What if every patient in every hospital and clinic across the country had documented daily goals for what they wanted to get from their care? A few weeks ago, I had the pleasure of interviewing a patient - Jamie - who had been in and out of the hospital over the last decade with various health problems. After talking about her care, our conversation turned to her job. Jamie is a school teacher, and each year she gets 20 new students. I asked if the students were mostly alike, and she said, "No. They're all very different.' So I asked how she taught them, given the differences. Jamie explained that she has a simple, but successful, formula: 1; Huddle with all the students' prior teachers and map out a history from their point of view.
2 | Meet with the family to understand the home context.
3 | Meet with the student and set goals for the year, month by month.
These three simple but essential steps, if translated to health care, are exactly what we mean by patient- and family-centered care. Many organizations are starting to implement processes like Jamie's, but not enough. Another recent experience exemplifies the problem.
A family member of mine was a patient at a hospital here in Boston. As his condition worsened, his care team grew, which resulted in decreased coordination and clarity of communication. One doctor told him to take as much pain medication as he needed; another warned him not to take too much. One doctor advised him to walk around a lot; another recommended rest. There were conflicting interpretations of test results, conflicting recommendations about colostomy, and throughout it all, a total absence of post-discharge planning.
