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Person-Centered Care:Equip, Enable, Empower, and Engage Persons in

Their HealthAimee E. Perron, PT, DPT, NCS, CEEAA


• Financial– None

• Nonfinancial– Employer has professional relationship with Insignia

Health for use of Patient Activation Measure

Disclosures


Objectives

1. Describe foundational elements and general principles of person-centered care

2. Understand and be able to describe how the person-centered care model fits in with the priorities of the current healthcare arena

3. Understand the importance of determining and incorporating person’s value, preferences, and expressed needs in to each plan of care

4. Evaluate the difference between task-oriented care versus shared decision-making

5. Introduce assessments tools which can be used to determine a person’s level of activation related to their current state of health


Objectives (cont.)

6. Apply learned concepts to better equip, enable, engage, and empower clients in making treatment decision and with becoming more active participants in their own self-care

7. Provide resources to support healthcare professionals and organizations in creating partnerships that results in shared decision-making with clients and their caregivers

8. Describe the importance of organizations having coordinated and integrated care as it related to discharge planning, better outcomes, and improved care transitions

9. Apply learned concepts and strategies to promote person centered and population health care through case-based examples and learning assessment


Chapter OneWhat Is Person-Centered Care?


Call to action: redesigning care

First Let’s Explore the Why


History


Six Dimensions of Healthcare Quality

1. Safety2. Effectiveness

3. Equity 4. Efficiency 5. Timeliness

6. Patient-centeredness

IOM report, Crossing the Quality Chasm.


“Three Maxims”

“For better or worse, I have come to believe that we—patients, families, clinicians, and the health care system as a whole—would all be far better off if we professionals recalibrated our work such that we behaved with patients and families not as hosts in the care system, but as guests in their lives.”

– Don Berwick

Three Maxims– “The needs of the

patient come first” • Mayo Clinic

– “Nothing about me without me”

• Diane Plamping, UK

– “Every patient is the only patient”

• Harvard Community Health Plan

https://www.healthaffairs.org


• An approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among patients, families, and health care professionals

• Partnerships at the clinical, program, and policy levels are essential to assuring the quality and safety of health care

• Includes– Dignity and respect – Information sharing – Participation – Collaboration

Johnson, B. H. & Abraham, M. R. (2012). Partnering with Patients, Residents, and Families: A Resource for Leaders of Hospitals, Ambulatory Care Settings, and Long-Term Care Communities. Bethesda, MD: Institute for Patient- and Family-Centered Care.

IPFCC Definition


CMS has stated– “…Facility staff members must implement person-

centered care approaches designed to meet the individual needs of each resident.”

– “…Competency involves staff’s ability to communicate and interact with residents in a way that promotes psychosocial and emotional well-being as well as meaningful engagements.”

CMS


Redesigning Care: Decision-Making


My Timeline


Persons-Centered Care

• Continuous healing relationships

• Customized based on patient needs and values

• Patient at the source of control

• Share knowledge and free flow of information

• Integrated and transparent coordinated care


Shared Decision-Making


• Undergoing screening or a diagnostic test• Different medical or surgical procedures

• Medication needs• Self-management of long-term condition• Participation in a psychological intervention

• Lifestyle changes

Common Situations Where Used


• Decrease use of emergency hospital services• Compliance (more likely to follow) treatment plans and

take medicine correctly• Satisfaction with care (reduce number of complaints)• Tend to choose less invasive and costly treatments

• More likely to engage in positive health behaviors resulting in better health outcomes

• As patient engagement increases, staff performance and morale increases

Positive Outcomes


• Improved admission process• Negotiate treatment plans with people with recurrent

health problems• Support people living with conditions to become more

effective self-managers• Limit prescribing medication that a patient will not take• Addresses health care demands of our ageing

population and the huge growth in long-term conditions

Positive Outcomes (cont.)


Actions individuals and caregiver take for themselves, their children, their families, and others to:

– Stay fit– Maintain good physical and mental health– Meet social and psychological need– Prevent illness or accidents– Care for minor conditions– Maintain health and well-being after an acute illness or

discharge from hospital

Self-Management


• Services put in place by health and social care organizations to support and enable persons with self-management

• Aims to enable persons to have the skills, knowledge, and expertise to make positive choices about their healthcare and long-term health behaviors

Self-Management Support


• Deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care

• Patient’s needs and preferences– Known ahead of time – Communicated at the right time to the right people– Used to provide safe, appropriate, and effective care

Integrated Coordinated Care


What is your comfort level with person-centered care? a) New to youb) Heard of it beforec) Made some individual changes into practicesd) Work on a team with changes into practicese) Organization fully embraces

Audience Poll:


Picker Institute

Person-Centered Care: A Deeper Dive

Patient preferences

Emotional support

Physical comfort

Information and education

Continuity and transition

Coordinated care Access to care

Family and friends


Person-centered

care

Improved persons

satisfaction

Better health

Person-Centered Care: A Deeper Dive (cont.)


https://www.youtube.com/watch?v=xfLjgEL0_Lc

WHO Video

https://www.youtube.com/watch?v=xfLjgEL0_Lc


Chapter TwoThe Patient Experience


Meet Patient A: Medical Model

• Hypertension • Atrial fibrillation • Type II diabetes• B gastrocnemius tear• Lymphedema B LE R>L• Hyperlipidemia• Peripheral vascular

disease• Recurring gout• 15 medications

• Right-sided hemiparesis with spasticity

• Mild expressive aphasia

62-year-old male after cerebrovascular accident in October 2009


Client A: Initial Hypothesis At first glance what do you think this patient prognosis or outcome may be in regards for returning to PLOF (living independently and returning to work)?

A. ExcellentB. Good C. Fair D. Poor

Audience Poll:


Who is Patient A: Dan

• Lives alone independently in an apartment

• Works full-time as computer engineer

• Retired from the Army• Father of three children and

grandfather of two• Travels frequent across

county• Loves to tell stories and jokes


• Who is he and what is important to him• Diagnosis does not form who he is as his identity

(separate from his disease)• Social and cultural background is important• Health status or condition (and how is it impact his life)

• Beliefs and preferences

“Dan”: Persons Centered Care Model


What Does Person at the Center Look Like?


