomes (e.g., increased access to healthcare providers). Self-sustaining strategies led to positive (self-reported) longer-term clinical outcomes, such as behavior change.

Conclusion

We identified two categories of strategies for successfully engaging complex, high-risk patients: facilitative and self-sustaining. Intensive primary care program leaders may consider thoughtfully building “self-sustaining” engagement strategies into program development. Future research can confirm their effectiveness in improving health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-023-08336-8.

INTRODUCTION

The quest to improve health outcomes and reduce healthcare costs among patients with high unmet needs and at the highest risk of adverse outcomes (“high-risk”) has led to a growth of intensive primary care (IPC) programs in recent years.^1–7 Typical features of IPC programs include interdisciplinary teams, motivational interviewing or health coaching, co-attending appointments with patients to facilitate care coordination, and increased access to healthcare providers, and a key goal usually includes getting patients more actively involved and engaged in their own healthcare.⁴ Patient engagement, in fact, is seen by some IPC program staff to be more potent outcome to define success in caring for complex patients than reducing costs or utilization.⁷

The Agency for Healthcare Research and Quality (AHRQ) defines patient engagement as “a set of behaviors by patients, family members, and health professionals and a set of organizational policies and procedures that foster both the inclusion of patients and family members as active members of the health care team and collaborative partnerships with providers and provider organizations”.^8,9 Over the past few decades, interventions seeking to increase patient engagement more generally (not population-specific) have highlighted strategies including personalized patient information, motivational interviewing, health coaching, question prompts, self-management education and support, incorporating patient feedback, and communication training for health professionals.¹⁰ Despite the IPC’s emphasis on patient engagement, however, it remains somewhat challenging.^3,4,11 Reported obstacles to patient engagement for high-risk patients are diverse and include challenges related to patients’ co-morbid mental health conditions, functional limitations, and socioeconomic factors, as well as care fragmentation and difficulties with patient-provider communication.^4,12

There is a growing number of frameworks that categorize domains, activities, and/or strategies for patient engagement for IPC patients.^8,9,13–16 For example, “key ingredients” staff perceive as important while caring for socially complex patients include team cohesion, flexible care delivery, addressing both clinical and psychosocial patient needs, and staying connected to patients through chaotic periods.⁷ Others differentiate engagement strategies based on how they provide services to support communication and use of services, activities for fostering trust and relationships with staff, and counseling.⁴

There is a dearth of research describing how high-need patients in IPC programs experience and respond to specific engagement strategies and, crucially, how certain strategies may result in sustained self-care. A recognized stumbling block to engaging patients with high unmet needs lies not only in initiating engagement, but also with maintaining engagement, i.e., keeping patients actively engaged in their own healthcare.¹¹ As such, a gap remains in the literature regarding the types of engagement strategies that may be more closely linked to patients’ ability to maintain long-term engagement and behavior change.

Such information could prove useful in planning for implementation of IPC programs, planning for patients’ graduation from IPC programs, or prioritizing the types of engagement strategies that patient-centered medical home (PCMH) teams can incorporate when caring for patients with complex needs.¹⁷

The Veterans Health Administration (VA) piloted and evaluated IPC as part of their PCMH care to improve services for high-risk patients^2,18 and offers an ideal setting in which to evaluate the types of engagement strategies deployed and experienced as successful. We conducted a qualitative analysis of both the patient’s and the provider/team member’s experiences as part of the larger VA IPC program evaluation.

METHODS

Setting

In 2013, the VA Office of Primary Care Services piloted an IPC program at five demonstration sites in five geographically distinct locations for high-risk and high-need patients, i.e., those with an average of seven chronic conditions,^2,18 who were in the top 10% of risk for 90-day hospitalizations with at least one hospitalization or emergency department visit in the prior 6 months.¹⁸ Patients had access to an interdisciplinary care team that delivered either all or a combination of the following services: home visits, comprehensive assessments, care coordination, chronic disease management, individualized health coaching, case management, social services, pharmaceutical services, and advanced care planning.^2,4 The demonstration was evaluated using a mixed-methods approach to assess the implementation and effectiveness of the program.¹⁸ This evaluation was conducted under the VA Office of Primary Care as a quality improvement activity.^19,20

Study Design and Participants

We conducted qualitative interviews with IPC team members from March to September 2015 and interviews with enrolled patients from February to August 2016, 3 years into implementation.

