A wholistic approach to patient-empowered care: a quality improvement report

Background and context

Current models of care in general practice do not adequately resource and empower wholistic and patient-centred partnership care. This dysfunction in the clinical delivery of primary care is widely documented and researched.^1,2

The ‘old medical model,’ as described by Jonathan Fuller,³ is the biomedical approach to health care, where biological dysfunction is treated through scientific and mechanistic reasoning. The rise of chronic disease and evidence-based medicine challenged this paradigm – people living with generally incurable diseases, often in combination, and clinical studies being privileged over mechanistic reasoning. The ‘new medical model’ adds to the old model concepts of prevention and management of long-standing disease and multi-morbidity through application of evidence-based medicine. Fuller highlights the limitations of reductionism in both these models and the value of a philosophical review of concepts of disease. Such insights highlight, for example, the role of psychological and social drivers in the prevention and management of chronic ill health, and how complex morbidity may be better considered in an integrated and wholistic way.

In much the same way, the definition of health, as posited in 1948 by the WHO – ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ – was challenged by Machteld Huber and colleagues⁴ as not being fit for purpose in the context of rising chronic disease. They proposed a change in emphasis in the face of social, physical, and emotional challenges towards health being ‘the capacity and ability to adapt and self-manage’. The proposition from this team was to use this notion of self-management as the starting point for a fresh way of conceptualising human health with a view to measuring dynamic features and engaging in discussions with key stakeholders, including patients and non-medical contributors. Huber and colleagues advocated that the first step towards this new definition of ‘health, as the ability to adapt and self-manage’ involves three domains – physical, mental, and social. A further domain, defined below and arguably the most important, is the spiritual. Huber’s definition of health requires a functional degree of self-efficacy. This is the belief of a person in their capacity and ability to achieve or complete a particular goal they have set. Such a locus of control moves responsibility for health outcomes away from the clinician towards the patient.

‘Spiritual health’ can be defined as ‘a state of being where an individual is able to deal with day-to-day life issues in a manner that leads to the realisation of one’s full potential, meaning and purpose of life and fulfilment from within.’⁵ Such a spiritual pillar provides the motivation needed for taking responsibility and making changes that enable the patient to adapt and self-manage.

Fuller’s summary statement regarding the new medical model is germane: ‘the new model represents the evolution of biomedicine in response to the rise of chronic diseases and evidence-based medicine, and it embodies a philosophy of care on a grand scale. Rising to the challenges that it poses will require both medical and philosophical wisdom.’

This Quality Improvement Report prompts consideration of the value of incorporating such a model of practice into health care on a grander scale.

The context for this project is an urban primary care general practice comprising 8500 patients across three locations in the New Zealand city of Tauranga in 2023–2024. It was led by Dr Andrew Corin, in his role as general practitioner and Clinical Director, and supported by the Family Doctors Operational and Governance Teams, with the purpose of enhancing quality care and exploring new delivery models. It also formed a Continuous Quality Improvement activity for Cornerstone Accreditation.

Assessment of the problem

The goal of this project is to perform a study to test and inform an evolved model of care to deliver wellbeing outcomes to a wide range of patients.

Methodology

There are two elements to this project: application for staff and initiative for patients. This is structured to train staff and then test the delivery to patients. Staff engagement was voluntary, supported, and confidential. During this process, questionnaires were used for the patient initiative to measure outcomes and improve the process of delivery. The intent is to scale the project for wider application to staff and patients across all Family Doctors’ locations and beyond. Cycles of delivery are planned, and measures from these will inform improvements. Facilitated group sessions were initially conducted over 4 weeks (90 min per session) supported by Project Me video and workbook resources from Positive Medicine. The resource content promoted the notion of a Hero’s Journey as a metaphor for the Positive Medicine catch-phrase of ‘Be the Project Manager of your own life,’ and supported participants to consider their ‘stock take,’ ‘vision,’ ‘challenges,’ and ‘journey’ or steps in their Hero’s Journey in the context of the Four Pillars (see Fig. 1).

Fig. 1.

Project Me summary.

Timetable

• September 2023 and beyond

  • Support Family Doctors staff to engage with Project Me for personal and professional development. The Project Me package was purchased by Family Doctors and provided at no cost to staff.

• September 2023–October 2023

  • Complete study phase 1 of facilitated Project Me sessions with patients.