Patient Preferences

• Treating individuals with respect– Maintains their dignity– Demonstrates sensitivity to their

cultural values, generational differences, feelings, beliefs, concerns, ideas, andexpectations

• Keeping individuals informed about their condition and involving them in decision-making

• Focusing on the person’s quality of life, which may be affected by their illness and treatment


• Helping to alleviate fear and anxiety the person may be experiencing

• Consideration of all their resources – Physical: health statute (physical status, treatment, and

prognosis)– Psychosocial: impact of their illness on themselves and

others (family, caregivers, etc.)– Financial: impact of their illness

Emotional Support


• Respect • Dignity

• High quality and safe care• Being treated as an individual• Timely access to care

• Clear communication about conditions• Clear communication about treatment options• Involvement in treatment decisions

Person Priorities


• Most important communication predictor of patients’ overall physician rating

• #hellomynameis campaign• How does one show respect?

– Autonomy: right to accept or refuse any treatment– Social acceptance of another person unconditionally – Recognize patient may be doing best they can

Frosch DL, Tai-Seale M. R-E-S-P-E-C-T--what it means to patients. J Gen Intern Med. 2014;29(3):427–428. doi:10.1007/s11606-013-2710-z

Respect


Enhancing individuals’ physical comfort during care– Pain management– Support with movement– Support with sleep– Support with the activities of daily living– Support with mood– Maintaining a focus on the hospital environment (e.g.,

privacy, cleanliness, comforts, accessibility for visits)

Physical Comfort


• Do we consistently ask the persons, “What is your goal for care?”

• May require finding out what are their intrinsic and extrinsic motivators?

Goals


Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing disability and change on individual patients: a report of a patient specific measure. Physiotherapy Canada, 47, 258-263

Patient Specific Functional Scale


• Identification of own outcome measure• Measured scored in standardized way

• Each goal is rated on five-point scale• Overall score is calculated by incorporating outcome

scores into a single aggregated T-Score

• Optional to have goals weight by importance or difficulty by the patient

Goal Attainment Scale


IHI - Ask Me Three: Good questions for your good health– What is my main problem?– What do I need to do?– Why is it important for me to do this?

Self-Management Techniques: Person


• Activity Card Sort (ACS)• Perceived Efficacy and Goal-Setting System• Home and Community Environment (HACE)• Patient Health Questionnaire (PHQ-9)• Life-Satisfaction Questionnaire - 9 or 11 (LISAT)• Craig Handicap Assessment and Reporting Technique

(CHART)- SF• ICF- Measure of Participation and Activities Screener

(IMPACT-S)• Community Integration Questionnaire II (CIQ-2)

Patient-Reported Measures


• How often did provider explain things in a way you could understand?

• Did staff talk with you about whether you would have the help you needed when you left the facility?

• Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

• Did staff consider your preferences and those of you family/caregiver into account when deciding what my healthcare needs would be?

• When you left the facility, did you have a good understanding of the things you were responsible for in managing your health?

• When you left the facility, did you clearly understood the purpose for taking each of your medications?

Patient-Reported Measures (cont.)


Ability to obtain, read, process, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment

– Studies reveal that only 12% of the adults in the U.S. have proficient health literacy

– 71% of adults older than age 60 had difficulty in using print materials

– 80% had difficulty using documents such as forms or charts

– 68% had difficulty with interpreting numbers and doing calculations

cdc.gov

Health Literacy


• Short Assessment of Health Literacy (SAHL)• Rapid Estimate of Adult Literacy in Medicine (REALM)

• Disease Specific and Other Language Tools - Health Literacy Tool Shed

• Newest Vital Sign (NVS)

Health Literacy Measures


Newest Vital Sign


Powers BJ, et al. Can this patient read and understand written health information? JAMA 2010 Jul 7;304(1):76-84

Health Literacy “Dan”


Patient VideoHealth Literacy: “Dan”


• Demonstrate• Teach back

• Use simple language• Use pictures, charts, brochures, videos• Group classes

• Routinely offer patient help with paperwork • mHealth tools• Patient portals

Health Literacy Techniques


• Difficulty planning/setting goals• Problems being organized

• Difficulty being flexible• Difficulty problem-solving• Difficulty prioritizing

• Decreased awareness of thinking changes in itself– Or lack of insight?

Cognitive Capabilities


Physical and Cognitive Threshold


Brief Cognitive Assessment Tool (BCAT) or BCAT-SF– Multi-domain cognitive screening tool– Administered in 10 to 15 minutes– Assesses: orientation, verbal recall, visual recognition,

visual recall, attention, abstraction, language, executive functions, and visuospatial processing

– Crosswalk to other selected measures– Site also includes the Self-Assessment of Cognition

(SAC)

Thebcat.com

Cognitive Screen


Competencies: knowledge, skills, and attitudes– Persons– Professional– Caregiver

Shared Decision-Making


Shared Decision-Making (cont.)


Person should:– Determine what matters the most to them – Review/gather useful and important information – Write down the main points from the discussion

• To ensure plan belongs to them and is easy to understand– Take time to think and talk to other people about the

different choices– Talk with care/support partner about what it means to

stay and live well • What are they able to do• What care and support they might need from other people

Shared Decision-Making (cont.)