IPC Team Members

The sampling frame consisted of the IPC staff at the five sites. All team leads and program coordinators were selected. When a site had more than one member in the same role,²¹ one was randomly selected. Individuals who declined were replaced by another randomly selected person of the same profession. Thirty-five potential participants received invitation emails, with up to three follow-up attempts by telephone or email. Of the 35 team members who were contacted, only one refused, while five were not eligible to participate (e.g., on extended leave, or no longer on the IPC team).

IPC Patients

We selected patients from among those who had been assigned to the intervention sites (n = 200 per site) who had at minimum four encounters with the IPC team, with at least one encounter in the month prior to the interview. Twenty patients at each site were mailed invitation letters, with a project team member following up and scheduling those who were interested. Patients were excluded if they could not be reached after three phone calls.

Data Collection

IPC Team Members

Three PhD-level members of the project team with training and expertise in qualitative methods conducted semi-structured telephone interviews from March to September 2015. Development of the interview guide was informed by the Consolidated Framework for Implementation Research (CFIR)²² and the Chronic Care Model.²³ Along with questions about patient engagement, interviews also included perceptions of the IPC’s purpose, processes, impact, effectiveness,²⁴ value, and sustainability, which are outside the scope of this analysis.

IPC Patients

We conducted semi-structured telephone interviews from February to August 2016. Interview topics included satisfaction with the IPC program, what the IPC team has been doing for them, what they liked most or least about the IPC program, their relationship with the IPC providers/team, their involvement in setting and taking actions to meet goals for their health care, and whether working with the IPC team had improved their health²⁴ and self-care. The interviews lasted between 10 and 40 min.

Both the provider/team and patient interviews were digitally recorded and professionally transcribed. Neither group received compensation for their participation.

Analysis

Starting with the provider/staff interviews, we took an a priori approach to coding based on the interview guide,^25,26 with two of the authors jointly developing a preliminary code list with a special focus on engagement strategies that were reported as deployed successfully. We refined and expanded the code list through a process of consensus building and inductive analysis, accounting for unanticipated themes that were introduced by the participants. Using Atlas.ti qualitative coding software, we tested the code list by two authors coding the same interview transcripts, after which one of the authors completed primary coding on the remainder of the transcripts, while the other performed secondary coding/checking on all transcripts, with regular meetings to resolve discrepancies.²⁶ Focusing on patient engagement answers or emergent material, we then ran code reports and reviewed and analyzed the content, creating categories representing different aspects of patient engagement. The same general protocol was followed with regard to the patient interviews.

RESULTS

Twenty-nine VA IPC team members participated in the interviews, including 7 program leads (6 physicians, 1 clinical nurse specialist) and 19 team members (16 core clinicians, e.g., primary care providers, nurses, psychologists, social workers, dietitians, 3 administrators and program support specialists, and 3 individuals who fell into categories of “other,” e.g., social work supervisor, telehealth manager, with some overlap in roles). On average, they had 12 years of clinical practice, 9 years of experience working for the VA, and 1 year and 8 months of experience as an IPC team member.

Seventy-one of the 100 patients contacted were eligible, and 51 completed interviews by telephone for a response rate of 72%. Eighty-four percent of patients were male and 16% were female. Eleven patients declined and 9 were unreachable after multiple call attempts. Of the 51 patients interviewed, 43% (n = 22) had 4–9 prior encounters with the IPC team and 57% (n = 29) had 10 + encounters.

Patient Engagement Strategies: Facilitative and Self-sustaining

IPC team members described utilizing numerous engagement strategies that they perceived as effective in getting IPC patients more actively engaged and involved either with their own healthcare, with the IPC team, and/or the VA. Although all strategies have the potential to support sustained patient engagement in self-care and overall healthcare, we observed two major types of engagement strategies: some were initially facilitated by and/or dependent on staff actions (“facilitative”), while others inspired ongoing patient self-care and behavior change, and were therefore more “self-sustaining.”

Patients highlighted how participating in IPC helped with improved engagement with their own healthcare. Similarly, analysis of the patient interviews revealed two types of patient engagement experiences: (1) those that were dependent upon IPC providers/team (“facilitative”), and (2) self-care activities that were initially supported by the IPC provider/team, but subsequently performed by patients (“self-sustaining”).

