Ms. Weiss is a Santa Monica, CA-based healthcare consultant.
The true primary care providers are not doctors, nurses, hospitals, or other healthcare professionals, according to David S. Sobel, MD. Hidden within each community are the real architects of health — the people themselves.
"Within each person resides the first and most effective health maintenance organization — the human brain," explained Sobel, regional director of patient education and health promotion, Kaiser Permanente Medical Group in Northern California.
For community health status to be significantly improved and costs contained, Sobel believes that some of the fundamental assumptions underlying healthcare need to be challenged and changed. During his recent keynote address to the Utah Hospital Association, he pointed to current research showing that more than 8 out of 10 symptoms are self-diagnosed and self-treated without the help of healthcare professionals.
The healthcare system must increase self-care competence and empower patients to become active partners in healthcare, stated Sobel. "There's a fairly simple art to self-care — knowing when to call your doctor and when to treat yourself," added Pamela Larson in an interview. Larson, director of Kaiser's Northern California Region Self-Care Program, continued: "It's an art that is learned through education. The more our members know about health and medical care, the more effective they will be in participating in their own healthcare decisions."
Psychosocial Factors
"Thoughts, feelings, and moods can have a significant effect on the onset of some diseases, the course of many, and the management of nearly all," said Sobel. "Many visits to the doctor are occasioned by psychosocial distress. Even in patients with organic medical disorders, functional health status is strongly influenced by mood, coping skills, and social support. Yet, the predominant approach in medicine is to treat people as though they were mindless machines and to seek physical and chemical treatments to fix the disordered machine."
Sobel believes the mismatch between psychosocial health needs and the usual medical response leads to frustration, ineffectiveness, and a waste of vital health resources.
"Psychological and behavioral interventions can help patients more directly address their distress and, in the process, help them become less dependent on costly medical care," he stated. "Healthier communities can equip people for safe, effective, and efficient self-care and mobilize the intrinsic healing capacities of the human brain."
Sobel explained that health promotion need not always be an arduous, pleasure-denying enterprise aimed at changing unhealthy behaviors. He pointed to scientific evidence suggesting that enjoying healthy pleasures — from sensuality to optimism to altruism — can measurably improve health.
Healthcare professionals need to help patients manage their diseases and their common underlying needs for psychosocial support, coping skills, and sense of control. This way, health outcomes and cost outcomes can be improved, said Sobel. "While the health system cannot be expected to address all the psychosocial needs of people, clinical intervention strategies can be brought into better alignment with the emerging evidence on the psychosocial determinants of health."
Helping Handbook
Kaiser Permanente has initiated a number of projects to create healthier communities. Recognizing the important role that self-care plays for its members, Kaiser has provided its 1.2 million Northern California member households with a handbook designed to give them the skills and confidence to practice self-care safely and effectively (also see Michelle Hey, "Self-Care, Values Lead to Healthy Communities," Health Progress, July-August 1994, pp. 70-72, 79).
The Kaiser Permanente Healthwise Handbook offers health tips on more than 170 common health problems, advising readers on preventing, identifying, self-treating, and seeking professional help for health problems. The guidelines include information on nutrition, exercise, stress reduction, mental and dental health, and how to make the most of a physician visit.
"Not only was the book developed to reflect our own practice guidelines, but the concepts of self-care are being integrated into all aspects of the Self-Care Program," states Ron Treleven, national media relations specialist for Kaiser Permanente. "Physicians, nurses, health educators, and other professionals work with members to support and encourage appropriate self-care efforts."
In a 1992 pilot study, Kaiser Permanente mailed copies of the handbook to 30,000 member households, reaching all 75,000 members in the Fairfield, CA, service area. Approximately 1,000 additional copies were distributed in Kaiser's Fairfield clinic.
Before members received the handbook, physicians and other staff attended orientation and training sessions and learned how to reinforce use of the book. Nurses and physicians then promoted the importance of self-care and use of the book to patients. In addition, handbooks were available in examination rooms. Posters throughout the clinic and inserts in Kaiser's quarterly four-page Planning for Health newsletter promoted the use of the Kaiser Permanente Healthwise Handbook.
"In this pilot study we found that Fairfield members used the book, found it helpful, and viewed it as a valuable healthcare resource," says Fairfield family practitioner Steve Freedman, MD, who is medical director of Kaiser Permanente's Self-Care Program. "Steps that an individual takes before coming in can sometimes be counterproductive, such as putting heat on or walking on a severely strained ankle. With the book as a resource, our members' self-care skills have improved. They seek professional attention more appropriately, and their health has improved as well."
Proven Success
A comprehensive analysis of visit utilization was conducted for the two years before and the year after handbook distribution. Six months after the book was mailed, a telephone survey of 440 persons investigated their reactions, attitudes, use of the self-care handbook, and perceptions about reductions in medical utilization. Phone calls to the clinic were tracked for one year before and one year after the handbook mailing. A written physician and nurse satisfaction and opinion survey was also conducted nine months after the mailing.
The results included:
- A 5.4 percent reduction in acute care visits in the first year.
- A 1 percent reduction in visits overall in the first year. Of the 73 percent of phone interviewees who reported using the book, 68 percent said that it saved at least one physician visit.
- A 5 percent reduction in phone calls in the first year. Of those interviewees who reported using the handbook, 76 percent said it saved at least one call for advice.
- An increase in member satisfaction. Forty-two percent of the interviewees said they were more satisfied with Kaiser as a result of receiving the handbook.
- Cost-neutrality within the first year based on the decrease in physician visits.
It cost Kaiser some $5 million to provide the handbook to its Northern California members. However, industry-wide studies indicate a potential cost savings resulting from a projected 7 percent to 15 percent decline in inappropriate use of medical services, particularly emergency rooms. Recently, a Spanish version of the Kaiser Permanente Healthwise Handbook was released.
Dozens of letters and comments about the handbook from Kaiser Permanente members have been very positive. They have expressed appreciation for the book's simple, easy-to-understand language; its design for quick access to whatever information is needed; its sensitivity to differences in gender, religion, and sexual orientation; and its help in saving members a trip to the doctor's office. Some also commented that they prefer the privacy offered by this method because they are too shy to talk to even a nurse about sensitive health concerns.
Preventive Care and Health Promotion
"The Self-Care Program isn't designed to 'keep members out,'" explains Treleven. "On the contrary, it's designed to increase accessibility for members who need to see a physician by providing them with safe appropriate tips that help them stay healthy, practice self-care, and know when to call for advice. The handbook helps members determine when it's appropriate to seek medical care, thus freeing up healthcare professionals to treat patients who really need medical attention."
For more information on Kaiser Permanente's Self-Care Program, call Ron Treleven, 510-271-5953.
Fever Care
The Kaiser Permanente Healthwise Handbook is just one of Kaiser Permanente's efforts in self-care. Another program, initiated nearly a decade ago, educates families on caring for a person who has a fever. Some 500 families viewed a 10-minute video in waiting areas before a physician visit and also received an educational pamphlet on fever.
This campaign resulted in:
- Increased confidence in managing fevers at home (an 88 percent rise in confidence after viewing the video versus a 55 percent rise in confidence after reading the pamphlet)
- Higher member satisfaction
- Increased interest (95 percent of those asked) in audiovisual programs
- Lower pediatric clinic utilization (35 percent fewer visits for fever and 25 percent fewer acute visits for fever, sore throat, vomiting, and diarrhea)
Copyright © 1995 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.