• Good relationships allow people to feel supported, develop skills, and build trust

• Ties within and across communities enable people to feel included and valued

• Engaging in groups/activities offers sense of purpose and shared identity

• Sense of control and collective voice can enable people to influence positive change

Family-Centered Family and Friend Support


• Multidimensional Scale of Perceived Social Support (MSPSS)

• Inventory of Socially Supportive Behaviors (ISSB)

Family and Friend Support Measures


AARP

Caregiver Advise, Record, Enable (CARE) Act


• “Social engagement is interacting with others, feeling connected to other people, doing purposeful activities with others and/or maintaining meaningful social relationships”1

– Structural component– Functional component– Quality component

• “Keeping engaged is socially good for your health!”2

• Growing evidence social engagement supports maintaining mental fitness, such as thinking skills and slow cognitive decline

1. Global Council on Brain Health (GCBH) 2. CDC

Family and Friend Support Social Engagement


Chapter ThreeTransformation of Healthcare Professional


• Respect for patient and family needs and values• Respect for diversity

• Empathy and compassion• Honesty• Self-reflectiveness

• Clear communication• Biopsychosocial perspective • Competency: top of license practice

Therapeutic Alliance: Mutually Beneficial Partnership


Ability to recognize and regulate your own emotions and the emotions of others

– Emotional Quotient Inventory (EQ-I)

Emotional Intelligence


They influence:– Attention, memory, and learning– Decision-making and judgment– Relationship quality – Physical and mental health– Everyday effectiveness

Emotions Matter


• Your attitudes and behaviors will influence and effect the attitudes and behaviors other around you

• All behaviors have a cause and effect; therefore, with patient care you will need to be aware of your influence at all times

• “Take responsibility for the energy you bring” – Jill Bolte Taylor, author of My Stroke of Insight

Integrated Experience


• Practicing to the full extent of your education and training

• Not spending time doing something that can be effectively done by someone else

• Practice consistent with “choose wisely” campaign • Behavior change and roll with resistance • Emotional intelligence• Use of EBP (and decrease variability in practice)• Prioritize discharge consultation• Health risk assessments

Top of License Practice


• Assess clinical needs of patient • Support shared decision-making and self-management techniques• Determine levels of activation and engagement • Establish patient goals and track progress• Provide outcome-focused care based on patient needs and values• Inform, educate, and engage patients and their families/caregivers• Meaningful documentation• Coordinate care with interprofessional caregivers• Facilitate safe patient transitions to next care setting• Assess and incorporate new technologies and evidence-based

practice

Person-Centered Care: Top of License Practice


• Ensure familiar with conditions, treatments, and other health issues (at the level they can understand)

• Provide tangible materials that are customized• What are your goals for their care and how will this goal

decrease their risk or improve their health• Joint decision in determining options for follow up• Pre-visit calls with reminders to bring materials

• Use health coaching and motivational interviewing techniques

Shared Decision-Making: Provider


• Measure of a person’s understanding, competence, and willingness to participate in care decisions and processes

• Includes understanding one’s role in the care process and having the knowledge, skill, and confidence to manage one’s health and health care

Patient Activation


A broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior such as seeking preventive care or exercising regularly

Patient Engagement


• Uses patient-facing survey questions • Covers six different patient characteristics

1. Ability to self-manage illness or problems2. Ability to engage in activities that maintain functioning and reduce

health declines3. Ability to be involved in treatment and diagnostic choices4. Ability to collaborate with providers

5. Ability to select providers and provider organizations based on performance or quality

6. Ability to navigate the healthcare system

Patient Activation Measure (PAM)


Survey questions addressing:– Whether the patient believes he/she is ultimately in

charge of his/her health– Whether he/she knows what each of his/her prescribed

medications does– Whether he/she understands the nature and causes of

his/her health conditions– Whether he/she can find solutions when a new health

issue arises

Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004;39(4 Pt 1):1005–1026.

Patient Activation Measure (PAM) (cont.)


Patient Activation Measure (PAM) (cont.)


Using the PAM tool, where would you rate yourself currently on how to initiate shared decision-making with your clients/patients?a) Disengaged and overwhelmedb) Becoming aware, but still strugglingc) Taking actiond) Maintaining behaviors and pushing further

Audience Poll:


“Dan’s” PAM Score


• Promote recovery, well-being, and self-management• Identify person’s needs and strengths

– Identification of risk

• Promote safety• Personal development and learning• Challenge inequality

Supporting Engagement


• Be compassionate• Identify barriers related to self-management

• Ask about patients’ priorities, experiences• Providing clear and useful information• Support patient/person set individualized and realistic

goals and make plans to live a healthier life (include focus on prevention)

Self-Management Support Techniques: Provider


• Customized education and skills training• Provide materials appropriate for different cultures and

health literacy levels• Use simulation and experiential learning to teach

patients how to self-monitor and manage chronic conditions

• Tailor coaching and support to patient and family needs and activation levels

• Making referrals to community-based supports/resources

Self-Management Support Techniques: Provider (cont.)


• Tailor to patients’ capacities and needs and level of activation • Translate medical/health-related information into plain language• Reinforce and reiterate information about conditions, diagnoses,

and treatment options at multiple points• Assess patient and family understanding of treatment options,

care instructions, or other health information (teach-back method)• Help patients learn how to share their needs and preferences• Encourage sharing of information by specifically inviting patients

and families to participate in conversations, ask questions, and state their preferences

Self-Management Support: Information and Education


Self-Management Support: Information and Education (cont.)

Educational support resources

– Do they have accurate health information?

– Are they well designed, easy to use?

– Are they patient centered?

– Healthfinder.gov– Medline Plus– Health.gov– NIH Senior Health– KidsHealth– National council on

patient information and education


• “Family engagement” as they are members of the same team

• Acknowledge and respect the role of the person’s family/friends

• Accommodate the individuals who provide the person with support during care

• Respecting the role of the person’s advocate in decision-making

• Supporting family members and friends as caregivers, and recognizing their needs

Self-Management Support: Family Centered


• Consider family/caregiver activation assessment• Use advocate/navigator programs

• Connect to peer support programs (online or in person)• Connect with online networks and resources

Self-Management Support: Family Centered (cont.)