Facilitative Patient Engagement Strategies

Enhancing Patient Access and Coordination of Care

IPC providers/staff discussed the facilitative patient engagement strategies they successfully deployed to improve patient access to care and services, such as conveying the substantially enhanced availability of the IPC provider/staff and making regular phone calls to patients and scheduling appointments on their behalf. With regard to scheduling, one provider detailed the often complex coordination of arranging same-day primary and specialty care appointments:

….One guy, it took several hours, basically…trying to coordinate with specialty appointments as well as getting back in touch with the Veteran; if not the Veteran, their caregiver, to see if this time works for their schedule, as well and then calling that point of contact through the specialty clinics to say, ‘Hey, this is a go for that appointment.’

IPC team members also described assisting patients to identify their most pressing questions and concerns prior to appointments with their providers, co-attending appointments with patients (including helping them prepare thoughts/notes in advance and advocating for patient concerns), helping with treatment plans, and giving extra assistance to patients for obtaining medication refills and with arranging transportation. They also noted how patients appreciated staff help with ordering or replacing medical devices/equipment.

Patients confirmed their satisfaction with their experiences related to some of the facilitative engagement strategies noted by the IPC team. For example, patients appreciated getting assistance with transportation to their appointments and receiving “persistent” reminders and encouragement to attend upcoming appointments (including why it was important to go) and hearing regularly from their IPC team members through unprompted follow-up/check-up courtesy calls after and between appointments. Patients described them as positive engagement experiences that impacted not only their access to care, but also their physical and psychological health and well-being. Because of receiving post-appointment check-up calls, one patient said, “Well to me, it seems like [the IPC provider] is concerned with my well-being.” Patients also reported great satisfaction with being able to see or communicate with their IPC providers or staff directly without an appointment. This access was perceived as unique from their prior experiences with primary care, and they described feelings of relief and confidence to better manage their health conditions as a result.

Patients also appreciated the enhanced care coordination and access to specialty care (e.g., quicker access to appointments and immediate processing in ER) that resulted from the facilitative actions of providers/team. As one patient explained, “when I get in a jam, then they help me to get the appointment that I need to schedule.” Another explained, “[The IPC provider] has really bent over backwards to get me with this sleep therapist and try to get me where I can sleep better than I have been sleeping.”

Trust-Building

IPC staff emphasized how initiating rapport-building was a key strategy to engage patients by gaining their trust and included uncovering and emphasizing shared backgrounds (e.g., shared military experience), interests, or other points in common with the patient, as well as meeting the patients’ adult children or significant others. One provider explained:

….This population has a lot more complex trauma…so I am very careful about how I think about interacting with them. I probably spend more time building rapport…than usual as opposed to just kind of diving right in and getting information that you need and sending them along.

Relationship-building between the patient and the whole IPC interdisciplinary team was also highlighted as important and set the foundation for patients to feel comfortable reaching out to or communicating with anyone on the team; this, in turn, facilitated delegation of tasks among team members. Expressing empathy/caring (e.g., through attentive listening) was also heavily emphasized as critical for engaging patients and led to key turning points with patients who began to trust IPC recommendations, such as those regarding pain medications. One provider said:

I really think the key is, and maybe this is very simplistic, maybe it’s very touchy-feely, but I really feel that you have to portray that you care about that patient before that patient will want to have anything to do with you.

Other facilitative strategies that fostered trust included unique and creative solutions such as bringing art supplies to a hospitalized patient to keep them occupied and less likely to leave against medical advice.

Addressing Social Determinants of Health

A key self-sustaining engagement strategy mentioned by IPC team members was addressing the social determinants impeding patient progress, such as transporting patients out of hospital and back so that they could pay their bills without being discharged against medical advice. As one provider explained:

….Your average normal patient that comes in with diabetes you’re going to want them to have a hemoglobin A1C goal. These patients, that’s not feasible. Sometimes these patients, their biggest thing is housing…before they’ll even take their insulin.

