IN CLINICAL PRACTICE, someone obtains vital signs, such as blood pressure, pulse, temperature, and respiration rate, to assess body functions before the patient is evaluated by a healthcare professional. CARE Vital Signs refers to a standard form created by practices to Check what matters to patients, Act on that assessment, Reinforce the actions, and systematically Engineer or incorporate actions into staff roles and clinical processes (Wasson et al., 2003). Thus, CARE Vital Signs offers a method for practices to routinely screen patients to determine whether they have common, important issues for which effective actions might be implemented without necessarily depending on an evaluation by a healthcare professional. For example, based on particular items in CARE Vital Signs, office staff might implement standing orders to provide specific screening tests or self-management education to the patient.
CARE Vital Signs has proven to be useful for both patients and practices. Patients benefit because this method offers the promise of reliable action for “what matters” to them: CARE Vital Signs supports patient-centered, collaborative care (Moore & Wasson, 2006). Practices benefit from using this approach in 2 ways. First, doctors and nurses find that knowing “what matters” to patients improves the efficiency and effectiveness of the care they deliver. For example, the presence of pain and emotional problems adversely impacts patient confidence with self-management, which, in turn, undermines the proven power of collaborative care (Wagner et al., 1996; Wasson et al., 2006b, 2008b). Second, as practices incorporate CARE Vital Signs, the professional and nonprofessional staff invariably uncover inefficient, behaviorally unsophisticated processes and invent better processes and means of deploying the practice's workforce. For example, instead of relying only on the physician, a medical assistant can be trained to help patients use valuable self-management resources for particular issues identified by CARE Vital Signs (Wasson et al., 2003).
The Institute for Healthcare Improvement has encouraged the use of CARE Vital Signs in its various collaboratives and programs to redesign office practices. On the basis of this experience, this article illustrates the typical lessons practices learn when they implement CARE Vital Signs.
In the actual order learned, the lessons are as follows:
- Who will do this? (Implementation)
- What will our patients say? (Population)
- What actions might we take and reinforce? (Behaviorally sophisticated actions)
- How do we build CARE Vital Signs or the concept of CARE Vital Signs into practice? (Resource planning)
CARE VITAL SIGNS: IMPLEMENTATION
The Institute for Healthcare Improvement faculty present CARE Vital Signs as a “standard form” to office practices (Appendices 1–3). The faculty inform practices that the questions on the form have been extensively tested and that there is an advantage to try it “as is” before considering modifications for their setting. Office staff are encouraged to begin using CARE Vital Signs with 10 patients, perhaps with 1 patient in the morning and 1 in the afternoon over the course of 5 working days. Most practices will be able to complete 10 CARE Vital Signs; those that have difficulty will need to improve practice function before proceeding (see “The How and Why of Balanced Measurement”; Wasson & Baker, 2009).
The simple request to complete 10 CARE Vital Signs engages the office in an evaluation of its patient flow. Who does what and why? Who will do CARE Vital Signs, when, and how? Michelle A. Eads, MD, a physician in Colorado Springs, offers the following guidance when implementing CARE Vital Signs:
I want to share a few tricks I've learned about using the CARE Vital Signs forms.
We do this only for annual preventative physical appointments (or for people we suspect need self-management support and won't go to www.howsyourhealth.org) and not at every encounter. The medical assistant takes the patient's vitals, enters them into the computer as usual, then gets the [CARE Vital Signs] provider form in front of her and gives the patient the patient [version of the CARE Vital Signs form]. They both fill out the forms simultaneously. The medical assistant tells the patient their vitals and body mass index (BMI), and then the patient looks at the pain/feelings/health habits charts [on the form], and tells my medical assistant what their numbers are. Then the patient brings in both copies to me and I circle/add the appropriate actions, scan the provider copy into the medical record, and give the patient their copy.
CARE VITAL SIGNS: POPULATION
By starting with a small sample of 10 patients, most practices will identify some new insights by chance alone or perhaps none at all. In order that staff do not draw erroneous conclusions based on an inadequate sample, it is important for a practice to identify how its population of patients is likely to respond. The following is an overview of responses from 85,000 adults, aged 19 to 59, who completed the HowsYourHealth.org web-based survey tool, from which a few survey items are excerpted as part of CARE Vital Signs.
Adult CARE Vital Signs emphasizes 6 items: pain, emotion, body mass index, general health habits, confidence with self-management, and possible illness related to medications. Across any 50 practices, the middle 25 practices (ie, the 25–75 interquartile range) have from 25% to 40% of their adult patients reporting no abnormality on CARE Vital Signs, as well as 6% to 17% reporting 3 or more abnormalities. Table 1 shows selected problems of patients based on the number of abnormalities reported on CARE Vital Signs.