• Peer support could lead to greater adherence to exercise-based interventions

• Interactions, socialization, and shared experiences may be motivating to many patients

• Patients are required to be more independent and self-reliant

• Supports efficient delivery of skilled therapy services, including the potential for more visits/efficiency of visits

Self-Management Support: Modes of Treatment


Change means doing something differently or modifying a response

– Requires• Opportunity• Capability • Motivation

Self-Management Support: Behavior Change


• Person-centered process based on behavior change theory• Supports motivation to self-manage and adopt healthy

behaviors• Entails patients setting self-determined goals• Best for people most in need of such

– Low levels of self-efficacy– Higher risks– Most severe symptoms– Low levels of self-management or medication adherence– Women, young people or much older people, minority ethnic

and vulnerable groups– Lowest levels of education

Self-Management Support: Health Coaching


• Person-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence

• Assumes that motivation is fluid and can be influenced• Focused and goal oriented, helping to resolve

ambivalence

• Increased the discrepancy between current behaviors and desired goals, while minimizing resistance

• Focuses responsibility for change on the patient, encourages self-management and self-determination

Self-Managing Support: Motivational Interviewing


Basic skills– Open-ended questions: allow the patient to focus on his

or her concerns at the time– Affirmations: validates the internal and external

resources upon which the patient can draw going forward– Reflective listening: demonstrates that your purpose is

to be “interested,” not “interesting.” Carefully listen for underlying concerns that may come from the patient or the caregiver

– Summary statements: allows the clinician to reiterate the main points shared by the patient and to verbalize an interest in the patient's concerns

Self-Managing Support: Motivational Interviewing (cont.)


• Express empathy– What do you find to be the drawbacks of your current behavior/practices?– What can I do to help you achieve your goal?

• Develop discrepancy– It seems like there are positives and negatives for your continuing current

practice. If you were to look into your future, what do you see yourself doing differently in six months?

– What are the costs/benefits of changing? What are the costs/benefits of current practice?

• Support self-efficacy– May I provide you with some literature to look over related to (goal

behavior)?– What do you think you can start to immediately change this month?

Motivation Interviewing: Powerful Questions


• Provide information regarding medication, physical restrictions, nutrition

• Coordinate ongoing treatment and services and sharing this information with the person and their family

• Provide information regarding access to supports (e.g., social, physical, and financial) on an ongoing basis

• Should provide opportunity to ask questions, clarify, and confirm

Continuity and Transitions in Care: The Patient Experience


• Replace “discharge” with “transition in care”• Identify opportunities for change/innovation

– Electronic tools

• High touch with upstream and downstream partners– Connect with community resources/providers– Share clinical determinants that may impact transitions in care

• Directly involve the patient/family– Ask about immediate concern and/or questions – Look at the process through the patient’s eyes– Use point of service documentation

Continuity and Transitions in Care: Handover Provider to Provider


• Burnout: – Human response to chronic emotional and interpersonal

stress at work, defined by exhaustion, cynicism, and inefficiency

• Resilience: – Process of personal protection from burnout

Resilience


• Joint Commission developed Quick Safety 50– Ability to adapt successfully

• Support systems to combat stress and promote culture of mutual openness

– System response to unforeseen, unpredictable, and unexpected demands

– Impacted by satisfaction, attitude, leadership, insight, support from colleagues, and work-life balance

Resilience (cont.)


Characteristics include:– Play to your strengths– Optimism, can do attitude– Practice “attitude of gratitude”– Self-compassion and time for self– Wellness – Mindfulness – Model resonant leadership style– Mission oriented

Resilience


Break


Chapter FourOrganization Care Delivery and

Transitions in Care


• Main goals are to improve:– Access to care– Transitions in care: integrated and coordinated care– Safety with care– Quality of care– Reduce cost of care

• Benefits include:– Improve patient health outcomes– Attain better financial performance– Improve market share– Increase employee satisfaction– Improve overall ranking

Person-Centered Care Organization Goals and Benefits


• Partnership with all involved• Well-being for all involved

• What can be standardized? Made easier?• Supporting training and competencies• Embrace alternative payment models of care

• Utilize technology• Connect on a larger scale

Person-Centered Care Organization Considerations


• What do your patients/families say?• What are your strengths?

• Who are your staff?• What are you barriers to team effectiveness?

– Working conditions– Resources– Team composition

Facility Assessment


Center Self-Assessment Tool

• Leadership/operations• Mission, vision, values

• Advisors• Quality improvement• Personnel

• Environment and design

• Information/education• Diversity and disparities

• Charting and documentation

• Care support


• Interview patients• Surveys

• Focus groups/forums• Comments care/suggestions boxes• Complaints

• Patients stories• Observation

Organization Assessment: Patient Experience


• Appointment times• Language support

• Flexible dining • Parking• Support with learning difficulties

• Improve patient privacy• Speed of response • Improved hand cleaning

Patient Experiences: Feedback


• Invite to team meetings to discuss their stay• Ask for their feedback on educational and informational

materials• Ask them to present at staff orientation and in-service

programs (or panel discussions)• Invite to participate in facility “walk-about”• Thank them for their feedback

• Invite them to continue to ask questions/make suggestions

Patient and Family Advisors


Consumer Assessment of Healthcare Providers and Systems (CAHPS)

– Surveys of patient experience with• Providers• Health conditions• Health plans• Care delivery

CAHPS Surveys and Guidance. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/cahps/surveys-guidance/index.html

CAHPS Surveys


• Equip with consistent and safe resources and effective communication strategies

• Enable them to develop skills and competency• Empower team to share their voice• Engage in the process and decisions

Equip, Enable, Empower, and Engage Team Members


• Greater ability to meet patient/family needs• Improve patient experience

• Improve staff retention • Reduced length of stay• Higher quality of care

Positive Outcomes of an Effective Team


https://www.mbaknol.com/business-communication/elements-of-the-communication-process/

Elements of Communication

https://www.mbaknol.com/business-communication/elements-of-the-communication-process/


• Flexible teamwork (contrast of stable teams)• Members bring individual experience and

accomplishments to the team • Includes being curious, passionate, and empathic• Professional must be comfortable with not knowing, not

being right, asking for help, and reporting mistakes• Adds depth to ideas and creates a more efficient work

flow

Teaming – Amy Edmondson

“Teaming”


• An evidence-based teamwork system to improve communication and teamwork skills among health care professionals

• Ready-to-use materials and a training including resources for – Leadership– Situation monitoring– Mutual support– Communication

https://www.ahrq.gov/teamstepps/index.html

TeamSTEPPS


• Provides a framework for effective communication between team members

• Includes– Situation: what is happening with the patient?– Background: what is the clinical background or context?– Assessment: what do I think the problem is?– Recommendation: what would I recommend?