Self-sustaining Patient Engagement Strategies

Patient Empowerment and Education

A key self-sustaining patient engagement strategy discussed by IPC team members was identifying patients’ goals through motivational interviewing and/or health coaching and providing health education and guidance for reaching those goals. As one provider described it,

[We] try to get them to talk about something that’s tangible so that they can connect with why their healthcare is important. With the Veterans that already have something that’s important to them, whether it’s cars or my grandchildren or my wife…if they already have something that they value, we find that it’s a lot easier to engage that Veteran; they have something to live for.

Team members also ensured patients understood the purpose of their appointments and why it was important for them to attend, provided hands-on medication management/education, emphasized collaborative decision-making, and encouraged patient participation in smoking cessation programs, exercise programs, boot camps (e.g., for heart failure management), chronic disease self-management groups, and groups for patients with post-traumatic stress disorder.

Patients highlighted positive changes in their self-care based on education and actions on behalf of IPC providers and staff that sparked longer-term changes. The self-care examples patients most frequently cited included improvements in diet and nutrition based on IPC staff education, including weight loss based on dietary education to the spouse or caregiver. One patient explained,

My blood pressure is much better because if you look at it, it was off the chain. Now, you know, it’s where my doctor’s not scolding me every time I roll up in there. So I think they’ve made a difference with that because [the IPC team] told me to watch out for hidden salt. ….And they said make sure like with the canned goods you know don’t do the soups. And then, if you do canned goods, rinse them first….

Improvements in medication knowledge and management were also described by patients, with one explaining:

I have congestive heart failure disease which is a serious problem with me. So I have to make sure I know my medications….. I can’t pronounce all of them but I pretty much know when I see them that I know exactly what they’re for, when to take them—these ladies make sure that the Vet knows their medications, what they stand for.

Increased exercise resulting weight loss based on IPC team encouragement was also mentioned by a number of patients, with one explaining, “….I actually exercise, which is something that [IPC staff] told me would be helpful in keeping my diabetes under control…. And that might be one of the reasons why my A1C is more under control.” A different patient described increased knowledge about chronic diseases and associated treatment regimens:

I’m rechecking my blood sugar and stuff which I hadn’t done for a couple of years before that. [IPC providers] just more or less encouraged me to do it and so I took a little interest and I have been doing it since then.

Additional patient-level outcomes resulting from patient empowerment and education included understanding the connection between mood and physical symptoms as a result of health coaching, increased knowledge and use of medical equipment (e.g., how to properly use an inhaler or bathroom scale, how to measure blood pressure), and improvements in movement through physical therapy (e.g., how to move and walk with stitches and/or pain, how to lift heavy items, how to get into a tub, how to properly walk down stairs with a cane).

Caregiver and/or Community Support

Coordinating and problem-solving with the patient’s caregivers/s or family (e.g., the importance of task-by-task reminding) were also emphasized by IPC providers/staff as highly valuable for increasing patient engagement. Strategies included educating how and how often to give the patient insulin, teaching a patient’s spouse how to turn the patient in bed, making adjustments to a patient’s home environment or assisting with financial impediments, or encouraging participation in social and community activities/groups (e.g., senior centers, YMCA) to prevent clinical deterioration. One patient described enhanced support from caregivers based on IPC staff caregiver education on how to change bandages.

Boundaries and Responsibilities

Encouraging patients to schedule/cancel their own appointments and establishing boundaries upfront for what providers/staff can and cannot do were also mentioned by IPC team members as particularly helpful engagement strategies to employ with patients in the IPC program.

DISCUSSION

The patient engagement strategies deployed by the VA IPC teams were either facilitative strategies that revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health or self-sustaining strategies oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. It may be important to note that setting boundaries and responsibilities could be interpreted as an attempt among providers to make a shift from a facilitative approach to self-sustaining.

For patients, these strategies created a foundation for access and coordination of care and patient empowerment and education in a way that they reported not having experienced in their healthcare previously. Some of the strategies utilized by IPC staff led to positive patient self-reported process and/or clinical outcomes as pertaining to their engagement with the IPC team, engagement with the VA healthcare system, or engagement with their own healthcare. For example, facilitative engagement strategies deployed by IPC providers/staff led to improvements in reported proximal outcomes reported by both groups (e.g., appointment access). IPC patients also reported improved clinical outcomes (e.g., weight loss) resulting from engagement strategies we categorize as self-sustaining. We did not identify any contradictions or conflicting accounts between engagement strategies reported by providers and engagement experiences described by patients. Some engagement strategies mentioned by staff were not explicitly voiced by patients, such as those related to trust-building, caregiver, social and/or community support, or boundaries and responsibilities, but it is possible the patients still appreciated or benefited from those strategies.