By assessing the number of reported CARE Vital Signs abnormalities, clinicians immediately understand that patients with few reported abnormalities, and therefore fewer problems, require fewer services. Table 1 underscores this clinical observation. Table 2 demonstrates a dramatic decrement in the quality of care when an increasing number of CARE Vital Signs abnormalities are reported.
The data in Tables 1 and 2 illustrate that CARE Vital Signs is a simple method for identifying patients who are likely to have few, some, and many medical and psychosocial issues, as well as few, some, and many deficiencies in quality of care.
CARE VITAL SIGNS: BEHAVIORALLY SOPHISTICATED ACTIONS AND RESOURCE PLANNING
Other lessons learned from the data in Tables 1 and 2 include the following:
- There are too many problems to be dealt with one at a time, even if the office visit time was extended.
- There is too much information for a patient to remember when it is communicated at one time.
- There is a need to segment patients into categories and provide effective generic solutions to problems because a disease-by-disease or a problem-by-problem intervention is not feasible.
The challenge, of course, is knowing what “generic solutions” are effective. Although this is still an area of active research, 4 interrelated actions have evidence of value:
- Segmentation of patients into meaningful categories for which specific actions are routinely prescribed (Wasson et al., 2006a).
- Problem solving and action planning as techniques to identify key issues of concern and simple, feasible strategies to begin addressing these issues (Ahles et al., 2006).
- Brief, repetitive intervention rather than overwhelming, 1-time exhortation (Stange et al., 2002; Von Korff et al., 1997).
- Confidence building so that patients become comfortable and adept at self-management (Wasson et al., 2006b).
Table 3 summarizes examples of initial generic solutions to problems reported as abnormalities on Adult CARE Vital Signs. All of these actions require collaboration and bidirectional information transfer between patients and a member of the office staff. (The office staff member does not need to be a clinician!) All interventions will require the office practice to be accessible and efficient.
In addition to the actions specified in Table 3 for specific problems identified from CARE Vital Signs responses, office practices need to assess the intensity of any action over time. Behavioral research underscores the importance of reinforcing most actions so that they have a sustained effect. For patients, this often implies feedback and follow-up. For professional and nonprofessional staff, actions need to be systematically engineered (ie, the “E” in CARE) into staff roles and clinical processes to improve reliability.
Resource planning enables providers to deliver higher quality, more efficient care to patients: if it is scheduled, it will happen; if it is not planned, it is difficult to make it happen. This approach requires knowledge of both “what is the matter?” and “what matters” and uses this information to segment patients into behaviorally meaningful categories such as patients with low needs, medium needs, and high needs. Resource planning also requires healthcare providers to match care that is known to be effective with the high-leverage “commonalities” among 80% of the patients in each category (Wasson et al., 2006a).
Resource planning for low-needs patients
Low-needs patients with no CARE Vital Signs abnormalities reported, regardless of diagnoses, generally require fewer services. About 40% of patients with adequate finances are low-needs patients versus 20% of poor patients. Should low-needs patients require services from the practice, they need immediate and unfettered access, high continuity and reliability of care, and very good information so that they may make appropriate adjustments in their care. Although some patients in this category may have chronic diseases, they are confident in self-management and have no pain or emotional issues that will impede their ability to manage their conditions (Wasson et al., 2008b). The clinician's role is to reassure them of their good health status, reinforce healthy behaviors, and provide proven preventive care. The HowsYourHealth.org registry function can be used to remind patients to complete the on-line health survey tool annually, helping ensure these patients maintain positive health behaviors and continue to do well.
Resource planning for medium-needs patients
Medium-needs patients with 1 to 2 CARE Vital Signs abnormalities do not achieve key care goals with consistency. Although the majority of these patients do not feel confident with self-management, those who do may need less reinforcement. However, as a general rule, these patients generally perceive that they have received low-quality information about their problems and can benefit from simple strategies to help them better understand and cope with identified issues.
CareSouth Carolina devised and tested a simple reinforcement strategy by medical assistants based on a “red-yellow-green” colored information sheet to improve patient understanding of their health problem and confidence in managing it. The results were dramatic in terms of increased patient confidence and better control of their blood pressure. (Wasson et al., 2008a)
In a controlled trial, 3 phone calls to patients to support self-management of patient and emotional problems proved significant and lasting. (Ahles et al., 2006)
In addition to the basic services required by low-needs patients, the practice may introduce some of the initial generic solutions (Table 3) and experiment with different types of reinforcement such as e-mail or phone follow-up. Because medium-needs patients have many other potential issues, full assessment by using the HowsYourHealth.org survey tool is a helpful way for clinicians to identify “what matters” and provide tailored information. The article in this series, “Activation of Patients for Successful Self-management,” contains additional resources for enhanced self-management support.