SBAR


• Briefing: discussion between two or more people, using succinct information pertinent to an event– Maps out the care plan and heightens awareness of the

situation– Identifies role and responsibilities– Permits the team to plan for the unexpected– Allows team members’ needs and expectations to be met– Encourages team members’ participation

• Debriefing: Informal information exchange session designed to improve team performance and effectiveness after each review– What went well? Should change? Needs adjusting?

Briefing and Debriefing


• Consider “huddles” in replace of “meeting”• Gathers team members to review patient data and

decide on a course of action• Can be requested by any team member at any time • Employs unplanned planning to reestablish situational

awareness, reinforce plans that are already in place, and assess any need to adjust the plan

Huddles


• Stress • Fatigue

• Cognitive workload• Design • Equipment

• Teams• Culture

Minimize Human Factors in Healthcare


Patient Video“To Err is Human” Trailer


• Quality assurance – Specification of standards for quality of service and

outcomes– Ongoing, both anticipatory and retrospective, in its efforts

to identify how the organization is performing

• Performance improvement– Continuous study and improvement of processes with

intent to improve outcome, identify areas of opportunity, and decrease likelihood of problems

QAPI


• Design methodology that provides a solution-based approach to solving problems

• Model proposed by Hasso-Plattner Institute of Design at Standford

• Reframing the problem in human-centric ways• Five stages:

– Empathize– Define (the problem)– Ideate– Prototype– Test

Apply Design Thinking


• Support patient/persons/families outside the office– Patient portal messages– Medication adherence apps– Automated phone calls– Leverage technology to support and manage the flow of

data across all healthcare providers and systems

• Embrace modern digital care – E-patient – mHealth or MyHealthEData– Health 2.0

Self-Management Support: Organization


• Includes patients’ preferences and priorities– Would they like to have friends and family close by?– Preferences about pain relief, sleep, or treatment options

• Helps share information that may not always be included at handover– Invite them to use the board

• Acts as a talking point to help staff get to know patients better

“What Matters to Me” Board


• Includes the patient and family as full partners• Discuss the five key areas to prevent problems at home

with patient and family• Educate the patient and family throughout stay• Assess how well healthcare professionals explain the

diagnosis, condition, and next steps in their care (teach back)

• Listen to and honor the patient and family goals, preferences, observations, and concerns

Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research and Quality; May 2013. AHRQ Publication No. 13-0033.

“IDEAL” Discharge Planning


Implement mechanisms that support clinicians’ emotional well-being and ability to care compassionately for patients

– Quadruple aim: improved clinician experience• Team documentation • Expand roles • Co-locate teams• Don’t push past eustress to distress (avoid shift burnout)• Standardize and synchronize

– IHI: “Improving Joy in Work”• Ask the clinicians

Support for Clinicians


www.theschwartzcenter.org

Implement Effective “Schwartz” Rounds

Patient Benefits • Improves person-centered care • Emotional needs more likely to be addressed

Staff Benefits

• Become more empathetic• More confident in handling sensitive issues and non-clinical

aspects of care• More open to expressing thoughts, questions, feelings• Improves communication• Staff are willing to reflect on emotional aspects of work and

become less stressed

OrganizationBenefits

• Creates a strong, open, transparent culture• Improves compassionate care• Improves quality of care • Empowers and motivates staff to reconnect with the

professional values


Which answer best reflects the five things needed for ensuring physical wellbeing?

a) Emotion regulation, nutrition, exercise, 8+ hours of sleep, and meditation

b) Family time, exercise, 6 to 8 hours of sleep, nutrition, and relaxation

c) Stress reduction techniques, 6+ hours of sleep, nutrition, exercise, and meditation

d) None of the above, as each person has different needs

Audience Poll:


Chapter FiveWhat About Population Health?


What creates health and well-being?– Health and well-being develop over a lifetime– Social determinants influences health and well-being

outcomes throughout the life course– Place (live, learn, work, play, pray) is a determinant of

health, well-being, and equity

Population Health


• “Health outcomes of a group of individuals, including the distribution of such outcome within the group”

• Good health is an important enabler of positive family and community life. It enables people to participate in, and contribute to, society in different ways– Family in good health can better support an ill child or parent– Having good health enables one to be able to take part in their

community impacting social cohesion– Healthier children have better educational outcomes leading to

more productivity in adulthood– Healthier people are less likely to be unemployed or need sick

days– Essential for a thriving society and economy

What is Population Health?


Social Determinants of Health (SDOH)

• Healthy behaviors– Diet and exercise– Use of tobacco,

alcohol, drugs– Sexual activity

• Clinical care– Access to care– Quality of care– Health literacy

• Social and economical– Education– Employment– Income– Family/social support– Community safety

• Physical environment– Air and water quality– Housing– Transit– Safety– Schools/recreation


Social Determinants of Health (SDOH) (cont.)

Poor academic

performance

Less likely to have a job/good

health as an adult

Poor wages

Poor ability to support family

Poor health

Limits access to• Public transportation• Healthcare• Nutrition• Housing• Education• Social • Employment

Conditions in which we are exposed influence behaviors


• CDC: Health Impact in 5 Years • Healthy People 2020

National Focuses and Health Objectives


• Health-Related Quality of Life (HRQOL-14)– HRQOL–4: General Health, Physical Health, Mental

Health, Limited activities

• Free for public use • In English and Spanish

• CDC reports cards (national, state, local)• National Health and Nutrition Examination Survey

https://www.cdc.gov/nchs/nhanes/hlthprofess.htm

CDC: Measuring Healthy Days


• Community Health and Economic Prosperity (CHEP Initiative)

• Advancing the national prevention strategy, healthy aging in action – “Overarching goal is to increase the number of

American’s who are healthy at every stage of life”• Promote health, prevent injury, manage chronic conditions• Facilitate social engagement• Optimize physical, cognitive, and mental health

