The concepts of patient-centered care and patient engagement are often used interchangeably in health policy debates. In fact, it is frequently – and implicitly – assumed that putting patients at the centre of care will more or less spontaneously lead to fully engaged patients. This chapter questions these assumptions. By focusing on the hospital's patient-centered reform in Italy, the chapter discusses the overlaps but also the discrepancies between the practices of putting patients at the centre and those of engaging patients. Discrepancies may appear at three levels: the new hospital model may challenge the establishment of a close alliance between patients and professionals, the new hospital spaces may not be perceived as a catalyst for improving patients' experiences, and the inter- and intra- professional struggles derived from the new configuration of hospital teams at an early stage may hinder patient care delivery. The chapter proposes some strategies for patient-centered hospitals to increase their capacity to engage patients and families in the management of their care plan.
TopIntroduction
Today, patient centeredness is considered an essential dimension of the quality of healthcare and a central element of the mission of healthcare organizations (Berwick, 2009; Institute of Medicine [IOM], 2001). Patient centeredness is an approach to health care that emphasizes the limitations of a disease-centered model and calls for an exploration of patients’ needs, preferences, values, and concerns with the aim of increasing patients' involvement in the management of their care plan (International Alliance of Patients Organizations [IAPO], 2007).
In a recently published article (Liberati et al., 2015), a narrative review was conducted on the concept of patient-centered care, which showed how this research field could be broadly classified into two main streams. The first and more traditional stream, which is labelled ‘dyadic’, addresses patient centeredness at a micro level and focuses on the relationship and interaction between individual clinicians and patients (Levenstein, Mccracken, Mcwhinney, Stewart, & Brown, 1986; Bensing, 2000; Stewart et al., 2000), a second stream of research includes more recent publications with a shared aim of identifying organizational facilitators and system-level barriers to patient-centered care. This organizational stream addresses patient centeredness at the macro level and looks at the structural, cultural, and procedural dimensions of healthcare organizations that can help achieve a patient-centered approach (Bergeson & Dean, 2006; Greene, Tuzzio, & Cherkin, 2012; Hernandez, Conrad, Marcus-Smith, Reed, & Watts, 2013; Luxford, Safran, & Delbanco, 2011; Shaller, 2007). This chapter leans on this organizational stream to address the specific challenge of improving healthcare services in the direction of patient centeredness, and it specifically considers the distinction between the concepts of “centered” and “engagement.” In fact, despite the overlap in recent debates of the terms “patient centeredness” with the concept of “patient engagement,” we argue that, when considering both the literature and the concrete practices through which healthcare services are designed and managed, the two terms may inform very different improvement plans.
Indeed, “patient centeredness” has become a buzzword that serves a variety of purposes and is interpreted according to a variety of meanings. Within the broader philosophy of patient centeredness, the concept of patient engagement has pushed further the idea that patients can experience different degrees of participation in their health care experience, thus affecting the cure process itself. In this scenario, it is often assumed that putting patients at the centre automatically leads to a condition of full patient engagement, whereby patients become participants and co-constructors of their health and are capable of improving their quality of life (Barello et al., 2015).
The concept of patient engagement qualifies the type of relationship that the patients establish with their healthcare system of reference (the provision of medical services) at different levels (Carman et al., 2013; Graffigna, Barello, Riva, & Bosio, 2014). The notion of engagement refers both to patient activation (namely the patient’s knowledge, skills, ability, and willingness to manage his or her own health and care, e.g., by adopting measures of preventive care, following a balanced diet, or exercising regularly) and to a broader set of interventions designed to increase patients’ participation in designing and managing the healthcare delivery systems themselves.
Focusing on the hospital’s patient-centered reform, the issue tackled in this chapter is whether or not designing and managing a hospital according to the philosophy of putting the patient at the centre implies active engagement and participation from the patient in his or her care and healing process.