Resource planning for high-needs patients
High-needs patients with 3 or more reported CARE Vital Signs abnormalities require much greater frequency and depth of interaction with the practice, as well as consultation and support from additional external sources. Given these patients' multiple needs, it is imperative that patients, family members, and all providers have a shared understanding of priorities and goals for managing identified problems. About 25% of poor patients have high needs versus 10% of patients with adequate finances.
In addition to providing the same services as those required by medium needs patients, a typical office practice will benefit from having a designated staff member who coordinates care for high-needs patients. Most importantly, this staff member needs to continuously provide brief, proactive reinforcement of self-management support and monitoring of important health concerns by phone, if possible, or at every office visit. Group visits are another beneficial way to fulfill the care needs of both medium-needs and high-needs patients (Improving Chronic Illness Care, 2008).
CARE Vital Signs has proven to be a useful tool for assisting practices that want to improve their provision of patient-centered, collaborative care. Three versions for adult, adolescent, and geriatric patients are included in the appendices. Any of these CARE Vital Signs forms can be customized by adding or deleting items, and items may be implemented in a staggered fashion over time to avoid overwhelming staff. A shorter version of the CARE Vital Signs is often used either initially by a practice to gain experience with the concept of CARE or as a tool for more frequently monitoring of the patients. The critical factors to determine which CARE Vital Signs items to use in a practice depend on the estimated frequency of abnormalities in a patient population and the ability of staff to adequately manage abnormalities when they are identified. Completing 30 CARE Vital Signs forms usually gives an office practice a good estimate of the frequency of expected abnormalities. However, we urge practices to be very careful about permanently eliminating measures of emotional health, confidence with self-management, and pain because these factors have decisive influence on patient outcomes (Wasson et al., 2008b).
On its face, CARE Vital Signs is a deceptively simple tool that, when properly used, can help a practice attain levels of efficiency and quality.
Ahles, T. A., Wasson, J. W., Seville, J. L., Johnson, D. J., Cole, B. F., Hanscom, B., et al. (2006). A controlled trial of methods for managing pain in primary care patients with or without co-occurring psychosocial problems. Annals of Family Medicine, 4
Retrieved from Improving Chronic Illness Care. (2008).
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Stange, K. C., Woolf, S. H., & Gjeltema, K. (2002). One minute for prevention: The power of leveraging to fulfill the promise of health behavior counseling. American Journal of Preventive Medicine, 22
Von Korff, M., Gruman, J., Schaefer, J., Curry, S. J., & Wagner, E. H. (1997). Collaborative management of chronic illness. Annals of Internal Medicine, 127
Wagner, E. H., Austin, B. T., & VonKorff, M. (1996). Organizing care for patients with chronic disease. Milbank Quarterly, 74
Wasson, J. H., & Baker, N. J. (2009). Balanced measures for patient-centered care. The Journal of Ambulatory Care Management, 32
Wasson, J. H., Ahles, T., Johnson, D., Kabcenell, A., Lewis, A., & Godfrey, M. M. (2006a). Resource planning for patient-centered, collaborative care
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Wasson, J. H., Anders, G. S., Moore, L. G., Ho, L., Nelson, E. C., Godfrey, M. M., et al. (2008a). Clinical microsystems, Part 2. Learning from micro practices about providing patients the care they want and need. Joint Commission Journal on Quality and Patient Safety, 34
Wasson, J. H., Godfrey, M. M., Nelson, E. C., Mohr, J. J., & Batalden, P. B. (2003). Planned care in microsystems, Part 4. Doing it right the first time for every single patient. Joint Commission Journal on Quality and Patient Safety, 29
Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. (2006b). Patients report positive impacts of collaborative care
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Wasson, J. H., Johnson, D. J., & Mackenzie, T. (2008b). The impact of primary care patients' pain and emotional problems on their confidence with self-management. The Journal of Ambulatory Care Management, 31
Welch, G. H., Albertsen, P. C., Nease, R. F., Bubolz, T. A., & Wasson, J. H. (1996). Estimating treatment benefits for the elderly: The effect of competing risks. Annals of Internal Medicine, 124
Wenger, N. S., Roth, C., Shekelle, P., & the ACOVE Investigators. (2007). Introduction to the assessing care of vulnerable elders—3 quality indicator measurement set. Journal of the American Geriatric Society, 555
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Adult CARE Vital Signs
Adolescent CARE Vital Signs
Geriatric Care Vital Signs
CARE Vital Signs for preteens and teens (aged 8–18) would give the distribution of findings shown in the following table on the basis of number of abnormal vital signs. (Analysis based on 3500 respondents to the HowsYourHealth.org Web-based survey tool). The age of respondents do not change by the number of abnormalities. Females are represented a bit more frequently in those with abnormalities: 53% for none, 60% for 1 to 2, and 65% for 3 or more. Overall, about 40% to 45% of preteen/teens will have no abnormalities, an equal number 1 to 2 and 10% to 15% will have 3 or more. The HowsYourHealth.org survey does not include an income question for preteens/teens.