HHS.gov

Surgeon General Priority


• Healthcare spending in the U.S. predominately on medical services and very little on health behaviors

• Support with increasing healthy behaviors in it accounts for ~50% of what actually makes people healthy

• Ensure common understanding of the negative impact of social isolation and need for actionable solutions while maintaining aging in place

Our Role in Advocacy


• Improve patient outcomes and reduce readmission rates requires caregiver engagement

• 70% of family caregivers spend between 10 and 40 hours a week performing medical tasks including wound cleaning, administering medications, operating tube feeding, supporting with physical and emotional/social needs

• Tools to support care may include– Trackable resources– Digital caregiver education – Remote monitoring

Broader Reach for Better Outcomes


• Inadequate social/emotional support• Lack of physical activity• Food insecurity• Lack of person engagement• Risk for rehospitalizations

– Risk for falls– Risk for medication mismanagement

• Risk for missing follow-up care– Financial– Transit

Identification of Risk


Impact on Well-being

• Wellness wheel– Physical– Emotional– Social– Financial– Academic– Environmental– Spiritual

• Seven pillars of self-care– Health literacy– Mental wellbeing– Physical activity– Health eating – Risk avoidance – Good hygiene– Rational use of

products


• Brain metabolism: process involves all chemical reactions that take place in A cell to support its survival and function. These reactions require oxygen and glucose, which are carried in blood flowing through the brain

• Nutrient dense diet of adequate carbohydrates, protein and fats

• May need screen for supplementation needs

Encourage and Support Health Diet/Nutrition


Encourage and Support Physical Activity/Exercise• Research has shown a positive

relationship between physical activity and cognitive function and that it combats cognitive decline

• Exercises should– Encouraging a daily dose of high

quantity exercise through multiple opportunities for practice (avoid under-dosing)

– Include instructions in easy-to-remember steps

– Include memory cues: physical, auditory, and visual

– Should be meaningful and individualized (match the client skills)


• Decrease in sleep can be an internal trigger and decrease functional capacity

• Intervention measures include– Routine in bed time and rise time– Quiet, comfortable, and dark room– Possibly discourage daytime napping– Encourage daily physical activity– Limit caffeine

Encourage and Support Sleep Hygiene


• Keeps mind active • Decreased incidence of mental illness

• Stimulating interactive activities which are meaningful decrease reactions

Encourage and Support Social Connections


• Prepare patients and families to partner with researchers in designing and conducting research studies

• Prepare patient and family representatives to partner with other stakeholders in local, state, and national policy and programmatic decisions

Population Health: Patient/Family Engagement


● Be honest and realistic with where you are on your journey toward better person-centered care (and develop your skills from there)

● Start with ensuring all persons are shown respect, dignity, and compassion

● Be a change agent in supporting peers, organizations, and communities with person-centered care

● “The good physician treats the disease; the greatphysician treats the patient who has the disease.”● William Osler

Final Take-Away


Break


Questions and Answers

Person-Centered Care: Equip, Enable, Empower, & Engage Persons in Their Health

PAGE 1

Key Terms and ConsiderationsAimee E. Perron, PT, DPT, NCS, CEEAA

What is person-centered care?• IPFCC definition: an approach to the planning, delivery, and evaluation of health care that is grounded

in mutually beneficial partnerships among patients, families, and health care professionals. Includes dignity and respect, information sharing, participation, collaboration

• Shared decision making: collaborative process in which persons are supported by their healthcare professional to make decisions and select tests, treatments and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values

• Self-management support: help given to people that enables them to manage and take an active role in their health care

• Integrating coordinated care: deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care

The patient experience considerations• Patient preferences: includes

• Treating individuals with respect

• Keeping individuals informed about their condition and involving them in decision making

• Focusing on the person’s quality of life, which may be affected by their illness and treatment

• Assessments should include

1. What are the person’s goals?

2. What is their health literacy?

3. What is the cognitive status?

4. Who are their family/friend supports?

5. What community supports are available?


PAGE 2

Transformation of healthcare professional• Therapeutic alliance: relationship between a client and healthcare professional in that the engagement

with each other generates a behavior change with goal to increase treatment adherence and outcomes is referred to as:

• Healthcare professional considerations include

• Emotional intelligence: ability to recognize and regulate your own emotions and the emotions of others

• Top of license practice: practicing to the full extent of your education and training

• Measurement and awareness of person activation and engagement

• Support persons with engagement, shared decision making and self-management techniques

• Ensure continuity with transitions in care throughout the continuum of care

• Be resilient

Organization care delivery and transitions in care• Organizational goals should include

• Access to care

• Integrated and coordinated transitions in care

• Quality of care

• Reduced cost of care

• Organizations considerations should include

• Utilization of facility assessment

• Establishment of strategies and systems to ensure:

• Effective communication

• Minimization of human factors

• Quality assurance and performance improvement

• Supports for shared decision making and self-management techniques


PAGE 3

What about population health?• Population health is: the health outcomes of a group of individuals, including the distribution of such

outcomes within the group

• Social determinant of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

• Health disparities: are the social, cultural, political, economic, commercial and environmental factors that shape the conditions in which people are born, grow, live, work and age

Considerations in person-center care include• Role in advocacy

• Support national health objectives

• Broaden the reach to more populations by

• Early identification of risks

• Equipping, enabling, empower, and engaging all person in their wellbeing

• Self-management supports for nutrition, exercise, sleep and social connections


1

Bibliography

MedBridge Person-Centered Care: Equip, Enable, Empower, & Engage Persons in Their Health

Aimee E. Perron, PT, DPT, NCS, CEEAA

1. American Physical Therapy Association iNNOVATION SUMMIT Collaborative Care Models. PT In Motion [serial online]. August 2013;5(7):26-32. Available from: CINAHL Complete, Ipswich, MA.

2. Anekwe, T. D., & Rahkovsky, I. 2018. Self-Management: A Comprehensive Approach to Management of Chronic Conditions. American Journal of Public Health, 108(Suppl 6), S430–S436.