It has been noted that direct patient care strategies have positive effects or potential benefits for adult patients with chronic conditions.²⁷ Our work confirms such benefits as they relate to the lived experiences of complex high-risk patients. But our work also provides a unique categorization of engagement strategies not developed previously. For example, our findings reveal how the engagement strategy of self-management education and support¹⁰ was a critical self-sustaining engagement strategy for this population. The importance of addressing psychosocial patient needs⁷ and of enhancing provider availability for high-need patients²⁸ are also corroborated by our findings as key facilitative strategies that made a difference to the IPC patients.

The actions of healthcare providers comprise only one part of patient engagement; the role that patients play themselves is equally and critically important.¹⁰ Patient activation (i.e., the skills, confidence, and knowledge for managing one’s own healthcare) is one specific aspect of patient engagement that has been linked to improving outcomes and reducing costs among patients more generally.^29,30 Highly activated patients have been shown to be more prepared for healthcare encounters, more informed about their conditions, more likely to adhere to treatment plans and recommendations, and more likely to receive health screenings and immunizations.³¹

The concept of patient activation may be closely linked to the self-sustaining engagement strategies that we identified and may at least in part address the existing challenges many IPC and primary care programs face with not just getting high-risk patients initially engaged, but keeping them engaged over time. In other words, it is possible that provider/team use of self-sustaining engagement strategies with patients may encourage or further support patient activation. It may be instructive for future research to explore whether self-sustaining engagement strategies deployed in similar interventions likewise have the potential to activate patients who did not previously have the skills, confidence, and knowledge or otherwise demonstrate a willingness to engage. It is also important to keep in mind that the “super utilizers” or complex patients of healthcare systems often face socioeconomic challenges that directly impact patient engagement (e.g., housing insecurity, reliant on public transportation) and addressing their material needs is particularly important.³² The existence of such social determinants of health can also often make it more challenging for providers to accurately assess patient engagement.³³

This analysis has some limitations and strengths. Generalizability may be limited by the small number of participants and the VA-specific context, and the patients interviewed may not be fully representative of the IPC high-risk patient population (e.g., patients available during business hours). Furthermore, the patients’ health/behavioral improvements are all self-reported or stated by the providers/staff and not based on other quantifiable measures. However, the findings do represent the range of activities that these particular patients reported as important or valuable. The limited scope of this project is also a strength because our findings primarily speak to provider and patient experiences in settings which serve high-need and high-risk populations using an interdisciplinary team. Further work would benefit from larger studies of a wider geographic nature. Replication of this work in other systems may provide both unique and generalizable insights into problems and solutions or potential intervention points.

CONCLUSIONS

Identification of facilitative and self-sustaining engagement strategies and understanding patient experiences with them open up an additional pathway for strategically incorporating them into IPC program design. As the Chinese philosopher Lao Tzu once said, “Give a man a fish and you feed him for a day. Teach him how to fish and you feed him for a lifetime.” These findings can also further hone work already underway to incorporate patient self-management of chronic diseases and personalized health care and planning into the primary care delivery of large integrated health care systems like the VA.^34,35 Those implementing services for high-risk patients within primary care or IPC programs should consider implementing the engagement activities and strategies detailed in our findings. It may also be useful for future research to explore the relationship between facilitative and self-sustaining engagement strategies, including how strategies of both types can be deployed in ways that inspire ongoing self-care among patients. For example, use of facilitative engagement strategies, such as rapport-building and expressing empathy/caring, might possibly inspire patients’ longer-term self-sustaining self-care actions. Finally, we are hopeful that both of these types of engagement strategies/experiences that were valued by our IPC patients and providers can be incorporated into patient-centered team-based primary care.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution

All authors listed have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline.

Funding

This project was funded by the Office of Primary Care Services, Veterans Health Administration (VHA), Department of Veterans Affairs (VA). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the US Government.

Data Availability

Data is available upon approval from the VHA Office of Primary Care. Requests for data must be in writing and can be directed to the corresponding author.

Declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.