Twenty percent of those with no abnormality have seen a counselor in the past year, whereas 31% of those with 3 or more abnormalities have seen a counselor.
The following table illustrates that preteen/teens with problems are less likely to talk about them, the more abnormalities they have.
The last table illustrates the quality of the discussions and percentage of discussions preteen/teens have had with a doctor or a nurse.
The analysis is based on 3500 responses of patients 70 years or older to the www.HowsYourHealth.org Web-based survey tool.
In a majority of practices, about 40% of the patients older than 70 will have no abnormal responses, 40% will have 1 or 2 abnormal responses, and 20% will have 3 or more. However, if a practice cares for patients with low financial status, the distribution will change dramatically with only 10% having no abnormalities and 60% having 3 or more. Appendix Table 1 provides samples of diagnoses, health habits, symptoms, use of assistive devices, and instrumental activities of daily living. Also, it provides days sick in bed and previous use of the hospital. Not surprisingly, every sample marker of illness increases with the number of abnormal Geriatric CARE Vital Signs.
Appendix Table 2 illustrates the quality of care for patients who have adequate finances on the basis of abnormalities on Geriatric CARE Vital Signs. The greater the number of abnormalities, the worse is the perception of care.
ILLUSTRATIVE ACTIONS THAT MIGHT BE TAKEN AFTER USING GERIATRIC CARE VITAL SIGNS
Patients whose Geriatric Vital Signs have no abnormalities are very low needs patients. Although some of them have chronic diseases, they are confident in self-management and have no pain or emotional problems that will impede their ability to manage their concerns (Wasson et al., 2008a). Except for the smokers among them, the vast majority will also have about a 5 years' longer life expectancy than average for their age (Welch et al., 1996).
A clinician's job is to reassure patients of their good health status, reinforce healthy behaviors, and provide proven preventive care after informing them of their likely life expectancy. The patients should also be encouraged to continue their self-management activities by performing a health check-up annually on-line by using free, noncommercial tools such as HowsYourHealth.org. If this survey tool is used, its registry function can be used to remind them every year to complete the HowsYourHealth.org tool to make sure that they are continuing to do well. They should also be reminded to complete or update an advanced care plan.
These patients have 1 to 2 abnormal responses to the Geriatric CARE Vital Signs. Appendix Table 3 illustrates the types of action an office might consider. (Similar lists of actions generated by expert panels are available elsewhere) (Wenger et al., 2007).
Within this category, the office staff can describe explicit actions and “standing orders” for each of the responses. Many of these actions need not be executed by a physician. In addition, group visits are a very useful enhancement for the typical office visit of a patient who has a few CARE Vital Sign problems.
Because these patients have so many other issues, a comprehensive tool such as HowsYourHealth.org might be used before the next office visit to tailor information for their need and help the clinical staff find out “what matters” to these patients. Patients with medium or high needs will often require family members assist them with the use of computers.
This group of patients represents a rather frail group of elderly patients. They invariably require many services and are at high risk for death, rehospitalizations, and harms associated with healthcare. However, despite their illness burden, about 1 in 4 do not have a clear idea about who will make decisions for them if they become too sick to speak for themselves. They also tend to overestimate their likelihood of survival.
Many of these patients will benefit from the same approaches suggested for medium-needs patients. Given these patients multiple needs, it is imperative that family members, the patient, and other providers are all on the “same page” about management issues, priorities, and goals. The special survey within www.howsyourhealth for frail patients may be invaluable for assessing their needs and providing basic education based on their needs. The tool can save much clinician time and help the family and the patient be sure they are on the “same page.”
If possible, the office should designate someone to look out for high-needs patients and coordinate their care. Most importantly, this member of the staff should continuously provide brief proactive reinforcement of self-management and monitoring of important health concerns by phone, if possible, or at every visit.