3. Atwood, K., S. Shamblen, T. Gaudet, A. Rindfleisch, D. Collins, C. Milovani, R. Greenfield, D. Kiefer, and D. Rakel. 2016. Impact of a clinical educational effort in driving transformation in health care. Family Medicine 48(9):711.

4. Béliveau, J. 2013. Middle managers’ role in transferring person-centered management and care. The Service Industries Journal 33(13-14):1345-1362.

5. Bernabeo, E., and E. S. Holmboe. 2013. Patients, providers, and systems need to acquire a specific set of competencies to achieve truly patient-centered care. Health Affairs 32(2):250-258.

6. Berwick, Donald (2002). "A User's Manual For The IOM's 'Quality Chasm' Report" (PDF). Health Affairs. 21 (3): 80–90.

7. Berwick DM, Nolan TW, Whittington J. 2008. The Triple Aim: Care, health, and cost. Health Affairs. 27(3):759-769.

8. Bodenheimer, T., and C. Sinsky. 2014. From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine 12(6): 573- 576.

9. Brega, A. G., J. Barnard, N. M. Mabachi, B. D. Weiss, D. A. DeWalt, C. Brach, M. Cifuentes, K. Albright, and D. R. West. 2015. AHRQ Health Literacy Universal Precautions Toolkit, Second Edition. (Prepared by Colorado Health Outcomes Program, University of Colorado Anschutz Medical Campus under Contract No. HHSA290200710008, TO#10.) AHRQ Publication No. 15-0023-EF. Rockville, MD: Agency for Healthcare Research and Quality.

10. Brown, A. K., Liu-Ambrose, T., Tate, R., & Lord, S. R. 2009. The effect of group-based exercise on cognitive performance and mood in seniors residing in intermediate care and self-care retirement facilities: A randomised controlled trial. British Journal of Sports Medicine. 43(8), 608-614.

11. Bozic, K. J., J. Belkora, V. Chan, J. Youm, T. Zhou, J. Dupaix, A. N. Bye, C. H. Braddock, 3rd, K. E. Chenok, and J. I. Huddleston, 3rd. 2013. Shared decision making in patients with osteoarthritis of the hip and knee: Results of a randomized controlled trial. Journal of Bone and Joint Surgery 95(18):1633-1639.

12. CAHPS Surveys and Guidance. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/cahps/surveys-guidance/index.html

13. Coleman, E. A., and S. J. Min. 2015. Patients’ and family caregivers’ goals for care during transitions out of the hospital. Home Health Care Services Quarterly 34(3-4):173-184.

14. Coleman, E. A., C. Parry, S. Chalmers, and S. J. Min. 2006. The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine 166(17):1822-1828.


2

15. Coleman, E. A., S. P. Roman, K. A. Hall, and S. J. Min. 2015. Enhancing the care transitions intervention protocol to better address the needs of family caregivers. Journal for Healthcare Quality 37(1):2-11.

16. Couët N., Desroches S., Robitaille H., et al. 2013. Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument. Health Expect. PMID: 23451939.

17. Coulmont, M., C. Roy, and L. Dumas. 2013. Does the Planetree patient-centered approach to care pay off?: A cost-benefit analysis. The Health Care Manager 32(1):87-95.

18. Craig C, Eby D, & Whittington J. 2011. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Institute for Healthcare Improvement.

19. deBronkart, Dave. 2015. From patient centred to people powered: Autonomy on the rise. BMJ. 350.

20. Delbanco, T., J. Walker, S. K. Bell, J. D. Darer, J. G. Elmore, N. Farag, H. J. Feldman, R. Mejilla, L. Ngo, J. D. Ralston, S. E. Ross, N. Trivedi, E. Vodicka, and S. G. Leveille. 2012. Inviting patients to read their doctors’ notes: A quasi-experimental study and a look ahead. Annals of Internal Medicine 157(7):461-470.

21. DeWalt, D. A., K. A. Broucksou, V. Hawk, C. Brach, A. Hink, R. Rudd, and L. Callahan. 2011. Developing and testing the health literacy universal precautions toolkit. Nursing Outlook 59(2):85-94.

22. Eckman, M. H., R. Wise, A. C. Leonard, E. Dixon, C. Burrows, F. Khan, and E. Warm. 2012. Impact of health literacy on outcomes and effectiveness of an educational intervention in patients with chronic diseases. Patient Education and Counseling 87(2):143-151.

23. Elwyn, G., D. Frosch, R. Thomson, N. Joseph-Williams, A. Lloyd, P. Kinnersley, E. Cording, D. Tomson, C. Dodd, S. Rollnick, A. Edwards, and M. Barry. 2012. Shared decision making: A model for clinical practice. Journal of General Internal Medicine 27(10):1361- 1367.

24. Ferguson, T., & Frydman, G. (2004). The first generation of e-patients. BMJ (Clinical research ed.), 328(7449), 1148-9.

25. Falvey JR, Burke RE, Malone D, Ridgeway KJ, McManus BM, Stevens-Lapsley JE. 2016.The Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Phys Ther. 96(8).

26. Frankel A, Haraden C, Federico F, & Lenoci-Edwards J. 2017. A Framework for Safe, Reliable, and Effective Care. IHI Innovation Series white paper. Institute for Healthcare Improvement and Safe & Reliable Healthcare.

27. Frampton S. B., S. Guastello, C. Brady, M. Hale, S. Horowitz, S. Bennett Smith, and S. Stone. 2008. Patient-centered care improvement guide. Derby, CT: Planetree, Inc., and Picker Institute.

28. Frampton, S. B., C. Wahl, and G. Cappiello. 2010. Putting patients first: Partnering with patients’ families. American Journal of Nursing 110(7):53-56.

29. Frampton, S. B., S. Guastello, L. Hoy, M. Naylor, S. Sheridan, and M. Johnston-Fleece. 2016. Harnessing Evidence and Experience to Change Culture: A Guiding Framework for Patient and Family Engaged Care. Discussion Paper, National Academy of Medicine, Washington, DC.