• October 2023–October 2024

  • Study phase 2 of individualised clinically focused sessions with patients who have completed Project Me. This involved each participating patient meeting with Dr Corin in a clinical consultation context for 45–60 min with a focus on the patient’s individual health journey using the framework (Fig. 2). The phrase ‘abundance healthcare’ is taken from the Family Doctors Team Canvas (strategic operational and aspirational frame) and Martin Seligman’s concepts in ‘Life Well Lived.’¹⁰

    • These were repeated at 6-monthly intervals, for a total of three contacts.

    • The QR code on the framework document is a link to the WHO Quality Of Life assessment.

  • Data collation, sharing, and review occurred throughout this period.

• October 2024 and beyond

  • Review the study with a Plan/Do/Study/Act lens.¹¹

  • Extend the programme to a broader group of patients, both at Family Doctors and in a wider clinical context.

Fig. 2.

Framework for patient health journey.

Results of assessment

The objectives and targets set at the beginning of the project were variably met (see Table 3).

Self-Efficacy scores

Self-Efficacy scores were determined at the beginning and end of the facilitated Project Me video modules, with an 18% average increase demonstrated (Fig. 3). A further 9.5% average increase was recorded at the end of the 12 month review.

Fig. 3.

New Generation Self-Efficacy change in patient scores after Project Me.

This improvement indicates both the effectiveness of the delivered video modules and ongoing patient-led capacity to further increase their self-efficacy.

Strategies for quality improvement

The Royal New Zealand College of General Practitioners’ (RNZCGPs'’s) commitment to framing general practice health care under Te Whare Tapa Whā and Meihana¹³ models requires intentional and bold commitment. Not only does the old model of health care demand challenge from the new; patients deserve and require a more active role in the healthcare interaction – to do this they need a strong sense of agency and self-efficacy.

This study has demonstrated that meaningful improvements in health can be achieved through shifting locus of control towards the patient and using tools to enhance a wholistic approach to the clinician–patient interaction.

Highly effective education and engagement in improving self-efficacy were achieved using the Positive Medicine video modules Project Me. The project involved four 90-min facilitated video sessions. Such sessions proved valuable in a group context as sharing of stories, challenges, and encouragement enhanced the messages of the videos. However, the modules and workbook are designed to be effective in a private/individual setting as well as in a group.

Individual extended clinician–patient consultations at 6-monthly intervals proved valuable in reviewing progress and challenges and resetting goals in a dynamic and clinically relevant way.

An important element of this project is to explore a move away from clinician-centric point-of-care systems in health care towards models that resource patients in their context. Although all of the eight patients in the study were new to each other, there was value in group discussions with sharing of challenges and goal-setting. Continuity of care from a GP with whom they have a relationship and from whom they receive agency and validation is a positive contributor to the outcomes. These aspects of mutual sharing and continuity of care can be considered additional benefits to the Project Me modules.

The opportunity to form a new model for appropriate patients is an important strategy in improving quality of care. With minimal requirement for training of clinicians, harnessing both the value of existing tools (such as those in the Positive Medicine suite) and the power of patient activation and self-efficacy, important improvements in health outcomes can be achieved with highly cost-effective investment.

Funding for the study was through a combination of discounted access to Project Me video modules, investment in clinical resources by Family Doctors, contributions to the consultation cost by patients, and voluntary contributions by the author. Funding for future application of this model of care may include initiatives from the Ministry of Health, Primary Health Organisations, Health Insurers, and effective use of current capitation and long-term condition funding in general practice.

Lessons and messages

Motivating effective behavioural change for patients is achievable with appropriate strategies and tools. An important element in this process under the Te Whare Tapa Whā model is the spiritual pillar; having a sense of meaning and purpose is a powerful driver for change in the other pillars and domains. Identifying such a spiritual pillar (what matters most to my patients) has previously been an effective tool in goal setting and therapeutic choices in my practice.¹⁴

The WHOQOL-BREF sub-analysis indicates that attending to the elements of the Four Pillars, coupled with self-efficacy and patient activation, supports the ability to adapt and self-manage health challenges without a decline in perception of wellbeing.

Furthermore, the enhanced wholistic and empathic connection between patient and doctor achieved in the project increased levels of satisfaction in the clinical context for both parties. The corollary of this includes improved outcomes and reduced complaints.¹⁵

In the current resource-constrained primary care environment, with access barriers to general practice care such as cost, clinician availability, and limited consultation time, consideration of alternative models is a necessary strategy for effective, efficient, and quality health care. The model presented in this paper requires limited investment, harnesses the power of the patient, and offers the clinician the opportunity for professional satisfaction as a guide and mentor.