30. Frosch DL, Tai-Seale M. R-E-S-P-E-C-T--what it means to patients. J Gen Intern Med. 2014;29(3):427–428. doi:10.1007/s11606-013-2710-z

31. Gazelle, G., J. M. Liebschutz, and H. Riess. 2015. Physician burnout: Coaching a way out. Journal of General Internal Medicine 30(4):508-513.

32. Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research and Quality; May 2013. AHRQ Publication No. 13-0033.


3

33. Hall, AM., Ferreira, PH., Maher, CG., Latimer, J., Ferreira, ML. 2010. The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review, Physical Therapy, 90 (8):1099–1110.

34. Harwood, JL., Butler, CA., Page, AE. 2016. Patient-Centered Care and Population Health: Establishing Their Role in the Orthopaedic Practice. J Bone Joint Surg Am. 18; 98 (10).

35. Hibbard, J.; Stockard, J.; Mahoney, E.R.; Tusler, M. Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers. Health Serv. Res. 2004, 39, 1005–1026.

36. Horn KK, Jennings s, Richardson G, Vliet DV, Hefford C, Abbott JH. 2012. The patient-specific functional scale: Psychometrics, clinimetrics, and application as a clinical outcome measure. JOSPT. 42(1):30-40.

37. Institute of Medicine. 2000. To err is human: Building a safer health system. Washington, DC: National Academy Press.

38. Jette A. M. 2018. Moving From Volume-based to Value-based Rehabilitation Care. Physical Therapy. 98 (1):1–2.

39. Johnson, B. H. & Abraham, M. R. (2012). Partnering with Patients, Residents, and Families: A Resource for Leaders of Hospitals, Ambulatory Care Settings, and Long-Term Care Communities. Bethesda, MD: Institute for Patient- and Family-Centered Care.

40. Kelley, J. M., G. Kraft-Todd, L. Schapira, J. Kossowsky, and H. Riess. 2014. The influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials. PLoS One 9(4):e94207.

41. Kindig DA, Mullahy J. 2010. Comparative effectiveness – of What? Evaluating strategies to improve population health. JAMA, 304(8), 901-902.

42. Légaré F, Stacey D, Turcotte S, Cossi M, Kryworuchko J, Graham ID, Lyddiatt A, Politi MC, Thomson R, Elwyn G, Donner-Banzhoff N. 2014. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews. 9. Art. No.: CD006732.

43. Levine DM, Linder JA, & Landon BE. 2016. The Quality of Outpatient Care Delivered to Adults in the United States, 2002 to 2013. JAMA Intern Med.176 (12):1778-1790.

44. Moore LG, & Wasson JH. 2006. An Introduction to Technology for Patient-centered, Collaborative Care. Ambulatory Care Manage. 29(3):195–198.

45. Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. 2011. The care span: The importance of transitional care in achieving health reform. Health Aff. 30(4):746- 754.

46. Nelson, K. M., C. Helfrich, H. Sun, P. L. Hebert, C. F. Liu, E. Dolan, L. Taylor, E. Wong, C. Maynard, S. E. Hernandez, W. Sanders, I. Randall, I. Curtis, G. Schectman, R. Stark, and S. D. Fihn. 2014. Implementation of the patient-centered medical home in the Veterans Health Administration: Associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Internal Medicine 174(8):1350-1358.

47. Nickel WK, Weinberger SE, Guze PA. 2018. Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper. Ann Intern Med. ;169:796–799.

48. Parrish RG. 2010. Measuring population health outcomes. Prev Chronic Dis.7(4). 49. Porter, ME., and Lee TH. 2013. The Strategy That Will Fix Health Care. Harvard Business

Review (91)10:50–70. 50. Powers BJ, et al. Can this patient read and understand written health information? JAMA 2010

Jul 7;304(1):76-84 51. Radtke, K. 2013. Improving patient satisfaction with nursing communication using bedside shift

report. Clinical Nurse Specialist 27(1):19-25.


4

52. Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M. 2017. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews. 6. Art. No.: CD000072

53. Rosemond, C. A., L. C. Hanson, S. T. Ennett, A. P. Schenck, and B. J. Weiner. 2012. Implementing person-centered care in nursing homes. Health Care Management Review 37(3):257-266.

54. Schaefer, J., D. Miller, M. Goldstein, and L. Simmons. 2009. Partnering in self-management support: A toolkit for clinicians. Cambridge, MA: Institute for Healthcare Improvement.

55. Smith, S.; Curtis, L.; Wardle, J.; Wagner, C.; von Wolf, M. 2013. Skill Set or Mind Set? Associations between Health Literacy, Patient Activation and Health. PLoS ONE. 8, e74373.

56. Sørensen, K.; Van den Broucke, S.; Fullham, J.; Doyle, G.; Pelikan, J.; Slonska, Z.; Brand, H. 2012. (HLS-EU) Consortium European Health Literacy Project. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 12, 80.

57. Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing disability and change on individual patients: a report of a patient specific measure. Physiotherapy Canada, 47, 258-263

58. Teutsch SM, Fielding JE. 2011. Applying comparative effectiveness research to public and population health initiatives. Health Affairs. 30, 349-355.

59. Tzelepis F, Sanson-Fisher RW, Zucca AC, Fradgley EA. Measuring the quality of patient-centered care: why patient-reported measures are critical to reliable assessment. Patient Prefer Adherence. 2015;9:831–835. Published 2015 Jun 24. doi:10.2147/PPA.S81975

60. Vogus, T. J., and L. E. McClelland. 2016. When the customer is the patient: Lessons from healthcare research on patient satisfaction and service quality ratings. Human Resource Management Review 26(1):37-49.

61. Weiss, D., Tilin, F.J., Morgan, M.J. 2018. The interprofessional healthcare team – leadership and development. Burlington, MA: Jones & Bartlett Learning.

62. Whittington JW, Nolan K, Lewis N, Torres T. 2015. Pursuing the Triple Aim: The first seven years. Milbank Quarterly. 93 (2):263-300.

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